Feasibility and effectiveness of laparoscopic transgastric stapler-assisted circumferential esophageal mucosectomy and simultaneous fundoplication in a pig model.

Laparoscopic transgastric stapler-assisted mucosectomy (SAM) has been described for minimally invasive circumferential en bloc resection of Barrett's esophagus (BE). Conceivably long-term disease control might be achieved by adding antireflux surgery after resection of BE by SAM. The aim of this study was to assess the feasibility of combined SAM and fundoplication in one laparoscopic procedure in six pigs. Furthermore, the competence of the gastroesophageal junction (GEJ) was assessed at baseline, after SAM, and after subsequent laparoscopic fundoplication. At each measuring point reflux measurements were repeated 6 times in each pig. Blue-colored water was infused into the stomach to provoke reflux. Intragastric yield pressure and volume were recorded until drainage of blue solution (DBS) was noted. Time to reflux was measured by DBS and by multichannel intraluminal impedance (MII). In all animals SAM followed by laparoscopic fundoplication was feasible in a single session. A weakening of the GEJ was found after SAM, indicated by decreased yield pressure (11.5 mmHg vs. 8.5 mmHg; P < 0.001), time to DBS (90 seconds vs. 60 seconds; P = 0.008) and MII (80 seconds vs. 33 seconds; P < 0.001). After additional Nissen fundoplication the GEJ competence was restored, with measurements returning to baseline values (time to DBS 99 seconds; P = 0.15; MII 76 seconds; P = 0.84). The yield pressure increased from 11.5 mmHg at baseline to 19.7 mmHg after SAM and fundoplication (P < 0.001). Laparoscopic fundoplication and SAM may be combined in a single laparoscopic session. Although the GEJ was weakened after SAM, Nissen fundoplication restored the GEJ as an effective reflux barrier in this experiment. For clinical validation, the results need to be confirmed in a prospective human trial.

Meta-analysis of hybrid natural-orifice transluminal endoscopic surgery versus laparoscopic surgery.

BACKGROUND: Hybrid natural-orifice transluminal endoscopic surgery (NOTES), combining access through a natural orifice with small-sized abdominal trocars, aims to reduce pain and enhance recovery. The objective of this systematic review and meta-analysis was to compare pain and morbidity in hybrid NOTES and standard laparoscopy. METHODS: A systematic literature search was performed to identify RCTs and non-RCTs comparing hybrid NOTES and standard laparoscopy. The main outcome was pain on postoperative day (POD) 1. Secondary outcomes were pain during the further postsurgical course, rescue analgesia, complications, and satisfaction with the cosmetic result. The results of meta-analysis in a random-effects model were presented as odds ratio (ORs) or standard mean differences (MDs) with 95 per cent confidence intervals. RESULTS: Six RCTs and 21 non-randomized trials including 2186 patients were identified. In hybrid NOTES the score on the numerical pain scale was lower on POD 1 (-0·75, 95 per cent c.i. -1·09 to -0·42; P = 0·001) and on POD 2-4 (-0·58, -0·91 to -0·26; P < 0·001) than that for standard laparoscopy. The need for rescue analgesia was reduced in hybrid NOTES (OR 0·36, 0·24 to 0·54; P < 0·001). The reduction in complications found for hybrid NOTES compared with standard laparoscopy (OR 0·52, 0·38 to 0·71; P < 0·001) was not significant when only RCTs were considered (OR 0·83, 0·43 to 1·60; P = 0·570). The score for cosmetic satisfaction was higher after NOTES (MD 1·14, 0·57 to 1·71; P < 0·001). CONCLUSION: Hybrid NOTES reduces postoperative pain and is associated with greater cosmetic satisfaction in selected patients.

[Laparoscopic versus open rectal cancer resection: oncologically equal?]. / Laparoskopische vs. offene Rektumresektion: onkologisch gleichwertig?

