[Colonic pouch reconstruction after low anterior rectal resection]. / Kolonpouchrekonstruktionen nach tiefer anteriorer Rektumresektion.

For many decades the coloanal anastomosis was traditionally created as an end-to-end anastomosis. Despite successful surgical restoration of the intestinal passage after low rectal resection and total mesorectal excision (TME), physiological continence and evacuation function cannot be achieved in many cases using end-to-end anastomosis. Subsequent complaints, such as fecal incontinence and urge problems, evacuation difficulties and high stool frequency (so-called low anterior resection syndrome, LARS) are the result. The combination of symptoms after TME known as LARS is described in the literature in up to 60% of cases. The increased occurrence of the imperative urge to defecate, frequent bowel movements and problems with fecal incontinence motivated surgeons to look for alternative anastomosis techniques. Side-to-end anastomosis, coloplasty pouch and colonic J­pouch have been shown in various studies to be superior to end-to-end anastomosis in terms of functional results. Current studies could show that the side-to-end anastomosis (even if this is not a pouch in the actual sense) and the two pouch techniques show comparable results in terms of functional outcome and the rate of anastomotic leakage. The alternative to coloanal anastomosis after TME is the abdominoperineal resection. Most, especially younger patients, prefer to try to maintain continence with the risk of the described functional problems. If the patients are well selected, TME can be carried out with the current techniques in such a way that continuity is maintained and a good defecation function is achieved for a large proportion of patients using the pouch-anal anastomosis or the side-to-end techniques.

Obstructive defecation syndrome: 19 years of experience with laparoscopic resection rectopexy.

BACKGROUND: In obstructive defecation syndrome (ODS) combinations of morphologic alterations of the pelvic floor and the colorectum are nearly always evident. Laparoscopic resection rectopexy (LRR) aims at restoring physiological function. We present the results of 19 years of experience with this procedure in patients with ODS. METHODS: Between 1993 and 2012, 264 patients underwent LRR for ODS at our department. Perioperative and follow-up data were analyzed. RESULTS: The female/male ratio was 25.4:1, mean age was 61.3 years (±14.3 years), and mean body mass index (BMI) was 25.2 kg/m(2) (±4.2 kg/m(2)). The pathological conditions most frequently found in combination were a sigmoidocele plus a rectocele (n = 79) and a sigmoidocele plus a rectal prolapse or intussusception (n = 69). The conversion rate was 2.3 % (n = 6). The mortality rate was 0.75 % (n = 2), the rate of complications requiring surgical re-intervention was 4.3 % (n = 11), and the rate of minor complications was 19.8 % (n = 51). Follow-up data were available for 161 patients with a mean follow-up of 58.2 months (±47.1 months). Long-term results showed that 79.5 % of patients (n = 128) reported at least an improvement of symptoms. In cases of a sigmoidocele (n = 63 available for follow-up) or a rectal prolapse II°/III° (n = 72 available for follow-up), the improvement rates were 79.4 % (n = 50) and 81.9 % (n = 59), respectively. CONCLUSIONS: LRR is a safe and effective procedure. Our perioperative results and long-term functional outcome strengthen the evidence regarding benefits of LRR in patients with an outlet obstruction. However, careful patient selection is essential.

Pancreatic carcinoma cell lines reflect frequency and variability of cancer stem cell markers in clinical tissue.

BACKGROUND: Pancreatic cancer is one of the most deadly malignancies with insufficient therapeutic options and poor outcome. Cancer stem cells (CSCs) are thought to be responsible for progression and therapy resistance. We investigated the potential of pancreatic cell lines for CSC research by analyzing to what extent they contain CSC populations and how representative these are compared to clinical tissue. METHODS: Six pancreatic cancer cell lines were analyzed by flow cytometry for CD326, CD133, CD44, CD24, CXCR4 and ABCG2. Subsequently, 70 primary pancreatic tissues were evaluated for CD326, CD133 and CD44 by immunohistochemistry. RESULTS: All the cell lines but one showed a stable expression pattern throughout biological replicates. Marker expression in clinical tissue of CD44 distinguished normal patients from pancreatic carcinoma patients with a sensitivity of 50% at 80% specificity and metastasized from nonmetastasized carcinomas with 69% sensitivity at 100% specificity. CONCLUSIONS: Our results indicate a link between elevated CD44 expression, malignancy and metastasis of pancreatic tissue. Furthermore, individual pancreatic cell lines show a substantial amount of cells with CSC properties which is comparable with interpatient variability detected in primary tissue. These pancreatic cancer cell lines could thus serve for urgently needed pharmacological CSC in vitro research.

