Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature.

BACKGROUND: Since January 1st, 2005, the current situation for bariatric surgery has been examined by means of a voluntary quality assurance study in Germany with a multicenter design in which 38 hospitals and surgical departments participated. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany). METHODS: Data describing peri-interventional characteristics were prospectively documented in an internet online data registry. All primary bariatric procedures performed since January 1st, 2005, were registered. In addition, reoperations in patients who had previously undergone primary surgical intervention were included. As a representative excerpt from the overall prospective multicenter observational study on obesity surgery, data on the type, regimen, and time course of deep venous thrombosis (DVT) prophylaxis were documented. From the number and spectrum of complications, the incidences of clinically manifest DVT or pulmonary embolism (PE) were derived during the in-hospital course and follow-up in conjunction with the type of surgical procedure and body mass index (BMI). RESULTS: Overall, 3,122 bariatric procedures were performed at 38 German hospitals between January 2005 and December 2007. These procedures were subdivided into 2,869 primary operations and 253 revisions (sex ratio, male to female = 25.6:74.4%). The average BMI of all patients was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. In 2005 and 2006, gastric banding (GB) was the most commonly performed operation, followed by Roux-en-Y gastric bypass (RYGBP). In 2007, RYGBP was carried out in 42.1% of all bariatric procedures. Interestingly, the incidence of deep venous thrombosis (DVT) was only 0.06%, whereas PE occurred in 0.06% of patients only after hospital discharge. The DVT prophylaxis protocol used has been changed for the last 2 years: the majority of patients with a BMI above 50 kg/m(2) received low-molecular-weight heparin twice a day. CONCLUSION: In Germany, a trend from GB to sleeve gastrectomy (SG) and malabsorptive approach has been evaluated. This trend is associated with differences of the DVT prophylaxis regimen in the profile of bariatric surgical patients depending on BMI and the type of bariatric procedure. Despite the low incidence of DVT and pulmonary embolism (PE) detected, there is a lack of evidence on a reasonable regimen for sufficient DVT prophylaxis in bariatric surgery; instead, there are only recommendations from the guidelines and statements of a specific medical society. Therefore, prospective studies are necessary to determine the optimal DVT prophylaxis for bariatric surgical patients as well as obese patients undergoing surgery.

A nationwide survey on bariatric surgery in Germany--results 2005-2007.

BACKGROUND: Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined since January 1st, 2005 with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany). METHODS: In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an Internet online data registry. In particular, perioperative characteristics, such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes, were investigated. RESULTS: During the study period, 629 surgical procedures were performed at 21 hospitals in 2005, 828 procedures at 32 hospitals in 2006, and 1,666 procedures at 35 hospitals in 2007. In 2005 and 2006, gastric banding was the most frequently performed operation, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean body mass index (BMI) was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. Follow-up data after 12 months were available for 63.8% of the patients in 2005 and 2006; these data showed greater reduction of BMI after malabsorptive rather than restrictive bariatric procedures. The mortality was 0.1% (30 days) and 0.16% (overall). CONCLUSION: As indicated by the worldwide trend, there is an ongoing change from restrictive bariatric procedures to malabsorptive procedures and sleeve gastrectomy. Although the BMIs of German patients undergoing bariatric surgery appear to be substantially higher than those of patients from most other countries, there were no differences in intraoperative and short-term complications or in overall outcomes during follow-up when compared with published studies.

Results of sleeve gastrectomy-data from a nationwide survey on bariatric surgery in Germany.

BACKGROUND: Beginning January 1, 2005, the status and outcomes of bariatric surgery were examined in Germany. Data are registered in cooperation with the An-Institute of quality assurance in surgery at the Otto-von-Guericke-University Magdeburg. The objective of this study was to examine the morbidity and mortality rates secondary to sleeve gastrectomy (SG) in Germany since 2006. METHODS: Data collection occurred prospectively in an online data bank. All primary bariatric procedures performed were recorded as were all re-operations in patients that had already undergone a primary operation. Specific data compiled on the sleeve gastrectomy procedure were evaluated with a focus on operative details and complication rates. RESULTS: The total study cohort contains 3,122 patients. From January 2006 to December 2007, 144 sleeve gastrectomy procedures were performed in the 17 hospitals participating in the study. The mean body mass index (BMI) of all patients was 48.8 kg/m(2). The BMI of patients undergoing SG was 54.5 kg/m(2). In total, 73.8% of the patients were female and 26.2% of the patients were male. There were no significant differences between patients undergoing SG. The general complication rate after SG was 14.1%, and the surgical complication rate was 9.4%. The postoperative mortality rate was 1.4%. CONCLUSIONS: The complication rate during the first 2 years after SG in Germany is similar to that published in the literature. In order to improve the quality of bariatric surgery, an evaluation of data from a German multicenter trial is necessary to evaluate the position of SG in the bariatric algorithm.

