Decellularised tissues obtained by a CO2-philic detergent and supercritical CO2.

Tissue decellularisation has gained much attention in regenerative medicine as an alternative to synthetic materials. In decellularised tissues, biological cues can be maintained and provide cellular environments still unmet by synthetic materials. Supercritical CO2 (scCO2 ) has recently emerged as a promising alternative decellularisation technique to aggressive detergents; in addition, scCO2 provides innate sterilisation. However, to date, decellularisation with scCO2 is limited to only a few tissue types with low cellular density. In the current study, a scCO2 technique to decellularise high density tissues, including articular cartilage, tendon and skin, was developed. Results showed that most of the cellular material was removed, while the sample structure and biocompatibility was preserved. The DNA content was reduced in cartilage, tendon and skin as compared to the native tissue. The treatment did not affect the initial tendon elastic modulus [reduced from 126.35 ± 9.79 MPa to 113.48 ± 8.48 MPa (p 〉 0.05)], while it reduced the cartilage one [from 12.06 ± 2.14 MPa to 1.17 ± 0.34 MPa (p 〈 0.0001)]. Interestingly, cell adhesion molecules such as fibronectin and laminin were still present in the tissues after decellularisation. Bovine chondrocytes were metabolically active and adhered to the surface of all decellularised tissues after 1 week of cell culture. The developed method has the potential to become a cost-effective, one-step procedure for the decellularisation of dense tissues.

The structure, thermal properties and phase transformations of the cubic polymorph of magnesium tetrahydroborate.

The structure of the cubic polymorph of magnesium tetrahydroborate (γ-Mg(BH(4))(2)) has been determined in space group Ia3d from a structural database of the isoelectronic compound SiO(2); this has been corroborated by DFT calculations. The structure is found to concur with that recently determined by Filinchuk et al. (Y. Filinchuk, B. Richter, T. R. Jensen, V. Dmitriev, D. Chernyshov and H. Hagemann, Angew. Chem. Int. Ed., 2011, DOI: 10.1002/anie.201100675). The phase transformations and subsequent decomposition of γ-Mg(BH(4))(2) on heating have been ascertained from variable-temperature synchrotron X-ray diffraction data combined with thermogravimetric and mass spectrometry measurements. At ~160 °C, conversion to a disordered variant of the ß-Mg(BH(4))(2) phase (denoted as ß') is observed along with a further unidentified polymorph. There is evidence of amorphous phases during decomposition but there is no direct crystallographic indication of the existence of Mg(B(12)H(12)) or other intermediate Mg-B-H compounds. MgH(2) and finally Mg are observed in the X-ray diffraction data after decomposition.

Adjuvant perioperative portal vein or peripheral intravenous chemotherapy for potentially curative colorectal cancer: long-term results of a randomized controlled trial.

BACKGROUND AND AIMS: The perioperative use of a single course adjuvant portal vein infusion chemotherapy in patients with potentially curable colorectal cancer has been shown to significantly improve overall survival but did not reduce the occurrence of liver metastases (SAKK 40/81) [Swiss Group for Clinical Cancer Research (SAKK) Lancet 345(8946):349-353, 1995]. The objective of the present prospective, three-arm randomized multicenter trial was to assess whether peripheral venous administration of adjuvant chemotherapy regimen based on 5-fluorouracil (5-FU) and mitomycin C decreases the occurrence of liver metastases as well as prolongs disease-free and overall survival. MATERIALS AND METHODS: Stages I-III colorectal cancer patients (n = 753) were randomized to receive either surgery alone (control arm), surgery plus postoperative portal venous infusion of 5-FU 500 mg/m(2) plus heparin given for 24 hours for seven consecutive days plus mitomycin C 10 mg/m(2) given on the first day (arm 2), or surgery and the same chemotherapy regimen administered by peripheral venous route (arm 3). RESULTS: The 5-year disease-free survival for the three treatment groups were 65% (control group), 60% (portal vein infusion, hazard ratio 1.18, p = 0.23), and 64% (intravenous infusion, hazard ratio 1.04, p = 0.76); the 5-year overall survival was 72% (control group), 69% (portal vein infusion, hazard ratio 1.21, p = 0.2), and 74% (intravenous infusion, hazard ratio 1.03, p = 0.86), respectively. A significant accumulation of early deaths were observed in the portal vein infusion group (p = 0.015). CONCLUSIONS: The present prospective randomized multicenter trial provides compelling evidence that short-term perioperative chemotherapy does not improve disease-free and overall survival in patients with potentially curative colorectal cancer. In contrary, the chemotherapy regimen administered in the present investigation seems to have potentially harmful effects, a finding which should be carefully considered in the planning of future trials. Postoperative short-term administration of 5-FU plus mitomycin C either through portal infusion or a central venous catheter is not recommended for routine use in patients with potentially curable colorectal cancer.