[Laparoscopic resection rectopexy as treatment for obstructive defecation syndrome]. / Die laparoskopische Resektionsrektopexie zur Therapie des obstruktiven Defäkationssyndroms.

Anorectal outlet obstruction constitutes one form of chronic constipation. Combinations of morphological alterations of the pelvis, the pelvic floor and the colorectum are nearly always evident. The goal of the diagnostic work-up is to identify those patients who will profit from a surgical intervention. Resection rectopexy aims at restoring the physiological anatomy thereby ameliorating the functional interaction of structures effected with the laparoscopic approach entailing all advantages of minimally invasive surgery. Besides a detailed description of the surgical technique used and an algorithm for indications to operate we present our results after 19 years of experience. Throughout this period, 264 laparoscopic resection rectopexies for outlet obstruction were performed. With a mean follow-up of 58.2 months the rate of improvement of obstructive symptoms was 79.5 % (n = 128 of 161 available for follow-up). Present studies suggest that (laparoscopic) resection rectopexy entails better results in comparison to non-resecting procedures and procedures with the implantation of allogenic material. Certainly, in order to achieve these results a correct patient selection and an expertise in laparoscopic surgery are essential. Both the perioperative and the functional results of our own collective fortify the advantages of laparoscopic resection rectopexy in patients with an outlet obstruction.

[CEUS as a tool to uncover an unusual cause of obstructive jaundice]. / KM-verstärkter Ultraschall zur Erkennung der seltenen Ursache eines obstruktiven Ikterus.

Aneurysms within the visceral arteries are rare. Among these, aneurysms of the splenic artery occur most frequently followed by aneurysms of the hepatic arteries. An early diagnosis is easily missed and almost all patients become symptomatic with an acute rupture associated with high mortality. Here we demonstrate the case of a 76-year-old patient who presented with acute upper abdominal pain accompanied by a single episode of vomiting and pyrexia of 39 °C. Laboratory results presented the picture of an obstructive jaundice without evidence for accompanying pancreatitis. Inflammatory markers were within normal limits at onset, but increased dramatically within the next few days. An acute calculous cholecystitis was diagnosed on abdominal ultrasound whereas gastroscopy revealed no relevant changes. Computed tomography was suspicious for pancreatitis of the head with obstruction of the bile duct. Choledocholithiasis was ruled out by ERCP, but symptoms persisted despite papillotomy. Due to raising inflammatory markers and an ongoing impairment of the patients condition, an abdominal CT scan was repeated which revealed the suspicion of a ruptured aneurysm of the common hepatic artery. At the time of transferral we were able to confirm the diagnosis by contrast-enhanced ultrasound and angiography. The patient was immediately forwarded to surgery due to lack of satisfactory endovascular procedures. In summary, the patient suffered from a ruptured spurial aneurysm of the right gastric artery thereby obstructing the common bile duct. Beside CT scans and angiography, this case documents a pivotal role for contrast-enhanced ultrasound in the work-up of visceral artery aneurysms.

Transperineal omentum flap for the anatomic reconstruction of the rectovaginal space in the therapy of rectovaginal fistulas.

