[Social Security Needs Social Medicine: Self-image of Physicians Practicing Social Medicine in Statutory Health Insurances and Social Security Systems]. / Soziale Sicherheit braucht Sozialmedizin Selbstverständnis von Ärztinnen und Ärzten in der sozialmedizinischen Begutachtung und Beratung.

OBJECTIVE: In January, 2014, the division "Social Medicine in Practice and Rehabilitation" of the German Society for Social Medicine and Prevention established a working group on the self-image of the physicians active in the field of social medicine (medical expertise and counseling). METHODS: The result of this work is the contribution presented here after consensus was achieved by specialists of social medicine from different fields and institutions (social security etc.) and in good cooperation with Prof. Dr. Gostomzyk and Prof. Dr. Robra. RESULTS: Based on the importance of an up to date social medicine for claimants and recipients of benefits on the one hand and the social security system on the other, and also on a description of the subjects, objectives and methods the following aspects are presented: · The perspective of social medicine. · Qualification in social medicine, concerning specialist training and continuing medical education. · The fields of duty of experts in social medicine. · The proceedings in social medicine. The working group identified challenges for the specialists in social medicine by a narrowed perception of social medicine by physicians in hospitals and practice, accompanied by an enlarged importance of expertise in social medicine, by the demand for more "patient orientation" and gain of transparency, and concerning the scientific foundation of social medicine. CONCLUSIONS: The working group postulates: · The perspective of social medicine should be spread more widely.. · Confidence in experts of social medicine and their independency should be strengthened.. · The not case-related consulting of the staff and executives should be expanded.. · Social medicine in practice needs support by politics and society, and especially by research and teaching.. · Good cooperation and transfer of experiences of the different branches of social security are essential for the impact of social medicine..

[Evaluation of stents in treating childhood benign esophageal strictures]. / Evaluation von Stents zur Behandlung der benignen Osophagusstenose im Kindesalter.

BACKGROUND: Esophageal stenting is a popular of treatment of esophageal strictures in adults. It has also been described for children with benign strictures who did not respond to standard dilatation therapy. The aim of the study was to evaluate weather esophageal stents could be used safely and effectively in the treatment of benign esophageal strictures in children. PATIENTS: From 1993 to 2005 stenting therapy was performed in 12 children with complicated esophageal strictures. Etiologies of the strictures were caustic burns in 9 patients, postoperative strictures due to complicated esophageal atresia in 2 patients and iatrogenic esophageal injury in 1 patient. METHOD: Esophageal silicon tubi, covered retrievable expandable nitinol and plastic stents were placed endoscopically. The clinical course and the long term follow up were evaluated retrospectively RESULTS: The stents and tubi were placed in all patients without complications and were later removed successfully. 6 patients were treated with a self expanding plastic stent. The plastic stents showed a distinct tendency to migrate but in 5/6 patients esophageal stricture was treated successfully. 3 patients were treated by a covered self expanding nitinol stent. No migration occurred. One patient was asymptomatic after therapy, one required further dilatation therapy and the third had esophageal resection. 3 patients were treated by esophageal tubi. 2 patients required surgery in the follow up, one patient is asymptomatic. CONCLUSION: The use of stenting devices in children to treat benign esophageal strictures is safe and efficient. The self expanding plastic stents had the best long term results but required high compliance of parents and children due to the tendency of stent migration. Self expanding nitinol stents are more traumatic at the extraction procedure and are useful in patients with low compliance. Recurrence of strictures occurred most often after esophageal tubi possibly due to the lack of radial expansion.

Efficacy of ERCP in infancy and childhood.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a well established diagnostic and therapeutic tool in adult and pediatric patients. Because of its inherent risks we analysed our series in an attempt to better define the diagnostic and therapeutic roles of ERCP and its effectiveness in children. METHODS: All ERCPs performed in our department during a 10-year period in patients age 14 years and under were reviewed retrospectively. Indications, diagnostic findings, therapeutic interventions and final outcome were documented. RESULTS: A total of 61 procedures were performed on 47 patients whose median age was 8.56 years. ERCP was successful in 53 of 61 interventions (89%) with a complication rate of 6%. Thirty patients underwent diagnostic ERCP. In these a pathological diagnosis was established in 57%. In patients without morphological changes in ultrasound or magnet resonance imaging ERCP failed to set diagnosis too. Seventeen patients had therapeutic ERCPs. All of these interventions were performed with similar or better outcome than in adults. CONCLUSION: Indications for diagnostic ERCP are morphologic biliary or pancreatic duct disorders, but only where higher resolution imaging is necessary for therapeutic decisions. Without morphologic changes on ultrasound or magnetic resonance imaging we rarely see any indication for diagnostic ERCP. Efficacy of therapeutic ERCP in childhood is similar or even better to that in adults. Prognoses are directly dependent from the basic disease of the patient.

