Metabolic risk factors in formerly obese women--effects of a pronounced weight loss by gastric band operation compared with weight loss by diet alone.

AIM: The aim of the present study was to evaluate differences in the metabolic risk profile in formerly obese women, in whom a significant weight loss was obtained by Swedish adjustable gastric band (SAGB) operation or by diet alone. METHODS: A total of 40 patients (24 after SAGB and 16 after diet) participated in the study. Clinical data, including body mass index (BMI), waist-to-hip ratio, body fat content and blood pressure values, as well as laboratory results [fasting glucose, insulin, homeostasis model assessment (HOMA) index, leptin, lipid values and markers of subclinical inflammation] were evaluated before a planned abdominoplastic operation. RESULTS: Patients in the SABG group had lost a significantly greater amount of weight (52.7 +/- 10.0 kg) compared with the diet group (20.0 +/- 11.5 kg; p < 0.001), and the percent excess weight loss was 69.1 +/- 11.4 in the SAGB group and 54.5 +/- 17.7 (p < 0.040) in the diet group. Before the abdominoplastic operation neither the mean BMI nor the percentage of fat mass revealed a significant difference between the groups. Fasting insulin (6.1 +/- 3.0 microU/ml) and the HOMA index (1.4 +/- 0.7) as a measure of insulin resistance were significantly lower in the SAGB than in the diet group (fasting insulin: 8.2 +/- 3.8 microU/ml; p < 0.048; HOMA index: 2.0 +/- 1.0; p < 0.031). Swedish adjustable gastric band patients showed significantly lower plasma leptin levels (9.4 +/- 10.8 ng/ml) than the dietary-treated patients (13.9 +/- 9.6 ng/ml; p < 0.014), while tumour necrosis factor-alpha serum levels were increased in the SAGB group (17.6 +/- 7.3 pg/ml) compared with the diet group (11.9 +/- 0.49 pg/l; p < 0.048). CONCLUSIONS: The extensive weight loss in formerly obese women after SAGB operation was paralleled by a favourable metabolic profile indicating a higher degree of insulin sensitivity than in women after a successful, but less pronounced weight loss by diet alone.

Bilateral hand transplantation: bone healing under immunosuppression with tacrolimus, mycophenolate mofetil, and prednisolone.

PURPOSE: Little is known about bone healing after composite tissue transplantation that requires pharmacologic immunosuppression. Bone integration and callus development were assessed in bilateral hand transplantation. METHODS: In this study the course of callus development and callus maturation were assessed by color Doppler sonography and radiography in a double hand transplant and compared with forearm replantation. RESULTS: After hand transplantation, ingrowth of small vessels at the bone junction was observed at week 3, calcified callus became visible at month 4, and bone union was completed at month 11. A similar time course of bone integration was observed after replantation. Plating offered sufficient stability. A recipient periostal flap is thought to have improved blood supply and favored development and induction of callus. CONCLUSIONS: Bone healing after hand transplantation under immunosuppression with tacrolimus, mycophenolate mofetil, and prednisolone is identical to that after forearm replantation.

A comparative study of three different biomaterials in the engineering of skeletal muscle using a rat animal model.

Defects caused by traumatic or postsurgical loss of muscle mass may result in severe impairments of the functionality of skeletal muscle. Tissue engineering represents a possible approach to replace the lost or defective muscle. The aim of this study was to compare the suitability of three different biomaterials as scaffolds for rat myoblasts, using a new animal model. PKH26-fluorescent-stained cultured rat myoblasts were either seeded onto polyglycolic acid meshes or, alternatively, suspended in alginate or in hyaluronic acid-hydrogels. In each of the eight Fisher CDF-344 rats, four capsule pouches were induced by subcutaneous implantation of four silicone sheets. After two weeks the silicone sheets were removed and myoblast-biomaterial-constructs were implanted in the preformed capsules. Specimens were harvested after four weeks and examined histologically by H&E-staining and fluorescence microscopy. All capsules were well-vascularized. Implanted myoblasts fused by forming multinucleated myotubes. This study demonstrates that myoblasts seeded onto different biomaterials can be successfully transplanted into preformed highly vascularized capsule pouches. Our animal model has paved the way for studies of myoblast-biomaterial transplantations into an ectopic non-muscular environment.

