Pedunculated, well differentiated liposarcoma of the oesophagus mimicking giant fibrovascular polyp.

We present a rare case of a big oesophageal liposarcoma causing dysphagia and weight loss in a 75-year-old patient. Endoscopically, a pedunculated lesion with subtotal obstruction of the oesophageal lumen had been detected and thoracoabdominal oesophageal resection with gastric sleeve reconstruction was performed. Surprisingly, a liposarcoma of the oesophagus was revealed on histopathological analysis, showing MDM2 overexpression. Oncological follow-up has been uneventful and the patient remains in good clinical shape at 15 months after surgery.

[Timing of esophagectomy in multimodal therapy of esophageal cancer: Impact of time interval between neoadjuvant therapy and surgery on outcome and response]. / Therapiepause in der multimodalen Behandlung des Ösophaguskarzinoms : Einfluss des Intervalls zwischen neoadjuvanter Therapie und Resektion auf Outcome und Response.

BACKGROUND: Neoadjuvant radiochemotherapy [n(R)CT] has become the standard of care in the multimodal therapy concept for patients with locally advanced esophageal cancer; however, optimal timing of surgery is not clearly defined. OBJECTIVES: The study analyzed whether the length of the interval between completion of n(R)CT and surgery can affect the postoperative outcome, tumor response and long-term survival. MATERIAL AND METHODS: A total of 106 patients with adenocarcinoma and squamous cell carcinoma of the esophagus, treated between 2006 and 2013, were included in this study. On the basis of the median time interval to surgery, patients were divided into two groups [group A ≤ 40 days (n = 54) and group B > 40 days (n = 52)] and compared concerning demographic data, preoperative risk scores, morbidity, outcome, tumor response and long-term survival. RESULTS: The groups were comparable in terms of demographics, preoperative condition of the patients, complications and outcome; however, group A showed a trend towards a higher mortality risk as preoperatively assessed by the physiological and operative severity score for the enumeration of mortality and morbidity in esophagogastric surgery patients (O-POSSUM) (p = 0.064) and group B showed a trend towards a higher rate of complete responders (p = 0.097). CONCLUSION: Concerning perioperative morbidity and mortality, delayed surgery after n(R)CT showed no benefit for the patient's outcome; however, the rate of complete tumor response was higher in patients with a time interval of more than 40 days, although this did not influence long-term survival or recurrence rates.

Antibiotic prophylaxis at urinary catheter removal prevents urinary tract infection after kidney transplantation.

BACKGROUND: Urinary tract infections (UTI) are common nosocomial infections in kidney transplant recipients, with limited evidence to guide antibiotic prophylaxis at urinary catheter removal. The aim of our study was to evaluate the effect of short-term antibiotic therapy at the moment of catheter removal after kidney transplantation. METHODS: Twenty kidney transplant recipients received 250 mg of ciprofloxacin orally twice daily 1 day before and at the day of the removal of the urinary catheter and were compared with 20 kidney transplant recipients without prophylaxis. UTI was diagnosed by use of urine culture and clinical signs. RESULTS: All patients were comparable in sex, age, etiology of end-stage renal failure, immunosuppression, donor type, and initial function. After catheter removal at the 6th postoperative day, a rapid rise of UTI in kidney transplant recipients without prophylaxis (n = 12, 60%) was observed, whereas in patients with antibiotic prophylaxis the rate of UTI could be significantly reduced to 20%. Escherichia coli was the most isolated pathogen in the patients with UTI and was detected at the catheter tip in more than 50% of cases. In 2 patients (10%) after antibiotic prophylaxis, a ciprofloxacin-resistant E coli strain was detected. CONCLUSIONS: The use of antibiotic prophylaxis during urinary catheter removal is recommended to prevent UTI in kidney transplant recipients.

Gender and strain-specific differences in the development of steatosis in rats.