Infrainguinal arterial reconstruction with autologous vein grafts: are the results for the in situ technique better than those of non-reversed bypass? A long-term follow-up study.

BACKGROUND: The aim of this study was to answer the question if the in situ technique in infrainguinal arterial reconstruction is better than the non reversed one in long-term follow-up. METHODS: Patients were included in a prospective study at operation. 387 infrainguinal arterial reconstructions in 367 patients performed from 10-88 to 12-98 were retrospectively analysed. RESULTS: 280 non-reversed and 107 in situ bypass procedures were performed. Primary patency rates at 60 months were 63.3% for non-reversed and 57.9% for in situ grafts (p=n.s.). Primary assisted patency rates were 81.8% and 84.5% respectively (p=n.s.). Limb salvage rate was not different in either group. The 30-day mortality was 1.9% in the in situ group and 0.7% in the non-reversed group (p=n.s.). CONCLUSIONS: There is no difference in outcome between in situ and non-reversed vein grafting. Absence of statistical difference between the two procedures may be mainly due to the routine use of angioscopic quality control.

[Surgical dogmas throughout history]. / Chirurgische Dogmen im Wandel der Zeit.

This article is a historical analysis of the role of dogmas and dogmatic thinking in surgery from the great pioneers and teachers of surgery of a hundred years ago to the present time. Medical knowledge applied schematically creates security and may benefit many patients, but when simplification and standardization degenerates into rigid dogma, creative thinking will be obstructed and the development of innovative concepts becomes difficult. In the old times of the 19th and early years of the 20th century, dogmas usually originated from the teaching of great and prestigious pioneers of surgery. Nowadays, dogmatic thinking may come as practice guidelines, protocols of consensus conferences and even from the interpretation of the results of prospective randomized studies. The author illustrates these thoughts by a number of examples taken from the history of surgery over the last one hundred years: The controversy between Sauerbruch's (under)pressurized chamber and the concept of intratracheal positive pressure ventilation and its influence on the development of thoracic surgery during the first half of the 20th century, the role of serendipity and undogmatic thinking in the development of damage control surgery towards the end of the 20th century, the fascinating history of two operations which kept their position as gold standard for almost a century, i.e. Halsted's radical mastectomy for breast cancer and the Miles operation for cancer of the rectum.

[Rupture of a sinus of Valsalva aneurysm in the left atrium]. / Rupture d'un anévrisme des sinus de Valsalva dans l'oreillette gauche.

Ruptures of sinus of Valsalva aneurysms are a rare complication, and very few cases of rupture in the left atrium have been described. In this clinical case we report the case of a patient hospitalised with a scenario of cardiac insufficiency revealing a very large posterior sinus of Valsalva aneurysm, associated with a bicuspid aortic valve, and rupture in the left atrium. The diagnosis was by transthoracic and transoesophageal multiplan echocardiography, and the treatment surgical, with a good result.

[Quality control in patient education. Results of a patient survey about the patient education protocol of the Swiss Society of Surgery in 6 Swiss hospitals]. / Qualitätskontrolle der Patientenaufklärung. Resultate der Patientenbefragung über das Aufklärungsprotokoll der Schweizerischen Gesellschaft für Chirurgie (SGC) in sechs Schweizer Spitälern.

