[Impact of COVID-19 on rheumatological care : A national survey in April 2020]. / Auswirkungen von COVID-19 auf die rheumatologische Versorgung : Eine nationale Umfrage im April 2020.

BACKGROUND: The preparations of healthcare systems to accommodate the large numbers of severely ill COVID-19 patients in March/April 2020 also had a substantial impact on rheumatological patient care. OBJECTIVE: The aim of this online survey was to assess the changes and current status of rheumatology departments and practices in Germany. MATERIAL AND METHODS: A web-based questionnaire was designed to differentiate the impact of the pandemic on inpatient and outpatient operations. Questions addressed the following issues: characteristics of the department, impact on patient care, application of recommendations, personal protective equipment (PPE), and organizational adaptations to the new framework conditions. The survey was available for 14 days and closed on 3 May 2020. RESULTS: A total of 66 complete answers were recorded and evaluated. In the first 4 weeks of the COVID-19 crisis the proportion of outpatients in the institutions decreased on average by -40.6%. The number of outpatients receiving infusions decreased by -25.6%. Of the inpatient facilities 81% reported an average decrease of hospitalized patients of -54.9% and 52% of the participants complained of a lack of PPE. Organizational adjustments are reported. CONCLUSION: The rheumatological services were significantly reduced 4 weeks after the SARS-CoV­2 pandemic had reached Germany on a large scale. The study showed that in this phase there were decisive turning points in patient care and implicated substantial organizational and ultimately also economic effects on the healthcare system, both in hospitals and private practices. As the survey cannot adapt to the daily dynamic changes in priorities it serves as a first snapshot, which requires follow-up studies.

Single-Layer Continuous Versus Double-Layer Continuous Suture in Colonic Anastomoses-a Randomized Multicentre Trial (ANATECH Trial).

PURPOSE: Apart from stapling methods, single- or double-layer continuous hand sutures are established techniques for colonic anastomoses. It is unclear which hand suture technique has superior anastomotic safety. This randomized trial evaluated the incidence of postoperative complications depending on anastomosis technique. METHODS: This multicentre randomized trial enrolled adult elective patients between February 2004 and June 2012 in four German university hospitals. Primary endpoint was incidence of clinical anastomotic leakage until 3 months postoperatively. Estimated sample size was 768 randomized patients. Main secondary endpoints were duration of anastomotic suture, postoperative morbidity and stool patterns at 3-month follow-up. Patients and postoperative outcome assessors were blinded to the group assignment. This trial is registered (NCT00996554). RESULTS: Due to slow recruitment, the trial was stopped prematurely. Two hundred fifty-two patients (129 to single-layer suture anastomosis (SLA), 123 to double-layer suture anastomosis (DLA)) were randomized and analysed. Nine patients (3.6 %) were lost during follow-up. Exploratory primary endpoint analysis by intention-to-treat principle showed no significant difference for clinical anastomotic leakage between suturing techniques (SLA, 4 of 129 (3.1 %) vs. DLA, 6 of 123 (4.9 %), p = 0.532). Secondary endpoint analysis showed on average a 6-min shorter suture duration for SLA than DLA (18 min (4-49) vs. 24 min (8-50), p < 0.001). At 3-month follow-up, subjective well-being and stool patterns were not significantly different between groups. CONCLUSIONS: The present study did not reach sufficient power and cannot confirm whether both techniques might be equally or if one technique might be superior. Exploratory analysis suggests that in elective colonic resections, the single-layer continuous hand suture technique may be equally effective as the double-layer technique regarding incidence of anastomotic leakage, length of hospital stay, overall postoperative complications, subjective short-term well-being and stool patterns. Lessons learned from this trial course are summarized. TRIAL REGISTRATION: This trial is registered (Trial registration: NCT00996554). Link: https://clinicaltrials.gov/ct2/show/NCT00996554 .

Sterilized mosquito net versus commercial mesh for hernia repair. an experimental study in goats in Mbarara/Uganda.

