[Novel uses of afterbirth tissues in regenerative medicine]. / Neue Verwendungsmöglichkeiten von Nachgeburtsgewebe für die Regenerative Medizin.

INTRODUCTION: Afterbirth tissues, which include the umbilical cord, placenta, amnion, and cord blood, are usually discarded. Recent progress in regenerative medicine suggests that we re-evaluate these tissues and assess their therapeutic potential. METHODS: Firstly the unique properties of afterbirth tissues and their current use in regenerative medicine are summarised. Then we introduce the cooperation of our institutions and our experiences regarding the collection and utilisation of afterbirth tissues. RESULTS: A literature survey suggests that besides the well-known transplantation of hematopoietic stem cells from cord blood, afterbirth tissues were also used as a source of stem cells, progenitor cells, differentiated cells, and blood vessels for tissue engineering purposes. According to our own experience, the two participating OB/GYN departments and the blood donation service were able to organise a sufficient supply of umbilical cords for research purposes. The yield correlated with incentives for the midwives. A total of more than 4,300 cords was collected for experiments designed to create small caliber vessel grafts. The contamination rate was low. Birth mode significantly affected umbilical vein function, whereas ischaemia for up to 40 h did not have any deleterious effects. Umbilical veins were cryopreserved with a moderate loss of function. Fresh umbilical veins were endothelium-denuded and reseeded with endothelial cells harvested from coronary artery disease patients to generate an autologous surface. CONCLUSIONS: Afterbirth tissues have unique properties which make them ideally suited for regenerative medicine. These tissues can be procured and utilised in research facilities even in the absence of an in-house birthing centre.

Management of venous port systems in oncology: a review of current evidence.

BACKGROUND: Over the last decades, many changes have occurred in oncology with new chemotherapy combinations and more complex application schemes becoming available. Central venous catheters and implantable venous port systems have become widely used and have facilitated the problem of vascular access. However, important complications are associated with permanent central venous catheters. MATERIAL AND METHODS: This review summarizes evidence on venous port system use published in Medline up to February 2007. Moreover, recent guidelines for the prevention and management of catheter-related infections issued by the Infectious Diseases Society of America, the American College of Critical Care Medicine, the Society for Healthcare Epidemiology of America, the Center for Disease Control and Prevention, Atlanta, and the Infectious Diseases Working Party of the German Society of Hematology and Oncology are included. RESULTS: Sterile precautions are essential when implanting and accessing port systems. Infections must be treated with adequate antimicrobial therapy. Catheter-related thromboembolic complications were found at a rate of 12-64% in retrospective studies. Five current clinical trials investigated the effect of prophylactic anticoagulation with either low molecular weight heparin or warfarin in cancer patients with central venous devices. On the basis of these results, routine anticoagulation cannot be recommended. CONCLUSIONS: This article reviews the current literature on long-term complications of venous port systems, focusing on infection and thrombosis. In addition, it summarizes the evidence regarding routine maintenance of port systems in follow-up care.

Sexual activity as cause for non-surgical pneumoperitoneum.

BACKGROUND: Pneumoperitoneum is usually seen after bowel perforations and surgical procedures. An increasing number of cases of non-surgical pneumoperitoneum related to sexual activity has been reported worldwide over the last years. CASE EXAMPLE: A typically young, otherwise healthy woman comes into the emergency department of Stanford University, California, complaining of recurrent chest pain. Free air under the diaphragm disclosed in the X-ray usually leads to intensive, costly and invasive diagnostics sometimes resulting in emergency laparotomy without any results. Finally, after thorough discussion of the sexual history of the patient is taken, vaginal insufflation during sexual activity is revealed as the cause of non-surgical pneumoperitoneum. DISCUSSION: Patients are often unaware of the open access between the vagina and abdomen. Insufflation pressure during vaginal insufflation with >100 mm Hg--used as a diagnostic tool in CO2-pertubation--can dilate genital organs and push remarkable amounts of air into the abdomen. Gas resorption can take up to several days, and the patient often does not connect the pain to its cause. Embarrassment and modesty often prevent the patient from talking about sexual activity. CONCLUSION: Sexual pneumoperitoneum is not a bizarre sex accident but a rare and serious patho-mechanism. In cases of atypical non-surgical pneumoperitoneum in sexually active women, a careful inquiry into the medical-sexual history can reveal the cause of pathophysiology without comprehensive, painful and unnecessary diagnostics. Sexual history as a diagnostic tool should always be considered in unclear cases.

