Predictors of Morbidity and Mortality in Esophageal Perforation: Retrospective Study of 80 Patients.

BACKGROUND AND AIMS: Esophageal perforation is a life-threatening disease. Factors impacting morbidity and mortality include the cause and site of the perforation, the time to diagnosis, and the therapeutic procedure. This study aimed to identify risk factors for morbidity and mortality after esophageal perforation. PATIENTS AND METHODS: This retrospective study analyzed data collected from all patients treated for esophageal perforation at the Department of Surgery, University of Schleswig-Holstein, Luebeck Campus, from January 1986 through December 2011. RESULTS: Altogether, 80 patients (52 men, 28 women; mean age 65 years) were treated. The cause of perforation was intraluminal in 44 (55%) (group A) and extraluminal in 2 (3%) (group B). Spontaneous perforations were observed in 12 (15%) (group C). Perforations were due to a preexisting esophageal disease in 22 (28%) (group D). The survival rate was higher for group A (82%) than for groups B (50%), C (57%), and D (59%). The distal third of the esophagus had the highest prevalence of perforations (49, 61%) independent of the cause. Mortality, however, was independent of the perforation site. Perforations were diagnosed within 24 h in 57% (n = 46) of patients, associated with a statistically significant lower mortality rate (p = 0.035). Altogether, 40 patients underwent non-operative treatment, and among those 27 had endoscopic treatment. Emergency thoracic surgery was performed in 40 patients: direct suture of the defect (n = 26), partial esophageal resection (n = 11), other (n = 3). Significantly higher morbidity (p = 0.007) and prolonged hospitalization (p < 0.0001) was observed among patients who underwent emergency surgery. Mortality was higher in the surgical group (14/40) than in the non-operative treatment group (9/40) but without statistical significance. CONCLUSION: Intraluminal perforations, rapid initiation of therapy, and non-operative treatment were associated with favorable outcomes. The perforation site did not have an impact on outcomes. Esophageal resection was associated with high mortality.

Influence of different substrates on the performance of a two-stage high pressure anaerobic digestion system.

The two-stage autogenerative high-pressure digestion technique is a novel and promising approach for the production of gaseous fuels or upgraded biogas. This new technique is described in the patent DE 10 2011 015415 A1 and integrates biogas production, its upgrading and pressure boosting in one process. Anaerobic digestion under elevated pressure conditions leads to decreasing pH-values in the digestate due to the augmented formation of carboxylic acid. Model calculations carried out to evaluate the two-stage design showed that the pH-value in the pressurized anaerobic filter has a major influence on the methane content of the biogas produced. Within this study, the influence of the nitrogen content as one of the most important buffering substances on the performance of the system has been tested. The results show that higher NH4 contents lead to higher pH-values in the digester and as a consequence to higher methane contents.

[Female patient with hematemesis and upper abdominal pain]. / Kontrastverstärkter Ultraschall der Skelettmuskulatur.

A 42-year-old female patient presented with acute pain of the upper abdomen, postprandial vomiting and hematemesis. An operation for gastric banding had been carried out 1 month prior to presentation. The abdominal X-ray and radioscopy revealed a posterior slippage of the gastric fundus following the gastric banding operation.

Different surgical strategies for chronic pancreatitis significantly improve long-term outcome: a comparative single center study.

OBJECTIVE: In general, chronic pancreatitis (CP) primarily requires conservative treatment. The chronic pain syndrome and complications make patients seek surgical advice, frequently after years of progression. In the past, surgical procedures involving drainage as well as resection have been employed successfully. The present study compared the different surgical strategies. - PATIENTS AND METHODS: From March 2000 until April 2005, a total of 51 patients underwent surgical treatment for CP at the Department of surgery, University of Schleswig-Holstein, Campus Lübeck. Out of those 51 patients, 39 (76.5%) were operated according to the Frey procedure, and in 12 cases (23.5%) the Whipple procedure was performed. Patient data were documented prospectively throughout the duration of the hospital stay. The evaluation of the postoperative pain score was carried out retrospectively with a validated questionnaire. RESULTS: Average operating time was 240 minutes for the Frey group and 411 minutes for the Whipple group. The medium number of blood transfusions was 1 in the Frey group and 4.5 in the Whipple group. Overall morbidity was 21% in the Frey group and 42% in the Whipple group. 30-day mortality was zero for all patients. During the median follow-up period of 50 months, an improvement in pain score was observed in 93% of the patients of the Frey group and 67% of the patients treated according to the Whipple procedure. CONCLUSION: The results show that both the Frey procedure as well as partial pancreaticoduodenectomy are capable of improving chronic pain symptoms in CP. As far as later endocrine and exocrine pancreatic insufficiency is concerned, however, the extended drainage operation according to Frey proves to be advantageous compared to the traditional resection procedure by Whipple. Accordingly, the Frey procedure provides us with an organ-preserving surgical procedure which treats the complications of CP sufficiently, thus being an alternative to partial pancreaticoduodenectomy if there is no suspicion of malignancy.

