[Minimally invasive robot-assisted gastric bypass after open Mason reduction gastroplasty]. / Minimal-invasive, roboterassistierte Magenbypassanlage nach offener Mason-Gastroreduktionsplastik.

BACKGROUND: The introduction of robot-assisted surgery in the treatment of morbidly obese patients has enlarged the armamentarium for surgeons involved in bariatric surgery. This article describes the experiences with a conversion surgery from a complicated open Mason gastroplasty to a Roux en Y gastric bypass using the da Vinci Xi robotic system. CASE: A 29-year-old female patient underwent a Mason reduction gastroplasty by laparotomy in 1995 (body mass index BMI 53.2 kg/m2). The course was complicated with a revision due to abscess formation and subsequent secondary healing. In 1996 an open revision of the gastroplasty due to persisting gastroesophageal reflux disease and outlet stenosis with dilatation of the outlet and an open cholecystectomy for cholecystolithiasis were performed . Abdominoplasty was performed for skin flaps in 2001 after the patient had lost 68 kg in weight. The patient presented at our hospital because of insufficient weight reduction even with weight gain since 2001 and treatment-refractive gastroesophageal reflux with adhesion problems. Clinical examination revealed normal scar tissue formation with no indications for an incisional hernia. The BMI was 48.2 kg/m2 with a body weight of 124 kg. The surgery was performed using a da Vinci Xi robotic system after access via a blunt dissection with the introduction of two trocars and adhesiolysis. The gastric pouch was created using Echelon 60 mm cartridges via an additional trocar. The gastroenterostomy was constructed with a 150 cm alimentary loop and a 60 cm biliodigestive loop resulting in a Roux en Y bypass. The operating time was 224 min. RESULTS: The postoperative course was uneventful. Enteral nutrition was resumed on day 2 and the patient was discharged from the hospital 4 days postoperation. CONCLUSION: This preliminary experience suggests that robotic revisional surgery can be performed safely even after complicated bariatric operations.

Antidepressant prescribing in five European countries: application of common definitions to assess the prevalence, clinical observations, and methodological implications.

PURPOSE: Drug utilization studies have applied different methods to various data types to describe medication use, which hampers comparisons across populations. The aim of this study was to describe the time trends in antidepressant prescribing in the last decade and the variation in the prevalence, calculated in a uniform manner, in seven European electronic healthcare databases. METHODS: Annual prevalence per 10,000 person-years (PYs) was calculated for 2001-2009 in databases from Spain, Germany, Denmark, the United Kingdom (UK), and the Netherlands. Prevalence data were stratified according to age, sex, antidepressant type (selective serotonin re-uptake inhibitors [SSRIs] or tricyclic antidepressants [TCAs]) and major indications. RESULTS: The age- and sex-standardized prevalence was lowest in the two Dutch (391 and 429 users per 10,000 PYs) and highest in the two UK (913 and 936 users per 10,000 PYs) populations in 2008. The prevalence in the Danish, German, and Spanish populations was 637, 618, and 644 users per 10,000 PY respectively. Antidepressants were prescribed most often in 20- to 60-year-olds in the two UK populations compared with the others. SSRIs were prescribed more often than TCAs in all except the German population. In the majority of countries we observed an increasing trend of antidepressant prescribing over time. Two different methods identifying recorded indications yielded different ranges of proportions of patients recorded with the specific indication (15-57% and 39-69% for depression respectively). CONCLUSION: Despite applying uniform methods, variations in the prevalence of antidepressant prescribing were obvious in the different populations. Database characteristics and clinical factors may both explain these variations.

Incidence rates and trends of hip/femur fractures in five European countries: comparison using e-healthcare records databases.