BACKGROUND: In industrialized countries alloplastic meshes are routinely used for hernia repair. However, in developing countries they are rarely available or affordable. This study compares textile properties and tissue response of commercial polypropylene mesh (PM) vs. sterilized nylon mosquito net (MN). METHODS: Textile properties were examined in vitro. In 12 goats one MN and one PM (5.5 x 8 cm) were implanted onto the posterior layer of the rectus sheath. Wound healing was clinically assessed. Histology was assessed after 4 or 16 weeks. RESULTS: MN was thinner and lighter, but weaker than PM. All wounds healed without complications. After 16 weeks foreign body granulomas in the MN group contained a higher proportion of inflammatory tissue (32.7 vs. 22.1%) and more giant cells (3.1 vs. 1.7/10 granulomas) with a significantly lower partial volume of foreign body (23.2 vs. 36.9%). Partial volume of fibrotic tissue was similar. MN was 1,000-fold cheaper than PM. CONCLUSIONS: PM was superior concerning strength and extent of inflammatory response. However, the findings indicate that MN might serve as a cheap substitute if an alloplastic mesh is needed but no commercial one is available or affordable. Further studies are justified which should include mosquito nets of different materials and long-term outcome.

Anaesthesia for elective inguinal hernia repair in rural Ghana - appeal for local anaesthesia in resource-poor countries.

Local anaesthesia has been identified as the most favourable anaesthesia for elective inguinal hernia repair with respect to complication rate, cost-effectiveness, and overall patient satisfaction. Operation theatre notes in all seven hospitals in the Northern Region in Ghana over the period of 1 year were reviewed. Only 22.4% out of 1038 repairs were performed under local anaesthesia while predominantly spinal and general anaesthesia were used (48.0 and 29.6%, respectively). African surgeons chose local anaesthesia far less frequently than visiting overseas surgeons (15.6 versus 27.7%, respectively). All surgeons in resource-poor countries should be encouraged to use local anaesthesia more frequently for elective inguinal hernia repair. Valuable resources in sub-Saharan African hospitals could be saved, especially if used in combination with outpatient surgery. The technique should be taught in teaching institutions. A simple step-by-step technique is described.

Morphological features of enlarged parathyroid glands in B-mode-ultrasound.

Successful preoperative localisation of parathyroid glands is essential for minimal-invasive surgery of hyperparathyroidism. The knowledge of the sonomorphology of the parathyroid glands, therefore, is an important prerequisite. This article shows that the sonomorphology of normal and pathologically transformed parathyroid glands is subject to a wide variety. The often simplified standard description of parathyroid glands as hypoechogenic and oval may lead to false negative cervical ultrasound examinations.

Local application of hyperthermia in the esophagus with a heatable malleable thermoplastic stent.

OBJECTIVE: This study measures the effect of hyperthermia applied through a heatable stent in the esophagus in order to investigate whether this procedure offers a therapeutic option for tumor treatment. MATERIAL AND METHODS: Thermoplastic malleable stents, with the capacity to be heated after implantation, were placed endoscopically in the middle third of the esophagi of 30 pigs. After placement the stents were heated in vivo for 60 min at temperatures ranging from 43 to 52 degrees C. Temperature was measured in the surrounding tissue at various distances from the stent, determining heat penetration. The esophagi were histologically examined after 7 days. RESULTS: The maximal heating temperature tolerated in the esophagi without transmural necrosis was 46.5 degrees C, when applied twice for 60 min with a pause of 48 h. With this procedure a tumor damaging temperature of 42.5 degrees C was achieved at a maximum distance of 12 mm surrounding the stent. CONCLUSION: Application of hyperthermia through a heatable stent in the esophagus is feasible. The maximal depth of therapeutic temperature achieved by this procedure (12 mm) is not sufficient to heal esophageal cancer, but may be of palliative value.

Endoscopic full-thickness resection of the stomach: an experimental approach.

BACKGROUND: Endoluminal endoscopic resections of the gastrointestinal (GI) tract have had increasing significance in recent years. Except for the extraperitoneal part of the rectum, endoscopic resections are restricted to the mucosal and submucosal layer to preserve the integrity of the GI tract wall. METHODS: The SurgAssist is the first flexible stapling device consisting of a 2,000-mm-long flexible shaft and a stapling magazine that can be positioned intraluminally and used with a remote control. To prove the principle, we investigated the endoluminal application of an endoscopically assisted and intraluminally visualized full-thickness resection of the gastric wall in a pilot study of three pigs and a series of three human exenterates. RESULTS: Full-thickness resection of the gastric wall in pigs can be performed with the SurgAssist flexible stapling device from an endoluminal access. However, due to the small lumen of the esophagus, the simultaneous transesophageal introduction of the stapler shaft and gastroscope is not possible in pigs. The same procedure in three human exenterates showed that the simultaneous introduction of the flexible stapler and a standard gastroscope could be achieved without damaging the esophageal wall. Full-thickness resections of up to 4 x 4 cm were carried out with the use of two or three stapler magazines. The resulting sutures were found to be airtight upon endoscopic inflation of the stomach. CONCLUSION: The clinical use of the SurgAssist intraluminal stapling device for endoscopic full-thickness resection of the gastric wall seems applicable for lesions in suitable locations of the stomach. Gastrointestinal stroma tumors and T1 tumors of the lower gastric corpus and antrum region are possible indications.

