[Surgical therapy for thyroid gland malignancies]. / Chirurgie der Schilddrüsenmalignome.

Surgical therapy for thyroid neoplasms is based on tumor histology and comprises stage-adapted procedures with a high degree of inter-individual variability. This can range from waiting and monitoring, to extensive multivisceral surgery. Grouping together histologically different types of malignancies leads to false assumptions when gauging the radicality of surgery necessary in each particular case. Surgical therapy requires not only an understanding of the biological behavior of the tumor and the risk that it or the therapy poses to the patient, but also knowledge of a wide surgical spectrum of limited and complex resection procedures in the neck and thorax region. The following recommendations are based primarily on the guidelines of the Surgical Working Group for Endocrinology of the German Society for General and Visceral Surgery as well as on the authors' own experience and, where indicated, the guidelines of other working groups.

[Inguinal hernia operations-Always outpatient?] / Leistenhernienoperationen ­ immer ambulant?

Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.

[Surgery for neuroendocrine tumors of the gastroenteropancreatic system (GEP-NET)]. / Chirurgie neuroendokriner Tumoren des gastroenteropankreatischen Systems (GEP-NET).

Surgical treatment is still the only curative treatment proven for patients with neuroendocrine tumors (NET) of the gastroenteropancreatic system. In addition to the therapy of incidental findings, the treatment of NET with variable aggressiveness and often good long-term prognosis requires a thorough preoperative assessment and a surgical procedure that is based on each individual case. Treatment can be surgery alone (if the disease is locally confined) or can be combined with other therapies. Early NET of the stomach and rectum can be cured endoscopically without further diagnostics, while early findings of the appendix can be treated by an appendectomy. Functionally active pancreatic NET and NET of the small intestine are often preoperatively diagnosed based on symptoms. Thus, it is possible to refer the patient to a NET center, if necessary. Stratification of the necessary treatment combination can be made early. An alternative to radical surgical treatment is the operative reduction of the tumor size and hormone production in metastasized NET, which can lead to improved life expectancy and quality of life. Combination with other treatment forms is absolutely necessary in these patients. It has been proven useful to divide the large group of NET based on the different tumor locations, hormone activity, and the degree of differentiation of the tumor. Early forms, locoregionally limited tumor stages, and tumor stages with distant metastases are considered separately.

Perioperative outcome in groin hernia repair: what are the most important influencing factors?

INTRODUCTION: Using registry analyses, a large number of influencing factors on the perioperative outcome of groin hernia repair has been identified. The interactions between several influencing factors and differences in the influencing value have to date been inadequately investigated. METHODS: This retrospective analysis of prospectively collected data from the Herniamed Registry included all fully documented cases with minimum age of 16 years and groin hernia repair. Patients were assigned to the risk groups unilateral, bilateral, recurrent and emergency groin hernia repair. Multivariable analysis was performed to investigate the influence of confirmatory defined patient- and procedure-related characteristics on the outcome parameters intraoperative, postoperative general and postoperative surgical complications, complication-related reoperation and total perioperative complications. RESULTS: A highly significantly unfavorable association with the total perioperative complication rate was identified for emergency groin hernia repair, scrotal hernia, anticoagulant medication and coagulopathy. A significantly unfavorable relation with the total perioperative complication rate was found for recurrence procedure, bilateral repair, high age, ASA score III/IV, femoral hernia, antithrombotic medication, smoking, COPD and corticosteroid medication. A significantly favorable correlation with the total perioperative complication rate was observed for the laparo-endoscopic techniques, smaller defects, female gender, normal weight and medial hernia. CONCLUSION: Both the number of potential influencing factors and their influencing value on the perioperative outcome should be considered when estimating the individual risk of a patient with groin hernia repair.

What is the reality in outpatient vs inpatient groin hernia repair? An analysis from the Herniamed Registry.