AIM: Deep rectovaginal fistulas are a rare entity and pose a delicate challenge for the surgeon. The present study introduces different operative interventions involved in transperineal omental flap surgery. METHOD: A retrospective analysis of all patients treated with a low or mid rectovaginal or enterovaginal fistula at the Department of Surgery of the University Hospital of Schleswig-Holstein, Campus Luebeck, was performed. Treatment results were discussed with respect to aetiology, localization, morbidity and outcome. RESULTS: Between the years 2000 and 2010, a total of nine patients with a low or mid rectovaginal fistula were treated at our clinic. After local fistulectomy, all patients were additionally treated by a laparoscopically assisted omental flap reconstruction of the rectovaginal and perineal space. Eight of the nine patients received a protective ileostomy or colostomy. Only the patient with a history of Crohn's disease had no ileostomy raised. At a median follow-up of 22 months, no patient experienced recurrence of a rectovaginal fistula. Perioperative mortality was zero and minor complications were observed in 22%. Major complications were an anastomotic insufficiency after low anterior resection that was treated without further interventions. Another complication was a persistent fistula within the sphincter that needed re-operation and bovine plug repair combined with a mucosa flap. CONCLUSIONS: Complete omental reconstruction of the rectovaginal space appears decisive in the operative therapy of deep rectovaginal or enterovaginal fistulas. Comparative studies on standard therapies are necessary although direct comparison of case series is difficult.

[Indications for laparoscopic pancreas operations: results of a consensus conference and the previous laparoscopic pancreas register]. / Indikation zur laparoskopischen Pankreasoperation: Ergebnisse einer Konsensuskonferenz und des bisherigen laparoskopischen Pankreasregisters.

Laparoscopic pancreatic surgery is not common practice in Germany and is only carried out in approximately 20 clinics but with an increasing trend. The reasons for this are manifold, such as the current selection of patients and both skills in laparoscopic and pancreatic surgery are necessary to perform this operation safely. In 2008 a registry called "Laparoscopic pancreatic surgery" was implemented to collect enough data in Germany to find out whether the resection is safe, feasible and beneficial for the patient.For further development of new laparoscopic techniques new data is needed. A group of experts performing laparoscopic pancreatic surgery in Germany supplied their data for the German registry for laparoscopic pancreatic resection and a consensus conference about the indications became necessary. This consensus conference discussed in particular the indications for laparoscopic pancreatic resection. A consensus was found by all members of the conference utilizing currently available evidence-based data.It was suggested that all data of laparoscopic pancreatic surgery should be evaluated in the German Registry. A consensus was made which diseases were either suitable for laparoscopic resection or not suitable or suitable in selected cases.

[A comparison of the use of electrochemical treatment and radio frequency ablation in porcine liver]. / Intrahepatische Ablation: Radiofrequenzablation versus Elektrochemische Lyse.

BACKGROUND: Radiofrequency ablation (RFA) and electrochemical treatment (ECT) are competing methods of intrahepatic ablation. We compared RFA and ECT in a perfusion model and in vivo in pigs. MATERIAL AND METHODS: Twenty-seven fresh porcine livers were obtained from a slaughterhouse and placed ex vivo into a perfusion model. RFA or ECT electrodes were inserted under ultrasound guidance in perivascular locations at a distance of 10 mm from a portal vessel. A total of 83 areas of ablation were created. In vivo ablations were performed at perivascular sites in 10 laparotomised pigs. Four areas of ablation were created per liver using RFA or ECL. Inflammatory parameters, liver values and cytokine levels were determined before and after surgery and on days 1, 3 and 7 after surgery. On day 7, the livers were harvested and specimens were analysed histo-logically by independent experts. RESULTS: In 29% of 59 ex vivo RFA ablations, the target temperature was not reached and the procedure was discontinued. Intact hepatocytes were detected in close proximity to 70 % of the vessels within necrotic areas. In 24 ECT applications, treatment time depended on the charge delivered and ranged between 50 min at 150 coulombs (C) and 200 min at 600 C. The pH level was 0.9 at the anode and 12.2 at the cathode. ECT always led to complete perivascular necrosis and vessel wall destruction. The animals had an in vivo -median weight of 39.5 kg. Neither RFA nor ECT caused major complications such as bleeding, bile leaks or abscesses. Treatment time was 67 min (200 C) for ECT and 12.4 min for RFA. In 73% of the cases, RFA led to incomplete perivascular areas of necrosis. ECT induced complete perivascular necrosis and vessel wall destruction. On day 1 after surgery, both ECT and RFA were associated with a significant increase in monocyte, C-reactive protein and aspartate aminotransferase levels. Leukocyte counts were elevated only after ECT, bilirubin levels only after RFA. There were no significant differences in interleukin-6 (IL-6), tumour necrosis factor-α (TNF-α) and IL-1ß. CONCLUSION: Both RFA and ECL are safe methods of intrahepatic ablation. As a result of a heat sink effect of blood flow in nearby vessels, RFA leads to incomplete necrosis in perivascular sites both ex vivo and in vivo. ECT has the disadvantage of long treatment times but the advantage of lower costs since the platinum electrodes are reusable. Without a reduction in liver perfusion, the central application of RFA in close proximity to vessels should be considered problematic.

