Anxiety in patients with gastrointestinal cancer undergoing primary surgery.

PURPOSE: Anxiety in the perioperative period is not only an unpleasant emotional state, but can also negatively affect the outcomes and quality of life of surgical patients. The present study investigated anxiety in patients with gastrointestinal cancer scheduled for primary surgery. METHODS: A total of 101 patients in four non-university surgical departments were included. Anxiety (GAD-7), depression (PHQ-9), distress (Distress thermometer), and illness perception (Brief IPQ) were assessed at four time points: first outpatient contact before surgery (t1), preoperative inpatient contact (t2), postoperative inpatient contact before hospital discharge (t3), and postoperative outpatient follow-up contact after 30 days (t4). RESULTS: 56% of patients had an episode of mild or moderate anxiety and 5% had an episode of severe anxiety and/or depression. Subjectively perceived anxiety and depression were highest at t1, followed by t3. 30% of patients had elevated anxiety and depression scores at t1. Regression analyses showed that high subjectively perceived mental distress at t1 was associated with higher anxiety scores at t3 and t4. Women, and younger women in particular, were significantly more likely to experience stress than men. Higher levels of subjectively perceived stress at t1 were associated with higher levels of anxiety at t3 and t4. Sociodemographic factors were not relevant predictors of anxiety. CONCLUSION: Anxiety and depression appear to be a persistent problem during the perioperative course in patients with gastrointestinal tumors. Identifying patients at risk for clinically relevant anxiety and depression remains a particular challenge. The results confirm the relevance of repeated screening for mental distress.

The RENAISSANCE (AIO-FLOT5) trial: effect of chemotherapy alone vs. chemotherapy followed by surgical resection on survival and quality of life in patients with limited-metastatic adenocarcinoma of the stomach or esophagogastric junction - a phase III trial of the German AIO/CAO-V/CAOGI.

BACKGROUND: Historical data indicate that surgical resection may benefit select patients with metastatic gastric and gastroesophageal junction cancer. However, randomized clinical trials are lacking. The current RENAISSANCE trial addresses the potential benefits of surgical intervention in gastric and gastroesophageal junction cancer with limited metastases. METHODS: This is a prospective, multicenter, randomized, investigator-initiated phase III trial. Previously untreated patients with limited metastatic stage (retroperitoneal lymph node metastases only or a maximum of one incurable organ site that is potentially resectable or locally controllable with or without retroperitoneal lymph nodes) receive 4 cycles of FLOT chemotherapy alone or with trastuzumab if Her2+. Patients without disease progression after 4 cycles are randomized 1:1 to receive additional chemotherapy cycles or surgical resection of primary and metastases followed by subsequent chemotherapy. 271 patients are to be allocated to the trial, of which at least 176 patients will proceed to randomization. The primary endpoint is overall survival; main secondary endpoints are quality of life assessed by EORTC-QLQ-C30 questionnaire, progression free survival and surgical morbidity and mortality. Recruitment has already started; currently (Feb 2017) 22 patients have been enrolled. DISCUSSION: If the RENAISSANCE concept proves to be effective, this could potentially lead to a new standard of therapy. On the contrary, if the outcome is negative, patients with gastric or GEJ cancer and metastases will no longer be considered candidates for surgical intervention. TRIAL REGISTRATION: The article reports of a health care intervention on human participants and is registered on October 12, 2015 under ClinicalTrials.gov Identifier: NCT02578368 ; EudraCT: 2014-002665-30.

Influence of pressures up to 50bar on two-stage anaerobic digestion.

The concept of pressurized two-stage anaerobic digestion integrates biogas production, purification and pressure boosting within one process. The produced methane-rich biogas can be fed into gas grids with considerably less purification effort. To investigate biogas production under high pressures up to 50bar, a lab scale two-stage anaerobic digestion system was constructed including one continuously operated pressurized methane reactor. This investigation examined the effects of different operating pressures in methane reactor (10, 25, 50bar) on biogas quantity and quality, pH value and process stability. By increasing operating pressures in methane reactor, the pH value decreased from 6.65 at 10bar to 6.55 at 50bar. Simultaneously, methane content increased from 79.08% at 10bar to 90.45% at 50bar. The results show that methane reactors can be operated up to 50bar pressure continuously representing a viable alternative to commonly used gas upgrading methods because of reduced purification effort.