[Surgical intervention in acute upper gastrointestinal bleeding]. / Die Operation als Notfalltherapie bei akuter gastrointestinaler Blutung.

BACKGROUND AND PURPOSE: Acute gastrointestinal bleeding (AGIB) requiring transfusion and surgical treatment still constitutes a life-threatening situation. The purpose of this paper was to examine the treatment outcome for this group of patients as a function of various risk factors and to present our diagnostic and therapeutic regime. METHODS: A retrospective analysis of data from 154 patients with AGIB who underwent surgical procedures and received massive transfusions in a university hospital between 1999 and 2008 was carried out. RESULTS: The patients were divided into two groups. Group I include 91 patients with acute upper gastrointestinal bleeding and group II included 63 patients with lower gastrointestinal bleeding. The average age was 67 years (range 29-93 years) in group I and 70 years (39-97 years) in group II. The initial hemoglobin level was 8.4 g/dl in group I and 10.5 g/dl in group II. Univariate analysis of mortality revealed the following significant risk factors for group I: postoperative need for ventilation (p=0.007), prolonged ICU stay (p=0.004) and anticoagulants in the medical history. The risk factors in group II were blood transfusions >10 units (p=0.031), postoperative need for ventilation (p=0.004), necessary reoperations (p=0.016) and an initial hemoglobin level <8.0 g/dl (p=0.043). The complication rate was 76.9% (mortality rate 34.1%) in group I and 60.3% (mortality rate 15.9%) in group II. CONCLUSIONS: Examination and stabilization of the patient is directly followed by diagnostic localization. The indication for surgery is mainly limited to peracute, uncontrollable and recurrent forms of gastrointestinal bleeding. The mortality rate for these critically ill, negatively selected patients remains high and could not be lowered in the last decade. Postoperative need of ventilation is a predictor for poor prognosis.

Intensified surveillance after surgery for colorectal cancer significantly improves survival.

BACKGROUND: Postoperative surveillance after curative resection for colorectal cancer has been demonstrated to improve survival. It remains unknown however, whether intensified surveillance provides a significant benefit regarding outcome and survival. This study was aimed at comparing different surveillance strategies regarding their effect on long-term outcome. METHODS: Between 1990 and 2006, all curative resections for colorectal cancer were selected from our prospective colorectal cancer database. All patients were offered to follow our institution's surveillance program according to the ASCO guidelines. We defined surveillance as "intensive" in cases where >70% appointments were attended and the program was completed. As "minimal" we defined surveillance with <70% of the appointments attended and an incomplete program. As "none" we defined the group which did not take part in any surveillance. RESULTS: Out of 1469 patients 858 patients underwent "intensive", 297 "minimal" and 314 "none" surveillance. The three groups were well balanced regarding biographical data and tumor characteristics. The 5-year survival rates were 79% (intensive), 76% (minimal) and 54% (none) (OR 1.480, (95% CI 1.135-1.929); p <0.0001), respectively. The 10-year survival rates were 65% (intensive), 50% (minimal) and 31% (none) (p <0.0001), respectively. With a median follow-up of 70 months the median time of survival was 191 months (intensive), 116 months (minimal) and 66 months (none) (p <0.0001). After recurrence, the 5-year survival rates were 32% (intensive, p = 0.034), 13% (minimal, p = 0.001) and 19% (none, p = 0.614). The median time of survival after recurrence was 31 months (intensive, p <0.0001), 21 months (minimal, p <0.0001) and 16 month (none, p <0.0001) respectively. CONCLUSION: Intensive surveillance after curative resection of colorectal cancer improves survival. In cases of recurrent disease, intensive surveillance has a positive impact on patients' prognosis. Large randomized, multicenter trials are needed to substantiate these results.