Hip fractures represent a major public health challenge worldwide. Multinational studies using a common methodology are scarce. We aimed to estimate the incidence rates (IRs) and trends of hip/femur fractures over the period 2003-2009 in five European countries. The study was performed using seven electronic health-care records databases (DBs) from Denmark, The Netherlands, Germany, Spain, and the United Kingdom, based on the same protocol. Yearly IRs of hip/femur fractures were calculated for the general population and for those aged ≥50 years. Trends over time were evaluated using linear regression analysis for both crude and standardized IRs. Sex- and age-standardized IRs for the UK, Netherlands, and Spanish DBs varied from 9 to 11 per 10,000 person-years for the general population and from 22 to 26 for those ≥50 years old; the German DB showed slightly higher IRs (about 13 and 30, respectively), whereas the Danish DB yielded IRs twofold higher (19 and 52, respectively). IRs increased exponentially with age in both sexes. The ratio of females to males was ≥2 for patients aged ≥70-79 years in most DBs. Statistically significant trends over time were only shown for the UK DB (CPRD) (+0.7% per year, P < 0.01) and the Danish DB (-1.4% per year, P < 0.01). IRs of hip/femur fractures varied greatly across European countries. With the exception of Denmark, no decreasing trend was observed over the study period.

[Impact of transtympanic miniature endoscopy of the middle ear--a conceptual cadaver study]. / Wertigkeit der transmyringealen Mini-Endoskopie des Mittelohres--Eine konzeptionelle Kadaver-Studie.

OBJECTIVE: Endoscopic inspections of the middle ear have already been described. So far, the low optical quality due to the small diameter is limiting this type of procedure. In this study the use of a miniature endoscope for visualization of the middle ear structures has been evaluated. MATERIAL AND METHODS: 8 human cadaveric head specimens have been inspected. Following myringotomy, 2 miniature endoscopes were placed into the middle ear and the promontory, the incudostapedial joint, the round und oval window niche with stapes footplate were visualized and fotodocumentated. After endaural approach all middle ear structures were visualized microscopically and the quality of pictures was compared. Technical picture quality and anatomical visualization were evaluated by 5 ear surgeons. In addition, 2 interventional procedures were performed (control of ossicular chain mobility and intratympanic substance application). RESULTS: Still, the technical picture quality was significantly better for the microscope. The anatomical visualization of the middle ear structures with the miniature endoscope was not inferior compared to the microscope. The feasibility of additional interventions, e.g. control of ossicular chain mobility or intratympanic substance application could be shown. An inspection of the correct prosthesis position after tympanoplasty could be evaluated, too. CONCLUSION: This study showed that middle ear structures can be visualized by trans-tympanic miniature endoscopy equal or even better compared to conventional microscopy in spite of reduced technical quality.

[Laparoscopic recovery continuity after the Hartmann procedure]. / Die laparoskopische Wiederanschlussoperation nach Hartmann-Resektion.

In the period from January 2003 to June 2009 923 complex laparoscopic colorectal procedures were performed by one surgeon. Data was as­sessed prospectively in a database including 152 variables. In 15 patients (10 f, 5 m), with a median age of 61 years (range: 35-83 years), discontinuity resection of the colon was performed including 3 patients with open discontinuity resection of the sigma and 12 patients with laparoscopic Hartmann procedures. In all cases continuity of the ­colon was recovered laparoscopically. Median op­er­ation time was 100 min, conversion to an open procedure was not necessary. No intra-operative complications occurred and only one wound infection (6.6 %) was recorded postoperatively with a median postoperative stay of 8 days. Although the laparoscopic approach to recover continuity of the colon is technically challenging, we con­clude that the experienced bowel surgeon is able to perform the laparoscopic approach with a low morbidity and mortality by retaining the well known advantages of laparoscopic colonic sur­gery.

Increased urinary orosomucoid excretion predicts preeclampsia in pregnant women with pregestational type 1 diabetes.