INTRODUCTION: Groin hernia repair is performed increasingly more often as an outpatient procedure across the world. However, the rates are extremely different and vary between below 10% and above 90%. The outpatient procedure appears to negatively impact the proportion of laparo-endoscopic repairs. To date, only very few studies have compared inpatient vs outpatient groin hernia repair. METHODS: All outpatient and inpatient primary elective unilateral groin hernia repairs performed between 2010 and 2019 were identified in the Herniamed Registry and their treatment and outcomes compared. RESULTS: The 737 participating hospitals/surgeons performed a total of 342,072 primary elective unilateral groin hernia repairs from 2010 to 2019. The proportion of outpatient repairs was 20.2% in 2013 and 14.3% in 2019. Whereas the proportion of laparo-endoscopic repairs among the inpatient cases was 71.9% in 2019, the last year for which data are available, it was only 34.3%.for outpatient repairs. In outpatient groin hernia repairs, the rates of patients aged ≥ 60 years, with ASA score III and IV and risk factors were highly significantly lower. Given this rigorous patient selection for outpatient groin hernia repair, a more favorable perioperative outcome was achieved. At 1-year follow-up there were no significant differences in the pain and recurrence rates. CONCLUSION: With an appropriate patient selection, outpatient primary elective unilateral groin hernia repair can be performed with acceptable risks and good outcomes. Since to date no studies have compared inpatient vs outpatient groin hernia repair, the impact of a higher rate of outpatient groin hernia repair cannot currently be evaluated.

What is the reality in epigastric hernia repair?-a trend analysis from the Herniamed Registry.

INTRODUCTION: The proportion of epigastric hernias in the total collective of all operated abdominal wall hernias is 3.6-6.9%. The recently published guidelines for treatment of epigastric hernias of the European Hernia Society and the Americas Hernia Society recommend the use of a mesh for defect size of ≥ 1 cm, i.e., a preperitoneal flat mesh technique for sizes 1-4 cm, and laparoscopic IPOM technique for defects > 4 cm and/or obesity. Against that background, this analysis of data from the Herniamed Registry now aims to explore trends in epigastric hernia repair. METHODS: To detect trends, the perioperative outcome was calculated separately for the years 2010 to 2019 and the 1-year follow-up for the years 2010 to 2018 and significant differences were identified. Analysis was based on 25,518 primary elective epigastric hernia repairs. The rates of postoperative surgical complications, pain at rest, pain on exertion, chronic pain requiring treatment and recurrence associated with the various surgical techniques were calculated separately for each year. Fisher's exact test for unadjusted analysis between years was applied with Bonferroni adjustment for multiple testing. RESULTS: The proportion of laparoscopic IPOM repairs declined from 26.0% in 2013 to 18.2% in 2019 (p < 0.001). Instead, the proportion of open sublay repairs rose from 16.5% to 21.8% (p < 0.001). That was also true for innovative techniques such as the EMILOS, MILOS, eTEP and preperitoneal flat mesh technique (8.3% vs 15.3%; p < 0.001). This change in indication for the various surgical techniques led to a significant improvement in the postoperative surgical complication rate (3.8% vs 1.9%; p < 0.001). CONCLUSION: The trend is for epigastric hernia repair to be performed less often in laparoscopic IPOM technique and instead more often in open sublay technique or the new innovative techniques.

Potential influencing factors on the outcome in incisional hernia repair: a registry-based multivariable analysis of 22,895 patients.

INTRODUCTION: Due to the paucity of randomized controlled trials, meta-analyses of incisional hernia repair can hardly give any insights into the influence factors on the various outcome criteria. Therefore, a multivariable analysis of data from the Herniamed Registry was undertaken with the aim to define potential influencing factors for the outcome. METHODS: Multivariable analysis of the data available for 22,895 patients with primary elective incisional hernia repair was performed to assess the confirmatory predefined potential influence factors and their association with the perioperative and 1-year follow-up outcomes. A model validation procedure was implemented using a bootstrap algorithm in order to account for the robustness of results. RESULTS: Higher European Hernia Society (EHS) width classification, open procedure, female gender, and preoperative pain have a highly significant association with an unfavorable outcome in incisional hernia repair. Larger defect width and open operation have a highly significantly unfavorable relation to the postoperative surgical complications, general complications, and the complication-related reoperations, while female gender and preoperative pain have a highly significantly unfavorable association with the rates of pain at rest, pain on exertion, and chronic pain requiring treatment at 1-year follow-up. The recurrence rate is significantly unfavorably influenced by higher EHS width classification, higher BMI, and lateral EHS classification. CONCLUSION: Higher EHS width classification, open procedure, female gender, higher BMI, and lateral EHS classification, as well as preoperative pain are the most important unfavorable influencing factors associated with a worse outcome in incisional hernia repair.

What is the outcome of the open IPOM versus sublay technique in the treatment of larger incisional hernias?: A propensity score-matched comparison of 9091 patients from the Herniamed Registry.