Transplantation of tracheal epithelial cells onto a prefabricated capsule pouch with fibrin glue as a delivery vehicle.

OBJECTIVE: The purpose of this study was to investigate whether in vitro cultured tracheal epithelial cells can be transplanted onto a prefabricated capsule surface in vivo for possible use in tracheal reconstruction. METHODS: Tracheal epithelial cells from 12 donor inbred rats were harvested for culture and expansion. In 16 recipient inbred rats, 2 sterile cylinders made of silicone rubber were implanted in each rat bilaterally in the folds of both the left and right anterior rectus sheath by wrapping the sheaths around the cylinders to induce a capsule formation. Ten days later, the cell cultures were divided and suspended in 1 of 2 delivery vehicles (standard culture medium or fibrin glue) and implanted onto the capsule surface. To compare the 2 delivery vehicles, we used fibrin glue on one side and the standard culture medium on the other. RESULTS: After 2 (group 1, n = 8) and 4 (group 2, n = 8) weeks, histologic findings, immunohistochemical staining, and electron microscopy demonstrated the capsule to be covered with a tracheal neoepithelium in group 1 and additional ciliated cells and secretory cells in a confluent layer in group 2 but only on the side with fibrin glue as the delivery vehicle. No viable epithelial cells were identified on the side with the standard culture medium in either group. CONCLUSION: We conclude that cultured epithelial cells can be successfully transplanted onto a prefabricated capsule surface with fibrin glue, which will differentiate into morphologic, nearly normal epithelium, showing potential for tracheal reconstruction.

Bladder reconstruction using a prevascularized capsular tissue seeded with urothelial cells.

PURPOSE: Recent advances in cell biology and tissue engineering have involved various avascular or acellular scaffolds with or without seeded cells. These techniques are frequently complicated by tissue necrosis, contracture and resorption. We used a vascularized matrix prelaminated with autologous cultured urothelial cells to reconstruct bladder wall defects. MATERIALS AND METHODS: A silicone block inserted into the right groin of 50 male Wistar rats directly superficial to the inferior epigastric vessels was used to induce capsule pouch formation. Urothelial cells harvested simultaneously and cultured were then suspended in fibrin glue and seeded into the newly formed capsule after removing the silicone block. After 1 week the prelaminated flap was transposed into a surgically created bladder wall defect. Experimental groups included rats with a urothelial cell seeded capsule pouch sacrificed at 1 and 4 weeks, respectively, after bladder reconstruction. In control rats scaffolds were treated only with fibrin glue or saline before transposition. RESULTS: Hematoxylin and eosin and immunohistochemical staining showed a continuous multilayered urothelial lining along the transposed prelaminated capsule flap in the experimental groups with better survival compared to controls treated only with fibrin glue (80% mortality) or saline (100% mortality). The surviving 3 control animals did not have a urothelial lining. CONCLUSIONS: Vascularized prefabricated flaps lined with culture derived urothelial cells were successfully used for bladder reconstruction in a rat model. The technique of prefabricating a vascularized scaffold lined with autologous urothelial cells may provide a method for future reconstruction of the genitourinary systems.

The lateral thoracic fasciocutaneous island flap for treatment of recurrent hidradenitis axillaris suppurativa and other axillary skin defects.