In the past years the number of malpractice suits due to lack of patient information has increased. Because there have been no generally accepted guidelines for preoperative patient information, the Swiss Society of Surgery has decided to work out an informative brochure tailored to the needs of patients. It takes into account that the need to know beforehand is increasing rapidly. In collaboration with the judiciary service of the Swiss Medical Federation all the items and points of legal relevance have been compiled to establish an informative brochure. Based on this protocol, patients in surgical departments of 6 Swiss community hospitals were asked before discharge to qualify the preoperative information offered to them. 2660 questionnaires were evaluated. The majority of patients considered the information regarding their diagnosis, the complications, risks, treatment and postoperative care, the sketches describing the operation and the overall degree of information as good or very good. Almost 60% of all patients stated that no alternative treatment had been discussed with them other than the planned procedure. In most of these patients operative procedures were chosen and carried out for which there were few or no other acceptable options. 2/3 of the patients asked for immediate preoperative written information, especially if they had malignant disease. Barely 4% of the patients were not reassured by the information provided to them. The fact that 2/3 of all patients re-read the informative protocol before the operation underlines how important it is to hand out a copy of the protocol to satisfy the informative needs of the patients. To our surprise the vast majority of patients uttered little concern about giving their signature to forms that were presented to them. Only 2% of the patients felt that giving a signature would cause them grave reservations. The informative protocol devised by the Swiss Society of Surgery is well adapted to the informative needs of the patients and allows for a structured conversation. It facilitates documentation and offers valid legal proof for the physician that he/she has provided adequate information.

Coverage of enterococci in community acquired secondary peritonitis: results of a randomized trial.

INTRODUCTION: The increasing number of enterococcal infections in hospitals and reports about the development of resistance of these bacteria make it necessary to review their importance as co-pathogens in secondary peritonitis. MATERIALS AND METHODS: A prospective randomized controlled trial on primary therapy of secondary peritonitis was carried out in six centers comparing cephalosporin-based antibiotic therapy to acylaminopenicillin-based therapy. RESULTS: Enterococci were only cultured in 6 of 110 cases from the abdomen and were found in only 5 cases of postoperative complications. No differences were found between penicillin-based vs. cephalosporin-based therapy. CONCLUSION: The study supports the view that these bacteria continue to play a minor role in secondary peritonitis. The point has to be emphasized, however, that the patients under study were in relatively good condition (APACHE II median 9 for cephalosporins and 10 for penicillins) and that postoperative cases of peritonitis were excluded.

Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair: a multicenter study of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC).

BACKGROUND: This article reports the results of a multicenter prospective audit of totally extraperitoneal (TEP) inguinal hernia repair conducted by the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC) from May 1995 to August 1996. METHODS: At 29 Swiss centers 1,605 inguinal hernia repairs were performed in 1,186 patients. Half of the repairs were performed by operators whose experience consisted of fewer than 51 procedures. Patients were followed up for 1 year. RESULTS: Bilateral repairs were performed in 35% of the patients, and 15% of all repairs were for recurrent hernia. Conversion rates to the transabdominal preperitoneal (TAPP) technique and open surgery were 1.8% and 1.6%, respectively. Main postoperative complications were hematoma and urinary retention. At 3 months, seroma was more frequent with slit prosthesis. The recurrence rate was 0.6% at 3 months and 1.6% at 1 year, not depending on the type of implant. The rate for recurrent hernias did not differ from that for primary repairs. CONCLUSIONS: Total extraperitoneal (TEP) repair can be performed with low morbidity and a high level of patient satisfaction. The effects of the learning curve are not to be neglected. The 1-year recurrence rate is 1.6%. Published data on TEP suggest that late recurrences may be less frequent than after open repair.

Prognostic value of beta1,6-branched oligosaccharides in human colorectal carcinoma.