INTRODUCTION: In an Expert Consensus guided by systematic review, the panel agreed that for open elective incisional hernia repair, sublay mesh location is preferred, but open intraperitoneal onlay mesh (IPOM) may be useful in certain settings. This analysis of data from the Herniamed Registry aimed to compare the outcomes of open IPOM and sublay technique. METHODS: Propensity score matching of 9091 patients with elective incisional hernia repair and with defect width ≥ 4 cm was performed. The following matching variables were selected: age, gender, risk factors, ASA score, preoperative pain, defect size, and defect localization. RESULTS: For the 1977 patients with open IPOM repair and 7114 patients with sublay repair, n = 1938 (98%) pairs were formed. No differences were seen between the two groups with regard to the intraoperative, postoperative and general complications, complication-related reoperations and recurrences. But significant disadvantages were identified for the open IPOM repair in respect of pain on exertion (17.1% vs. 13.7%; p = 0.007), pain at rest (10.4% vs. 8.3%; p = 0.040) and chronic pain requiring treatment (8.8% vs. 5.8%; p < 0.001), in addition to rates of 3.8%, 1.1% and 1.1%, respectively, occurring in both matched patients. No relationship with tacker mesh fixation was identified. There are only very few reports in the literature with comparable findings. CONCLUSION: Compared with sublay repair, open IPOM repair appears to pose a higher risk of chronic pain. This finding concords with the Expert Consensus recommending that incisional hernia should preferably be repaired using the sublay technique.

What are the trends in incisional hernia repair? Real-world data over 10 years from the Herniamed registry.

INTRODUCTION: There is an increasingly controversial debate about the best possible incisional hernia repair technique. Despite the good outcomes of laparoscopic IPOM, concerns about the intraperitoneal mesh placement and its potential intraabdominal complications have risen. Against that background, this paper now analyzes changes and trends in incisional hernia repair techniques in the recent decade. METHODS: Between 2010 and 2019 a total of 61,627 patients with primary elective incisional hernia repair were enrolled in the Herniamed Registry. The outcome results were assigned to the year of repair and summarized as curves to visualize trends. The explorative Fisher's exact test was used for statistical calculation of significant differences. Since the number of cases entered into the Herniamed Registry for the years 2010-2012 was still relatively small, the years 2013 and 2019 were compared for statistical analysis. RESULTS: In the analyzed time period, the proportion of incisional hernias repaired in open suture technique remained unchanged at about 10%. The proportion of laparoscopic IPOM repairs decreased significantly from 33.8% in 2013 to 21.0% (p < 0.001) in 2019. Conversely, the proportion of open sublay repairs increased significantly from 32.1% in 2013 to 41.4% (p < 0.001) in 2019. Starting in 2015, there has also been the introduction and increasing use (4.5% in 2013 vs. 10.0% in 2019; p < 0.001) of new minimally-invasive techniques with placement of a mesh into the sublay/retromuscular/preperitoneal abdominal wall layer (E/MILOS, eTEP, preperitoneal mesh technique). CONCLUSION: Analysis of data from the Herniamed Registry shows a significant trend to the disadvantage of the laparoscopic IPOM and to the advantage of the open sublay operation and the new minimally-invasive techniques (E/MILOS, eTEP, preperitoneal mesh technique). Despite all the recommendations in the guidelines, 10% of incisional hernias continue to be treated by means of a suture technique.

Comparison of outcomes in rectus abdominis diastasis repair-which data do we need in a hernia registry?

INTRODUCTION: Rectus abdominis diastasis (RAD) ± concomitant hernia is a complex hernia entity of growing significance in everyday clinical practice. Due to a multitude of described surgical techniques, a so far missing universally accepted classification and hardly existing comparative studies, there are no clear recommendations in guidelines. Therefore, "RAD ± concomitant hernia" will be documented as a separate hernia entity in the Herniamed Registry in the future. For this purpose, an appropriate case report form will be developed on the basis of the existing literature. METHODS: A systematic search of the available literature was performed in March 2021 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library. 93 publications were identified as relevant for this topic. RESULTS: In total 45 different surgical techniques for the repair of RAD ± concomitant hernia were identified in the surgical literature. RAD ± concomitant hernia is predominantly repaired by plastic but also by general surgeons. Classification of RAD ± concomitant hernia is based on a proposal of the German Hernia Society and the International Endohernia Society. Surgical techniques are summarized as groups subject to certain aspects: Techniques with abdominoplasty, open techniques, mini-less-open and endoscopic sublay techniques, mini-less-open and endoscopic subcutaneous/preaponeurotic techniques and laparoscopic techniques. Additional data impacting the outcome are also recorded as is the case for other hernia entities. Despite the complexity of this topic, documentation of RAD ± concomitant hernia has not proved to be any more cumbersome than for any of the other hernia entities when using this classification. CONCLUSION: Using the case report form described here, the complex hernia entity RAD ± concomitant hernia can be recorded in a registry for proper analysis of comparative treatment options.