A series of eight axillary skin defect reconstructions in seven patients using the lateral thoracic island fasciocutaneous flap is presented. The defects originated from wide excision of recurrent hidradenitis axillaris suppurativa and in one case from radical melanoma resection with axillary lymph node clearance. The technique used to cover the resulting large defects is advancement or transposition of an island flap from the lateral thoracic wall, pedicled on two or three nourishing vessels arising from the lateral thoracic or thoracodorsal vessels. No flap complications occurred and the results with respect to donor site morbidity, functional and aesthetic outcome were very satisfactory.

Autoimmune reactions in patients with silicone breast implants.

Silicone breast implants have been surgical routine for over 30 years. An association between silicone augmentation and immune related diseases has been reported in approximately 100 cases. In a retrospective single center study we investigated 36 non-selected women with silicone breast implants and 36 sex- and age-matched controls. Autoimmune reactions were evaluated by measuring antinuclear antibodies (ANA), rheumatoid factor (RF) and thyroid gland antibodies (TMS), along with angiotensin-converting enzyme (ACE), C-reactive protein (CRP) and other immunological and laboratory parameters. In the controls only 3 (8%) women had an elevated ANA titer and 1 demonstrated thyroid autoantibodies (microsomal), giving a total of 4 (11%) women with detectable autoantibodies. By contrast, 12 (33%) of the 36 women with silicone augmentation had raised ANA titers (> or = 1 : 80), a significantly higher percentage than in the control group (p < 0.02). Of the 12 women, 1 showed antismooth muscle antibodies (ASMA; titer 1 : 40) and 2 of the patients displayed antineutrophilic cytoplasm antibodies (ANCA; 1 : 320 and 1 : 40, respectively), one of the latter also being positive for rheumatoid factor. 2 further women demonstrated thyroid autoantibodies (microsomal), giving a total of 14 (39%) women in whom significant autoantibodies were detectable. Clinical symptoms (musculoskeletal) were present in 1 patient. Most of the observed autoantibodies were organ-unspecific, with a predominance of elevated ANA titers of the heterogeneous type and not related to a distinct clinical entity. However, none of the investigated women with silicone breast implants showed clinical symptoms or signs of connective tissue disease according to ARA criteria.

Wound closure at the trunk by microvascular free flap transfer.

Defects of the thoracic or abdominal wall can be congenital or caused by trauma or tumour resection. There may be other problems, such as infection and irradiation effects. In most cases those defects can be closed by local cutaneous and fasciocutaneous or by muscle and myocutaneous flaps. In some rare instances, the use of pedicled flaps may be limited. The size of the defect, the impossibility of closing the donor site, an impaired blood supply, or poor quality of local tissues represent such limitations. In these cases microvascular flap transfer has enlarged our choice of alternative methods. Advantages of this method are the one-stage procedure and the wound coverage by well-vascularized tissue. This is especially beneficial in areas of infected or irradiated tissue. On the other hand microvascular flap transfer requires high technical skill and extensive perioperative and postoperative care.

Autotransplanted jejunum in patients with carcinomas of the head and neck: transport of immunosurveillance against tumor cells?

Autologous jejunum, transplanted as a functional replacement immediately after radical dissection of advanced stages of squamous cell carcinomas of the head and neck and subsequently irradiated, was examined by immunohistochemistry (APAAP/PAP-technique). Biopsies from 9 patients were taken at the time of transplantation and up to 24 months thereafter (group 1) and from 5 patients only once after transplantation (group 2). Twenty-six monoclonal antibodies (mAbs) were used as surface markers to give an overview about phenotypical changes with respect to T-, B- and M phi-antigens. 1) B cells: a general increase of CR2+ (CD21, p less than 0.01) could be noticed after transplantation, immunoglobulin positive cells remained unchanged expect for a significant decrease of IgM+ (p less than 0.01) and IgA1+ (p less than 0.01) cells. 2) The number of T cells (CD3+) showed no significant differences although TcR gamma/delta+ cells decreased (p less than 0.01) in the autotransplant. ICAM-1 (CD54) and IL-2R (CD25) were found on a significant (p less than 0.01) higher number of cells after transplantation. 3) Cells with M/M phi morphology showed increased expression of the Fc gamma receptors (CD64, p less than 0.001; CD32, n.s.; CD16, p less than 0.001), of the complement receptors CR1 (CD35, (p less than 0.001) and CR3 (CD11b, p less than 0.02), of HLA-DQ (p less than 0.01), and of the antigens 25F9 (mature M phi; p less than 0.01) and CD4 (p less than 0.02). Correlation analyses of data obtained from the biopsies of the 14 autotransplanted jejunum cases revealed a CD35+ and a 25F9+ subpopulation of M/M phi. Our findings indicate that despite irradiation autotransplanted jejunum contained cells with immunological capacities. Therefore, the replacement of larynx by autologous jejunum may facilitate not only mechanical but also immunological functions.