Kinetics of biogas production in Anaerobic Filters.

This study investigates methane production kinetics from individual volatile fatty acids (VFA) in an Upflow Anaerobic Filter (AF). 1gCOD in the form of acetic (HAc), propionic (HPr) or butyric acid (HBu) was injected into the AF while operating at an organic loading rate (OLRCOD) of 3.5gL(-1)d(-1). A new method is introduced to separate gas production of the baseload from the product formation of VFA degradation after the injection. The lag phase, fractional rate of gas production and half-life has been determined for the methane production of the three VFAs. The half-lives were in the order HAc

Laparoscopic versus open reversal of a Hartmann procedure: a single-center study.

PURPOSE: Re-anastomosis after a Hartmann procedure is associated with a higher morbidity and mortality than other elective colorectal operations. The goal of this comparative study was to evaluate whether laparoscopic reversal is a justified operative approach, although the initial operation is most often an emergency laparotomy. METHODS: A retrospective analysis was conducted on data collected on all 70 patients who underwent laparoscopic and open reversal of a Hartmann procedure at the Department of Surgery, University of Schleswig-Holstein, Campus Lübeck, between January 1999 and December 2011. Together with general demographic data, the analysis included the indication for the initial Hartmann procedure, time to reversal, intraoperative findings, the choice of operative method, operating time, postoperative pain control, return of normal bowel function, length of hospital stay, and peri- and postoperative morbidity and mortality. RESULTS: In most patients, the Hartmann procedure was performed after a perforated sigmoid diverticulitis. We were not able to find any statistically significant differences with respect to gender, body mass index (BMI) and American Society of Anesthesiologists classification between the laparoscopic group (LG) (N = 24 patients) and the open group (OG) (N = 46). In the LG, patients were significantly younger (p = 0.019). The median operating time was 210 min (75-245) in the LG, which was significantly longer than in the OG (166 min; 66-230). The statistical analysis of the duration of postoperative analgesic therapy (LG 7 days; OG 12 days), return to normal diet (LG 3 days; OG 4 days), return of normal bowel function (LG 3 days; OG 4 days) and length of hospital stay (LOS) (LG 10 days; OG 15 days) detected significant differences in advantage for the LG. Unplanned return to theatre during index admission was only necessary in the OG (N = 7, 15.2 %). With a median follow-up of 8 months (range 1-20), we observed a comparable number of minor complications in both groups but a significantly higher number of major complications in the OG (N = 27, 58.7%) (p = 0.001). Conversion occurred in three cases (12.5%). There was no mortality in either of the two groups. CONCLUSIONS: This study was able to demonstrate the feasibility of the laparoscopic approach. In terms of postoperative results it should be seen as equivalent to the open procedure. However, the laparoscopic approach requires profound surgical expertise. The indication should be made after a careful risk/benefit analysis for each individual patient.

Exponential model describing methane production kinetics in batch anaerobic digestion: a tool for evaluation of biochemical methane potential assays.

Biochemical methane potential assays, usually run in batch mode, are performed by numerous laboratories to characterize the anaerobic degradability of biogas substrates such as energy crops, agricultural residues, and organic wastes. Unfortunately, the data obtained from these assays lacks common, universal bases for comparison, because standard protocols did not diffuse to the entire scientific community. Results are usually provided as final values of the methane yields of substrates. However, methane production curves generated in these assays also provide useful information about substrate degradation kinetics, which is rarely exploited. A basic understanding of the kinetics of the biogas process may be a first step towards a convergence of the assay methodologies on an international level. Following this assumption, a modeling toolbox containing an exponential model adjusted with a simple data-fitting method has been developed. This model should allow (a) quality control of the assays according to the goodness of fit of the model onto data series generated from the digestion of standard substrates, (b) interpretation of substrate degradation kinetics, and (c) estimate of the ultimate methane yield at infinite time. The exponential model is based on two assumptions: (a) the biogas process is a two-step reaction yielding VFA as intermediate products, and methane as the final product, and (b) the digestible substrate can be divided into a rapidly degradable and a slowly degradable fraction.