[Foreign body in the urinary bladder after vascular surgery]. / Ein Corpus alienum in der Harnblase nach gefässchirurgischem Eingriff.

INTRODUCTION: We are presenting a rare complication after femorofemoral bypass surgery. CASE REPORT: In a 61-year-old male patient, a femorofemoral crossover bypass graft was inadvertently placed through the urinary bladder. Postoperatively, the patient developed macrohematuria, which cleared spontaneously. The diagnosis of an intravesical graft was made 3 months after surgery by cystoscopy performed because of dysuria. The patient underwent open bladder surgery 7 months later as he refused earlier intervention. The misplaced graft, which was not infected and showed good function and perfusion, was extravesically relocated. At a 16-month follow-up examination, the patient is free of urological symptoms and the bypass functions well. CONCLUSIONS: In case of dysuria or macrohematuria after vascular surgery in the vicinity of the urinary bladder, a misplaced bypass should be excluded.

Acute respiratory failure after deep cervical plexus block for carotid endarterectomy as a result of bilateral recurrent laryngeal nerve paralysis.

We report about a case of acute respiratory distress (73-year-old female), which occurred minutes after a deep cervical plexus block (40 ml ropivacaine 0.5%) for carotid endarterectomy (CEA) and required immediate endotracheal intubation of the patient's trachea and consecutive mechanical ventilation. Subsequently, CEA was performed under general anaesthesia (TIVA) with continuous monitoring by somatosensory-evoked potentials. After a period of 14 hours, the endotracheal tube could be removed, the patient being in fair respiratory, cardiocirculatory and neurological conditions. Retrospectively, acute respiratory distress was caused by a combination of ipsilateral plexus blockade-induced and pre-existing asymptomatic contralateral recurrent laryngeal nerve (RLN) paralysis confirmed by a postoperative ENT-check and related to previous thyroid surgery more than 50 years ago. RLN paralysis, often being asymptomatic, represents a typical complication of thyroid and other neck surgery with reported incidences of 0.5-3%. Therefore, a thorough preoperative airway check is advisable in all patients scheduled for a cervical plexus block. Particularly in cases with a history of respiratory disorders or previous neck surgery a vocal cord examination is recommended, and the use of a superficial cervical plexus block may lower the risk of respiratory complications. This may prevent a possibly life-threatening coincidence of ipsilateral plexus blockade-induced and pre-existing asymptomatic contralateral RLN paralysis.

Biodegradation of absorbable sutures in body fluids and pH buffers.

OBJECTIVE: This study measures the influence of body fluids on the loss of tensile strength of absorbable sutures in vitro. METHODS: Nine synthetic absorbable sutures were incubated in different gastrointestinal fluids, as well as in blood and three buffers. Stretch tests were performed after days 0, 7, 14, and 21. RESULTS: Tensile strength varied from 18.5 to 32.8 N, and elasticity varied from 9.5 to 51% of the initial length. The influence of pH, blood, and gastric juice was negligible on all sutures except PDS II. Except for Monocryl, all sutures, especially Polysorb and Vicryl, lost tensile strength much faster in bile, jejunal and pancreatic juices than in the corresponding buffers. CONCLUSION: The biodegradation of sutures varies greatly in different body fluids independent of differences in pH.

Atraumatic intracutaneous skin closure with self-made fishing line suture compared to commercial thread.

OBJECTIVE: The aim of this study was to prove, whether the intracutaneous skin closure with self made fishing line suture is equivalent to commercial sutures. DESIGN: It was a randomised blinded animal study. SETTING: The study was performed in December 2002 at the Muhimbili University College of Health Sciences in Dar-es-salaam. SUBJECTS: Both German surgeons from Mannheim, and Tanzanian surgeons from Dar es salaam operated on nine one year old Tanzanian domestic sheep. INTERVENTIONS: 108 standardised cutaneous wounds on the backs of the animals were closed by intracutaneous sutures either with self produced fishing line suture or a commercial nylon suture (Ethilon). MAIN OUTCOME MEASURES: The clinical and histological outcomes, as well as the costs of this self-made fishing line suture, with a commercial nylon thread were evaluated and compared. RESULTS: There are no significant differences between the two sutures in histological or clinical findings, or in the reported ease of use by the surgeons. The cost of a self-produced atraumatic thread is US$ 0.12, less than one-twentieth of the cost of the commercial thread. CONCLUSION: Self-made fishing nylon suture has characteristics and properties in sheep skin wounds comparable to commercial nylon suture. The advantage of the commercial thread is the guaranteed quality assurance. It is discussed whether this quality assurance justifies the large price difference, and whether the self-produced thread should be recommended to surgeons in countries where the costs of surgical material often remains an obstacle for life saving operations.