The oncological equivalence of laparoscopic and open rectal cancer resection was evaluated in four multicenter randomized controlled trials. The COLOR II and the COREAN trials demonstrated oncological equivalence; however, the ACOSOG and the ALaCaRT studies came to a different conclusion. In the latter two studies a composite endpoint that assessed the quality of the mesorectal specimen, the completeness of tumor-free circumferential and distal resection margins was chosen. In both trials a higher success rate for open surgery was shown; nevertheless, the validity of this composite endpoint has not been proven and no conclusions on solid oncological endpoints can be drawn. The COLOR II and the COREAN trial therefore remain the only available studies which investigated solid oncological endpoints, such as local recurrence and disease-free survival over an adequate follow-up time period of 3 years; however, the comparability of the study groups at least of the COLOR II trial needs to be called into question as only the experience of the laparoscopic surgeons was assessed. With a local recurrence rate of 5 % in both groups the oncological quality seems nevertheless to be good; therefore, a systematically inadequate control group should not be assumed. At this point it can be concluded that a good oncological outcome can be achieved with laparoscopic rectal resection in the hands of experts. For a final assessment the long-term results of the on-going trials needs to be awaited. If the promising results for laparoscopic surgery of the COLOR II trial are confirmed laparoscopic rectal resection should be preferred to open resection in the future. This conclusion is based on the generally known perioperative benefits of minimally invasive surgery.

Transvaginal access for NOTES: a cohort study of microbiological colonization and contamination.

BACKGROUND AND STUDY AIMS: Animal data and limited clinical evidence suggest a low incidence of infection following transvaginal natural orifice transluminal endoscopic surgery (NOTES). However, a systematic microbiological evaluation has not yet been carried out. The aim of this prospective cohort study was to evaluate the extent of microbiological contamination of the peritoneal cavity caused by the transvaginal access for NOTES and the impact of preoperative vaginal disinfection on vaginal colonization. PATIENTS AND METHODS: Consecutive female patients with symptomatic cholecystolithiasis were offered either transvaginal rigid-hybrid cholecystectomy (tvCCE) or conventional laparoscopic cholecystectomy. Patients who opted for tvCCE were prospectively evaluated between February and June 2010. Disinfection in patients undergoing tvCCE included hexetidine tablets and octenidine applied vaginally. All patients received a single dose of perioperative cefuroxime. Swabs were obtained from the posterior fornix and the peritoneal cavity at different intervals. RESULTS: Of 32 patients, 27 (84 %) opted to undergo tvCCE. One patient (4 %; 95 % confidence interval [CI] 0.7 % - 18.3 %) had a positive bacterial culture in the Douglas pouch prior to transvaginal access compared with two patients (7 %; 95 %CI 2.1 % - 23.4 %) following colpotomy closure (P = 1.000). Vaginal disinfection significantly decreased vaginal bacterial load (P = 0.001) and bacterial growth in routine cultures (P < 0.001); in 16 patients (59 %; 95 %CI 40.7 % - 75.5 %) vaginal swabs were sterile after disinfection. No postoperative surgical site infections occurred (95 %CI 0 % - 12.5 %). CONCLUSIONS: In selected patients and following vaginal antisepsis, transvaginal access for NOTES is associated with microbiological contamination of the peritoneal cavity in a minority of patients, indicating a low risk of peritoneal contamination caused by the transvaginal access.

Transvaginal rigid-hybrid NOTES cholecystectomy: evaluation in routine clinical practice.

BACKGROUND AND STUDY AIMS: Cholecystectomy using a rigid-hybrid transvaginal natural orifice transluminal endoscopic surgery (NOTES) approach (tvNCC) reduces abdominal wall incisions and might decrease surgical trauma by combining endoluminal access and laparoscopic techniques. We assessed the feasibility and safety of rigid-hybrid tvNCC in routine practice for symptomatic cholecystolithiasis or acute cholecystitis in a patient population with low selection. PATIENTS AND METHODS: From September 2008 to July 2009, all female patients with cholecystectomy indications were evaluated for tvNCC. Exclusion criteria were: refusal of tvNCC; inability to give informed consent; gynecological or urological contraindications; lack of preoperative gynecological examinations; need for cholangiography/choledochus revision; anesthesiological contraindications to pneumoperitoneum; liver failure; or coagulopathy. Age, obesity, previous surgery, or degree of gallbladder inflammation were not exclusion criteria. Preoperative and 2-weeks' postoperative gynecological examinations were performed. Sexual function was assessed preoperatively and at 6 weeks postoperatively. RESULTS: 102 of 137 consecutive patients (74.5 %) with symptomatic cholecystolithiasis (n = 74) or cholecystitis (n = 28) were scheduled for rigid-hybrid tvNCC with nine different surgeons. Patient mean age was 52.3 +/- 17.8 years (range 18 - 87) and mean body mass index 27.3 +/- 6.3 kg/m (2) (17.6 - 43.8). Two patients had conversion to conventional laparoscopic cholecystectomy. There were no intraoperative complications. Two major complications occurred: one stroke and one herniation within the transumbilical access. Minor complications were reported in 13 patients (12.7 %) and there were no serious postoperative gynecological findings. At 6 weeks postoperatively, there were fewer dyspareunia symptoms than preoperatively ( P = 0.049). CONCLUSIONS: Rigid-hybrid tvNCC is feasible and safe in routine practice for symptomatic cholecystolithiasis and acute cholecystitis.