Serum biomarkers for improved diagnostic of pancreatic cancer: a current overview.

PURPOSE: Complete resection constitutes the only curative approach in pancreatic cancer but is possible only in a minority of patients due to advanced stages upon diagnosis. Consequently, early detection is crucial for curative treatment. Clinical routine still lacks efficient, non-invasive screening assays, and 80-90% of pancreatic carcinomas are detected at unresectable stages. A wide range of serum proteins have been in the focus of intensive search for biomarkers specific for pancreatic cancer. This article will give an overview on serum biomarkers with screening potential for pancreatic malignancy. DESIGN AND METHODS: PUBMED database was searched for articles, and 43 manuscripts were selected that provided data regarding biomarkers used, type of assay, study population, sample cohort quality and diagnostic performance. RESULTS: Superior values for diagnostic performance were shown for MIC-1, PAM4, OPN, HSP27, TPS, TSGF, and CAM17.1 as individual markers. Panels of biomarkers comprised CA 19-9, MCSF, CEA, SAA, Haptoglobin, TSGF, CA 242, and HSP27. Individually or in concerted form, sensitivity and specificity ranged from 77 to 100% and 84-100%, respectively. CONCLUSIONS: While the above named markers show high screening potential for pancreatic cancer, standardized validation studies using multiplex assays are required to pave the way for clinical routine application.

The role of organ preservation in the surgical therapy of traumatic spleen injury.

BACKGROUND: New findings on immunological und haematological functions of the spleen, the postoperative risks following splenectomy, as well as improved surgical techniques resulted in an increased interest in organ preservative surgery after traumatic spleen injury in recent years. MATERIAL AND METHODS: The data of all patients who underwent surgery for traumatic spleen injuries between 1995-2009 were recorded prospectively and analysed concerning type of operation, intra-and postoperative complications and the postoperative course. RESULTS: A total of 214 patients with splenic trauma underwent surgery. The spleen could be preserved in 80 patients (37.4%, group 1), using thermocoagulation, suture, glue sealant, splenorhaphy and partial spleen resection or combined techniques. 4 of those patients (5%) required a revision operation, in which two spleens could be salvaged by application of glue sealant. Eight of the patients of group 1 could be treated laparoscopically (10%). CONCLUSION: Under consideration of the surgical segment anatomy of the spleen and the surgical techniques presented, organ preservation is possible with high success rates, even in patients with severe splenic damage. In stable patients with minor splenic injury, laparoscopic or conservative treatment can be considered. Splenectomy should be reserved for patients with complete shattering of the spleen or instable patients.

MIS approach for diverticula of the esophagus.