Radiation of jejunal interposition in T3-T4 upper aerodigestive tumours.

30 patients with T3 and T4 tumours of the upper aerodigestive tract had their tumours resected by pharyngolaryngectomy. This was followed by reconstruction of a gullet or creation of a siphon as a tracheohypopharyngeal shunt for voice restoration with a free jejunal autograft. All patients were treated postoperatively with 60Co gamma radiation, 6 MeV photons or 7.5 to 10 MeV electrons of a beta-tron, with a dose of 50-65 Gy in the area of the primary tumour and 50-65 Gy to the neck. 4 patients refused further treatment after a depth dose of between 16 and 32 Gy. Local recurrence occurred in 40% of cases. The survival rate was 36.6% (11/30) after a mean follow-up time of 21.5 months, although 2 patients died of intercurrent diseases without recurrence of their tumours. The results obtained justify active surgical intervention with postoperative irradiation even at an advanced stage of the tumour.

[The ultrasonic diagnosis of an ulnar nerve lesion in the sulcus area]. / Ultraschalldiagnostik der Nervus-ulnaris-Läsion im Sulkusbereich.

The diagnostic accuracy of ultrasound in ulnar nerve irritation syndrome was evaluated. 7 patients were examined and compared to a control group of 5 healthy persons. We correlated pathological changes with clinical signs and symptoms, nerve conduction velocity and with the operation report. Ultrasound yielded no false negative or false positive results and is therefore a valuable method for the evaluation of the ulnar nerve irritation syndrome especially in cases of vague localisation of the nerve lesion.

[Histologic study of the effect of postoperative irradiation on free transplanted jejunal segments]. / Histologische Studie über den Einfluss der postoperativen Bestrahlung auf frei transplantierte Jejunalsegmente.

After the reconstruction of defects resulting from the resection of advanced tumors from the upper aerodigestive tract using free microvascular anastomized jejunum, the autotransplant is influenced by local radiotherapy (cumulative dose 50-70 Gray). Biopsies were taken from 15 patients, stained with haemotoxilin-eosin and Giemsa and compared by means of light microscopy with jejunum taken at the time of transplantation. It was possible to observe a widened mucosal and submucosal space two to three months after radiotherapy, similar to the clinical impression of a radiogenic enteritis. The villi were flat and shortened with no or slight epithelial lesions. Additionally, it was possible to observe an inflammatory infiltration consisting mainly of neutrophilic granulocytes, edemas, and telangiectases. The latter were also evident in nonirradiated autotransplanted jejunum and are therefore not only caused by irradiation. One year after radiotherapy the mucosal membrane was atrophic. Fibrosis was to be seen in the lamina propria, accompanied by widened muscularis mucosae. The submucosal space was also widened and fibrotic to a varying degree. It was possible to detect varying stages of alteration in the vascular system up to a complete obliteration. After two years, changes were more pronounced. At no time could any alteration in the nervous system of the plexus submucosus be observed. All of these changes have to be interpreted as a consequence of irradiation. However, lubrication of the mucosal surface and the motility of the transplant are not altered severely by irradiation and therefore the desired functions of the free transplanted jejunal grafts, such as swallowing and phonation, are carried out sufficiently.(ABSTRACT TRUNCATED AT 250 WORDS)

[Differential treatment of post-traumatic carpal tunnel syndrome]. / Differenzierte Behandlung des posttraumatischen Karpaltunnelsyndroms.