AIMS: We evaluated the urinary orosomucoid excretion (UOE) as a biomarker of preeclampsia and preterm delivery in pregnant women with type 1 diabetes. METHODS: Singleton pregnant women with pregestational type 1 diabetes were included provided one urine sample had been collected before 17 gestational weeks. Serum and urinary orosomucoid were analysed by immunoturbidimetry. Primary outcome measurements were development of preeclampsia (blood pressure>140/90mmHg and proteinuria) and preterm delivery before 37 weeks. RESULTS: In total 173 women were included. The UOE increased during pregnancy. Preeclampsia developed in 20 women and 65 women delivered preterm. Using logistic regression analysis we found that UOE>1.37mg/l (OR: 6.85 (95% CI: 1.97-23.88; p<0.003)), nulliparity (3.88 (1.10-13.72); p<0.04), systolic blood pressure>120mmHg (4.12 (1.35-12.59); p<0.02) and duration of diabetes>20 years (3.69 (1.18-11.52); p<0.03) independently predicted the development of preeclampsia. Independent predictors of preterm delivery were duration of diabetes and HbA1c>7%. The remaining covariates included in the regression models were BMI, serum creatinine, smoking and microalbuminuria. CONCLUSIONS: Increased UOE early in pregnancy predicted preeclampsia in women with pregestational type 1 diabetes independently of albuminuria and other known risk factors. No association to preterm delivery was found.

One-day or two-day procedure for sentinel node biopsy in melanoma?

PURPOSE: We compared the outcome of a 1-day and a 2-day sentinel node (SN) biopsy procedure, evaluated in terms of lymphoscintigraphic, surgical and pathological findings. METHODS: We studied 476 patients with melanoma from two melanoma centres using static scintigraphy and blue dye. A proportional odds model was used for statistical analysis. RESULTS: The number of SNs visualized at scintigraphy increased significantly with time from injection to scintigraphy and activity left in the patient at scintigraphy, and depended on the melanoma location. The number of SNs removed at surgery increased with the number of SNs visualized at scintigraphy and time from injection to surgery. The frequency of nodal metastasis increased with increasing thickness and Clark level of the melanoma, and was highest for two SNs visualized at scintigraphy. CONCLUSION: This study showed that early vs. late imaging and surgery do make a difference on the outcome of the SN procedure and confirmed the importance of the scintigraphic visualization of all true SNs.

[Twenty years of experience with bariatric surgery in a general hospital]. / Entwicklung der Adipositaschirurgie am Krankenhaus der Maximalversorgung: Uber 20 Jahre Behandlungserfahrung.

BACKGROUND: Bariatric surgery has been performed since 1983 at the Bad Cannstatt Hospital near Stuttgart, Germany. The aim of this study was to investigate the development of bariatric surgery during the past 25 years. METHODS: Data were collected retrospectively. The parameters were number of surgical procedures, hospital stay, and postoperative complications. RESULTS: In the 25-year period 1,041 primary bariatric operations were performed. Open horizontal bypass and open vertical banded gastroplasty were performed initially. Starting in 2003 there was a change to laparoscopic procedures (gastric banding and Roux-en-Y bypass). The mean hospital stays were 14.7+/-5.1 days for open procedures and 6.7+/-4.2 days for laparoscopic methods, with 30-day mortalities of 0.8% and 0.0% and short-term complications at 16.9% and 7.8%, respectively. CONCLUSIONS: Perioperative complications and hospital stay were reduced by performing laparoscopic bariatric surgery. Our study emphasizes the advantages of the laparoscopic procedures which are standard at our hospital and fit in with the remaining operations in a department of visceral surgery.

[Ultrasonic scissors. New vs resterilized instruments]. / Ultraschallscheren. Neue vs. resterilisierte Einmalinstrumente.

BACKGROUND: The aim of this study was to compare reliability in handling and function of resterilized and single-use disposable ultrasonic scissors. METHODS: In a prospective randomized study, the surgeon blindly tested new and resterilized ultrasonographic scissors. The parameters were force of activation, cutting effect, coagulation effect, error messages, and disturbing generator noise. RESULTS: Fifty-one new and 49 resterilized instruments in 94 operations were evaluated. The differences in force of activation, cutting effect, and coagulation were not significant. Error messages and disturbing noises were rare in both groups. Six new instruments and two resterilized instruments had to be exchanged because of problems during surgery. CONCLUSION: This study demonstrates comparable reliability in function and handling of resterilized and new ultrasonic scissors. The use of resterilized instruments leads to distinctly reduced costs and could contribute to efficiency in laparoscopic surgery.