Non-alcoholic fatty liver disease (NAFLD) is a common problem with a wide variety of phenotypes. While its pathogenesis is still not fully understood, several risk factors for disease progression have been identified. Therefore, defining adequate animal models may serve to unreveal the pathogenesis in NAFLD. We studied Lewis and Sprague-Dawley rats of both genders (n = 6) fed standard (Std) or high-fat (HF) diet for three weeks. Disease stage was assessed by haematoxylin-eosin, Azan Heidenheim and Oil-Red staining, apoptosis by single-stranded DNA (ssDNA) detection and liver regeneration by Ki-67 staining. Serum markers of liver injury and lipid metabolism including adipocytokines were analysed. Livers of both strains and genders fed with HF diet demonstrated evidence of steatosis. Lewis rats developed microvesicular steatosis whereas Sprague-Dawley rats presented macrovesicular steatosis accompanied by pronounced fibrosis. Female gender of both strains was associated with lower steatosis grade and higher proliferation rate (P < 0.05). Gender-specific differences were most prominent in Lewis rats on a HF diet, where females showed lower alkaline phosphatase, cholesterol, triglyceride and leptin levels and a more favourable low-density lipoprotein/high-density lipoprotein ratio than males (P < 0.05). Reverse transcriptase-polymerase chain reaction analysis was performed to demonstrate changes in expression of various genes important for liver regeneration, fibrosis and steatosis. HF diet induced downregulation of proangiogenic genes such as vascular endothelial growth factor receptor 1 and 2 (P < 0.05) in males was not present in females. In conclusion, strain and gender served major roles in disease progression. These differences should be considered when designing studies and may offer new ways to advance therapeutic strategies.

Renal graft outcome in combined heart-kidney transplantation compared to kidney transplantation alone: a single-center, matched-control study.

BACKGROUND: Renal allograft outcome in heart-kidney transplantation (HKTx) might be affected by hemodynamic instability and high levels of calcineurin inhibitor-dependent immunosuppression. METHODS: From November 1999 to March 2008, 13 patients who received HKTx were compared with a matched control group of 13 kidney transplantation (KTx) recipients with similar cardiovascular risk factors. Graft function, rejection periods, and patient survival were analyzed. RESULTS: Renal allograft rejection was noted in three patients (23%) after HKTx and in four patients (31%) after KTx. Serum creatinine levels were comparable at 1 week, 1 month, 1, 2, and 3 years after transplantation. Patient survival rates at 1, 2, and 3 years were 100% for HKTx recipients and 100, 92, and 92% for isolated KTx patients. Graft survival was 92% at 1, 2, and 3 years after HKTx and 100% at 1 year and 92% at 2 and 3 years after isolated KTx. CONCLUSIONS: Our results with excellent long-term graft function and survival after combined HKTx indicate that this procedure is a valuable option for a growing number of patients suffering from coexistent cardiac and renal failure.

Timing of conversion to mammalian target of rapamycin inhibitors is crucial in liver transplant recipients with impaired renal function at transplantation.

BACKGROUND: Renal dysfunction, primarily related to long-term use of calcineurin inhibitor-based immunosuppression, is the most common complication after liver transplantation. OBJECTIVE: To evaluate whether liver transplant recipients with impaired kidney function at transplantation can benefit from early conversion to mammalian target of rapamycin inhibitor therapy (mTORi) compared with patients with late induction of mTORi-based therapy. MATERIALS AND METHODS: Between 2003 and 2008, therapy was changed to an mTORi-based regimen in 57 patients. Patients were divided into 4 groups: group 1, early conversion (≤3 months after orthotopic liver transplantation) to mTORi therapy, and with impaired perioperative renal function; group 2, early conversion to mTORi therapy, and with normal perioperative renal function; group 3, late conversion to mTORi therapy, and with impaired perioperative renal function; and group 4, late conversion to mTORi therapy, and with normal perioperative renal function. RESULTS: One month after conversion, the mean (SD) increase in calculated glomerular filtration rate in groups 1 (early conversion) and 3 (late conversion) was comparable: 8 (9) mL/min vs 7 (10) mL/min. At month 3, the increase in calculated glomerular filtration rate between groups 1 and 3 was significant (15 [11] mL/min vs 9 [15] mL/min; P = .04), an effect that persisted at month 6 (16 [12] mL/min vs 10 [12] mL/min; P = .05) and month 12 (22 [14] mL/min vs 12 [15] mL/min; P = .04). CONCLUSION: In liver transplant recipients with perioperatively impaired renal function, early conversion to mTORi therapy should be performed because this approach seems to be more effective in improving long-term renal function.