[Personal contextual factors, part I]. / Personbezogene Kontextfaktoren, Teil I.

The International Classification of Functioning, Disability and Health (ICF) does not yet classify personal contextual factors. To determine the interaction of these factors on activities and participation of a person as well as their influence on the probable outcome of interventions, they must be taken into account in individual sociomedical expertises. Therefore, a group of medical experts working for the social health insurance medical advisory boards in Germany compiled a proposal for a systematic classification of personal contextual factors into domains, categories and items with respect to the ethical guidelines of the ICF. In a second step the main issues were transferred into the preliminary draft for a short version which will be published later to give support for practical daily use in health insurance matters.

Depth of endoscopically placed sutures: an experimental study in a human cadaver model.

BACKGROUND: Endoscopic suturing devices offer interesting access for interventional procedures used on the gastrointestinal tract. For the time being, the main indication is endoluminal suturing at the gastroesophageal junction for the management of gastroesophageal reflux disease. There is some evidence that endoluminal endoscopic suturing offers an alternative to the closure of esophageal fistulas and to the fixation of feeding tubes and stents in the near future. A review of the literature found no anatomic data on wall layers stitched by sutures. The aim of this study was to determine the depth of sutures placed endoscopically in the esophagus of a human cadaver model. METHODS: Altogether, 62 sutures were placed in the esophagi of 10 cadavers (complete exenterative cadaver model) at three different suction levels (0.4, 0.6, and 0.8 bar) using the EndoCinch suturing machine. After preparation of the esophagus from its mediastinal bed, all sutures were fixed in formalin and stained with hematoxylin and eosin for histologic examination. RESULTS: No sutures were placed in the mucosa alone. As observed, 1.6% were placed in the submucosa, 4.8% in the circular muscularis propria, and 56.5% in the longitudinal muscularis propria, with 37% placed transmurally. At a suction level of 0.4 bar (0.6, 0.8 bar), 0% (0%, 1.6%) were placed in the submucosa, 3.2% (0%, 1.6%) in the circular muscularis propria, and 11% (25.8%, 12.9%) in the longitudinal muscularis propria, with 12.9% (6.5%, 17.7%) placed transmurally. CONCLUSIONS: This study reports, for the first time, a systematic examination of the depth of sutures placed endoscopically in the esophagus. Most of the sutures were found in the muscular wall of the esophagus at a suction level of 0.6 bar. Also, transmural placements were seen. Reduction of suction pressure may lead to a decrease in transmural sutures.

Endoscopic treatment of postoperative colorectal anastomotic strictures.

BACKGROUND: The postoperative development of benign colorectal anastomotic stricture remains a frequent and unsolved problem. METHODS: From 1996 until 2002, we analyzed 94 consecutive patients with postoperative colorectal anastomotic stenosis who were treated endoscopically. RESULTS: Sixty-eight patients were initially resected for malignant disease, and 26 patients for benign conditions. Most frequently, hydrostatic balloon dilatation was performed; in selected cases, it was combined with a laser or argon plasma coagulation (APC) incision, or a laser incision only. Dilatation was successful in 59% of patients resected for cancer and 88% resected for a benign condition. Complications developed in 17 patients (benign restenosis, perforation, abscess); they were significantly more frequent after initial cancer resection than after resection for a benign condition ( p < 0.05). CONCLUSION: High success and low complication rates make endoscopic dilatation the treatment of choice to avoid high-risk reoperations in patients with benign anastomotic stricture. The presence of stapler anastomosis, postoperative leakage, and/or radiotherapy does not significantly impede successful endoscopic dilatation.

[Results of emergency ERCP in the treatment of acute biliary pancreatitis]. / Ergebnisse der notfallmässigen ERCP bei der Behandlung der akuten biliären Pancreatitis.