Ultrasound scissors: new single-use instruments vs. resterilised single-use instruments - a prospective randomised study.

BACKGROUND: The aim of this study was to compare reliability in handling and function of resterilised and single-use disposable ultrasonic scissors. METHODS: In a prospective randomized study, the surgeon blindly tested new and resterilised ultrasonic scissors. The parameters were force of activation, cutting effect, coagulation effect, error messages and disturbing generator noise. RESULTS: 51 new and 49 resterilised instruments in 94 operations were evaluated. The differences in force of activation, cutting effect and coagulation were not significant. Error messages and disturbing noises were rare in both groups. 6 new instruments and 2 resterilised instruments had to be exchanged because of problems during surgery. CONCLUSION: This study demonstrates comparable reliability in function and handling of resterilised and new ultrasonic scissors. The use of resterilised instruments leads to distinctly reduced costs and could contribute to efficiency in laparoscopic surgery.

Neurotrophin-3, but not nerve growth factor, promotes survival of human intestinal mast cells.

Neurotrophins are potent regulators of neuronal cell survival and function. Nerve growth factor (NGF) was shown to reduce apoptosis in cord blood-derived mast cells. Here, we examined the effect of the neurotrophins NGF and neurotrophin (NT)-3 on survival and mediator release of human intestinal mast cells. Mast cells isolated from normal intestinal tissue were cultured in the presence of NGF, NT-3, or stem cell factor (SCF) alone or in the presence of SCF together with each neurotrophin. NGF or NT-3 alone did not promote mast cell survival. In contrast, mast cell recovery was increased twofold when mast cells were cultured with NT-3 in addition to SCF for 14 days compared with control. Mast cell recovery was further increased following a combined addition of NT-3, SCF and IL-4. NT-3 mediated mast cell growth was dependent on the primary receptor for NT-3 TrkC. NGF in combination with SCF or with SCF and IL-4 showed no effect on mast cell survival. Histamine release and histamine content per mast cell remained unchanged, whereas leukotriene C4 release decreased if mast cells were cultured with NGF or NT-3 in addition to SCF. In summary, NT-3 affects mature human mast cells by promoting mast cell survival, whereas NGF does not.

[The laparoscopic pancreas resection]. / Die laparoskopische Pankreasresektion.

Laparoscopic surgery of the pancreas has been used for diagnostic but also for therapeutic purposes in increasing number. Case reports and multicenter studies summarizing the European and world wide experience have been published recently. The results show that laparoscopic surgery can be used for tumor staging of pancreatic cancer but also for the treatment of acute necrotizing pancreatitis and treatment of chronic pancreatitis, benign cystic lesions and solid tumors. In particular left sided pancreatic resection (90 % of the cases) is the preferred approach delivering good results. Recent studies show that the conversion rate is 14 % and mortality can be as low as 0 %. The reoperation rate is 6.3 % and the fistula formation is 17 % which is comparable to the results of open pancreatic surgery. The postoperative hospital stay seems to be limited to a mean of 7 days as compared to pancreatic surgery in the open abdomen. The laparoscopic Whipple resection with less than 3 % of the cases in the literature remains the exception.

[Obesity surgery: the refusal rate of health care cost reimbursement despite expert opinion]. / Adipositaschirurgie: Ablehnung der Kostenübernahme trotz ärztlicher Gutachten.