New adhesion prevention concept in gynecological surgery.

Postsurgical adhesion formation is a common but significant problem. This is the first clinical evaluation of a new barrier material designed to reduce or eliminate postsurgical adhesions. SprayGel can be delivered laparoscopically or via laparotomy to form a strongly adherent hydrogel film. In this multicenter study, we evaluated the safety and effectiveness of SprayGel absorbable adhesion barrier system in patients undergoing open or laparoscopic myomectomy procedures. Here, we discuss the results of our evaluation conducted at the University of Kiel and Polyclinic of Bordeaux, and assess some of the features of this novel adjunct to prevent formation of postsurgical adhesions.

Intraoperative evaluation of laparoscopic insufflation technique for quality control in the OR.

OBJECTIVE: With increasing technology and computerized systems in the OR, the physician's responsibility is growing. For intraoperative evaluation of insufflation techniques, a data acquisition model for quality control study of potential insufflation problems is necessary. METHODS: A computer-based, online data acquisition model was designed with a Pentium notebook, PCMCIA data acquisition board PCI-460-P1 and a Visual Designer 3.0 measurement program (both Intelligent Instrumentation, Inc., Tucson, AZ), temperature meters Therm 2280-1 and 2283-2 (Ahlborn, Holzkirchen, Germany) and temperature probes 401 AC and 402 AC (YSI, Inc., Yellow Springs, OH) and T-430-2R (Ahlborn, Holzkirchen, Germany). Gas flow was measured with laminar flow element LFE 1 and flow meters Digima premo 720 (both Special Instruments, Noerdlingen, Germany). During 73 standard laparoscopic procedures, gas flow (L/min) in the insufflation hose, pressure (mm Hg) in the hose and abdomen as well as temperature (degrees C) in the hose, abdomen and rectum were measured continuously at 3 Hz rate. RESULTS: Actual values measured show a wide range often not identical with insufflator presetting. Pressure in the abdomen is usually less than hose pressure. Intra-abdominal pressure peaks (< or = 50 mm Hg) occurred during insufficient anesthesia, while leaning on the abdomen, during trocar insertion and other manipulation. Blood-irrigation fluids found in the hose (n=3/73) can lead to bacterial contamination. Negative pressure (-50 mm Hg) was measured due to Endobag removal. Negative flow (< or = 15 L/min) was caused by pressure on the abdomen, insufflator regulation and an empty CO2 gas tank. Gas temperature in the hose equals room temperature but can decrease in the abdomen to 27.7 degrees C due to high gas flow, large amounts of gas used and prolonged insufflation. Further insufflation-related problems were documented. CONCLUSIONS: This computer-based measurement model proved to be useful for quality control study in the OR. Results demonstrate the need for intraoperative evaluation of insufflation techniques for laparoscopy. Although no obvious complication related to insufflation problems occurred, some findings potentially question patient security.

Hypertensive Disorders of Pregnancy - A Life-Long Risk?!

Background: Arterial hypertension is one of the most important causes of cardiovascular diseases, and the latter are responsible for almost half of the deaths in the industrialised nations. Hypertensive disorders of pregnancy constitute one of the most frequent causes of feto-maternal morbidity and mortality; on the other hand the occurrence of a hypertensive disorder of pregnancy represents a risk for the later development of hypertension and the cardiovascular risks resulting therefrom. The aim of this article is to demonstrate the association of hypertensive disorders of pregnancy with consecutive cardiovascular diseases. Materials and Methods: Specific selective literature research. Results: After the occurrence of a hypertensive disorder of pregnancy the relative risks for hypertension are 3.7 (2.70-5.05), for ischaemic heart disease 2.2 (1.86-2.52), for cerebral insult 1.8 (1.45-2.27) and for mortality resulting from cardiovascular causes 1.5 (1.05-2.14) and are thus significant. According to a recent study 56 % of internal specialists and 23 % of gynecologists do not know about the association of preeclampsia with ischemic heart disease, 48 % and 38 % respectively are not aware of the link with stroke and 79 % and 77 % respectively are not aware of the association with a reduced life expectancy after preeclampsia. The presence of hypertension is not known by many of the patients, merely 28-38 % receive an appropriate therapy. Conclusion: Adequate follow-up after hypertensive disorders of pregnancy and the early recognition of and therapy for hypertension represent the cornerstones in the prevention of late cardiovascular sequelae. General practitioners, specialist for internal medicine and gynaecologists have a special responsibility with regard to the reduction of later complications.