The pathogenesis and treatment of posttraumatic compression of the median nerve in the carpal canal are analysed in 36 patients. Nine patients had mal-union of a Colles' fracture. In these patients the symptoms of median nerve compression were completely relieved by correction osteotomy of the radial metaphysis, which also improved radiocarpal joint function. At follow-up examination after four years the results were satisfactory and the median nerve appeared normal in clinical and electro-physiological tests. In the other twenty-seven patients there had been a Colles' fracture in seventeen, healed with a deviation of less than 10 degrees; a carpal bone fracture in three cases; in seven patients no osseous lesion was found. In these patients the flexor retinaculum was split and resected. An anterior callus was removed in three cases. At reexamination after four years four patients still noticed diminished sensibility in the median nerve distribution, and in four cases there was wrist joint pain in relation to exercise.

[Value of free, microvascular anastomosis of a small intestine transplant in reconstructive surgery following resection of T4 tumors of the upper aerodigestive tract]. / Die Wertigkeit des freien, mikrovasculär anastomosierten Dünndarminterponates in der Wiederherstellungschirurgie nach Resektion von T4-Tumoren des oberen aerodigestiven Traktes.

The jejunal graft with microsurgical vascular anastomoses is now recognised as one of the most reliable methods for reconstructing large and various defects of the upper aero-digestive tract. After resection of T4-tumours and reconstruction of phonation, deglutition and aesthetics 50% of our patients could be resocialized within the first postoperative month.

Survival of a free musculocutaneous flap after early loss of arterial blood supply.

A 30 X 15 cm free musculocutaneous flap survived nearly completely when its supplying artery was ligated on the 17th postoperative day to control bleeding from a ruptured septic aneurysm. Similar cases in the literature are reviewed and the factors influencing flap survival are discussed.

[A new method of surgical voice rehabilitation: microsurgical jejunum transplantation]. / Neue Methode zur chirurgischen Stimmrehabilitation: Mikrochirurgische Jejunum-Transplantation.

A new method of surgical rehabilitation of the voice is being presented. A shunt is introduced between the trachea and the hypopharynx or the entrance to the oesophagus, by the use of a jejunal graft which is sutured isoperistaltically. By microsurgical anastomoses the jejunum is revascularized by the cervical vessels. Seven patients, having undergone total laryngectomy because of carcinoma of the larynx, have been treated by this procedure. In one case a venous thrombosis developed and the graft had to be resected. The other patients regained a voice, able to meet all requirements of daily life. The voice shows a remarkable low phonatory pressure, a good modulation capacity and a phonatic duration of up to 20 seconds.

[Reconstruction of defects following pharyngolaryngectomy with free transplanted jejunum]. / Rekonstruktion von Defekten nach Pharyngo-Laryngektomie mit frei transplantiertem Jejunum.

We report 10 patients undergoing pharyngo-laryngectomy in whom the pharyngeal defect was reconstructed with a free jejunal graft. This method is technically demanding. The advantages are excellent healing due to the excellent blood supply of the edges of the graft, and the almost unlimited supply of jejunum. The use of this method is justified by the immediate restoration of deglutition.

Jejunal grafts for reconstructing a phonatory neoglottis in laryngectomized patients.

After laryngopharyngectomy and reconstruction of the upper digestive tract, a free jejunal graft can be anastomosed in an isoperistaltic direction end-to-end to the trachea and the hypopharynx in order to form a shunt for vocal rehabilitation. Following placement of the shunt, no special care is required nor does any patient show any aspiration. Because of a low-flow resistance of the shunt, patients so treated possess long-lasting phonation with loud and modulated voices.