Prospective study examining the impact of multichannel intraluminal impedance on antireflux surgery.

BACKGROUND: Reflux monitoring using combined multichannel intraluminal impedance (MII) and pH-metry increases the sensitivity for identifying gastroesophageal reflux episodes. The likelihood of a positive symptom index (SI) for patients with reflux disease (gastroesophageal reflux disease [GERD] or nonerosive reflux disease [NERD]) receiving proton pump inhibitor (PPI) treatment has been used to select candidates for antireflux surgery. Little is known about the advantages of MII-pH monitoring compared with pH monitoring alone for evaluating GERD/NERD patients off PPI treatment considered as candidates for antireflux surgery or for assessing changes in MII-pH-detected reflux episodes after antireflux surgery. This study aimed to determine the additional value of MII over pH-metry alone for patients off PPI treatment before and after antireflux surgery. METHODS: For this study 12 patients (4 women and 8 men; mean age, 45 years; range, 27-74 years) were evaluated using ambulatory MII-pH monitoring before and 3 months after mesh-augmented hiatoplasty. Reflux events were identified by MII-pH (A) and pH-metry (B) as patients recorded symptoms on a data logger. For each symptom, a symptom index was calculated for reflux events identified by MII-pH and by pH-monitoring alone. RESULTS: Preoperatively, MII-pH monitoring identified 71.9 +/- 8.4 reflux episodes, whereas pH monitoring identified only 51.0 +/- 7.8 (p < 0.05). Postoperatively, MII-pH monitoring identified 35.5 +/- 6.6 reflux episodes, whereas pH monitoring identified only 19.6 +/- 4.7 (p < 0.05). The pre- and postoperative symptom index for MII-pH monitoring was higher than pH monitoring (preoperative 91.7% vs 25%, p = 0.006; postoperative 50% vs 16.7%, p = 0.012). CONCLUSION: Combined MII-pH-metry improves the pre- and postoperative assessment of GERD patients off PPI and results in a higher symptom-reflux association.

Adhesion of fluid vesicles at chemically structured substrates.

The adhesion of fluid vesicles at chemically structured substrates is studied theoretically via Monte Carlo simulations. The substrate surface is planar and repels the vesicle membrane apart from a single surface domain gamma , which strongly attracts this membrane. If the vesicle is larger than the attractive gamma domain, the spreading of the vesicle onto the substrate is restricted by the size of this surface domain. Once the contact line of the adhering vesicle has reached the boundaries of the gamma domain, further deflation of the vesicle leads to a regime of low membrane tension with pronounced shape fluctuations, which are now governed by the bending rigidity. For a circular gamma domain and a small bending rigidity, the membrane oscillates strongly around an average spherical cap shape. If such a vesicle is deflated, the contact area increases or decreases with increasing osmotic pressure, depending on the relative size of the vesicle and the circular gamma domain. The lateral localization of the vesicle's center of mass by such a domain is optimal for a certain domain radius, which is found to be rather independent of adhesion strength and bending rigidity. For vesicles adhering to stripe-shaped surface domains, the width of the contact area perpendicular to the stripe varies nonmonotonically with the adhesion strength.

99mTcO(BAT-NI), a novel nitroimidazole tracer: in vivo uptake studies in ischaemic myocardium.