[Are leukocytes and CRP early indicators for anastomotic leakage after esophageal resection?]. / Sind Leukozyten und C-reaktives Protein geeignete Parameter als Frühindikatoren der Anastomoseninsuffizienz nach Osophagusresektion?1.

BACKGROUND: Anastomotic leaks represent the most common severe postoperative complications after esophagectomy. In this study standard inflammatory laboratory parameters [leukocytes, C-reactive protein (CRP)] were evaluated as indicators for anastomotic leakage after esophagectomy. PATIENTS AND METHODS: Between 1 / 1997 and 12 / 2006 a total of 558 patients with esophageal cancer underwent an Ivor-Lewis esophagectomy. Among these patients, all those (n = 50, 8.9 %) suffering from an anastomotic leak were matched to 50 patients without anastomotic leakage. Leukocytes, CRP level and clinical parameters (body temperature, cardiac / respiratory problems, wound secretion) were retrospectively analysed at short-term intervals in both groups. RESULTS: Patients with anastomotic leaks showed significant continuously increased CRP levels and leukocyte counts from the second or, respectively, 5 (th) postoperative day onwards compared to patients without anastomotic leaks. Using a stepwise regression, an 80 % sensitivity for leakage detection has been calculated by a cut-off value for CRP set at 13.5 mg / dL from day 2 onwards or, respectively, for leukocytes at 10.5 Gpt / L from day 8 onwards. Concomitantly, patients with anastomotic leaks suffered significantly more from respiratory problems and abdominal pain. CONCLUSION: CRP appears to be a reliable and predictable indicator for anastomotic leakage after esophagectomy and should, therefore, be routinely used as a screening marker to provide a reason for extended diagnosis.

[Laparoscopic inguinal herniorrhaphy in children--experiences in a primary medical care center]. / Die laparoskopische herniorrhaphie des leistenbruches im kindesalter--erfahrungen in einem krankenhaus der grund--und regelversorgung.

AIM: Children undergoing laparoscopic herniorrhaphy may benefit from a minimally invasive access and the possible exploration of the contralateral groin. In this prospective feasibility study, the experiences and results after introduction of this method in a tertiary referral medical center are reported. METHODS: 50 laparoscopic herniorrhaphies were performed in 44 children (32 boys and 12 girls, range: 17 months-11 years) with open inner inguinal rings between January 2001 and March 2007. In 6 children (13.6 %) an additional contralateral open inner inguinal ring was detected. Laparoscopic access was obtained with a 5-mm laparoscope which was inserted transumbilically and two 2-mm needle holders were inserted through the inferolateral abdominal wall. The open inner inguinal rings were closed in 8 children using a resorbable Z-suture and in 36 children using a monofilamentous non-absorbable suture. Follow-up examinations included records of intra- and postoperative complications, recurrence rate and economic aspects. RESULTS: No intra- or perioperative complications occurred. Median operation time was 19 minutes. 43 / 44 operations were carried on an outpatient basis. Average material costs were about 20 Euro without any difference from the open access. During 36 months the follow-up rate was 91 %. Two children who had previously received an absorbable suture suffered from a recurring groin hernia within the first 6 months. CONCLUSION: Laparoscopic herniorrhaphy in children represents a safe and effective surgical method that can be recommended for tertiary referral medical centers with training facilities and experience in minimally invasive surgery.

Randomized clinical trial of the influence of intraperitoneal local anaesthesia on pain after laparoscopic surgery.