PURPOSE: diverticula of the esophagus represent a rare pathological entity. Distinct classifications of the disease imply different surgical concepts. Surgery should be reserved for symptomatic patients only. Minimally invasive surgery (MIS) for treatment of esophageal diverticula encompasses rigid and flexible intraluminal endoscopy, thoracoscopy and laparoscopy. We here give an overview on the pathogenesis of esophageal diverticula, the minimally invasive surgical techniques for treatment and the recent literature. Additionally, we present our own experience with MIS for midthoracic diverticula. METHODS: we analyzed the cases of patients who underwent MIS for midthoracic diverticula with regard to preoperative symptoms, perioperative and follow-up data. RESULTS: three patients (two female, one male, age 79, 78 and 59 years) received thoracoscopic surgery for midthoracic diverticula. All patients reported of dysphagia and regurgitation. In two patients pH-investigation showed pathological reflux but manometry was normal in all patients. Operating time was 205, 135 and 141 minutes. We performed intraoperative intraluminal endoscopy in all patients. There were no intraoperative complications and although no surgical complications occured postoperatively one patient developed pneumonia which advanced to sepsis and lethal multi organ failure. Upon follow-up the two patients did not have recurrent diverticula or a recurrence of previous symptoms. CONCLUSIONS: surgery for diverticular disease of the esophagus has been associated with high rates of morbidity and mortality. Despite the lethal non-surgical complication we encountered, with regard to recent publications minimally invasive apporaches to treat patients with symptomatic esophageal diverticula entail lower rates of complications with better long term results in comparison to open surgery.

Different surgical strategies for chronic pancreatitis significantly improve long-term outcome: a comparative single center study.

OBJECTIVE: In general, chronic pancreatitis (CP) primarily requires conservative treatment. The chronic pain syndrome and complications make patients seek surgical advice, frequently after years of progression. In the past, surgical procedures involving drainage as well as resection have been employed successfully. The present study compared the different surgical strategies. - PATIENTS AND METHODS: From March 2000 until April 2005, a total of 51 patients underwent surgical treatment for CP at the Department of surgery, University of Schleswig-Holstein, Campus Lübeck. Out of those 51 patients, 39 (76.5%) were operated according to the Frey procedure, and in 12 cases (23.5%) the Whipple procedure was performed. Patient data were documented prospectively throughout the duration of the hospital stay. The evaluation of the postoperative pain score was carried out retrospectively with a validated questionnaire. RESULTS: Average operating time was 240 minutes for the Frey group and 411 minutes for the Whipple group. The medium number of blood transfusions was 1 in the Frey group and 4.5 in the Whipple group. Overall morbidity was 21% in the Frey group and 42% in the Whipple group. 30-day mortality was zero for all patients. During the median follow-up period of 50 months, an improvement in pain score was observed in 93% of the patients of the Frey group and 67% of the patients treated according to the Whipple procedure. CONCLUSION: The results show that both the Frey procedure as well as partial pancreaticoduodenectomy are capable of improving chronic pain symptoms in CP. As far as later endocrine and exocrine pancreatic insufficiency is concerned, however, the extended drainage operation according to Frey proves to be advantageous compared to the traditional resection procedure by Whipple. Accordingly, the Frey procedure provides us with an organ-preserving surgical procedure which treats the complications of CP sufficiently, thus being an alternative to partial pancreaticoduodenectomy if there is no suspicion of malignancy.

[Current state of laparoscopic hepatic surgery: results of a survey of DGAV-members]. / Stand der laparoskopischen Leberchirurgie: Ergebnisse einer Umfrage der DGAV-Mitglieder.