Outcome and management of invasive candidiasis following oesophageal perforation.

The regular colonisation of the oesophagus with a Candida species can, after oesophageal perforation, result in a contamination of the mediastinum and the pleura with a Candida species. A patient cohort of 80 patients with oesophageal perforation between 1986 and 2010 was analysed retrospectively. The most common sources with positive results for Candida were mediastinal biopsies and broncho-alveolar secretions. Candida species were detected in 30% of the patients. The mortality rate was 41% in patients with positive microbiology results for Candida, whereas it was 23% in the remaining patient cohort. This difference did not reach statistical significance (P = 0.124). Mortality associated with oesophageal perforation was attributed mainly to septic complications, such as mediastinitis and severe pneumonia. During the study period we observed a shift towards non-albicans species that were less susceptible or resistant to fluconazole. In selected patients with risk factors as immunosuppression, granulocytopenia and long-term intensive-care treatment together with the finding of Candida, an antimycotic therapy should be started. A surgical approach offers the possibility to obtain deep tissue biopsies. The antimycotic therapy should start with an echinocandin, as the resistance to fluconazole is growing and to cover non-albicans Candida species, too.

Metachronous metastasis- and survival-analysis show prognostic importance of lymphadenectomy for colon carcinomas.

BACKGROUND: Lymphadenectomy is performed to assess patient prognosis and to prevent metastasizing. Recently, it was questioned whether lymph node metastases were capable of metastasizing and therefore, if lymphadenectomy was still adequate. We evaluated whether the nodal status impacts on the occurrence of distant metastases by analyzing a highly selected cohort of colon cancer patients. METHODS: 1,395 patients underwent surgery exclusively for colon cancer at the University of Lübeck between 01/1993 and 12/2008. The following exclusion criteria were applied: synchronous metastasis, R1-resection, prior/synchronous second carcinoma, age < 50 years, positive family history, inflammatory bowel disease, FAP, HNPCC, and follow-up < 5 years. The remaining 421 patients were divided into groups with (TM+, n = 75) or without (TM-, n = 346) the occurrence of metastasis throughout a 5-year follow-up. RESULTS: Five-year survival rates for TM + and TM- were 21% and 73%, respectively (p < 0.0001). Survival rates differed significantly for N0 vs. N2, grading 2 vs. 3, UICC-I vs. -II and UICC-I vs. -III (p < 0.05). Regression analysis revealed higher age upon diagnosis, increasing N- and increasing T-category to significantly impact on recurrence free survival while increasing N-and T-category were significant parameters for the risk to develop metastases within 5-years after surgery (HR 1.97 and 1.78; p < 0.0001). CONCLUSIONS: Besides a higher T-category, a positive N-stage independently implies a higher probability to develop distant metastases and correlates with poor survival. Our data thus show a prognostic relevance of lymphadenectomy which should therefore be retained until conclusive studies suggest the unimportance of lmyphadenectomy.

Intrahepatic radiofrequency ablation versus electrochemical treatment ex vivo.

BACKGROUND: Radiofrequency ablation (RFA) and electrochemical treatment (ECT) are two methods of local liver tumor ablation. A reproducible perfusion model allowed us to compare these methods when applied in proximity to vascular structures. MATERIAL AND METHODS: In a porcine liver perfusion model, we used RFA (group A) and ECT (group B) to perform ablations under ultrasound guidance within 10 mm of a vessel and examined the induced necrosis macroscopically and histologically. RESULTS: We created 83 lesions (RFA: 59, ECT: 24) in 27 livers. In group A (mean liver weight: 2046 g), perfusion was macroscopically found to limit necrosis in 52.5% of the procedures. Histology demonstrated the destruction of only 30.4% of the vessel walls within the ablation areas. In group B (mean liver weight: 1885 g), we detected reproducible and sharply demarcated ablation areas both macroscopically and histologically. Necrosis was unaffected by nearby vessels. No viable cells were found perivascularly. Histology showed destruction of the vascular endothelium without any discontinuities. We measured pH values of 0.9 (range: 0.6-1.8) at the anode and 12.2 (range: 11.4-12.6) at the cathode. Treatment time was 100 min when a charge of 300 coulombs was delivered. CONCLUSIONS: Electrochemical treatment is a method of ablation that creates reproducible and predictable volumes of necrosis. It produces sharply demarcated areas of complete necrosis also in perivascular sites. ECT, however, requires much longer treatment times than RFA. In our model, the effects of RFA were considerably limited by perfusion, which caused incomplete areas of necrosis in proximity to vessels.