Indication for emergency ERCP (< 48 hours after onset of symptoms) with stone extraction from the common bile duct (CBD) in patients with biliary pancreatitis remains controversial. In our hospital emergency ERCP with stone extraction from CBD is part of the therapeutical concept in patients with biliary pancreatitis. The aim of the study was to elucidate retrospectively results and impact of this concept on morbidity and lethality in surgical intensive care patients. We included all patients with a documented indication for emergency ERCP. Among 4 466 patients (1. 1. 1999-31. 12. 2000) treated in the SICU, 37 (0.9 %) required an emergency ERCP due to a biliary pancreatitis. (26 females/11 males, 62.0 +/- 15.4 years). After ERCP stones were present in 32 of the 37 patients with subsequent successful endoscopic extraction in all cases but one. The mean duration from admission to ERCP was 11.6 +/- 10.1 hours. Bilirubin as well as amylase and lipase decreased after ERCP (p < 0.05). Only in one case an elevation of pancreatic enzymes over the pre-ERCP values was observed, an aggravation of pancreatitis was not seen in our series. In 5 of the 37 cases bile duct stones were not found after ERCP despite strong clinical suggestion (elevation of bilirubin and pancreatic enzymes, ultrasound). During the observational period 2 patients died, in one case possibly due to the ERCP. Emergency ERCP removed in our series the pancreatitis causing agent. Still considering the limitations of a retrospective study these positive results are stimulating us to continue with our therapeutical concept.

Correlation of postoperative survival and angiogenic growth factors in pancreatic carcinoma.

BACKGROUND/AIMS: VEGF (vascular endothelial growth factor) and EGF (epidermal growth factor) are promoters of angiogenesis. It was the aim of this study to investigate a possible coexpression of both growth factors in tumor samples of pancreatic cancer patients in relation to survival after resection of the tumor. METHODOLOGY: We investigated the expression of VEGF165 and EGF in tumor specimen from 19 patients that underwent pancreaticoduodenectomy. Growth factor expression was determined using immunohistochemical methods. RESULTS: Coexpression of VEGF165 and EGF was observed in tumor samples of 9 (47%) patients. VEGF165 and EGF expression in the same tumor correlates significantly (P < 0.05, Fisher-test). UICC stage III pancreatic carcinoma patients with VEGF165 negative tumor cells had a significantly better outcome after surgery compared to UICC stage III patients with VEGF165-positive tumor cells (median survival time 19 months vs. 9 months respectively; P < 0.05, Wilcoxon-test). CONCLUSIONS: Antiangiogenic therapy after surgery for pancreatic cancer may be beneficial, especially for UICC III patients.

[A new video documentation system for rigid procto-rectoscopy]. / Ein neues Video-Dokumentationssystem für die starre Prokto-Rectoskopie.

INTRODUCTION: Disadvantages of rigid procto-rectoscope systems are the lack of sufficient visual documentation, data processing and the insufficient demonstration for educational purposes. Therefore a video documentation system for rigid procto-rectoscopy (Endovision Telecam SL) was developed. METHOD: For evaluation of the Endovision Telecam SL, the system was compared to the conventional technique over a 6-month period. RESULTS: The Endovision Telecam SL offers the advantage of flexible video-endoscopy and displays an excellent quality of documentation for rigid procto-rectoscopy. The handling of the system is slightly more time-consuming and difficult and the use is limited to cases without severe bleeding and stool contamination. CONCLUSIONS: The Endovision Telecam SL combines the advantages of flexible video-endoscopy in documentation, demonstration and data processing with the practibility of rigid instruments for procto-rectoscopy. In the present set-up the system is still limited to special indications and should be combined with conventional procedures.

[Anastomotic insufficiencies of the esophagus--early surgical endoscopy and endoscopic therapy]. / Anastomoseninsuffizienzen am Osophagus--Frühoperative Endoskopie und endoskopische Therapie.

Therapeutic value of flexible endoscopy regarding treatment of esophagoenteric anastomotic leakage was retrospectively analyzed in 56 patients (female n = 13, male n = 43, age 60 years, 1/1992-4/2000). Endoscopic treatment was performed in 44 patients (self-expanding metal stent n = 38, fibrin glue n = 16, feeding tube/decompression tube n = 20, endoscopic percutaneous jejunostomy n = 8), interventional radiological technique in 4 patients and surgical treatment in 11 patients. All patients with open surgical reintervention developed reinsufficiency of the anastomosis. Successful endoscopic therapy was achieved in 75% with a mortality of 21.4%. Endoscopic treatment of esophageal anastomotic insufficiency is an effective alternative to conventional re-thoracotomy. The appropriate endoscopic intervention needs to be decided individually depending on diagnosis and location.

[Colonoscopy in patients over 80 years of age. Indications, methods and results]. / Die Koloskopie bei über 80-Jährigen. Indikationen, Methodik und Ergebnisse.