New insights into the epidemiology and etiology of Fournier's gangrene: a review of 33 patients.

BACKGROUND: Fournier's gangrene is a necrotizing fasciitis involving the perineal and genital regions. Even today, this often polymicrobial infection still carries a high mortality rate and continues to be a major challenge to the medical community. The purpose of this study was to report our experience with this condition and to compare it with those reported in published studies. We also introduce our approach to treatment. METHODS: We analyzed data from 33 patients with Fournier's gangrene who were managed in our hospital from 1996 to 2007, focusing on patient gender, age, etiology, predisposing conditions, comorbidities, bacteriology, sepsis, blood results, mortality, and spread of gangrene. RESULTS: 18 (54.5%) of the 33 patients had been referred to our department by smaller district hospitals. The patient cohort consisted of 23 men and ten women with a median age of 59 years (range 40-79 years). The median time between the onset of symptoms and progression to gangrene was 6 days (range 2-28 days). An underlying cause was identified in 27 patients (81.8%). The commonest etiological events were perianal and perirectal abscesses (n = 13; 39.4%). Predisposing factors included diabetes mellitus in 12 cases (36.4%), chronic alcoholism in ten cases (30.3%), immunosuppression in six cases (18.2%), and prolonged immobilization in five cases (15.2%). 17 patients (51.5%) had a body mass index (BMI) of 25 or higher, and 13 patients (39.4%) had a BMI of 30 or higher. Positive cultures were obtained in 30 cases (90.9%). In 26 cases (78.8%), multiple microorganisms were recovered, including nine cases (27.3%) with both aerobes and anaerobes. Sepsis was present in 26 patients (78.8%). The mortality rate was 18.2%. CONCLUSION: Fournier's gangrene remains a major challenge with a high mortality. Our results suggest that women are more commonly affected than has generally been assumed. Contrary to published reports, we found that anorectal sources appear to account for more cases of Fournier's gangrene than urological sources.

[Does the third staple line of a new endostapler offer an advantage?]. / Bringt die dritte Klammernahtreihe eines neuen Endostaplers einen medizinischen Vorteil?

BACKGROUND: In laparoscopic colon surgery, endostaplers generate 2 parallel rows of staples. The aim of this paper is to analyse whether the introduction of a new endostapler generating a third row of staples influences the rate of anastomotic leakage and bleedings. METHOD: 362 patients of the Department of Surgery, University Clinic of Schleswig-Holstein, Campus Lübeck, were included in this study. All patients underwent colon resection with performance of double-stapling anastomosis. In Group I (n = 148; 7 / 2004 to 12 / 2005), the Endopath TSB 45 endostapler (2 rows of staples) was used, whereas in Group II (n = 214; 7 / 2006 to 12 / 2007), the Echelon60 EC60 stapler (3 rows of staples) was used. All further operational steps were identical for both groups. Target parameters were the postoperative anastomotic leakage and anastomotic bleeding rates. RESULTS: Between July 2004 and December 2005, the number of anastomotic leaks (Stapler Endopath, TSB 45) was n = 4 (2.7 %), for the second period (Stapler Echelon60 EC60), it was n = 9 (3.7 %) (not significant). Using the Endopath TSB 45 stapler, the number of anastomotic bleedings was n = 12 (8.1 %), and for the Echelon60 EC60 stapler, it was n = 8 (3.7 %) (p = 0.074; not significant). Within the 18-month period between July 2006 and December 2007, the number of endoscopic colon operations (n = 214) rose by 44.6 % compared to the 18-month period between July 2004 and December 2005 (n = 148). CONCLUSION: The application of the advanced Echelon endostapler has no impact on the number of anastomotic leaks, and reduces the number of anastomotic bleedings slightly but not significantly. The increased number of endoscopic procedures in the second period results both from the growing number of indications for the application of endoscopic techniques and the positive findings of recent studies carried out by our own and other working groups.