BACKGROUND: There is controversy about the effectiveness of intraperitoneal local anaesthesia (LA) in laparoscopic surgery. The aim of the present randomized clinical trial was to compare the analgesic effect of pre-emptive (preoperative) versus postoperative intraperitoneal LA in two different types of laparoscopic surgery. METHODS: Between July 2004 and January 2005, 133 consecutive patients scheduled to undergo laparoscopic fundoplication or hernia repair were randomly assigned to one of three treatments: placebo solution (50 ml 0.9 per cent saline) or LA (50 ml 0.5 per cent lidocaine) administered immediately after creation of the pneumoperitoneum, or LA (50 ml 0.5 per cent lidocaine) at the end of the operation. Analgesic requirements were analysed, and pain was assessed using a visual analogue scale (VAS) from 0 to 100 at 6, 12, 24 and 48 h after surgery. RESULTS: The duration of pneumoperitoneum (median 66 versus 46 min respectively; P < 0.001) and overall pain intensity (median VAS score 46.7 versus 6.5; P < 0.001) were higher for laparoscopic fundoplication than for hernia repair. Preoperative application of LA reduced abdominal pain (median 28.6 versus 74.9; P < 0.005), shoulder pain (median 24.3 versus 43.8; P = 0.004) and analgesic consumption (mean(s.d.) 11.1(5.0) versus 18.5(5.4) mg piritramide per 48 h; P = 0.002) after fundoplication, but had no analgesic effects after hernia repair. CONCLUSION: Pre-emptive application of LA reduced postoperative pain and analgesic requirements after laparoscopic fundoplication.

[Anti-reflux surgery in patients with adequate response to proton pump inhibitors - is there an indication?]. / Antirefluxchirurgie bei patienten mit adäquatem ansprechen auf protonenpumpeninhibitoren - sinnvoll oder übertherapiert?

BACKGROUND: The indication for anti-reflux-surgery in patients with gastroesophageal reflux disease (GERD) who are totally symptom-free under conservative treatment with proton pump inhibitors (PPI) is still seen controversially. Arguments for PPI-treatment include the missing trauma and few side-effects, arguments against include the life-time-long drug intake. We prospectively observed the indication of anti-reflux-surgery in symptom-free patients in comparison to patients with remaining symptoms under treatment with PPI. PATIENTS AND METHODS: Between January 1999 and December 2001, 317 patients with GERD were treated by laparoscopic hemifundoplication and grouped in patients with adequate response to PPI (n = 103) and patients with residual discomfort in spite of or by PPI (n = 214). Preoperative diagnostic included endoscopy, ph-testing, manometry and quality of life scoring by a standardized questionnaire. Peri- and postoperative morbidity as well as quality of life were analyzed and compared with healthy individuals (n = 50). RESULTS: Patient demographics and surgical procedures did not differ between the two groups. After a median follow-up of 49 months and a follow-up rate of 89.9 %, the recurrence rate was 2.5 % and perioperative complication rate was 6.3 % without any significant differences between the groups. Patients with GERD and adequate response to PPI showed preoperatively during PPI omission a significant lower incidence of esophagitis (3.9 % vs. 18.2 %) and higher quality of life score (93.7 +/- 11.3 vs. 75.3 +/- 12.6), which significantly decreased in comparison to healthy individuals (132.9 +/- 10.5). After anti-reflux surgery the quality of life has been increased in both groups (130.5 +/- 11.4 vs. 121.8 +/- 13.2). However, only patients with adequate response to PPI reached the quality of life score of healthy individuals. CONCLUSION: Patients with preoperatively adequate response to PPI profit of anti-reflux surgery in terms of postoperative quality of life. Concerning the indication for anti-reflux surgery in these patients, one has to balance between the individual inconvenience due to the long-lasting drug intake on the one hand and the operative risk, morbidity and outcome of a specialized surgical department on the other hand.

Reconstruction of ureteral necrosis in kidney transplantation using an ileum interposition.