BACKGROUND AND OBJECTIVE: Diseases of the colon, especially cancer, are age-specific and thus occur more frequently in an aging population. Early diagnosis is prognostically decisive. Indications for coloscopy are often delayed in the elderly. It was the aim of this study to determine advantages and disadvantages of coloscopy in those aged over 80 years. PATIENTS AND METHODS: A total of 157 coloscopies in patients aged over 80 years (average 83 years, oldest patient 94 years) were retrospectively analysed (63 males, 94 females) regarding indications, results and complications, with special reference to cancer of the colon. The main indication for coloscopy in this cohort was occult faecal blood or non-acute rectal bleeding (27%), which together were important indicators of endoscopically significant findings (in 76%). Not only blood in the stool but manifold other signs can point to colorectal carcinoma. CONCLUSION: Even in patients aged over 80 years coloscopy is a safe and well-tolerated investigation. Its results can be improved by thorough pre-investigational intestinal preparation so that repeat examination is unnecessary. The high incidence of significant findings and the easy accessibility to the site of colon cancer should provide an earlier and more common indication of total coloscopy in this age group.

Foreign body aspiration in children.

BACKGROUND: There is still considerable controversy about the diagnostic procedure, the endoscopic approach, and the complication rate with foreign body aspiration in children. METHODS: Review of our data for 98 children suspected for foreign body aspiration between January 1990 and December 1998 was performed. RESULTS: In this data review, 78% of the children studied were younger than 2 years. A foreign body aspiration was identified in 70%, and 67% had a definite history of aspiration. Predominant clinical features were fever (46%), pneumonia (39%), and coughing (29%). Pathologic chest radiographs were found in 84% of the children. Sixty-two percent of the foreign bodies were trapped in the right lung, and 87% were of organic in origin. In 93%, a single endoscopic procedure was successful in removing the foreign bodies. The mean time between aspiration and bronchoscopic extraction was 5.4 days (range, 1 h to 36 weeks). The procedure-related morbidity rate was 0.96% and the mortality 0. CONCLUSIONS: Outcome and complications were found to depend mainly on the time the foreign body stayed in the tracheobronchial system. Early bronchoscopy is paramount in any case of suspected foreign body aspiration, and it is mandatory to increase the awareness of the population and medical professionals.

Thermoplastic stents: a new concept for endoluminal prosthesis.

BACKGROUND AND STUDY AIMS: Intraluminal stenting of organs with stenoses or fistulae in anatomically difficult locations (for instance cardia, pylorus, large bowel), with a tendency to kinking or increased motility, still carries a high risk of stent dislocation. In the search for a solution, we report on the use of a new thermoplastic stent in animal experiments. MATERIAL AND METHODS: The new stent consists of a plastic-coated wire mesh which can be heated electrically. Once it is warmed up to 55 C, its size and shape can be changed. After being expanded by a dilatation balloon across the stenosed area, the stent can be fitted onto the inner organ surface. This guarantees a low dislocation risk and high stability. In an animal experiment, stents were endoscopically placed in the trachea and the surgically stenosed esophagus of two dogs. The animals were observed for 3 months. RESULTS: The thermostents were implanted easily and without complications. It was possible to mold the thermostent evenly onto the intraluminal wall. No stent dislocation, bleeding or perforation was observed. Upon histologic evaluation, granulation tissue was found to be growing through the wire mesh of the stent. CONCLUSION: It was shown that the stent described here can be implanted without major problems. The greater effort of the implantation procedure, in comparison with self-expanding stents, is compensated by the special mechanical characteristics of the stent. These characteristics may permit implantation in anatomically difficult locations where up to now stenting has been impossible or inadequate.

Treatment of endoscopic esophageal perforation.

BACKGROUND: The increasing usage of flexible endoscopy leads to a higher incidence of esophageal perforations, whose treatment strategies (conservative or operative) still are discussed controversially. We present our experiences and therapy concepts in relation to 75 iatrogenic esophageal perforations. PATIENTS: Between 1983 and 1997, 75 patients were treated for endoscopic perforation of the esophagus. The gender distribution was 31 females (41.3%) and 44 males (58.7%), with a mean age of 64.4 years (range 2-90 years). RESULTS: Therapeutic endoscopy was the most common cause of perforation (73 of 75 patients; 97.3%). Diagnostic endoscopy caused perforation in 2 patients (2.7%). The perforation was located in the cervical part of the esophagus in 7 patients (9.3%), the intrathoracic part in 25 patients (33.3%), and the abdominal part in 43 patients (57.3%). In this study population, 25 patients (33.3%) were treated surgically, and 50 patients (66.7%) conservatively. The overall in-hospital mortality rate was 14 of 75 patients (18.7%). In the surgically treated group the rate was 6 of 25 patients (24%) and in the conservative group 8 of 50 patients (16%). CONCLUSIONS: The decision of a treatment strategy depends on different factors such as the location and extent of the injury, the time interval between perforation and treatment onset, the preexisting diseases, and the patient's general condition. In view of these factors, an individual therapy concept should be determined for every patient.

