Observational study on preservation of the superior rectal artery in sigmoid resection for diverticular disease.

AIM: Recent investigations have shown improved patient reported outcome after preservation of the inferior mesenteric artery in sigmoid resection for diverticular disease. We report on our experience with preservation of the superior rectal artery (SRA). METHODS: This is an observational single center study in a high-volume, level II inner city hospital from 2006 to 2008. Inclusion criteria were all patients with diverticular disease. Exclusion criteria were stoma formation, cancer, and iatrogenic perforation. Patients were investigated in group A with preservation of the SRA, and group B ligation of the SRA. Outcomes assessed, included incidence of anastomotic breakdown, intraoperative complications, hospital stay, and risk factors. RESULTS: The patient population included 259 patients, 46 patients were excluded, leaving 100 patients in group A and 113 patients in group B. Patients in both groups were comparable regarding age, gender, co-morbidities and stage of disease. Anastomotic breakdown occurred in one patient in group A and in eight patients in group B (p = 0.038). Incidence of intraoperative bleeding, wound dehiscence, and length of stay was increased in group B (p < 0.03; p < 0.04; p = 0.05). Obesity was an independent risk factor for anastomotic dehiscence in group B (p < 0.04). CONCLUSION: Our data comprise the largest patient population reported so far on vascular preservation in surgery for diverticular disease. The results of this study support the establishment of evidence based recommendations on the level of dissection in diverticular disease. Specifically obese patients are at risk of anastomotic breakdown with ligation of the SRA.

Recurrent High-Flow Arterio-Venous Malformation of the Thyroid Gland.

BACKGROUND: Vascular malformations and hemangiomas of the thyroid gland are rare disorders. The first case of a patient with recurrent high-flow arterio-venous malformation of the right thyroid gland involving the right endolarynx is presented. PATIENT FINDINGS: In June 2013, a 42-year-old female patient presented to the surgical department with recurrent hoarseness and a soft, vibrating mass on the right side of her neck. In 1993, she underwent right subtotal hemithyroidectomy with embolization on the day before surgery for a high-flow arterio-venous malformation of the thyroid gland. Diagnostic work-up in 2013 demonstrated a complex recurrent high-flow arterio-venous malformation on the right side of her neck involving the endolarynx. Full function of the right vocal fold could not be ascertained. The lesion was embolized again and excised the following day. Intraoperative gross bleeding and scar tissue prevented visualization and monitoring of the recurrent laryngeal nerve. Gross bleeding was also noted on hemithyroidectomy after embolization in 1993. No therapy was needed for the endolaryngeal part of the lesion. Histology showed large arterio-venous malformations with thyroid tissue. She remains well without signs of recurrence 18 month later but with a definitive voice handicap. SUMMARY: This is the first report of a recurrent high-flow arterio-venous malformation originally developing from the right thyroid gland involving the right endolarynx. Counseling, diagnostic, and therapeutic work-up of the patient was possible only with an interdisciplinary team. The endolaryngeal part of the hemangioma dried out after embolization and completion hemithyroidectomy. Her hoarseness has greatly improved but a definitive voice handicap remains. CONCLUSION: High-flow arterio-venous malformations of the thyroid gland are a rare disease, and recurrent lesions have not been reported. Interdisciplinary management of these patients is mandatory due to the complex nature of the underlying pathology. Recurrence might develop after long free intervals.

[Transvaginal cholecystectomy: results of a randomized study]. / Transvaginale Cholezystektomie: Ergebnisse einer randomisierten Studie.

BACKGROUND: Transvaginal cholecystectomy (TVC) is regarded as a model operation in the newly developed field of natural orifice transluminal endoscopic surgery (NOTES). Randomized, controlled trials to assess TVC as a surgical strategy are largely missing. MATERIALS AND METHODS: The study was a double blind, randomized, controlled, single center trial in female patients > 18 years with symptomatic cholecystolithiasis comparing laparoscopic cholecystectomy (CLC) and TVC. The study investigated pain reduction of ≥ 1 point on a visual-numeric rating scale with a follow-up after 7 days. Secondary endpoints were complications and patient reported outcome. Groups were established using computer-generated randomization and sealed envelopes in the operating theatre. At the end of the surgical procedure all patients received a standard 4-trocar dressing as for CLC and a vaginal tamponade. RESULTS: A total of 426 patients were asked to participate, of which 97 were randomized, 51 in the CLC, 41 in the TVC groups and 5 were excluded from the study. Patients were comparable regarding age, body mass index (BMI) and American Society of Anesthesiologists (ASA) grade. Surgical and anesthesia times were significantly different. There was no difference in postoperative pain. The majority of patients were satisfied with both procedures and TVC was recommended to other patients by 93 % of patients in the TVC group. CONCLUSION: The results did not show superiority of TVC over CLC with regards to postoperative pain. With no differences in postoperative pain and high patient satisfaction, TVC can be recommended to future patients as an alternative method. For confirmation of this evaluation of TVC further randomized trials are needed.