PURPOSE: Ureteral necrosis is a serious problem in kidney transplantation. Sometimes re-ureterocystostomy is possible, while other cases require an elaborate reconstruction to maintain kidney function. We report our experience with ileum interposition for ureteral reconstruction. METHODS: After 9 years of dialysis treatment a 58-year-old patient was grafted using the left kidney of a 59-year-old donor with a cold ischemic time of 9.5 hours. The early postoperative course was uneventful apart from delayed graft function. Immunosuppression consisted of an IL-2-receptor antibody, calcineurin inhibitor, mycophenolate mofetil, and corticosteroids. Discharge serum creatinine was 2.3 mg/dL. In month 4 the patient showed a pararenal urinoma; cystoscopy revealed necrosis of the distal ureter. Operative revision showed urine leakage from the renal pelvis through the urinoma into the bladder. As the whole ureter was necrotic, a re-ureterocystostomy was not possible. The patient's own ureter had been extirpated, and the bladder was too small to do a direct anastomosis between it and the kidney. Consequently, an ileum interposition was performed. RESULTS: The postoperative course was uneventful. Kidney function was stable with a nadir creatinine concentration of 2.0 mg/dL 18 months' posttransplantation, and 14 months' post ileal interposition the kidney function was still satisfactory, with a creatinine level of 2.0 mg/dL. CONCLUSION: Ureteral necrosis is a serious complication following kidney transplantation. Whenever a re-ureterocystostomy or an uretero-ureterostomy is not possible, the interposition of the ileal segment represented a safe procedure to deal with this problem.

Long-term experience of treating 185 patients with gastroesophageal reflux disease (GERD) by anti-reflux surgery respecting the functional-morphological restoration of the esophagus.

BACKGROUND: According to anatomical investigations the whole esophagus plays a crucial role as reflux barrier in the pathogenesis of gastroesophageal reflux disease (GERD). Morphologically, the spirally arranged muscle fibres present a tension-dependent "stretch closure" and in the event of any reduction of tension, as for example caused by an axial hiatus hernia, the organ may become inefficient. The aim of this study was to evaluate quality of life as the main success criterion after anti-reflux surgery based strictly on the restoration of functional morphology. METHODS: Between January 1999 and December 2000, 185 patients with GERD were treated by surgery in accordance with functional-morphological principles. After dissecting the mediastinum, the gastroesophageal junction was displaced into the abdomen with consecutive retensioning the esophagus. The esophageal hiatus was reconstructed with non-absorbable single knot sutures and strengthened with alloplastic material. The application of a 180 degrees fundus cuff around the posterior esophageal circumference served as a "spacer" and also restored the angle of His. Preoperatively, all patients underwent endoscopy, pH metry and manometry. During postoperative follow-up, recurrence rate and quality of life were evaluated via a disease-specific scale. RESULTS: Preoperatively, 85% of the patients had an elevated DeMeester Score with a median of 81.4; 64% had reflux esophagitis and 37% had reduced lower esophageal sphincter pressure. All 185 operations were performed without conversion in a median operating time of 74 min. In one patient a lesion of the esophagus was treated during the operation; two patients had lesions of the splenic capsule which were also dealt with during the operation. Postoperatively, pleural effusions occurred in 15 patients and puncture was deemed necessary in one subject. Ninety-three percent were followed up for a median of 45 months and the recurrence rate was 2.3%. The quality of life index was 81.6+/-12.4 points preoperatively, and had significantly improved to 125.2+/-12.7 points in the follow-up. CONCLUSION: Through the functional-morphological concept of anti-reflux surgery comprising the restoration of the tension-dependent "stretch closure" of the esophagus, significant long-term improvement in quality of life with a low recurrence rate and perioperative morbidity can be achieved.

[Prevention of bile duct injuries after laparoscopic cholecystectomy. "The critical view of safety"]. / Der ''Sicherheits-Blic'' als Beitrag zur Risikoreduktion bei der laparoskopischen Cholezystektomie.