BACKGROUND: To date laparoscopic hepatic surgery is only common in a few centres for a specific selected patient group. The intention of this survey was to estimate the current state of affairs for laparoscopic hepatic surgery in Germany at 2008. MATERIALS AND METHODS: A questionnaire was prepared and sent out by e-mail in May 2009 to the members of the DGAV (German Society of General and Visceral Surgery). The feedback was evaluated anonymously. RESULTS: A total of 181 answers were received by 31st July 2009 (return rate of 15.9%). The return rate of basic and standard care hospitals was 9.2%, specialized hospitals 23.6%, hospitals with maximum care 50% and university hospitals had a return rate of 71.9%. The question whether laparoscopic hepatic surgery had been performed in 2008 was answered with YES by 125 (69.1%) and NO by 54 (29.8%) members. The number of laparoscopic hepatic surgery interventions (laparoscopic ultrasound, laparoscopic radiofrequency ablation and resection) in 2008 was given as more than 50 by 4 (2.2%) hospitals, between 20 and 50 by 11 (6.1%) hospitals, between 10 and 20 by 23 (12.7%) hospitals, between 5 and 10 by 45 (24.9%) hospitals and between 0 and 5 by 54 (29.8%) hospitals. In 2008 the frequency of laparoscopic ultrasound during intraoperative staging to confirm the diagnosis ranged from 2 to 250, whereby 96.4% of the hospitals had less than 50 and only 2 hospitals (2.7%) had 211 and 250 examinations, respectively. 50 hospitals carried out laparoscopic radiofrequency ablation (RFA). 69 (38.1%) of the interviewed hospitals reported hepatic laparoscopic resections (n=551). CONCLUSION: Laparoscopic liver surgery has been done in Germany in patients with benign or malignant liver lesions. Pure laparoscopy is the most common access. Atypical resections are the primarily indication followed by left lateral resections. All further types of resection have been done in a very small number. Laparoscopic liver surgery has been performed in all types of hospitals.

[Surgical intervention in acute upper gastrointestinal bleeding]. / Die Operation als Notfalltherapie bei akuter gastrointestinaler Blutung.

BACKGROUND AND PURPOSE: Acute gastrointestinal bleeding (AGIB) requiring transfusion and surgical treatment still constitutes a life-threatening situation. The purpose of this paper was to examine the treatment outcome for this group of patients as a function of various risk factors and to present our diagnostic and therapeutic regime. METHODS: A retrospective analysis of data from 154 patients with AGIB who underwent surgical procedures and received massive transfusions in a university hospital between 1999 and 2008 was carried out. RESULTS: The patients were divided into two groups. Group I include 91 patients with acute upper gastrointestinal bleeding and group II included 63 patients with lower gastrointestinal bleeding. The average age was 67 years (range 29-93 years) in group I and 70 years (39-97 years) in group II. The initial hemoglobin level was 8.4 g/dl in group I and 10.5 g/dl in group II. Univariate analysis of mortality revealed the following significant risk factors for group I: postoperative need for ventilation (p=0.007), prolonged ICU stay (p=0.004) and anticoagulants in the medical history. The risk factors in group II were blood transfusions >10 units (p=0.031), postoperative need for ventilation (p=0.004), necessary reoperations (p=0.016) and an initial hemoglobin level <8.0 g/dl (p=0.043). The complication rate was 76.9% (mortality rate 34.1%) in group I and 60.3% (mortality rate 15.9%) in group II. CONCLUSIONS: Examination and stabilization of the patient is directly followed by diagnostic localization. The indication for surgery is mainly limited to peracute, uncontrollable and recurrent forms of gastrointestinal bleeding. The mortality rate for these critically ill, negatively selected patients remains high and could not be lowered in the last decade. Postoperative need of ventilation is a predictor for poor prognosis.

Intensified surveillance after surgery for colorectal cancer significantly improves survival.

BACKGROUND: Postoperative surveillance after curative resection for colorectal cancer has been demonstrated to improve survival. It remains unknown however, whether intensified surveillance provides a significant benefit regarding outcome and survival. This study was aimed at comparing different surveillance strategies regarding their effect on long-term outcome. METHODS: Between 1990 and 2006, all curative resections for colorectal cancer were selected from our prospective colorectal cancer database. All patients were offered to follow our institution's surveillance program according to the ASCO guidelines. We defined surveillance as "intensive" in cases where >70% appointments were attended and the program was completed. As "minimal" we defined surveillance with <70% of the appointments attended and an incomplete program. As "none" we defined the group which did not take part in any surveillance. RESULTS: Out of 1469 patients 858 patients underwent "intensive", 297 "minimal" and 314 "none" surveillance. The three groups were well balanced regarding biographical data and tumor characteristics. The 5-year survival rates were 79% (intensive), 76% (minimal) and 54% (none) (OR 1.480, (95% CI 1.135-1.929); p <0.0001), respectively. The 10-year survival rates were 65% (intensive), 50% (minimal) and 31% (none) (p <0.0001), respectively. With a median follow-up of 70 months the median time of survival was 191 months (intensive), 116 months (minimal) and 66 months (none) (p <0.0001). After recurrence, the 5-year survival rates were 32% (intensive, p = 0.034), 13% (minimal, p = 0.001) and 19% (none, p = 0.614). The median time of survival after recurrence was 31 months (intensive, p <0.0001), 21 months (minimal, p <0.0001) and 16 month (none, p <0.0001) respectively. CONCLUSION: Intensive surveillance after curative resection of colorectal cancer improves survival. In cases of recurrent disease, intensive surveillance has a positive impact on patients' prognosis. Large randomized, multicenter trials are needed to substantiate these results.