[Intraoperative fluorescence angiography in colorectal surgery]. / Intraoperative Fluoreszenzangiographie in der kolorektalen Chirurgie.

BACKGROUND: Fluorescence angiography with indocyanine green (ICG-FA) is frequently used in colorectal surgery to assess the blood perfusion in the region of an anastomosis. Previous studies with ICG-FA in both open and laparoscopic surgery could show a low rate of anastomotic leakage, e.g. the PILLAR II study with a leakage rate of 1.4%. This article presents own results, the current status of ICG-FA and the fields of application. OBJECTIVE: The aim of the study was to analyze whether the results obtained so far with ICG-FA are sufficient to recommend an extended use of this relatively new method in colorectal surgery. MATERIAL AND METHODS: From July 2009 to June 2019 a total of 378 colorectal resections (280 colon resections and 98 rectal resections) with intraoperative examination of the anastomosis using ICG-FA were performed. In 13 patients (3.4%) there was reduced intraoperative perfusion, which led to a change in the operative procedure (resection of the anastomosis and new anastomosis, colostomy). RESULTS: The total anastomotic leakage rate was 3.7% with 8 leaks in the colon (2.9%) and 6 in the rectum (6.1%). Without the intraoperative change in 13 patients the rate of leakages could have increased to 7.1% (27/378). The use of ICG-FA in the group of patients studied potentially led to a reduction of the leakage rate by 48%. Current publications show similar results with a potential decrease in the rate of anastomotic leaks in colorectal surgery. CONCLUSION: The results show a very low rate of anastomotic leakage when using ICG-FA. These results are promising in colorectal surgery but controlled randomized studies are lacking and should be carried out before final recommendations can be given.

[Perspectives in long-term care insurance]. / Perspektiven der Pflegeversicherung.

Twelve years after its introduction, long-term care insurance is back on the agenda and up for political reform. This paper shows why long-term care insurance needs to be reformed. The two central aspects on which reform projects focus are addressed: firstly, the structural improvement of nursing care and long-term care insurance and, secondly, the creation of a sustained financing. The principal conclusion is that, while there is a broad consensus about the structural improvement of long-term care insurance, opinions differ widely in the matter of its sustained financing. As a consequence, a coherent financing concept has yet to emerge.

Impact of weight loss-associated changes in detailed body composition as assessed by whole-body MRI on plasma insulin levels and homeostatis model assessment index.

BACKGROUND/OBJECTIVES: We assessed the effect of weight loss-associated changes in detailed body composition on plasma insulin levels and homeostatic model assessment (HOMA) index to calculate the magnitude of reduction in different adipose tissue depots required to improve insulin sensitivity. SUBJECTS/METHODS: A total of 50 subjects aged 20-69 years were studied. The participants were compiled from low-calorie diet interventions and bariatric surgery and differed in their baseline body mass index (BMI; range 21.6-54.4 kg/m2) and degree of weight losses (range -3.3 to -56.9 kg). Detailed body composition and liver fat were measured using whole-body magnetic resonance imaging (MRI). Insulin resistance was assessed by HOMA. RESULTS: Mean body weight decreased by -16.0±13.6 kg. Significant changes were observed in total adipose tissue (TATMRI, range -0.5 to -36.0 kg), total subcutaneous adipose tissue (SATMRI), visceral adipose tissue (VATMRI), skeletal muscle, liver fat, plasma insulin levels and HOMA. Decreases in insulin and HOMA were correlated with reductions in TATMRI, SATMRI, VATMRI (just with HOMA) and liver fat. Losses of 2.9 and 6.5 kg body weight, 2.0 and 5.0 kg TATMRI as well as 1.6 and 6% liver fat were required to decrease plasma insulin levels by 1 µU/ml and HOMAadjusted for baseline HOMA by 1 point. Multiple regression analysis showed that baseline liver fat and changes in liver fat explained 49.7% and 55.1% of the variance in weight loss-associated changes in plasma insulin and HOMA, respectively. CONCLUSIONS: Decreases of adipose tissues and liver fat are the major determinants of reduction in plasma insulin levels and improvement in HOMA index.