INTRODUCTION: Iatrogenic injuries of the bile duct and hepatic artery represent a continuous problem after laparoscopic cholecystectomy. In this observational study we report about our experiences applying the "critical view of safety", defined as unambiguous identification of the cystic duct and artery by creation of an infundibular window, in order to minimise bile duct lesions and conversion rate. METHODS: Between July 2002 and November 2004 100 consecutive laparoscopicly started cholecystectomies were prospectively investigated. The central surgical step of dissection aimed at reaching the "critical view of safety" and its photo printing before cutting the cystic duct and artery, otherwise a conversion was carried out without exception. Primary endpoints of the study were the conversion rate, secondary endpoints the incidence of intra- and postoperative complications, operation time and histological results. RESULTS: 53 of the 100 primary laparoscopic operated patients showed the signs of an acute cholecystitis, 44 patients offered partially multiple abdominal operations in their history. In 19 patients we performed a "therapeutic splitting". Only in 3 patients it was not possible to apply the "critical view of safety" resulting in a conversion to open cholecystectomy. The mean operation time was 81 minutes and the postoperative hospital stay ranged to 5.4 (1-18) days. Postoperatively an insufficiency of cystic duct, a navel infection, an abdominal wall haematoma, an urinary tract infection and a pneumonia occurred in one patient each. DISCUSSION: Pivotal factors leading to bile duct injury after laparoscopic cholecystectomy are systematic mistakes in the surgical technique, an insufficient surgical training and human failure of the surgeon. The introduction of the "critical view of safety" represents an objective, understandable and compulsory criterion for minimising the risk of iatrogenic injuries of the bile duct and decision on conversion to open cholecystectomy.

Acute liver failure: from bench to bedside.

Acute liver failure constitutes a challenge to clinicians and scientists alike. The course of the disease, usually unpredictable and polarizing, is associated with a high mortality unless liver transplantation is feasible, but can end in a spontaneous restitution. It poses many scientific questions regarding the mechanisms of liver cell damage and regeneration and the possibility of new therapeutic approaches. However, the performance of clinical studies in patients in acute liver failure presents problems because of the varied etiology, the small number of cases, and furthermore due to ethical and logistical difficulties. For this reason experimental investigations have gained a special importance. Arising from the improved understanding of the mechanisms of liver cell damage in acute liver failure, which may be primarily due not to the initial noxious agent alone but may also be triggered secondarily by the release of proinflammatory mediators, there are numerous options for liver cell protection, some of which have already proved successful in experimental studies. New insights into the mechanisms of regulation of liver regeneration and the physiological liver mass, gathered in particular from experimental models of partial hepatectomy and by the use of gene-manipulated animals, have contributed to the development of new therapeutic approaches for the stimulation of liver cell regeneration. Temporary liver support systems have already been successfully employed in some cases under clinical conditions. Although the systematic experimental investigation of many of the questions of acute liver failure has significantly contributed to a better understanding of liver cell damage and regeneration, the application of this new knowledge to clinical practice is to some extent made difficult by the artificial simplification that experimental studies inevitably entail and needs to be validated by controlled clinical studies.

[Laparoscopic versus open appendectomy: which factors influence the decision between the surgical techniques?]. / Laparoskopische vs. offene Appendektomie: Welche Faktoren beeinflussen die Wahl der Operationsmethode?