Myocardial perfusion single-photon emission tomography (SPET) performed with cationic technetium-99m complexes indicates ischaemic areas as cold lesions. By contrast, nitroimidazole derivatives labelled with fluorine-18 or (99m)Tc have recently shown promising results for hot spot imaging of ischaemic myocardium. This study evaluates (99m)TcO(BAT-NI), a new (99m)Tc complex comprising the nitroimidazole ligand, 2,10-dimercapto-2,10-dimethyl-4,8-diaza-6-[4-(2-nitroimidazolyl)butyl]undecane, in a low-flow in vivo model of myocardial ischaemia in thoracotomised rats. To elucidate the influence of the 2-nitroimidazole group on ischaemia-induced uptake, comparisons with ligand derivatives were performed where (a) the 2-nitro group was deleted [(99m)TcO(BAT-I)], (b) the 2-nitroimidazole functionality was replaced by a Br atom [(99m)TcO(BAT-Br)] and (c) the (99m)TcO(BAT) moiety was replaced by an iodine-125 iodophenoxybutyl ligand ((125)IP-NI). The radiolabelled compounds were i.v. injected 15 min after reducing resting myocardial blood flow by 50-60% and the uptake of radioactivity was assessed 90 min post injection. Autoradiography of left ventricular short-axis slices showed median uptake ratios of ischaemic/non-ischaemic myocardium (I/N) of 3.4, 4.5 and 3.4 for (99m)TcO(BAT-NI), (99m)TcO(BAT-I) and (99m)TcO(BAT-Br), respectively. In contrast, (125)IP-NI was not preferentially taken up by ischaemic myocardium. Accumulation of (99m)TcO(BAT-NI) in ischaemic heart regions was comparable to that in the liver. Biodistribution studies showed a median uptake of 0.65% ID/g of (99m)TcO(BAT-NI) in ischaemic tissue and an I/N of 3.3. On planar images of the thorax and upper abdomen the ischaemic hearts were visualised faintly; the median heart to lung count ratio for (99m)TcO(BAT-NI) was 1.7, and the median heart to liver count ratio was 1.0. We conclude that uptake of (99m)TcO(BAT-NI) in ischaemic myocardium does not depend on the nitroimidazole moiety but is intrinsic to the BAT complex. Clinical use of the (99m)TcO(BAT)-labelled tracers seems unlikely owing to their low uptake and their low ischaemic tissue contrast on planar images in vivo.

Cryptosporidium parvum-specific antibody responses among children residing in Milwaukee during the 1993 waterborne outbreak.

A major gastroenteritis outbreak among >400,000 residents of Milwaukee, Wisconsin, in April 1993 was attributed to Cryptosporidium parvum oocysts in drinking water. Plasma specimens obtained from children (6 months to 12 years old) for routine blood lead level surveillance March-May 1993 were assayed by ELISA for levels of IgG antibody against the immunodominant Triton-17 and 27-kDa C. parvum antigens. Over a 5-week period, the seroprevalence for antibodies to the 2 antigens increased from 15% to 82% and from 17% to 87%, respectively, in samples from children living in southern ZIP code areas (n=218), whereas smaller increases (20% to 43% and 22% to 46%, respectively) were noted among samples from children living in northern ZIP code areas (n=335; P<.0001). The results demonstrate that C. parvum infection was much more widespread than previously appreciated and confirm that infection was associated with residence in the area served by the southern water treatment plant.

Screening for pediatric lead poisoning. Comparability of simultaneously drawn capillary and venous blood samples.

OBJECTIVE: To determine the ability of capillary blood lead levels to accurately reflect true blood lead levels in children at risk for lead poisoning. DESIGN: A correlation study in which lead levels of capillary blood specimens obtained by four different methods were compared with lead levels of simultaneously drawn venous blood specimens. SETTING: A central-city pediatric primary care clinic and door-to-door home visits in one central-city neighborhood. PATIENTS: Two hundred ninety-five children at high risk for lead poisoning aged 6 months to 6 years. MAIN OUTCOME MEASURES: Blood lead levels of simultaneously drawn capillary and venous blood specimens. RESULTS: Lead levels of all four capillary sampling methods were highly correlated (correlation coefficient > or = 0.96) with matched venous blood lead levels, with mean capillary-venous differences less than 0.05 mumol/L (1 microgram/dL). CONCLUSIONS: Capillary sampling is an acceptable alternative to venipuncture for lead-poisoning screening in young children.

[Program system for quantitative evaluation of computed tomograms using a digital masking technic for isolation of organs of interest and organ regions from the value matrix]. / Ein Programmsystem zur quantitativen Auswertung von Computertomogrammen unter Anwendung einer digitalen Maskentechnik zur Isolierung interessierender Organe und Organbereiche aus der CT-Wertematrix.