Protein profiling of genomic instability in endometrial cancer.

DNA aneuploidy has been identified as a prognostic factor in the majority of epithelial malignancies. We aimed at identifying ploidy-associated protein expression in endometrial cancer of different prognostic subgroups. Comparison of gel electrophoresis-based protein expression patterns between normal endometrium (n = 5), diploid (n = 7), and aneuploid (n = 7) endometrial carcinoma detected 121 ploidy-associated protein forms, 42 differentially expressed between normal endometrium and diploid endometrioid carcinomas, 37 between diploid and aneuploid endometrioid carcinomas, and 41 between diploid endometrioid and aneuploid uterine papillary serous cancer. Proteins were identified by mass spectrometry and evaluated by Ingenuity Pathway Analysis. Targets were confirmed by liquid chromatography/mass spectrometry. Mass spectrometry identified 41 distinct polypeptides and pathway analysis resulted in high-ranked networks with vimentin and Nf-κB as central nodes. These results identify ploidy-associated protein expression differences that overrule histopathology-associated expression differences and emphasize particular protein networks in genomic stability of endometrial cancer.

Evaluation of the quality of life after surgical treatment of chronic pancreatitis.

OBJECTIVE: Pain is the main symptom of chronic pancreatitis. However, in addition to an improvement in pain symptoms, an increase in the quality of life also influences therapeutic success. The present paper evaluates the influence of surgery on chronic pancreatitis, and the early and late postoperative quality of life. PATIENTS: From March 2000 until April 2005, 51 patients underwent surgical treatment for chronic pancreatitis at our institution. INTERVENTION: Thirty-nine (76.5%) patients were operated on according to the Frey procedure and, in 12 (23.5%) patients, a Whipple procedure was performed. STUDY DESIGN: Patient data were documented throughout the duration of the hospital stay. Postoperative follow-up data were recorded retrospectively. MAIN OUTCOME MEASURES: Postoperative follow-up with postoperative pain scores and quality of life were carried out using a standardized questionnaire. RESULTS: During a median follow-up period of 50 months, an improvement in pain scores was observed in 92.3% of the patients in the Frey group and in 66.7% in the Whipple group. The indices for global quality of life and for physical and emotional status increased in both surgical groups. CONCLUSION: For patients with chronic pancreatitis, the decisive factor is the quality of life, particularly concerning pain and metabolic changes. The Frey procedure seems to offer advantages with respect to long-term freedom of pain and low risk of surgery-induced pancreatic insufficiency.

How to do it--laparoscopic resection rectopexy.

INTRODUCTION: A variety of surgical strategies have been suggested and many surgical techniques, both abdominal and perineal, have been introduced for treatment of rectal prolapse. All these techniques and approaches are based on the attempt to restore the normal anatomy and physiologic function. METHODS: In 1992, Berman et al. published the first laparoscopically performed rectopexy. Meanwhile, many different minimally invasive procedures have been described. Throughout the past century, more than 100 different surgical techniques have been introduced to treat patients with rectal prolapse. Unfortunately, there is still lack of one generally accepted standard technique for the surgical treatment of rectal prolapse. RESULTS AND DISCUSSION: Our current data strongly supports laparoscopic resection rectopexy to be a safe, fast, and very effective procedure to improve function in patients with rectal prolapse. More evaluations of long-term outcome are needed that focus on each particular laparoscopic procedure to adequately compare different techniques. The indication to perform a laparoscopic resection rectopexy in patients with a previous perineal procedure and a recurrent prolapse should be stated critically because these patients seem to have a high risk to develop yet another recurrence.

A pilot study on the improvement of the lying area of finishing pigs by a soft lying mat.