BACKGROUND: Although in hospitals focussing on minimal invasive surgery laparoscopic appendectomy (LA) is widely practiced as method of choice in patients with acute appendicitis, the decision for the laparoscopic or the conventional technique (OA) is usually ensued by individual viewpoints. Aim of this prospective observation study was to analyse the decision algorithm for both procedures in patients with the presumptive diagnosis "appendicitis". PATIENTS AND METHODS: Between January 1996 and July 2001 512 patients with the presumptive diagnosis "acute appendicitis" underwent surgery and, assigned by intention-to-treat, were subdivided in a laparoscopic (I) and a conventional group (II). The choice of surgical procedure was analysed with regard to patient characteristics (age, gender, comorbidity), severity of appendicitis (clinical manifestation, preoperative inflammation signs), surgeon (clinical experience) and daytime (during the day, in the evening, at night). Furthermore, the outcome of either method was related to postoperative diagnosis, perioperative morbidity, analgesia, length of hospital stay and cosmetic results. RESULTS: In group I 265 patients and in group II 247 patients underwent surgery. Conversion from LA to OA was necessary in 6.4 %. Group I consisted of significantly more female (67.9 % vs. 45.7 %) and younger patients (21 yrs. vs. 30 yrs.) with less medical history as well as minor severity of tissue inflammation and significantly lower preoperative serum inflammation parameters (leukocytes (1000/ml): 10.6 +/- 4.3 vs. 13.5 +/- 4.9; CRP (mg/l): 2.3 +/- 3.3 vs. 5.6 +/- 7.5, I vs. II: p < 0.001). In group I more patients underwent surgery during day-time as well as by more laparoscopic-experienced surgeons. In the postoperative histopathologic evaluation there were significantly fewer cases with complicated appendicitis (33.2 % vs. 52.2 %, p < 0.001). Additionally, patients after LA revealed a lower postoperative complication rate (9.3 % vs. 18.3 %), length of hospital stay (median 3 vs. 4 days) and duration of analgesia (2.1 +/- 1.8 vs. 4.1 +/- 7.1 days). CONCLUSIONS: Important factors for decision algorithm between a laparoscopic or an open appendectomy include severity of appendicitis, gender, day-time as well as the surgeon's individual laparoscopic experience. With appropriate indication for each technique, both procedures are of equal value in the treatment of acute appendicitis. Furthermore the positive patient selection for laparoscopic appendectomy contributed to a better postoperative outcome in this study.

Feasibility of surgical technique and evaluation of postoperative quality of life after laparoscopic treatment of intrathoracic stomach.

BACKGROUND: Because of the risk of life-threatening complications, the discovery of a complete intrathoracic stomach demands urgent surgery with the aim of repositioning the stomach and gastropexy, and secondarily, to improve life quality. In this study the feasibility of surgical technique and postoperative quality of life after laparoscopic treatment of complete intrathoracic stomach has been evaluated. METHODS: From June 1999 to December 2001 16 patients with an intrathoracic stomach (hiatus hernia Types IIB and III) were treated by laparoscopic techniques, including the repositioning of the stomach, hemi-fundoplication and anterior gastropexy. During the postoperative follow-up the recurrence rate and quality of life (Eypasch index) were evaluated. RESULTS: All operations were performed laparoscopically without conversion, with a mean operating time of 155 min. Pleural injuries occurred in 31% of patients and pleural effusions in 38%, which required puncture in three cases. Complete follow-up showed no recurrences at a median of 14 months. The median quality of life index was 84.6 preoperatively and had significantly improved to 117.8 after the operation. CONCLUSION: Laparoscopic access for the treatment of intrathoracic stomach represents a minimally invasive and safe treatment option for complete intrathoracic stomach, with a low level of perioperative morbidity and significant improvement in quality of life.

Development and evaluation of an experimental model for investigating the pathogenesis and therapeutic strategies of acute liver failure.

Because of the various etiologies of acute liver failure (ALF) a clinically relevant model must fulfill four criteria--reversibility, reproducibility, ALF-induced death, and a sufficient time interval for diagnosis and therapy between induction and death. In this study an experimental model was evaluated for these criteria. A total of 49 rats were randomized into seven groups: First, a pilot study was performed regarding the survival rate after different treatments: In group I, animals underwent a 70% liver resection. In group II, 70% liver resection was combined with ascending doses of postoperative endotoxin administration up to 400 microg/kg (group IIc). In group III, animals only underwent liver mobilization. In group IV, ALF was induced according to the protocol of group IIc, but with additional treatment of an endothelin-A-receptor (ETAR) antagonist. Animals in group V received only 400 microg endotoxin. After induction of ALF, all animals died within the first day, showing significantly elevated bilirubin and ammonium levels and severe damage to hepatocellular integrity. Application of the ETAR antagonist resulted in the survival of 6/7 animals until the 14th day; the biochemical and histomorphological changes were reversible. All other animals survived to the 14th day. A clinically relevant model of ALF in rats can be created by the combination of 70% liver resection and endotoxin application to produce an inflammatory component.