BACKGROUND AND OBJECTIVE: Surgery is an effective method to treat patients with morbid obesity. However health insurance companies frequently refuse to cover the costs for the procedure despite an existing DRG-code for this operation. Individual medical expertise are necessary to receive reimbursement. In the present study the acceptance of medical expertise to receive cost coverage was analysed in our patients of the years 2000-2003 eligible for obesity surgery. PATIENTS AND METHODS: 617 medical expertise of patients eligible for obesity surgery in our hospital were reviewed and the acceptance rate was evaluated. Parameters such as body mass index, personal medical history, diets, comorbidity and prognosis were included. Expertise were submitted to the health care insurance companies and in case of acceptance the operation was performed. RESULTS: The average age of our patients was 39.1 +/- 11.2 years, 72.1% were female, 27.9% male. The average BMI was 47.5 +/- 7.4 kg/m2. There was a high incidence of comorbidity in these patients (58.7% arterial hypertension, 38.6% diabetes mellitus, 95.8% dyspnoea, 96.1% arthropathy, 89.0% psychosocial disorders). The difference between accepted and non-accepted regarding these secondary complications was not significant. 209 patients (33.8%) were operated. 14 patients of these paid the costs themselves. Only in 195 cases (31.6%) the health care insurance company covered the costs for the operation. CONCLUSION: The high number of refusals of medical expertise is not justified in view of the strict criteria for indication, the high frequency of comorbidity and the good results after the operation.

Prospectively randomized trial using perioperative low dose octreotide to prevent organ related and general complications following pancreatic surgery and pancreatico-jejunostomy.

BACKGROUND: The aim of the study was to evaluate the influence of low dose perioperative Octreotide on the prevention of complications (pancreatic fistula and general complications) in patients undergoing pancreatic surgery followed by pancreatico-jejunostomy. MATERIAL AND METHODS: 105 patients were randomized to receive either Octreotide 0.1 mg subcutaneously 3 times/day for a total of 7 days or no Octreotide. The primary endpoints were the occurrence of a pancreatic fistula and/or general complications including the length of hospital stay. There were 25 surgical draining procedures performed and 80 duodeno-pancreatectomies with or without preservation of the pylorus. Twenty-six (24.8%) of the patients were treated for chronic pancreatitis, 8 (7.6%) for benign tumoral disease and 71 (67.6%) for carcinoma. All patients underwent pancreatico-jejunostomy. RESULTS: 56 patients received Octreotide and 49 did not. The incidence of fistula formation in the Octreotide group was 8.9% (n=5) and in the control group 8.2% (n=4) for a total incidence of 8.5%. The difference between the two groups was not statistically significant. There was one death in the Octreotide group and none in the control group for an overall mortality of 0.9%. The morbidity, except fistulas, was 10.7% in the Octreotide group and 12.2% in the control group. The length of hospital stay was 23.1 +/- 15.1 days in the group receiving Octreotide vs 20.4 +/- 8.1 days in the control group (p = 0.808). Stratifying the data for duodenopancreatectomy and for draining procedures there was no difference between the groups either. CONCLUSION: In patients undergoing pancreatic surgery and pancreatico-jejunostomy, the perioperative use of 3 x 0.1 mg Octreotide for 7 days does not reduce general complications nor fistula formation.

Contact dermatitis to hair dyes in a Danish adult population: an interview-based study.

BACKGROUND: Contact allergy to hair dye ingredients is a well-known entity seen both in consumers using hair dyes and among hairdressers with occupational contact dermatitis. Surveys show that consumers with even severe adverse skin reactions to hair dyes only rarely contact the healthcare services. The frequency of hair dye-induced skin reactions in the consumer population is unknown. OBJECTIVES: An epidemiological investigation with the aim of establishing the proportion of hair dye-induced skin reactions was performed in a population-based sample. METHODS: A representative random sample (n = 4000) was taken of the Danish adult population. Personal interview questions were asked regarding adverse skin reactions to hair dyes, either compatible with a classical allergic eczematous reaction with redness, scaling and itching or a severe allergic reaction with oedema of the forehead and face. The response rate was 65.2%. RESULTS: A total of 18.4% of the male respondents and 74.9% of the female respondents had at some point dyed their hair. The median age at first hair dyeing was 16 years (range 1-80). Adverse skin reactions to hair dyes compatible with an allergic reaction were reported in 5.3% of individuals who had ever used hair dye. Of these, only 15.6% had been in contact with healthcare services after the hair dye reaction. Having had a temporary tattoo was not a significant risk factor for an adverse reaction to hair dyes. CONCLUSIONS: The rate of adverse allergic skin reactions to hair dyes was higher than expected from patch-test studies. Only by studying the clinical types of adverse reactions to hair dyes will it be possible to gather a complete epidemiological picture of the nature and extent of the problems related to hair dye ingredients.