[Pancreatic hyperinsulinism--changes of the clinical picture and importance of differences in sporadic disease course (experience with 144 patients operated in the period 1986-2009)]. / Pankreatischer Hyperinsulinismus--Wandel des Krankheitsbildes mit spezifischen Unterschieden auch bei sporadischen Erkrankungsformen (Eigene Erfahrung an 144 operierten Patienten von 1986-2009).

The diagnoses of pancreatogenic hyperinsulinism and insulinoma (benign or malignant) were almost synonomously used during the last decades. Only familial forms of hyperinsulinism, i. e., in patients with multiple endocrine neoplasia type 1 were separately discussed. The surgical literature concentrated on technical questions, comparing open and minimal invasive techniques. The clinical diagnosis of patients with pancreatogenic hypo-glycaemia syndrome (NIPHS) and the pathological diagnosis of insulinomatosis has now opened up new questions in the diagnosis and therapy of pancreatogenic hyperinsulinism. On the basis of our experience from 144 patients operated on for pancreatogenic hyperinsulinism during the last 22 years with 16 NIPHS patients and with the help of the relevant literature, we explain the prerequisites that surgical therapy has to fulfil in the treatment of patients with pancreatogenic hyperinsulinism today.

Presentation of 6 cases with parathyroid cysts and discussion of the literature.

INTRODUCTION: Cystic lesions of the parathyroid glands are uncommon, and rare are those that cause primary hyperparathyroidism. Preoperative diagnosis can be challenging and some of these tumors might be misinterpreted as parathyroid carcinoma. With an expertise of more than 1700 patients operated on primary hyperparathyroidism, we present six cases with cystic degeneration of a parathyroid gland causing primary hyperparathyroidism in five patients. CASE REPORTS: A woman at the age of 67 presented with hypercalcaemic crisis due to persistent primary hyperparathyroidism after an operation four years ago. As cervical exploration was unsuccessful, sternotomy was performed and a cystic adenoma of a parathyroid gland could be resected from the anterior mediastinum. The second patient - a 63-year-old female with severe hypercalcaemic crisis, operated on under suspicion of a parathyroid carcinoma - had a functional cyst of the parathyroid gland with a parathyroid hormone level of 700,000 pg/ml in the aspirated fluid. Third, operation on a 70-year-old woman with a benign euthyreot goiter and the laboratory findings of primary hyperparathyroidism revealed a cystic adenoma adjacent to the thyroid gland, whose aspirate had a parathyroid hormone level of 1,500,000 pg/ml. In the fourth case of a 67-year-old female with an adenoma of the right inferior parathyroid gland localized by ultrasonography, the cystic parathyroid adenoma was operated on by video-assistance. A cystic structure in the upper mediastinum was diagnosed in the fifth patient, a 66-year-old woman. It was suspected to be a thyroid cyst at the left-lower pole of the thyroid gland. After hemithyroidectomy pathological evaluation revealed a large parathyroid cyst. The last case of a 56-year-old male illustrates the extensive preoperative work-up of a patient with primary hyperparathyroidism who was preoperatively diagnosed as having a thyroid cyst. Final histopathological examination exposed multiple gland disease with a parathyroid adenoma as well as a cystic parathyroid gland. DISCUSSION: Cystic adenomas of the parathyroid glands are often misdiagnosed as thyroid cysts or - in the case of extremely elevated parathyroid hormone levels - even as parathyroid carcinoma. The routine preoperative diagnostic tools, such as ultrasonography or (99m)Tc-sestamibi-scintigraphy, cannot clearly distinguish between these entities and might be jeopardized by mediastinal localization, which is not uncommon in parathyroid adenomas with cystic degeneration.

[Abdominal preoperation. No contraindication for laparoscopic transabdominal adrenalectomy]. / Abdominelle Voroperationen. Keine Kontraindikation für eine laparoskopische transabdominelle Adrenalektomie.