[Reconstruction of bile duct lesions by an autologous vein graft and a bio-degradable endoluminal stent in an animal model: technique and clinical impact]. / Rekonstruktion von Gallengangsdefekten mit autologem Veneninterponat und resorbierbarem Stent im Tiermodell: Technik und klinische Bedeutung.

INTRODUCTION: In this study a new treatment of bile duct lesions was investigated. A segment of the bile duct was replaced by an autologous venous interponate which had been endoluminally stented with a braided bio-degradable stent. METHODS: A total of 18 pigs (20-28 kg) was divided into three equal groups (I-III). In each group a 2 cm segment of the jugular vein was harvested. The animals in Group I (vein group, n = 6) underwent resection of a 2 cm long segment of the common bile duct which was replaced solely by the venous interponate, in Group II (stent group, n = 6) the venous interponate had been endoluminally stented by a braided bio-degradable stent. Group III (control group, n = 6) underwent only a circular mobilization of the common bile duct. Postoperatively survival rate, general condition as well as the weight were observed and checked for 6 months. During surgery and finally after sacrifice after 6 months blood and tissue samples were taken and semiquantitatively scored concerning grade of inflammation and fibrosis. RESULTS: In the stent and control group all animals survived in good condition. 3 pigs of the vein group died within 3 weeks showing signs of biliary peritonitis, another one died due to a high grade stenosis of the common bile duct with secondary biliary cirrhosis after 4 months. In the stent group all animals survived until sacrifice after 6 months. On examination the venous interponate was laminated with bile duct epithelium showing the diameter of the implanted stent. CONCLUSION: The reconstruction of bile duct lesions by a venous interponate in combination with a bio-degradable stent is easy to perform and represents a clinically interesting alternative to the biliodigestive anastomosis because of the preservation of the sphincter oddi. After 6 months the stent is completely absorbed and the venous interponate is laminated with bile duct epithelium.

Achilles tendon healing: long-term biomechanical effects of postoperative mobilization and immobilization in a new mouse model.

The aim of the study was to investigate the long-term effects of postoperative immobilization as opposed to mobilization on the biomechanical attributes of healing Achilles tendons in a new experimental mouse model. In 114 Balb-C-mice the left Achilles tendon was transected and sutured by the Kirchmayr-Kessler technique. The tendons healed either under postoperative immobilization effected by fixing the upper ankle joint in equinus position or under mobilization through a limited range of movement. The contralateral Achilles tendons served as internal control. All tendons were tested biomechanically at short intervals up to the 112th postoperative day in terms of load to failure [N], tendon deflection [mm] and tendon stiffness [N/mm], and were evaluated histologically after 8 and 112 days. Postoperative mobilization resulted in a continuous and significantly more rapid restoration of load to failure in comparison to the immobilization group. Tendon deflection was decreased by postoperative mobilization, whereas under immobilization it paradoxically increased still further in the later course. After 112 days the tendons of the mobilization group had regained their original tendon stiffness, whereas the tendons after immobilization reached only about half the values seen in the control tendons. Histologically, postoperative mobilization led to increased immigration of inflammatory cells in the early phase. In the late phase, as compared to immobilization, tendon structure was more mature, with fibre bundles arranged in parallel and interposed tendocytes. Tensile loading of the healing tendon by postoperative mobilization leads to fundamental changes in the biological process of tendon healing resulting in accelerated restoration of load to failure and reduced tendon deflection.