Xanthogranuloma of the dura in systemic Weber-Christian disease.

A 51-year-old woman who had systemic Weber-Christian disease (WCD) displayed multiple xanthomatous lesions and a large xanthogranuloma of the tentorium cerebelli with signs of brainstem and cerebellar compression. Three other cases of dural xanthomatous lesions associated with systemic WCD have been reported. These dural and leptomeningeal xanthomatous lesions in WCD, a nonsuppurative inflammatory condition, are similar to those of Hand-Schüller-Christian disease, a quasi-neoplastic process.

Case report: acute hemorrhagic multifocal angioencephalopathy.

A 53-year-old chronic alcoholic male developed an acute febrile, fulminant fatal encephalopathy which lasted 2.5 weeks. Necropsy showed focal, acute hemorrhagic necrotizing lesions of the diencephalon, cingulate gyrus, and amygdala, apparently due to a vasculopathy involving mainly small veins. The case is unique, but the pathology is somewhat similar to an idiopathic disorder described as subacute diencephalic angioencephalopathy [DeGirolami et al. 1974, Kinney et al. 1980].

Occurrence of breast carcinoma within a fibroadenoma. A review.

Sixty-two cases of carcinoma within a breast fibroadenoma are adequately documented in the literature, including the present case. All are found in women. The mean age of occurrence is 42.4 years. This corresponds to the peak age of lobular in situ breast cancer but is much higher than the peak age for breast fibroadenomas. Sixty-five percent of patients harboring cancer within a fibroadenoma have lobular in situ malignant neoplasms. In 42% of the cases the surrounding breast tissue is also involved by cancer, a fact that dictates generous surgical margination of all fibroadenomas excised, especially in older women. The data indicate that the presence of the fibroadenoma is a parameter independent of the development of cancer in either the ipsilateral or contralateral breast and does not influence the clinical course of the malignant neoplasm, other than that it contributes to its earlier detection. Treatment should follow the general principles of therapy for the in situ or infiltrative breast cancers.

Protein thiol-disulfide interchange and interfacing with biological systems.

Disulfide-containing proteins offer unique advantages for mechanistic studies of the formation of native three-dimensional structure from unordered, reduced precursors. The main advantage is that covalent intermediates are formed; by characterizing these intermediates, one obtains substantial information about the reaction pathway. Thiol-disulfide interchange is a major component of most oxidative mechanisms carrying thiol to disulfide; thus, it required some attention in its own right. Afinsen's descriptions of a "shuffle-ase" enzyme led us to examine the rates of the uncatalyzed exchange under physiologically plausible conditions. Somewhat surprisingly, we found that the rates for formation of several native proteins in uncatalyzed systems containing GSSG and GSH are as great as with the "shuffle-ase" enzyme, suggesting that a substantial portion of biological thiol oxidations proceed by uncatalyzed exchange. While thiol-disulfide exchange of course results in no net change in the oxidation level of a system, catalytic linkage of thiol or disulfide to other redox systems provides a mechanism for achieving net changes.

[Treatment of chronic proliferative glomerulonephritis using acetylsalicylic acid and dipyridamole]. / Lécba chronické proliferativní glomerulonefritidy kyselinou acetylosalicylovou a dipyridamolem.

Fourteen patients with chronic proliferative glomerulonephritis were given for the period of one year 400 mg acetylsalicylic acid and 225 mg dipyridamole per day. During this treatment the thrombocyte aggregation became normal, however, the mean reduction of antiheparin plasma activity was not statistically significant. Normal synthesis of renal prostacyclin declined significantly as a result of treatment, while the renal thromboxane A2 synthesis remained normal even during treatment. Treatment did not influence proteinuria. The mean annual decline of glomerular filtration was greater during the investigation period than the mean annual decline in previous years, the difference was, however, only at the borderline of statistical significance. The authors did not prove a favourable effect of this treatment in patients with chronic proliferative glomerulonephritis.

[Prostaglandins and chronic proliferative glomerulonephritis]. / Prostaglandiny a chronická proliferativní glomerulonefritida.

In 14 patients with chronic proliferative glomerulonephritis, corrected arterial hypertension and normal or marginal glomerular filtration the authors assessed plasmatic and urinary metabolites of PGI2 and TXA2. They found that the production of both PGI2 and TXA2 was raised in the organism and they assume that in the stimulated synthesis hypertension and its treatment participated. The production of both prostaglandins in the kidneys was, however, normal.