[Increasing clinical applications of stem cells from umbilical cord blood and consequences for the handling of this biomaterial]. / Steigende klinische Anwendung von Stammzellen aus Nabelschnurblut und Konsequenzen für den Umgang mit diesem Biomaterial.

Umbilical cord blood (UCB) of a newborn contains stem cells with a remarkably high differentiation and regeneration potential. They are therefore useful for application in regenerative medicine. In this review current clinical applications are summarised and the necessity for the storage of UCB stem cells is derived and discussed. A Medline search for publications regarding clinical application of UCB stem cells was carried out and other data bases were reviewed. The transplantation of UCB stem cells, a special class of adult stem cells, has not only been established successfully in a variety of haematoblastoses but could also improve the prognosis in diseases which are related to degeneration and/or injuries of body cells and organs. The current focus in worldwide research is tissue engineering of bioartificial heart valves and vessels as well as applications of UCB stem cells in acute myocardial infarction, diabetes mellitus type 1 and neurodegenerative diseases. In urology the first results regarding the successful application of UCB stem cells in incontinence have been published. This definite progress in adult stem cell research as well as in clinical application requires a more rational handling of the resource UCB stem cells. Personal strategies as well as governmental concepts for storage of UCB stem cells for personal precautions, for donation to others or for research, respectively, have to be developed.

Analysis and cryopreservation of hematopoietic stem and progenitor cells from umbilical cord blood.

BACKGROUND: Umbilical cord blood (UCB) is an important source of hematopoietic stem and progenitor cells (HSC/HPC) for the reconstitution of the hematopoietic system after clinical transplantation. Cryopreservation of these cells is critical for UCB banking and transplantation as well as for research applications by providing readily available specimens. The objective of this study was to optimize cryopreservation conditions for CD34+ HSC/HPC from UCB. METHODS: Cryopreservation of CD34+ HSC/HPC from UCB after mononuclear cell (MNC) preparation was tested in a research-scale setup. Experimental variations were concentration of the cryoprotectant, the protein additive and cell concentration. In addition, protocols involving slow, serial addition and removal of DMSO were compared with standard protocols (fast addition and removal of DMSO) in order to avoid osmotic stress for the cryopreserved cells. Viability and recoveries of MNC, CD34+ cells and total colony-forming units (CFU) were calculated as read-outs. In addition, sterility testing of the collected UCB units before further processing was performed. RESULTS: The optimal conditions for cryopreservation of CD34+ HPC in MNC preparations were 10% DMSO and 2% human albumin at high cell concentrations (5 x 10(7) MNC/mL) with fast addition and removal of DMSO. After cryopreservation using a computer-controlled freezer, high viabilities (89%) and recoveries for CD34+ cells (89%) as well as for CFU (88%) were observed. Microbial contamination of the collected UCB samples was reduced to a rate of 6.4%. DISCUSSION: Optimized cryopreservation conditions were developed for UCB MNC in respect of the composition of the cryosolution. In addition, our results showed that fast addition of DMSO is essential for improved cryopreservation and post-thaw quality assessment results, whereas the speed of DMSO removal after thawing has little influence on the recoveries of CD34+ cells and CFU.

[Private umbilical cord blood banking does not reduce the number of samples for scientific stem cell research]. / Privates Nabelschnurblutbanking reduziert nicht die Probenanzahl für wissenschaftliche Stammzellforschung.