Factors of importance for scintigraphic non-visualisation of sentinel nodes in breast cancer.

PURPOSE: The aim of this study was to analyse different factors of possible significance for non-visualisation of sentinel nodes (SNs) by preoperative lymphoscintigraphy, in order to enable improvement of the success rate of SN visualisation through modification or alteration of some of the factors. METHODS: Between March 1998 and January 2003 we analysed a series of 442 women with unilateral stage T1 and clinical N0 breast cancer. Lymphoscintigraphy was performed after periareolar or peritumoural injection of 99mTc-albumin nanocolloid, with image acquisition after 2-6 h or 18-24 h. Until January 2001, all patients received around 20 MBq tracer, irrespective of time to operation. From January 2001, patients injected on the day before surgery received at least 100 MBq while patients injected on the day of surgery received around 50 MBq. RESULTS: An SN was visualised in 87% of the patients, and at surgery the SN was detected with the hand-held gamma probe in 42% of the remaining patients. By multiple logistic regression analysis, statistically significant independent variables that increased the risk for non-visualisation were increasing age (p=0.0007), increasing body weight (p=0.0189) and peritumoural injection (p<0.0001). Significant interaction was found for imaging time and injected activity (p=0.0017). CONCLUSION: This study conclusively shows that the risk of unsuccessful SN imaging increases with age and body weight. Our findings suggest that the scintigraphic success rate may be improved by periareolar (rather than peritumoural) injection. Early and late imaging procedures are equally efficient, but if a late imaging procedure is used, activity (adjusted for physical decay) in the patient on day 2 should be more than 10 MBq.

Life saving abdominal decompression in a patient with severe acute pancreatitis.

Severe acute pancreatitis can be complicated early in its course by life threatening conditions such as abdominal compartment syndrome. We report a patient who needed abdominal decompression three days after admission to the intensive care unit because of intra-abdominal hypertension and end stage organ dysfunction. The clinical course was protracted, but the patient survived and was discharged from the hospital.

The influence of desmopressin and vasopressors in the donor management on graft function following pancreas transplantation.

INTRODUCTION: The use of desmopressin and vasopressors in cadaveric organ donors is considered a risk factor for graft dysfunction following pancreas transplantation by influencing the microcirculation. The aim of this study was to investigate the influence of these substances on early graft function. PATIENTS AND METHODS: This single-center retrospective trial included 59 patients who underwent simultaneous or solitary pancreas transplantation. The corresponding donor charts were reviewed for the use of vasopressors and desmopressin. Impaired graft function was determined as graft thrombosis or as insulin-dependence for more then 3 days posttransplant. Daily amylase and lipase concentrations from abdominal drains were measured to quantify reperfusion pancreatitis and fistula formation. RESULTS: Overall, pancreas thrombosis was observed in 4 of 59 (6.8%) recipients. There were no significant differences in thrombosis rate whether the donors received desmopressin (3/38 vs 1/21, P >.1) or the needed vasopressors (3/53 vs 1/9, P >.1). The number of patients who required insulin for more than 3 days posttransplant was comparable whether the donors received desmopressin (9/38 vs 4/21, P >.1), or vasopressors (9/46 vs 3/8, P >.1). At present all recipients with functioning pancreatic grafts (ie, 92.7%) are free of exogenous insulin therapy at 2 to 80 months posttransplant. The amylase/lipase concentrations of peritoneal fluid were independent of the administration of desmopressin or vasopressors in the donors. CONCLUSION: In this study donor desmopressin and vasopressor administration did not influence graft function after pancreas transplantation.