Comparison of panorama ultrasonography, conventional B-mode ultrasonography, and computed tomography for measuring liver size.

PURPOSE: The objective of the present study is to compare the utility of extended field-of-view ultrasonography and conventional B-mode ultrasonography for determining liver size. MATERIALS AND METHODS: The liver size in the medioclavicular line (MCL) was determined in 104 inpatients (females: n = 47; males: n = 57) using both ultrasound methods (Philips HDI 5000). The liver size measured in computed tomography (CT; MX 8000 IDT, Philips) served as the gold standard. The body mass index (BMI), ultrasound scanning conditions, and hepatomegaly identified by CT were evaluated as possible factors affecting the measurement accuracy of the sonographic methods. RESULTS: The standard deviation of the differences between the measured pairs of values shows less dispersion in B-mode ultrasonography (18.7 mm) than panorama ultrasonography (20.8 mm). The mean value of differences between the measured pairs (bias) in the ultrasonographic methods compared to CT is considerably higher in panorama sonography (15.3 mm; SD = 20.8) than in B-mode ultrasonography (0.27 mm; SD = 18.7). A paired t-test of the mean values shows a significant difference between the ultrasonographic methods (p < 0.0001). In diagnosing or excluding hepatomegaly, B-mode sonography is consistent with CT findings in 84 (80.8 %) of 104 patients and panorama ultrasonography is consistent with CT findings in 77 (74.0 %) of 104 patients. Ultrasonographic methods show moderate agreement with each other (Kappa = 0.4265). Higher BMI and limited scanning conditions lead to an increase in the mean difference of measured pairs of values (bias) as well as to an increase in standard deviation of the differences (dispersion). CONCLUSION: The determination of liver size in the medioclavicular line using panorama ultrasonography often leads to the false-positive diagnosis of hepatomegaly. Therefore, the method should not be recommended for routine diagnostic scans. In cases of significant hepatomegaly, however, panorama ultrasonography offers superior visualization compared to conventional B-mode ultrasonography.

Prevention and treatment of urinary tract infection with probiotics: Review and research perspective.

The spiralling costs of antibiotic therapy, the appearance of multiresistant bacteria and more importantly for patients and clinicians, unsatisfactory therapeutic options in recurrent urinary tract infection (RUTI) calls for alternative and advanced medical solutions. So far no sufficient means to successfully prevent painful and disabling RUTI has been found. Even though long-term oral antibiotic treatment has been used with some success as a therapeutic option, this is no longer secure due to the development of bacterial resistance. One promising alternative is the use of live microorganisms (probiotics) to prevent and treat recurrent complicated and uncomplicated urinary tract infection (UTI).The human normal bacterial flora is increasingly recognised as an important defence to infection. Since the advent of antibiotic treatment five decades ago, a linear relation between antibiotic use and reduction in pathogenic bacteria has become established as medical conventional wisdom. But with the use of antibiotics the beneficial bacterial flora hosted by the human body is destroyed and pathogenic bacteria are selectively enabled to overgrow internal and external surfaces. The benign bacterial flora is crucial for body function and oervgrowth with pathogenic microorganisms leads to illness. Thus the concept of supporting the human body's normal flora with live microorganisms conferring a beneficial health effect is an important medical strategy.

Mesh migration following obturator hernia repair presenting as a bezoar inducing small intestinal obstruction.

This is the first report on synthetic mesh migration following obturator hernia repair. Obturator hernias have a low incidence--with fewer than 700 published case studies to date--usually occur in elderly women and are difficult to diagnose. Since 1976, there have been no more than 29 reported cases in which synthetic materials were used in obturator hernia repair. Thus, information relevant to the surgical repair of this type of hernia is based on small numbers only. The use of synthetic mesh for the repair of obturator hernias is a recent development, and to date no complications have been reported with this type of repair. We report here on the outcome of a patient with mesh migration after obturator hernia repair. This report provides a short overview of mesh migration as a complication following the use of synthetic grafts for surgical repair.