Benign adrenal gland tumors smaller than 6 cm are nowadays the indication for minimally invasive surgery. Until now there has been no significant difference between retroperitoneoscopic and transabdominal adrenalectomy. Intestinal adhesions could be a contraindication against transabdominal laparoscopic adrenalectomy, and therefore the retroperitoneoscopic approach could be an advantage in these cases. A prospective study concerning this question has not been published yet. Our clinical investigation here includes 114 adrenalectomies during the last 5 years. We show that in any case of abdominal preoperation, laparoscopic adrenalectomy can be performed by transabdominal approach and without conversion to open surgery. Discussed are the different indications for laparoscopic adrenalectomy, operating time, conversion rate to open surgery, and amount and type of abdominal preoperation. We compared patients with and without abdominal preoperations.

[HerniaSurge: international guidelines on treatment of inguinal hernia in adults : Comments of the Surgical Working Group Hernia (CAH/DGAV) and the German Hernia Society (DHG) on the most important recommendations]. / HerniaSurge: internationale Leitlinie zur Therapie der Leistenhernie des Erwachsenen : Kommentar der Chirurgischen Arbeitsgemeinschaft Hernie (CAH/DGAV) und der Deutschen Herniengesellschaft (DHG) zu den wichtigsten Empfehlungen.

SURGICAL TECHNIQUES: The HerniaSurge guidelines have the highest evidence with respect to a strong recommendation for mesh-based surgical techniques. This evidence is equally valid for the Lichtenstein procedure as for the minimally invasive procedures TEP/TAPP. In the case of discrete symptomatic or asymptomatic inguinal hernias, watchful waiting can be an option, taking into account health status and social circumstances. Femoral hernias, on the other hand, should be treated promptly with mesh insertion. Also favored are laparoendoscopic techniques. The Shouldice repair achieves the least recurrences from the suturing procedures and may be an acceptable alternative when indicated or when the patient does not desire mesh reinforcement. In this case, a detailed patient education is necessary. MESH CHOICE: The complication potential of plastic meshes should be explained. The weight is no longer considered a suitable parameter for the classification of meshes and is no longer recommended for mesh selection. Large pore (>1-1.5 mm) monofilament implants have the best integration potential and should have a tear strength of approximately 16 Nm2. Traumatic mesh fixation is only recommended for large medial hernias (M3-EHS). Primarily not recommended are Plug & Patch, double-layered plastic implants (such as the PHS system) or other three-dimensional devices, as this could affect both the anterior and posterior planar layers and complicate the complementary surgical technique in the event of recurrence. In addition, the higher costs have to be considered. PERIOPERATIVE AND POSTOPERATIVE ASPECTS: Perioperative antibiotic prophylaxis in open repair procedures is recommended only in patients with an increased risk of infections. In laparoendoscopic procedures, antibiotic prophylaxis should not be performed or used with the utmost restraint. Careful preparation reduces chronic inguinal and testicular pain. In the case of interference of mesh and nerve, the nerve can be resected. A return to daily activity is recommended within 3-5 days. QUALITY ASSURANCE: The documentation of patient data should be done by establishing hernia registers for quality assurance and for the development of further treatment options. The implementation of the guidelines is supported by HerniaSurge.

[Surgical anatomy of the abdominal wall]. / Chirurgische Anatomie der Bauchdecke.

Knowledge of the anterolateral abdominal wall anatomy is crucial for a surgical approach to the abdominal cavity and for reconstructive surgery of abdominal wall defects. Furthermore it can help the surgeon ensure optimal surgical results by avoiding anatomical complications. This overview presents the surgical relevant anatomy and emphasizes surgical principles and pitfalls in abdominal wall surgery.

[New aspects in hernia surgery]. / Aktuelle Aspekte der Hernienchirurgie.

In the last 10 years in Germany we have seen a lot of hernia repairs using mesh.Meta-analysis shows the advantages of using meshes in hernia surgery; recurrence rates in inguinal hernia surgery are less than 3% in studies. There is some discussion about minimally invasive surgery in Germany.In incisional hernia surgery there is no discussion about using meshes. The role of minimally invasive surgery has not yet been defined.

Sequence analysis of porcine immunoglobulin light chain cDNAs.

A porcine cDNA library was constructed using poly(A)+ RNA isolated from the spleen of an adult Minnesota miniature swine. Screening the library with antisera specific for porcine immunoglobulin light chains resulted in the selection and isolation of two recombinant clones, PLC18 and PLC3, which encode for kappa and lambda light chains, respectively. These cDNAs contain sequence information for a portion of the variable region and all of the constant region. The lengths of the constant regions are 105 amino acids for lambda and 108 amino acids for kappa. The deduced amino acid sequences of porcine immunoglobulin light chains share a high degree of homology with similar sequences from other species in both the fourth framework region and the constant region.