[Surgical management of peripheral arterial disease. Operative methods and results]. / Die chirurgische Behandlung der arteriellen Verschlusskrankheit. Operationsmethoden und Ergebnisse.

Various operative and interventional methods are available to treat patients with peripheral arterial disease (PAD). The selection of the appropriate therapy should be made after a careful review of the patient's general condition, the morphology of the arterial occlusion, the risk of possible complications, and the likelihood of long-term success for each type of treatment. The different procedures complement one another in their technical possibilities and their risk profile The combination of surgical and interventional methods offers new therapeutic possibilities. The different surgical procedures and their long-term outcome are presented in this publication.

[CTA and MRA in peripheral arterial disease--is DSA out?]. / CTA und MRA bei PAVK--ist die DSA "out"?

New developments in technique and postprocessing have led to further improvement in diagnosing and evaluating peripheral arterial disease (PAD) by noninvasive computed tomographic angiography (CTA) and magnetic resonance angiography (MRA). Under clinical conditions diagnostic conventional angiography (DSA) will be increasingly replaced by CTA and MRA. The radiologist has to become familiar with the field of indications, the different techniques, postprocessing tools, and effective visualization. In consideration of the current literature some methodological aspects and the role of CTA and MRA in PAD will be discussed.

[Complicated course of oesophageal perforations because of fungal infections]. / Erschwerter Verlauf von Osophagusperforationen durch Pilzinfektion.

Perforations of the oesophagus are characterized by a high mortality rate, varying between 7 and 49%. In the analyzed group of patients between the years 1986 and 2003, the mortality rate of 28% was caused by septic complications such as mediastinitis and pneumonia. Microbiological examinations of samples from different locations and various secretions, detected mycoses in 28% of the patients (n = 16). Compared with the total of mycoses, a higher mortality of 50% was calculated. The invasive Candida infection of the oesophagus itself can cause a perforation. In perforations of the oesophagus, simultaneous mycoses arise by fungi invading sterile compartments or by haematogenous and lymphogenous dissemination up to sepsis. Uncomplicated courses do not need antimycotic therapy. At the beginning of the treatment, a microbiological monitoring should be provided, particularly with regard to the intraoperative facts. In relation to the course and the risk factors of the patients, an antimycotic therapy is initiated. Surgical clearing and sufficient drainage of the collateral compartments such as pleural and mediastinal compartments is highly significant.

Determination of the dynamics of the odour release from a pig house, using an electronic odour sensor.

The widely fluctuating operating conditions in pig husbandry, due to climatic and biological changes (changes in temperature and air flowrate between day and night, as well as between summer and winter, increasing animal mass during the fattening process, etc.) exert a significant influence on the amount of actual odour emission. The project presented here comprised the measurement of seasonal (fattening course), daytime-related, and short-term (feeding) dynamic effects of odour release, as well as the identification of potential factors which influence the amount of odour emitted. In parallel with "classic" olfactometry, an electronic odour sensor with a chemosensor array of ten metal oxide sensors was employed. The highest odour emissions are measured on hot summer days, while the lowest emissions were determined on cold winter days. On the one hand, the sensor signals of the electronic odour sensor exhibited considerable differences on days with large volume flow alterations. On the other hand, continuous measurement with the electronic odour sensor allowed changes in the gas- and odorant composition of the exhaust air during feeding times to be shown. From the measurement results, recommendations for odour sampling, the consideration of seasonal odour emission fluctuations, and the use of electronic odour sensors for the evaluation of odour emissions have been derived.

Influence of different pig housing systems on odor emissions.