Adult liver transplantation using liver grafts from donors over 70 years of age.

UNLABELLED: The increasing organ shortage calls for widening the selection criteria for liver transplant donors. However, concern exists about the use of grafts from donors older than 70 years. We report our clinical experience with graft-age related outcomes, presenting data on 41 patients transplanted with grafts from older donors. PATIENTS/METHODS: Between January 1995 and October 2003, 41 liver grafts were transplanted from donors older than 70 years. We analyzed patient and graft survival, incidence of retransplantation, initial nonfunction (INF), rejection, intra- and postoperative requirement for red blood cells. We also recorded cholestasis, protein synthesis and urinary retention. RESULTS: The mean donor age was 73.4 +/- 0.37 years. After one year, the patient survival was 91% and the graft survival 86%. The retransplantation rate was 9.75%; only one graft was lost due to INF. We observed an incidence of 11 rejection episodes. Of these, five patients needed OKT3 therapy for steroid-resistent rejection. The intra- and postoperative requirement for red blood cells was 4.0 +/- 0.65 and 1.4 +/- 0.25 units. Cholestasis, protein synthesis, and urinary retention parameters were within normal limits. CONCLUSIONS: Among donors of mean age 73.4 years, patient and graft survivals were excellent. One organ was lost due to INF. The intra- and postoperative need for red blood cells was within acceptable ranges. Liver function tests, cholestasis, and retention parameters were normal after 1 year follow up. Thus, we recommend to accept liver grafts from donors older than 70 years to expand the organ pool.

Statistical testing of drug accumulation in skin tissues by linear regression versus contents of stratum corneum lipids.

This investigation is a contribution to standardization in in vitro drug penetration measurements using excised human skin and to statistical treatment of the observations. The wide variations observed in measurements of drug accumulation in and drug permeation through the stratum corneum are caused not only by analytical errors but also by the variability of the horny layer lipid composition. The last-mentioned systematic influence can be compensated for by stepwise (multiple) linear regression using the contents of the main lipid classes as independent variables. In consequence, the S.E. of estimate given by the regression calculation is lower than the S.E. of the means of the observations. Significant differences in drug quantities accumulated in skin tissues (stratum corneum and dermis) are sensitively detected by Chow's F-test of structural change. Accumulation data of flufenamic acid and hydrocortisone penetrated from different bases are given as examples. The calculation mode is exemplarily explained and discussed. The results of the test for structural change, two-independent-groups t-test and paired-samples t-test are compared. The F-test of structural change proves to be a helpful statistical method suitable to the assessment of biopharmaceutical quality parameters and to measurements using biological materials.

Trichogramma exiguum (Hymenoptera: Trichogrammatidae) releases in North Carolina cotton: evaluation of heliothine pest suppression.

Field studies were conducted in 1996 and 1997 to reevaluate the use of augmentative releases of Trichogramma wasps for heliothine management in cotton. In 1996, nine releases of Trichogramma exiguum Pinto & Platner, spaced 3-4 d apart, were made into three 0.4-ha cotton plots. Six weekly releases were made in 1997, each containing two T. exiguum cohorts developmentally staggered by 45 degrees C degree-days. Field release rates, estimated from laboratory and field quality control data, averaged 108,357 T. exiguum female female per hectare per cohort per release in 1996 and 193,366 female female per hectare per cohort per release in 1997. In 1996, mean +/- SD adult emergence under laboratory conditions for released cohorts was 92 +/- 7%; 62 +/- 5% of emerged adults were females, 3 +/- 2% of females displayed brachyptery (nonfunctional wings), mean female longevity under laboratory conditions was 15 +/- 4 d, and mean +/- SD field emergence was 97 +/- 2%. Quality control measurements were similar in 1997. In 1996, mean +/- SD percent parasitism of heliothine eggs in field plots on the sampled dates ranged from 67 +/- 4 to 83 +/- 5% in T. exiguum release plots and 25 +/- 9 to 55 +/- 8% in control plots. In 1997, parasitism levels ranged from 74 +/- 4 to 89 +/- 5% in T. exiguum release plots and 18 +/- 18 to 69 +/- 11% in control plots. Despite increased parasitism levels in T. exiguum release plots, there were no significant differences in density of fifth instars, boll damage, or yield between T. exiguum release and control plots. Therefore, it is concluded that Trichogramma augmentation is not an effective heliothine management tool in North Carolina cotton.