In this pilot study, we tested whether a soft mat (foam covered with a heat-sealed thermoplastic) reduces alterations and injuries at the skin and the leg joints.The soft mat in the lying area of partly slatted pens was compared to a lying area consisting of either bare or slightly littered (100 g straw per pig and day) concrete flooring. In this study we focused on skin lesions on the legs of finishing pigs as indicators of impaired welfare. Pigs were kept in 19 groups of 8-10 individuals and were examined for skin lesions around the carpal and tarsal joints either at a weight of <35 kg, or at close to 100 kg. The likelihood of hairless patches and wounds at the tarsal joints was significantly lower in pens with the soft lying mat than in pens with a bare concrete floor. Pens with a littered concrete floor did not differ compared to pens with a bare concrete floor. The soft lying mat thus improved floor quality in the lying area in terms of preventing skin lesions compared to bare and slightly littered concrete flooring. Such soft lying mats have thus the potential to improve lying comfort and welfare of finishing pigs.

Laparoscopic resection rectopexy for rectal prolapse: a single-center study during 16 years.

BACKGROUND: Many different techniques to treat rectal prolapse have been introduced. Laparoscopic resection rectopexy has been shown to entail benefits regarding both perioperative results and short-term outcome, whereas data for long-term outcome are scarce. METHODS: Between 1993 and 2008, all laparoscopic resection rectopexies for rectal prolapse II° or III° were selected from a prospective laparoscopic colorectal surgery database. We analyzed demographic, perioperative, and follow-up results. We defined two periods (1993-2000 and 2001-2008) for comparison of data. Long-term follow-up was obtained by sending questionnaires to all patients. Evaluation included constipation, incontinence, and recurrence of prolapse. RESULTS: Between January 1993 and November 2008, we performed 152 laparoscopic resection rectopexies for rectal prolapse. Median age was 64.1 years (± 14.6). Conversion rate was 0.7% (1), mean operation time was 204 (± 65.3) min, and was significantly shorter in the second period compared with the first (P < 0.0001). Mortality was 0.7% (n = 1). Complication rates were 4% (n = 6; major) and 19.2% (n = 29; minor), respectively. Mean length of hospital stay was 11.3 (± 6.4) days and was significantly shorter in the second period compared with the first period (P < 0.0001). Mean time of follow-up was 47.7 (± 41.6) months. Improvement or complete elimination of constipation was stated by 81.3% (65), and improvement or elimination of incontinence was stated by 67.3% (72). Overall recurrence rate was 11.1% (n = 10) with a rate of 5.6% (n = 5) for a 5-year period. Of those patients with previous perineal surgery for rectal prolapse, 53.8% (7/13) experienced recurrent prolapse after laparoscopic resection rectopexy in contrast to 3.9% (3/77) of patients without previous perineal prolapse surgery (P < 0.0001). CONCLUSIONS: Our data support the benefits of laparoscopic resection rectopexy for rectal prolapse regarding both perioperative results and long-term functional outcome. Preceding perineal or open abdominal operations have an impact on recurrence after laparoscopic resection rectopexy.

Fournier's gangrene: is the female gender a risk factor?

OBJECTIVE: Fournier's gangrene is a necrotizing fasciitis that affects the perineal, genital, or perianal regions. The objective of this study was to highlight this uncommon condition with a particular focus on the disease course in females. MATERIALS AND METHODS: From 1996 to 2008, we prospectively collected data from 38 patients with Fournier's gangrene (12 women, 26 men) and retrospectively analyzed relevant parameters. RESULTS: The mean age was 60.9 +/- 11.3 years for females (group I) and 56.2 +/- 11.7 years for males (group II). In both groups, the main predisposing factors were diabetes mellitus and obesity (body mass index of 30 or higher). Twelve men (46.2%), but no women, had chronic alcoholism. The most commonly isolated agents were Escherichia coli (n = 22), streptococcal species (n = 18), Pseudomonas aeruginosa (n = 9), and Staphylococcus aureus (n = 7). Mortality was significantly higher among females (50%) than males (7.7%; p = 0.011). Peritonitis was present in seven group I patients (58.3%) and in two group II patients (7.7%). The retroperitoneum was involved in seven female patients (58.3%) and four male patients (15.4%). CONCLUSION: The female gender is a risk factor for mortality in patients with Fournier's gangrene and is associated with a higher incidence of inflammation of the retroperitoneal space and abdominal cavity. Differences in male and female genital anatomy may be the reason for the rapid spread of infection to the retroperitoneum and the fatal outcome in women. Fournier's gangrene as a high-risk disease in females should attract exceeding attention.