OBJECTIVE: Private umbilical cord blood (UCB) banking after delivery has increased over the last decade. For adult/somatic stem cell research UCB is an essential source of stem cells and researchers question if the number of UCB samples for research might be reduced by private banking. METHODS: A survey among seven private blood banks in Germany and analysis and comparison of the number of UCB samples donated for research within the STEMMAT project with private blood banking were performed from 03/2003 to 06/2005 at the Frauenklinik (OB/GYN), Technical University Munich, Germany. RESULTS: Within 27.5 months 1,551 UCB samples were collected for research purposes; the effective recruitment rate was higher than expectations at an effective 66.2 %. Private UCB banking [n = 24] was distributed among three cord blood banks [n = 16, 6 and 4]. The rate of private blood banking was 0.99 % for all deliveries, thus reducing the effective rate for research purpose by only 1.5 %. CONCLUSION: Under the assumption of active and successful recruitment of scientific UCB samples, private blood banking does not significantly reduce this rate and therefore is a negligible rival in the competition for sufficient numbers of UCB samples for research.

[Prevention of preeclampsia]. / Prävention der Präeklampsie.

Preeclampsia is accompanied by high fetal and maternal morbidity and mortality and to a high degree responsible for preterm delivery. The pathophysiologic mechanisms underlying this disease remain poorly understood. Accordingly, only few causative or preventive therapeutical strategies are known. One such example for a preventive strategy is the use of aspirin (ASA) which directly affects the imbalance of vasodilative prostacycline and vasoconstrictive thromboxane. Recently, some studies are indicating a preventive effect of vitamin C and E substitution. In contrast, early antihypertensive therapy did not prevent later progression of the disease. Furthermore, sodium restriction, calcium and magnesium substitution, fish oil substitution, or steroid therapy are without any effect regarding the later development of preeclampsia. It is of utmost importance to further elucidate underlying pathophysiological mechanisms to improve therapeutical and preventive strategies.

[The STEMMAT-project as part of health initiative BayernAktiv: adult stem cells from umbilical cord and cord blood as alternative to embryonic stem cell research]. / Das STEMMAT-Projekt als Teil der Gesundheitsinitiative BayernAktiv: Adulte Stammzellen aus Nabelschnur und -blut als Alternative zur embryonalen Stammzellforschung.

Adult stem cells from umbilical cord and cord blood are an interesting alternative to embryonic stem cells because such research is commonly recognized as ethical undisputed and many aspects are still insufficiently investigated. In the context of the STEMMAT research project (STEM = Stem Cell and MAT = Material) different aspects of stem cells from umbilical cord and cord blood are investigated, to improve basic science understanding and potentially leading someday to a clinical application.

Reduction or elimination of postoperative pain medication after mastectomy through use of a temporarily placed local anesthetic pump vs. control group.

OBJECTIVE: We evaluated the efficacy of a temporarily placed porous catheter with continuous application of a local anaesthetic(ON-Q( by l-Flow-Corp., Lake Forest, CA, USA) post mastectomy vs. patients without this device regarding postoperative need for opioid medication. MATERIAL AND METHODS: At Fayette Medical Center, Alabama, a retrospective evaluation of all consecutive mastectomies (n = 49) within a five-year-period from 1/1997-12/2001 and statistical analysis regarding postoperative need for opioids was performed. The ON-Q pain management pump with continuous 0.25% Sensorcaine (Bupivacaine and Epinephrine) application for about 72 h (n- 22) was compared vs. a control group without pain management pump (n- 27). RESULTS: There were no statistical significant differences regarding patient demographics in both groups. Patients in the ON-Q group with no need of postoperative opioid pain medication were: 18.2 vs. 3.7 % (P - 0.1), no need for opioids after postoperative day 1: 68.2% vs. 11.1 % (P 0.001), total opioids usage in dose equivalents (DE): 1.25 vs. 3.36 DE (-62.8%) (P-0.016), opioids usage postoperative day 1: 0.65 vs. 1.82 DE (-64.6%) (P - 0.016),opioids usage postoperative day 2: 0.24 vs. 0.75 DE (-68.4%)(P - 0.011). The length of stay in hospital was 2.35 vs. 2.93 days(n.s.), and postoperative stay in PACU: 384 vs. 43.3 min (n. s.).OR time for placement of catheter and pump is only slightly increased. No complications occurred. CONCLUSION: Use of an ON-Q pain management pump could significantly reduce or even eliminate postoperative need for opioids analgesics.