Comparison of pheromone-mediated mating disruption and conventional insecticides for management of tufted apple bud moth (Lepidoptera: Tortricidae).

Large-plot studies were used to compare pheromone-mediated mating disruption and conventional insecticide applications for management of tufted apple bud moth, Platynota idaeusalis (Walker), in North Carolina in 1993 and 1994. Pheromone trap catches were reduced in mating disruption blocks, and traps placed in the lower stratum of the canopy had a higher level of trap capture reduction compared with traps placed in the upper stratum. First-generation tufted apple bud moth exposure to either pheromones for mating disruption or insecticides affected second generation pheromone trap catches in the lower and upper canopy. More second generation male moths were caught in pheromone traps placed in the upper compared with the lower canopy in blocks treated with pheromones for mating disruption during the first generation, whereas the opposite was true in blocks treated with insecticides during the first generation. Despite reduced trap catches in pheromone-treated blocks, egg mass densities were not reduced in these blocks compared with insecticide-treated blocks. Furthermore, fruit damage was not significantly different between mating disruption blocks and conventionally treated blocks in orchards with relatively low populations of tufted apple bud moth, but damage was greater in mating disruption blocks in orchards with higher moth densities.

Effect of specific and generic sex attractant blends on pheromone trap captures of four leafroller species in mid-Atlantic apple orchards.

The responses of tufted apple bud moth, Platynota idaeusalis (Walker), the leafroller P. flavedana Clemens, redbanded leafroller, Argyrotaenia velutinana (Walker), and obliquebanded leafroller, Choristoneura rosaceana (Harris), to the pheromone blends of each, as well as to 3 putative generic blends (two- and three-component blends containing pheromone elements of each of the 4 species) were evaluated in small orchard plots. P. idaeusalis and P. flavedana, and A. velutinana and C. rosaceana comprise 2 pairs of species, each pair with broad overlap in pheromone blend, and quite different from one another. Each generic blend suppressed trap captures of all 4 species. The blends for P. idaeusalis and P. flavedana each reduced captures for these species. Furthermore, the blend for P. idaeusalis also suppressed captures of A. velutinana. The P. flavedana blend did not reduce captures of A. velutinana; in fact, at times captures increased. This study determines relative abilities of several sex attractant blends to reduce captures of 4 leafroller species in pheromone traps, presumably reflecting the ability of a blend to reduce orientation of males to females in a large block situation. This is a requisite 1st step in the development of a multispecies mating disruption blend.

Synthetic inhibitor of matrix metalloproteinases (batimastat) reduces prostate cancer growth in an orthotopic rat model.

BACKGROUND: Increased concentrations of metalloproteinases are associated with the invasive and metastatic behavior of several human malignant tumors. Normally, enzymatic activity is tightly regulated by nonspecific mechanisms and specific inhibitors. The aim of the study was to determine the potential of a synthetic metalloproteinase inhibitor, batimastat, to show its in vitro effect on MatLyLu cancer cells and its in vivo effect on tumor growth in orthotopic cancer (R3327 Dunning tumor) in rats. METHODS: In vitro, a dose response curve of batimastat was generated over 4 days using the MTT assay. Prostate cancer was injected in vivo in male Copenhagen rats by inoculating R3327 Dunning tumor cells (MatLyLu) into the ventral prostatic lobe of 30 rats. Each of 10 rats received batimastat (30 mg/kg body weight) or vehicle administered once a day by i.p. application beginning the day of cell inoculation. Ten rats remained untreated. The effect on local tumor growth was evaluated by measuring tumor weights 20 days after tumor cell inoculation. RESULTS: Significant inhibition of tumor cell proliferation in vitro occurred at 400 and 4,000 ng/ml batimastat. After orthotopic cell inoculation, tumors grew to mean weights of 18.9 g in the control group without treatment, to 22.3 g in the vehicle group, and to 11.1 g in the treated group. In comparison to the control group and to the vehicle group, tumor weights increased significantly less under treatment with batimastat. CONCLUSIONS: Batimastat is able to reduce tumor growth in the standard prostate cancer model. Using this model, activity against cancer progression of future inhibitory agents can be reliably assessed.