Increase of beta1,6-branched oligosaccharides is possibly associated with tumor progression and lymph node metastasis. The aim of this study was to determine the prognostic value of beta1,6 branches in human colorectal carcinoma. Expression of beta1,6 branches was histochemically evaluated using the leukoagglutinating Phaseolus vulgaris lectin, PHA-L, in 92 clinically documented colorectal carcinomas, of which 31 had formed lymph node metastases. The follow-up time ranged between 4 and 14 years (median, 10.3 years). A PHA-L staining index (SI), taking into account staining intensity and its percentage of tumor cut surface area, was established. The carcinoma SI was highly associated with the disease-free survival (P = 0.004) and overall survival (P = 0.005). Patients with a carcinoma SI of >1, as compared to those with a SI of < or =1, were at significantly higher risk for tumor recurrence, with a shorter disease-free survival (hazard ratio = 2.59, P = 0.005) and significant higher risk of death with shorter overall survival (hazard ratio = 2.51, P = 0.007). The carcinoma SI was also associated with the presence of lymph node metastases. We conclude that PHA-L staining in human colorectal carcinoma sections provides an independent prognostic indicator for tumor recurrence and patient survival and is associated with the presence of lymph node metastases.

Total mesorectal excision for cancer of the rectum.

The concept of total mesorectal excision (TME) was first described by R. J. Heald in 1982 as a radical cancer operation based on the anatomy of fascial planes and fibrous spaces of the pelvis. The ampulla recti is invested by a fascia propria which is a part of the visceral pelvic fascia. The fascia propria is separated from the parietal pelvic fascia by the pelvirectal fibrous space, which is a compartment of the subperitoneal space of the pelvis. The lateral ligaments of the rectum divides the pelvirectal space into a prerectal and a retrorectal part. TME is defined as the resection of the rectum with its surrounding fatty and lymphatic tissue contained within the visceral sheet of the pelvic fascia. The dissection proceeds in the nearly avascular cleavage plane between the visceral and the parietal fascial sheets, allowing maximal protection of the hypogastric nerves and the inferior hypogastric plexus. Continuity of the prerectal and retrorectal parts of the field of dissection is established by dividing the lateral ligaments of the rectum slightly inside the point where they swing away from the parietal fascia of the pelvic side wall. By following this plane of dissection it is possible to achieve en bloc excision of the total mass of perirectal lymphatic and fatty tissue down to the pelvic floor.

[Toxic megacolon: surgical timing important!]. / Toxisches Megakolon: Operationszeitpunkt nicht verpassen!

Toxic megacolon is defined as a fulminant attack of colitis with total or segmental dilatation of the colon. Toxic megacolon is mostly a complication of nonspecific ulcerative colitis or Crohn's colitis but it may also occur in pseudomembranous colitis and other forms of infectious colitis. Toxic dilatation of the colon is a sign of transmural acute inflammation in which perforation of the colon is impending or may already have occurred. Free perforation means a fourfold increase in the mortality of a fulminant attack of colitis. Dilatation of the colon is not by itself an indication for immediate operation. The dilatation may increase, fluctuate or even disappear, leaving the patient still severely ill with toxic colitis requiring immediate surgery. The indication and optimal timing of surgical intervention require optimal interdisciplinary collaboration between surgeons and gastroenterologists. The procedure of choice for surgical treatment of toxic megacolon is colectomy and ileostomy. The mortality and morbidity of urgent surgery have been decreased by avoiding rectal excision. The rectal stump is either closed as a pelvic Hartmann's pouch or the sigmoid remnant is exteriorized as a mucous fistula or closed subcutaneously. Progress in intensive therapy and perioperative patient management has relegated simple decompression by diverting loop ileostomy and skin-level colostomy as advocated by Turnbull et al nearly 30 years ago to the role of an obsolete procedure which seems hardly ever preferable to resection of the diseased bowel.

Septic complications after biliary tract stone surgery: a review and report of the European prospective study.