Transanal endoscopic microsurgery: indications and results after 100 cases.

OBJECTIVE: Transanal endoscopic microsurgery (TEM), a minimally invasive technique has been employed in the excision of benign and well-selected malignant rectal tumours since June 1998. We present a prospective descriptive study and analyse the currently accepted indications. PATIENTS AND METHODS: Over a 4-year period 100 patients underwent TEM for treatment of rectal tumours located between 4 and 18 cm from the anal verge. RESULTS: TEM was performed in 71 cases for adenomas, 20 potentially curative excisions for pre-operative staged low-grade carcinoma, 3 palliative procedures for advance carcinoma, 5 carcinoids and 1 solitary ulcer. The local complication rate included wound breakdown in 7 patients, three of them requiring ileostomy. Conversion to laparotomy was performed in two patients. Five adenomas recurred and were successfully treated by TEM. Of the cancers, four patients required immediate salvage therapy by means of total mesorectal excision. Three patients underwent palliative TEM procedures combined with radiotherapy. A single cancer recurrence was treated by means of abdomino-perineal resection after radiotherapy. CONCLUSIONS: TEM appears to be an effective method of excising benign tumours and selected T1 carcinomas of the rectum. The superior exposure of tumours higher in the rectum combined with the greater precision of excision make this minimally invasive technique an attractive surgical approach.

[Twist-guided thread control: a technique for faster and atraumatic continuous sutures]. / Fortlaufende Nähte mit Fadendrill -- Eine Zeit sparende und schonende Operationstechnik.

A simple technique by twisting the thread in clockwise or counter clockwise direction before tightening the suture can help to produce a regular vascular suture line. In a blinded experiment with 60 vascular anastomosis it was proved that the time needed for suture can be reduced by 15%, and that traumatic touch with surgical instruments can be diminished by 63%.

Small volume resuscitation with 7.5% hypertonic saline solution--treatment of haemorrhagic shock in the tropics.

Rapid intravenous injection of 4 mL/kg body weight of a 7.5% hypertonic sodium chloride solution immediately increases intravascular osmotic pressure and intravascular volume after haemorrhage. This 'small volume resuscitation' rapidly improves blood pressure and microcirculatory perfusion in patients with hypovolaemic shock after large blood losses. Pathophysiological findings as well as practical application approaches are described. Small volume resuscitation is an effective and economic method in the first-line treatment of acute haemorrhagic shock.

Megestrol acetate to correct the nutritional status in an adolescent with growth hormone deficiency: Increase of appetite and body weight but only by increase of body water and fat mass followed by profound cortisol and testosterone depletion.

Megestrol acetate (MA) is a synthetic, orally active derivative of the naturally occurring hormone progesterone. MA is increasingly used to correct loss of appetite and improve the nutritional status. We used MA in an adolescent with growth hormone (GH) deficiency due to former irradiation therapy in order to evaluate if MA can improve the nutritional status. In fact, MA increased appetite and weight dose-dependent. The energy expenditure measured by indirect calorimetry changed from hypo- to normometabolism. However, weight gain was first primarily due to an increase in body water and then in fat mass. The gain of fat mass was much more prominent than the gain of fat free mass. As important side-effect, MA lead to rapid and profound cortisol and testosterone depletion after only 10 days with a long-lasting effect on testosterone depletion. Therefore, MA as a single therapy cannot be recommended to improve the nutritional status. If MA is given, cortisol and testosterone levels have to be monitored and supplemented as needed.

The improvised atraumatic suture: a cost-reducing technique, not only for the tropics?

A simple technique to produce your own atraumatic suture is described. All that is needed is a simple injection needle and any kind of thread.The thread is introduced into the cavity of the needle and fixed by squeezing its end after having broken the hub. This method is very easy to apply and extremely economical.

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.

[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.