Diverticular disease is associated with an enteric neuropathy as revealed by morphometric analysis.

BACKGROUND: The pathogenesis of diverticular disease (DD) is attributed to several aetiological factors (e.g. age, diet, connective tissue disorders) but also includes distinct intestinal motor abnormalities. Although the enteric nervous system (ENS) is the key-regulator of intestinal motility, data on neuropathological alterations are limited. The study aimed to investigate the ENS by a systematic morphometric analysis. METHODS: Full-thickness sigmoid specimens obtained from patients with symptomatic DD (n = 27) and controls (n = 27) were processed for conventional histology and immunohistochemistry using anti-HuC/D as pan-neuronal marker. Enteric ganglia, nerve and glial cells were quantified separately in the myenteric, external and internal submucosal plexus compartments. KEY RESULTS: Compared to controls, patients with DD showed significantly (P < 0.05) (i) reduced neuronal density in all enteric nerve plexus, (ii) decrease of ganglionic nerve cell content in the myenteric plexus, (iii) decreased ganglionic density in the internal submucosal plexus, (iv) reduced glial cell density in the myenteric plexus, (v) decrease of ganglionic glial cell content in the myenteric plexus and increase in submucosal plexus compartments, (vi) increased glia index in all enteric nerve plexus. About 44.4% of patients with DD exhibited myenteric ganglia displaying enteric gliosis. CONCLUSIONS & INFERENCES: Patients with DD show substantial structural alterations of the ENS mainly characterized by myenteric and submucosal oligo-neuronal hypoganglionosis which may account for intestinal motor abnormalities reported in DD. The morphometric data give evidence that DD is associated with structural alterations of the ENS which may complement established pathogenetic concepts.

Laser microdissection as a new tool to investigate site-specific gene expression in enteric ganglia of the human intestine.

BACKGROUND: Myenteric ganglia are key-structures for the control of intestinal motility and their mRNA expression profiles might be altered under pathological conditions. A drawback of conventional RT-PCR from full-thickness specimens is that gene expression analysis is based on heterogeneously composed tissues. To overcome this problem, laser microdissection combined with real-time RT-PCR can be used to detect and quantify low levels of gene expression in isolated enteric ganglia. METHODS: Fresh unfixed full-thickness specimens of sigmoid colon were obtained from patients (n = 8) with diseases unrelated to intestinal motility disorders. 10 microm cryo-sections were mounted on membrane-coated slides and ultra-rapidly stained with toluidine blue. Myenteric ganglia were isolated by laser microdissection and catapulting for mRNA isolation. Real-time RT-PCR was performed for selected growth factors, neurotransmitter receptors and specific cell type markers. KEY RESULTS: Collection of 0.5 mm(2) of ganglionic tissue was sufficient to obtain positive RT-PCR results. Collection of 4 mm(2) resulted in ct-values allowing a reliable quantitative comparison of gene expression levels. mRNA analysis revealed that neurotrophic growth factor, neurotrophin-3, serotonin receptor 3A, PGP 9.5 and S100 beta are specifically expressed in myenteric ganglia of the human colon. CONCLUSIONS & INFERENCES: Laser microdissection combined with real-time RT-PCR is a novel technique to reliably detect and quantify site-specific expression of low-abundance mRNAs (e.g. growth factors, neurotransmitter receptors) related to the human enteric nervous system. This technical approach expands the spectrum of available tools to characterize enteric neuropathologies underlying human gastrointestinal motility disorders at the molecular biological level.