Factors predicting the postoperative outcome of lower gastrointestinal hemorrhage.

PURPOSE: To examine the treatment outcome for patients with acute bleeding from the lower gastrointestinal tract requiring transfusion and acute surgical care as a function of various risk factors MATERIALS AND METHODS: Between 1999 and 2007, we collected data on 59 patients (39 male and 20 female patients) who received surgical intervention for acute lower intestinal hemorrhage requiring transfusion at our university clinic. Treatment complications and mortality were analyzed retrospectively. RESULTS: The average age of the patients in this study is 70.0 +/- 12.2 years (range, 39 to 97 years) with an overall mortality of 15.3%. Blood transfusions >10 U (p = 0.031), postoperative need for ventilation (p = 0.004), necessary reoperations (p = 0.016), and an initial hemoglobin level <80 g/L (p = 0.043) proved to be significant risk factors for death. Blood transfusions >10 U (p = 0.028), necessary reoperations (p = 0.001), and an initial hemoglobin level <80 g/L (p = 0.033) were found to be significant risk factors for postoperative complications. All other parameters have no significant impact. CONCLUSIONS: The decisive factors for the outcome of lower gastrointestinal hemorrhage requiring surgery are the severity of bleeding, beginning of treatment (initial hemoglobin level, need for packed red blood cells), and treatment efficiency (necessary reoperation).

Crohn's disease-a chameleon during pregnancy.

BACKGROUND: In the past, women with Crohn's disease (CD) as a risk factor in pregnancy were discouraged from becoming pregnant. Today, by contrast, gestation is medically acceptable in these patients despite several severe complications. MATERIALS AND METHODS: We present the course of five female patients with CD requiring surgery during pregnancy and giving birth at our institution between 1998 and 2008. These cases as well as our treatment recommendations for patients wishing to have children and our approaches to the management of complications during pregnancy are discussed in the light of the literature. RESULTS AND CONCLUSION: Three of five women had a preterm delivery (26 to 31 weeks' gestation) with a decreased neonatal weight. Generally, the diagnosis of CD is often delayed and diagnostic errors (four of five women) are not uncommon. The symptoms vary widely and include those typical of pregnancy. Three patients had to have a cesarean and only two patients were able to deliver vaginally. Especially in pregnant patients, the course of the disease is highly variable and difficult to predict. Our experience suggests that patients should be advised to conceive during remission. Indications for surgery in pregnant patients are the same as for nonpregnant women and include perforation, obstruction, hemorrhage, and abscess. The advantages of endoscopic surgery also apply to pregnant patients with acute manifestations. A stoma is not a contraindication to vaginal delivery.

Development of a dynamic model to predict PM10 emissions from swine houses.

Influences on dust emissions from livestock operations are number, weight, and kind of animals and characteristics of the housing system. Differences between facilities cannot be explained solely by mechanistic input variables. The objective of this study was to characterize the main input variables for modeling emissions of particulate matter with a mass median diameter < or = 10 microm (PM10) from swine facilities using a data-based model. Investigations were performed in mechanically ventilated facilities for weaning, growing-finishing, and sows in Italy and Germany. The measurements included inside and outside concentration of airborne PM10 particles (scatter light photometry), ventilation rate (calibrated measuring fans), indoor air climate at a measuring frequency of 60 s, feeding times, and animal-related data such as weight and animal activity. Dust concentration and emission were simulated using a dynamic transfer function. The results indicated that the average PM10 emission rate was influenced considerably by housing system. The simulation of the PM10 emission rate resulted in a mean percentage error per data set of 21 to 39%, whereas the average simulated and measured emission rate per data set differed by about 4 to 19%. High prediction errors occurred especially during situations in which the absolute level and spatial location of the measured activity peaks did not correspond with the measured dust peaks. Further recommendations of the study were to improve continuous and accurate measurements of input variables, such as the activity level in animal houses, and to optimize the amount of measuring days in relation to the model accuracy.