Hematopoietic α7 nicotinic acetylcholine receptor deficiency increases inflammation and platelet activation status, but does not aggravate atherosclerosis.

BACKGROUND: The autonomic nervous system attenuates inflammation through activation of the α7 nicotinic acetylcholine receptor (α7nAChR), a pathway termed the cholinergic anti-inflammatory reflex. Interestingly, α7nAChR is expressed on immune cells and platelets, both of which play a crucial role in the development of atherosclerosis. OBJECTIVE: To investigate the role of hematopoietic α7nAChR in inflammation and platelet function in atherosclerotic ldlr(-/-) mice and to identify its consequences for atherosclerotic lesion development. METHODS: Bone marrow from α7nAChR(-/-) mice or wild-type littermates was transplanted into irradiated ldlr(-/-) mice. After a recovery period of 8 weeks, the mice were fed an atherogenic Western-type diet for 7 weeks. RESULTS: Hematopoietic α7nAChR deficiency clearly increased the number of leukocytes in the peritoneum (2.6-fold, P < 0.001), blood (2.9-fold; P < 0.01), mesenteric lymph nodes (2.0-fold; P < 0.001) and spleen (2.2-fold; P < 0.01), indicative of an increased inflammatory status. Additionally, expression of inflammatory mediators was increased in peritoneal leukocytes (TNFα, 1.6-fold, P < 0.01; CRP, 1.8-fold, P < 0.01) as well as in the spleen (TNFα, 1.6-fold, P < 0.01). The lack of α7nAChR on platelets from these mice increased the expression of active integrin αIIb ß3 upon stimulation by ADP (1.9-fold, P < 0.01), indicating increased activation status, while incubation of human platelets with an α7nAChR agonist decreased aggregation (-35%, P < 0.05). Despite the large effects of hematopoietic α7nAChR deficiency on inflammatory status and platelet function, it did not affect atherosclerosis development or composition of lesions. CONCLUSIONS: Hematopoietic α7nAChR is important for attenuation of inflammatory responses and maintaining normal platelet reactivity, but loss of hematopoietic α7nAChR does not aggravate development of atherosclerosis.

Processing, mixing, and particle size reduction of forages for dairy cattle.

Adequate forage amounts in both physical and chemical forms are necessary for proper ruminal function in dairy cows. Under conditions in which total amounts of forage or particle size of the forage are reduced, cows spend less time ruminating and have a decreased amount of buoyant digesta in the rumen. These factors reduce saliva production and allow ruminal pH to fall, depressing activity of cellulolytic bacteria and causing a prolonged period of low ruminal pH. Insufficient particle size of the diet decreases the ruminal acetate-to-propionate ratio and reduces ruminal pH. The mean particle size of the diet, the variation in particle size, and the amount of chemical fiber (i.e., NDF or ADF) are all nutritionally important for dairy cows. Defining amounts and physical characteristics of fiber is important in balancing dairy cattle diets. Because particle size plays such an important role in digestion and animal performance, it must be an important consideration from harvest through feeding. Forages should not be reduced in particle size beyond what is necessary to achieve minimal storage losses and what can be accommodated by existing equipment. Forage and total mixed ration (TMR) particle sizes are potentially reduced in size by all phases of harvesting, storing, taking out of storage, mixing, and delivery of feed to the dairy cow. Mixing feed causes a reduction in size of all feed particles and is directly related to TMR mixing time; field studies show that the longest particles (>27 mm) may be reduced in size by 50%. Forage and TMR particle size as fed to the cows should be periodically monitored to maintain adequate nutrition for the dairy cow.

[Standards in diagnosis of diverticulitis]. / Standards in der Diagnostik der Divertikulitis.

The diagnostic procedure is determined by the severity of the diverticulitis. In complicated cases of diverticulitis, it is necessary to detect those patients with obstructive ileus, perforation, and peritonitis who require instant emergency surgery. In all other cases, diagnostic procedures serve as a tool to determine the best therapeutic options. The CT scan of the abdomen seems to have the highest reliability for determining therapy. Other investigations such as barium enema and coloscopy are not indicated in emergency cases or cannot exactly describe the stage of the diverticular disease. Many surgeons still prefer an enema with water-soluble contrast medium in emergency cases to visualize a perforation. CT scans have the same ability to answer this question, but they are more expensive and are not available everywhere at any given time.