Laparoscopy-assisted endoscopic bowel anastomosis stenosis revision with stapler: report of two cases.

Anastomosis stenosis is a complication after bowel surgery. We performed laparoscopy-assisted endoscopic revision of bowel anastomosis stenosis with a stapler in two cases: first, for secondary anastomosis stenosis 14 months after sigmoid colon resection, and second, for inadequate-size primary anastomosis after segmental colon resection requiring immediate revision. A stapler, an endoscopic linear cutter Endopath ETS (Ethicon Endo-Surgery, Cincinnati, Ohio, U.S.A.), is transanally inserted and fired once into the stricture to enlarge the inner lumen. The procedure seems to be fast and safe, less invasive, and cost-effective. This new technique can be used to avoid open surgery in cases of postoperative anastomosis stenosis as well as initially to increase the anastomosis diameter of the lower colon.

437 classic intrafascial supracervical hysterectomies in 8 years.

STUDY OBJECTIVE: To report technical aspects and practical long-term experience with classic intrafascial supracervical hysterectomy (CISH). DESIGN: Retrospective evaluation (Canadian Task Force Classification II-2). SETTING: Local community hospital in rural northwest Alabama. PATIENTS: Four hundred thirty-seven women. INTERVENTION: The procedure was performed as described originally but with slight modifications (vaginal manipulator, ETS stapler). MEASUREMENTS AND MAIN RESULTS: Follow-up was 44.7 months (range 3-97 mo). Average operating time was 1 hour 10 minutes (range 46 min-6 hrs, 10 min), average blood loss was 68 ml (range 10-765 ml), average length of hospital stay was 22 hours (range 10 hrs-5 days), and average return to work was 14 days (range 3-28 days). Complications were 11 bleeding cervices (7 occurring within 21 days after surgery, and 4 between 2 and 4 yrs after surgery), 1 case of uterine artery bleeding, 1 ileus, 1 pelvic hematoma, and 5 mucoceles between 2 and 27 months postoperatively. There were three conversions, one because of morbid obesity (185 kg) and two because of large uterus:pelvis ratio. CONCLUSION: CISH leaves the pelvic floor intact, has short recuperation and high patient satisfaction, and is cost effective at a low complication rate. It is an advanced laparoscopic procedure, is initially technically challenging, and has a learning curve.

[Three case reports of breast abscess after nipple piercing: underestimated health problems of a fashion phenomenon]. / Drei Fallbeispiele von Brustabszess nach Brustwarzenpiercing: Unterschätzte Gesundheitsprobleme eines Modephänomens.

OBJECTIVE: Piercing is a growing fashion trend among young people. Nipple piercing has shown an increase over the last years. We report about three coincidental cases of breast abscess after nipple piercing within the last months in our clinics and discuss the related problems for health and society. MATERIAL AND METHODS: Retrospective analysis of three case reports regarding course of illness and reasons as well as review of literature and internet. RESULTS: Three patients average age 31.9 (28-35) years were hospitalized with breast abscess after nipple piercing (2 x left, 1 x right). The distance piercing to infection was on average 7.7 (5-12) months. In all patients the abscess was incised and the abscess cavity removed, two had an irrigation tubing for a three days, all received i. v. antibiotics postoperatively. Evidence for bacteria was found in case 1: PCR-confirmation of atypical mycobacteria and coagulase negative staphylococcus, case 2: coagulase negative staphylococcus and group B-streptococcus and case 3: green and microaerophilic staphylococcus. The length of hospital stay was on average 8.0 (6-9) days/case, the hospital costs were 3 624,54 e (3 000,26-4 310,58 e) euro;/case. In a follow-up period of 10,0 (5-15) months one relapse occurred which had to be re-operated. CONCLUSION: Nipple piercing has grown in popularity within the last years and is in general not a stigma of a subculture or lower social classes any more. However, the risk for breast infection is on the one hand underestimated by the women and on the other hand played down by piercing studios. Breast infection after nipple piercing is rarely documented in scientific literature and data bases. Only seven case reports are scientifically published so far. Healing of the wound channel varies and can take up to 6-12 months. The risk for infection is approximately 10-20 %, often in a interval of months after the procedure. Insufficient understanding as well as inconsequent performance of hygienic preparation of the wound beneath other risk factors like nicotine abuse, wrongs size of jewelry, post breast enlargement with prosthesis etc. increase the risk of breast infection after nipple piercing. Due to obvious under documentation this is the largest series of breast infection after nipple piercing in the world.