A program system for the quantitative analysis of CT images is described and its versatile applicability is demonstrated by practical examples. Using a semi-automatic digital masking technique, the system allows to isolate single organs or regions of organs with good reproducibility and to process their CT values separately. For processing of the complete image matrix or of isolated areas of the matrix, evaluation programs have been developed, which--in addition to the standard image evaluation functions available in modern CT systems--provide the possibility for various CT value transformations and special statistical analyses of original and transformed CT values. The demonstrated applications of the program system include determination of the venous capacity of the lower extremities by CT, separation of different components of the brain from a cranial CT, ventilation analyses of the respiratory lung parenchyma, calculation of the fat content in a fatty liver and approximate measurement of the iodine concentration in a contrast-enhanced kidney.

[Objective procedure for determining the contrast-detail-diagram in computed tomography]. / Objektives Verfahren zur Bestimmung des Kontrast-Detail-Diagramms in der Computertomographie.

Complete information on the power of resolution of a computer tomograph is supplied by the contrast detail diagram. The authors present the development of an objective determination method. Evaluation of the images of a wire and water phantom is performed via the computer of the CT equipment. This method yields objective and reproducible results.

[Bolus geometry and dynamics after intravenous injections of contrast media Studies using chronography]. / Bolusgeometrie und -dynamik nach intravenöser Kontrastmittelinjektion. Studien mit Hilfe der Chronographie.

Studies of contrast bolus geometry and dynamics were carried out by means of a chronogram - a digital serial radiographic method. Four situations were considered - contrast volume, speed of injections, subsequent saline injections and rapidly repeated contrast boli. Peak values, maximum duration and half-life of the bolus and maximum contrast enhancement were recorded. The results have shown that a larger volume of contrast with reduced injection speed leads to a lengthening of the peak period. More rapid injection speed up to 8 ml/sec leads to a higher peak and increased contrast enhancement. Further increases of injection speed beyond 8 ml/sec does not further increase contrast enhancement. The subsequent injection of saline has no recognisable effect on bolus geometry or dynamics.

[The value of the rapid pentagastrin test]. / Untersuchungen zur Aussagefähigkeit des Pentagastrinschnelltestes.

The evidence of the pentagastrin rapid test inaugurated by Johnston and Jepson in contrast to the usual analysis of the gastric secretion (DAB 7 GDR) was controlled on altogether 256 patients. Of them 121 patients were examined according to the well-known method and 135 patients with the shortened pentagastrin test. The same efficiency could be verified for the pentagastrin rapid test. The stimulated acid secretion may be sufficiently exactly established with the help of this test for the daily practice and may be recommended for the use in the outpatient practice. The limits of the normal values established up to the existence of a sufficiently large number of test persons, a norm region of 3-25 mmol/h should be taken as a basis.

[Modified CT imaging by reduction factor transformations (author's transl)]. / Modifizierte CT-Bildwiedergabe durch Schwächungswertetransformationen.

The possibilities of CT image modification which had existed so far for given matrix of attenuation values (window setting, highlighting, black-and-white or colour reversal and logarithmic distortion of the video signal) are supplemented by the method of attenuation value transformation. As a specific case a linear interval by interval attenuation value transformation is described. First of all, the intirety of the measured CT values is transformed into the corresponding CT quotients (CTQ) and then subdivided into 5 optional intervals. Each one freely selected CTQ value can be allocated to the first and to the last interval; the intermediate 3 intervals can be linearly transformed at random. The article discusses the influence of such a manipulation on CT image reproduction; this is of particular importance for the image visualisation of the results of quantitative organ analyses by means of computed tomography. The presented paper also points to the possibility of effecting further attenuation transformations.

[Consistometric study of meat and meat products. 6. Comparative determination of raw sausage consistency during curing]. / Konsistometrische Untersuchungen an Fleisch und Fleischprodukten. 6. Mitteilung: Vergleichende Bestimmungen der Konsistenz von Rohwürsten während des Reifungsverlaufes.

Comparative consistometric tests, using two different measuring methods, were applied to raw sausages in a random sampling process over a somewhat extended period of time. A close relationship (r= -0.819) was found to exist between the data obtained from a modified Höppler consistometer, on the one hand, and those measured by means of a penetrometer, on the other. The penetrometer proved to be suitable for measurement under practice conditions, while more specific strength parameters (S/2, tan alpha) were successfully measured by means of the modified Häppler consistometer.