The odor emissions from two different housing systems were determined during three fattening periods from October 1999 to November 2000 by analyzing weekly samples by means of dynamic olfactometry. The objects of the investigations were a standard housing system with fully slatted floor and forced ventilation (FF) compared with a kennel housing system with natural shaft ventilation (KN) in parallel operation. Only little data but with a wide range of odor emission values are available from the literature and these are difficult to compare and interpret, because of missing standards in presenting the results and experimental conditions. Therefore minimum requirements for measuring odor emissions from livestock buildings have been derived. In the scope of the measurements during the first two fattening periods (October 1999 to June 2000), no differences in odor emissions could be determined with mean values related to the livestock units (1 LU = 500 kg life weight) of 85 (FF) /87 (KN) in period A and 60 (FF) / 61 (KN) (OU/s)LU(-1) in period B. The overall range of the results of all measurements in periods A and B was 4 to 355 (OU/s)LU(-1). In period C (August-November 2000), the system FF showed higher odor emissions with 193 (28-550) compared to system KN with 105 (25-218) (OU/s)LU(-1). The air flow rates and odor concentrations at the three different naturally ventilated exhaust shafts of system KN differed considerably from each other. Odor measurement techniques with a higher temporal resolution than olfactometry are necessary to give evidence for the main factors influencing the odor formation and release.

Biofilters--the influence of different filter materials and different operating conditions on the reduction efficiency.

A series of biofilter materials were tested for performance efficiency in treating ventilation air from pig sheds. Two different phases were conducted. In phase A five different biofilter materials were tested with the aim of selecting the best material regarding the odor reduction and over all efficiency. In conclusion of phase A, biochips, a new filter material, was selected due to its high average odor reduction (81%) in combination with a very low flow resistance (less than 30 Pa for filter volume loads of 600 m3 h(-1) m(-3)). In phase B, biochips and coconut fiber peat were tested under different operating conditions. Biofilters number 3 and 4 each with down-flow air supply could realize a higher average odor reduction than biofilter 5 with up-flow air supply. All three filter materials had the same moisture, however the two biofilters with down-flow air supply showed a more homogenous moisture distribution but they also used approximately three times more water than biofilter 5. Like in phase A the specific odor cleaning efficiency was mainly influenced by the specific odor loading rate and showed only slight differences between the five biofilters differing in bulk layer height (0.5 m and 1.0 m) and air supply mode. All in all the investigation showed that the efficiency of biofilters can be optimized by using an new filter material and a appropiate operating mode.

Detection of the dynamics of odour emissions from pig farms using dynamic olfactometry and an electronic odour sensor.

The dynamics of odour emissions from a pig house was investigated by olfactometry and using an electronic odour sensor. In addition, several suggested influencing factors on the odour emission were measured to get insight into the reasons for the fluctuation of the odour emission. Odour emission tended to increase over the fattening period f rom August to November 2000 by a factor of two to three, although temperature and air-flow rate decreased according to the seasons. Feeding caused a significant temporary rise in animal activity, dust and odour concentration resulting in an increase of odour emission. The sensor signals of an electronic odour sensor increased simultaneously and showed a good relation to the odour concentration. There is a promising potential of electronic odour sensors to detect the dynamic and the level of odour concentrations. Further investigation will be done, to ensure a standardised measuring protocol and to obtain a calibration of electronic odour sensor signals direct to odour concentrations.

Sugar beet mash silage as a component of a total-mixed-ration for dairy cows--effects on parameters of digestion and animal performance.

Sugar beet mash silage (BMS) was offered in amounts up to 35% of DM to dairy cows as a component of a total-mixed-ration (TMR). Barley and molasses in the control ration were replaced by BMS half in ration BMS 1/2 and in total in ration BMS 1/1 on the basis of the calculated contents of net energy for lactation. Two trials were carried out. In trial I each ration was tested on parameters of rumen fermentation and digestibility of crude nutrients using 4 Holstein cows with rumen fistula. Chewing activity was tested on 2 Holstein cows for each ration. With the BMS rations the ruminal NH3 concentration was lower and the drop in pH was less than in the control ration. The pattern of volatile fatty acids in the rumen fluid from the BMS groups tended towards more propionic and butyric acid. The feeding of BMS showed no negative impact on chewing and rumination. Energy digestibility raised significantly from 59.8% in the control ration to 72.6% in the BMS 1/1 ration. In trial II the same rations were fed in a change-overdesign to a herd of 24 Holstein cows to test feed intake and animal performance. The results showed no significant effects of BMS rations on DM intake and milk production. The results of both trials indicate that even high amounts of cereals can be replaced by BMS without negative effects on rumen fermentation, milk yield and milk composition with slight drop in fat content. For a better handling of BMS, it is of advantage to include it in a TMR.