Prospective clinical trial of SprayGel as a barrier to adhesion formation: an interim analysis.

STUDY OBJECTIVE: To evaluate SprayGel, a new sprayable adhesion barrier developed for laparoscopic and open pelvic and abdominal surgical procedures. DESIGN: Prospective, randomized, controlled, multicenter trial (Canadian Task Force classification I). SETTING: University clinic and private clinic. PATIENTS: Forty-five women, 24 randomized to treatment and 21 to control group. INTERVENTIONS: Open or laparoscopic myomectomy with and without application of SprayGel, followed by second-look laparoscopy (SLL) to evaluate postoperative adhesions. MEASUREMENTS AND MAIN RESULTS: Application of SprayGel was fast and easy. On average, 10 weeks after surgery, 18 treated patients (75%) and 13 (61.9%) controls had SLL. That procedure showed 5 (27.8%) of 18 treatment patients to be adhesion free versus 1 (7.7%) of 13 controls (p = 0.163). Patients randomized to SprayGel were 3.6 times more likely to be adhesion free than controls. Mean tenacity scores were significantly lower than in controls (0.5 vs. 1.7), a difference of 0.9 (95% CI 0.3, 1.5, p = 0.003) or 47% (95% CI 17%, 77%) less. Mean adhesion area was reduced in the treatment group (4.1 vs. 5.6) but not significant (p = 0.6747, 95% CI-5.4, 8.4). No adverse events regarding application of SprayGel were seen. CONCLUSION: SprayGel was effective in reducing postoperative adhesion severity, and showed a trend toward reducing frequency and extent of adhesions after laparoscopic and open myomectomy. Further studies are necessary to confirm the promising results of this interim analysis.

Measurement of CO(2) hypothermia during laparoscopy and pelviscopy: how cold it gets and how to prevent it.

STUDY OBJECTIVE: To evaluate intraabdominal CO(2) temperature during a variety of standard operative laparoscopy procedures with different insufflators (BEI Medical, Snowden & Pencer, Storz Laparoflator, Storz Endoflator, Wolf) and devices to maintain body temperature (Bair Hugger, fluid warmer, Blanketrol blankets). DESIGN: Prospective, nonrandomized study (Canadian Task Force classification II-1). SETTING: Community hospital in rural Alabama. PATIENTS: Sixty-two consecutive patients (53 women, 9 men; average age 56.8 yrs, range 21-94 yrs). INTERVENTIONS: Patients underwent standard laparoscopic and pelviscopic procedures during which intraoperative temperature changes in the insufflation system, abdomen, and rectum were measured. MEASUREMENTS AND MAIN RESULTS: Carbon dioxide was at room temperature in the insufflation hose ( approximately 23 degrees C). During insufflation, intraabdominal gas temperature decreased to as much as 27.7 degrees C (average 32.7 degrees C) depending on length of operation (23 min-5 hrs 8 min), amount of gas used (12.8-801 L), gas flow (up to 20 L/min), and leakage rate. Preoperative and postoperative temperature comparisons showed no decline in rectal temperature (average +0.18 degrees C) because warming equipment was sufficient. CONCLUSION: The decrease in intraoperative intraabdominal gas temperature is remarkable and can potentially harm the patient. It can be limited by restricting gas flow and leakage. In operations longer than 1 hour, substantial core body temperature drop should be prevented with appropriate heating and hydration devices. An insufflator with internal gas heating (Snowden & Pencer) had no significant clinical effect. (J Am Assoc Gynecol Laparosc 6(3):289-295, 1999)