We report a prospective, controlled study of the incidence of septic complications following biliary tract stone surgery. This study included a total of 280 patients operated on in eight hospitals in various European countries. In this study the computer program "Surgery" was used. Of 280 patients, 77 (27.5%) were male and 203 (72.5%) were female. The age ranged from 20 to 92 years (mean 54.8 years); 78.9% of the cases corresponded to clean-contaminated surgery; 85% of the patients received antibiotic prophylaxis with cefazolin. Twenty-one patients developed postoperative septic complications (7.5%) of which 12 (4.3%) were wound infections; five patients (1.8%) had intra-abdominal infections. The wound infection rate was 3.2% in clean-contaminated surgery, 7.7% in contaminated and 20% in dirty (p < 0.02). In laparoscopic cholecystectomy the global rate of septic complications was 3.6% vs. 12.6% in open cholecystectomy (p < 0.01); 2.4% and 6.3% wound infection respectively. The mean age of patients who developed postoperative septic complications was 61.5 years and 54.2 years old who did not develop any complications (p < 0.03). The duration of the postoperative period was 5 days in patients without infection and 13 days in patients with infection (p < 0.0001). Two patients died, one of them (0.4%) caused by sepsis. In addition to the European prospective study, a review of the problems of sepsis in biliary surgery was carried out.

[The value of diagnostic peritoneal lavage in emergency situations]. / Der Stellenwert der diagnostischen Peritoneallavage in der Notfallsituation.

PURPOSE: The literature on diagnostic peritoneal lavage in the assessment of blunt abdominal trauma reflects an ongoing controversy. Therefore we conducted a prospective evaluation of the diagnostic management of blunt abdominal trauma used at our clinic, in which this procedure plays a substantial role. During the years 1993 and 1994 a total of 75 patients could be included in the study. The study population consisted of all patients with a diagnosis of blunt abdominal trauma. In addition, all trauma patients who were unresponsive on admission to the emergency receiving unit underwent the same program of diagnostic work-up. This group included polytraumatized patients, patients with craniocerebral injuries and all those who had been intubated prior to admission. Patients with stable vital signs were evaluated first by sonography of the abdomen, whereas those showing signs of hypovolemic shock received a diagnostic peritoneal lavage as the first evaluation of abdominal trauma. In order to assess the relative value of the two diagnostic methods, all patients who had had ultrasound as their first examination subsequently also underwent peritoneal lavage. RESULTS: 37 patients (49%) had lavage evidence of intraperitoneal bleeding. Of these 22 (29% of the total) subsequently underwent emergency laparotomy with lesions requiring surgical treatment found in 21 (95%). Only in one patient (1.3% of the study population) laparotomy failed to reveal a lesion requiring surgical correction. The accuracy of peritoneal lavage findings as an indication for laparotomy was 99%, compared to 82% for ultrasonography used as a initial diagnostic procedure. Diagnostic peritoneal lavage is quick, safe and almost independent of the experience of the investigating physician. It can be performed during other diagnostic procedures and can be repeated at will. If beyond macroscopical evaluation the lavage fluid is assessed chemically, even duodenal and pancreatic lesions as well as injuries to other hollow viscera can be suspected. With a sensitivity of 100% and a specificity of 98%, diagnostic peritoneal lavage is an extremely reliable diagnostic tool. It should be used as the initial diagnostic procedure in all hypovolemic and/or unresponsive patients suspected of having suffered blunt abdominal trauma. In conscious patients with stable vital signs, ultrasonography can be used for initial diagnosis. It should, however, be complemented by subsequent peritoneal lavage whenever the clinical course gives rise to suspicion.

[Necrotizing fasciitis cause by beta-hemolytic streptococci with fatal outcome--a case report]. / Nekrotisierende Fasziitis durch B-hämolysierende Streptokokken mit letalem Ausgang--Ein Fallbericht.

The authors report two cases of necrotizing fascilitis (NF) occurring after surgical interventions on the breast (reduction mammoplasty in one patient and mastectomy for breast cancer in the other). In both cases the etiologic agent were group A pyogenic streptococci and both patients died. NF caused by hemolytic streptococci is a highly lethal disease (over 70% in literature). It starts typically with a purple lesion of the skin, followed by necrotizing fascial infection with secondary necrosis of the overlying skin and rapid progression to septic shock and multiorgan failure. This development is characteristic for NF and allows, together with microbiological results, to distinguish NF from other necrotizing soft tissue infections. Early recognition and aggressive surgical debridement are the mainstays of successful management. Antibiotics and intensive care therapy are indispensable. Hyperbaric oxygen or other supportive therapies do not lower death rate.