New insights into the epidemiology and etiology of Fournier's gangrene: a review of 33 patients.

BACKGROUND: Fournier's gangrene is a necrotizing fasciitis involving the perineal and genital regions. Even today, this often polymicrobial infection still carries a high mortality rate and continues to be a major challenge to the medical community. The purpose of this study was to report our experience with this condition and to compare it with those reported in published studies. We also introduce our approach to treatment. METHODS: We analyzed data from 33 patients with Fournier's gangrene who were managed in our hospital from 1996 to 2007, focusing on patient gender, age, etiology, predisposing conditions, comorbidities, bacteriology, sepsis, blood results, mortality, and spread of gangrene. RESULTS: 18 (54.5%) of the 33 patients had been referred to our department by smaller district hospitals. The patient cohort consisted of 23 men and ten women with a median age of 59 years (range 40-79 years). The median time between the onset of symptoms and progression to gangrene was 6 days (range 2-28 days). An underlying cause was identified in 27 patients (81.8%). The commonest etiological events were perianal and perirectal abscesses (n = 13; 39.4%). Predisposing factors included diabetes mellitus in 12 cases (36.4%), chronic alcoholism in ten cases (30.3%), immunosuppression in six cases (18.2%), and prolonged immobilization in five cases (15.2%). 17 patients (51.5%) had a body mass index (BMI) of 25 or higher, and 13 patients (39.4%) had a BMI of 30 or higher. Positive cultures were obtained in 30 cases (90.9%). In 26 cases (78.8%), multiple microorganisms were recovered, including nine cases (27.3%) with both aerobes and anaerobes. Sepsis was present in 26 patients (78.8%). The mortality rate was 18.2%. CONCLUSION: Fournier's gangrene remains a major challenge with a high mortality. Our results suggest that women are more commonly affected than has generally been assumed. Contrary to published reports, we found that anorectal sources appear to account for more cases of Fournier's gangrene than urological sources.

[Does the third staple line of a new endostapler offer an advantage?]. / Bringt die dritte Klammernahtreihe eines neuen Endostaplers einen medizinischen Vorteil?

BACKGROUND: In laparoscopic colon surgery, endostaplers generate 2 parallel rows of staples. The aim of this paper is to analyse whether the introduction of a new endostapler generating a third row of staples influences the rate of anastomotic leakage and bleedings. METHOD: 362 patients of the Department of Surgery, University Clinic of Schleswig-Holstein, Campus Lübeck, were included in this study. All patients underwent colon resection with performance of double-stapling anastomosis. In Group I (n = 148; 7 / 2004 to 12 / 2005), the Endopath TSB 45 endostapler (2 rows of staples) was used, whereas in Group II (n = 214; 7 / 2006 to 12 / 2007), the Echelon60 EC60 stapler (3 rows of staples) was used. All further operational steps were identical for both groups. Target parameters were the postoperative anastomotic leakage and anastomotic bleeding rates. RESULTS: Between July 2004 and December 2005, the number of anastomotic leaks (Stapler Endopath, TSB 45) was n = 4 (2.7 %), for the second period (Stapler Echelon60 EC60), it was n = 9 (3.7 %) (not significant). Using the Endopath TSB 45 stapler, the number of anastomotic bleedings was n = 12 (8.1 %), and for the Echelon60 EC60 stapler, it was n = 8 (3.7 %) (p = 0.074; not significant). Within the 18-month period between July 2006 and December 2007, the number of endoscopic colon operations (n = 214) rose by 44.6 % compared to the 18-month period between July 2004 and December 2005 (n = 148). CONCLUSION: The application of the advanced Echelon endostapler has no impact on the number of anastomotic leaks, and reduces the number of anastomotic bleedings slightly but not significantly. The increased number of endoscopic procedures in the second period results both from the growing number of indications for the application of endoscopic techniques and the positive findings of recent studies carried out by our own and other working groups.