Fibrin sealing in peptic ulcer bleeding: the fate of the clot.

BACKGROUND AND STUDY AIMS: The injection of fibrin tissue glue is a promising endoscopic method for hemostasis of peptic ulcer bleeding. So far, no clinical study has focused on the ulcer healing process after endoscopic fibrin injection. PATIENTS AND METHODS: A morphological study was performed on all resection specimens from patients operated on between 1 January 1994 and 31 December 1996 for gastroduodenal ulcer bleeding with prior endoscopic injection of fibrin glue. The fibrin clot was characterized histologically for its size, location and aspect. RESULTS: Of 227 patients endoscopically treated with a double-lumen needle, 20 underwent resection. The interval between fibrin injection and resection ranged from 6 hours to 9 days. In 15 patients the ulcer was identified in the resection specimen. No fibrin remnants were detectable in three, sparse fibrin deposits were seen in eight and large amounts of fibrin were noted in the submucosa or subserosa in four specimens. With increasing time, the clot was gradually organized by phagocytes and angio-fibroblasts and was finally replaced by endogenous granulation tissue. An exuberant or tissue-destructive reaction did not appear. CONCLUSIONS: In this study, endoscopic fibrin sealing of bleeding ulcers resulted in appearance of a bland fibroblast-rich granulation tissue. The depth of fibrin glue injection is difficult to standardize with the aid of double-lumen needles.

[Cavernous hemangioma of the rectum--a rare cause of peranal hemorrhage]. / Das cavernöse Hämangiom des Rectums--eine seltene Ursache peranaler Blutung.

We report the case of a 34-year-old woman with severe rectal bleeding since the age of 17. The cause of the bleeding was a cavernous haemangioma of the rectum. The extent of the disease was not realised for many years. Sclerosing injections, laser coagulation and even suture ligation were helpful in acute bleeding episodes but did not result in definitive healing. Finally cure was achieved by resection of the rectum and colo-anal sleeve anastomosis. The clinical presentation and the management are described and discussed.

Surgery for early gastric cancer: a European one-center experience.

Between 1972 and 1995 a total of 251 patients with early gastric cancer underwent resection in our department of surgery. At the time of the operation 10.8% of the patients were proved to have lymph node involvement, and two already had distant metastases. A subtotal gastric resection was performed in 59.8% of cases (n = 150), a total gastrectomy in 33.8% (n = 85), and either a proximal or an atypical resection in 6.4% (n = 16). Since 1985 subtotal distal resection and total gastrectomy were accompanied by a systematic lymphadenectomy of compartments I and II. The overall postoperative morbidity was 18.3%, and the hospital mortality, 4.9%; it was only 1.6% within the last decade. Concerning these short-term results there were no statistically significant differences between the different surgical procedures. The cumulative overall 5-year-survival rate was 82.6%. There was no statistically significant influence of either the different surgical procedures or the histologic types according to the Japanese classification of early gastric cancer.

The "knot before loop" technique for the endoscopic ligation and suture-instrument set. Knot formation and application.

BACKGROUND: In minimally invasive surgery intracorporal knot-tying is complicated by a limited field of vision and depth perception. METHODS: The "knot before loop" technique aims to reduce intraabdominal movements in number and space needed. A grasping instrument 3 mm in diameter guides a slipfit hollow knot pusher with a notch to hold the thread, when extracorporally forming the knot on the instrument tip and an axial slot. The loop is finished under endoscopic vision, yet a second loop is created along the thread. The knot is tightened and secured by closing the second loop without troublesome instrument change. RESULTS: The strength of the knot was tested and the feasibility of the instrument set was proven in pigs and 25 cholecystectomies and hernia repairs in humans. CONCLUSIONS: Endoscopic application of a secured slip knot is simplified by the "knot before loop" technique. The independent formation of the knot by the assisting personnel allows quick application, equivalent to the use of clips and staples. The benefit in cost saving is high.