[Large Brunner's adenoma of the duodenal bulb--a case report]. / Grosses Brunner'sches Adenom im Bulbus duodeni--Ein Fallbericht.

Benign proliferative changes of the Brunner's glands account for about 10% of neoplasias of the duodenal bulb. Since the first description by Cruveilhier in 1835 about 120 cases have been reported in the English literature. The authors present a case of adenoma of Brunner's gland of unusual dimensions (10 x 5.5 x 2.8 cm). Clinical presentation was by melena, anemia and vague epigastric discomfort. Treatment was by laparotomy with duodenotomy and surgical polypectomy. Proliferative changes of Brunner's glands may manifest as diffuse or localized nodular hyperplasia and Brunner's adenoma. They are localized in the submucosa and small superficial endoscopic biopsies may fail to confirm the diagnosis. Malignancy seems to occur only very rarely with only 14 cases reported in the literature. As the majority of Brunner's adenomas are quite small, endoscopic polypectomy will confirm the diagnosis and cure the condition in most instances. Large symptomatic adenomas may require surgical resection.

[Intraoperative cholangiography in laparoscopic cholecystectomy: a simple, cost-effective techniques]. / Die intraoperative Cholangiographie bei der laparoskopischen Cholezystektomie: eine einfache, kostengünstige Technik.

Description of an easy technique to perform an intraoperative cholangiography (IOC) during laparoscopic cholecystectomy at low cost. After puncture of the abdomen in the right hypochondrium with a commercial vein cannula used as a "mini-trocar", this cannula is mounted by an ureteral catheter (UC). By means of the inlying metal-mandrin the UC can be performed in a slightly curved fashion, which permits an easy cannulation of the Ductus cysticus. Furthermore the mandrin prevents an obstruction of the lumen by the metal clip used to fix the UC in the D.cysticus. After withdrawal of the mandrin the IOC can be performed by use of a commercial syringe fitting to the light-blue plastic adapter delivered with the UC. The method is safe, quick and easy and with a price of less than Swiss francs 10.- per IOC it is unrivalled regarding the costs.

Anatomical basis and rationale of total mesorectal excision.

The concept of TME for cancer of the mid rectum has been introduced by Heald in 1982. Since then the evidence in favor of routinely applying TME in all operable cases of mid and low rectal cancer has kept growing. TME has been shown to reduce the number of R1 resections and increase the number of R0 resections, resulting in a significantly reduced recurrence rate compared to traditional surgical technique. The authors have produced a video which illustrates the anatomical basis and technical details of TME. TME is the resection of the rectum together with the fatty and lymphatic tissue contained within the visceral sheet of the pelvic fascia. This paper details the anatomical basis of TME, describing the fascial structures and fibrous spaces along which the dissection must proceed.

[Sepsis score in surgical intensive care medicine]. / Sepsis-Score in der operativen Intensivmedizin.

In a prospective study (400 patients, intensive care stay > 18 h) the following data were documented daily: Clinical sepsis, a modified sepsis score, Apache II-score, number of organ failure, Elastase-concentrations and injury severity score (ISS > or = 20 = polytrauma). On admission day a prognostic assessment for early diagnosis of septic complications during intensive care could be demonstrated by a combination of the modified sepsis score and the number of organ failures and the presence of polytrauma. All other parameters did not have any predictive value.

[Full-thickness abdominal wall closure of laparoscopic trocar incision sites: a new, simplified technique]. / Der mehrschichtige Bauchwandverschluss laparoskopischer Trokareinstichstellen: eine neue, vereinfachte Technik.

Description of a safe, quick, easy and cheap technique of suture closure of laparoscopic trocar sites utilizing a reusable instrument ("hook-needle") developed for the purpose. The procedure is done under laparoscopic vision without the need for laparoscopic suture handling and results in a one stage closure of all relevant layers of the abdominal wall. Other techniques recently published for the same purpose are critically reviewed.