Posttraumatic venous gas in the liver - a case report and review of the current literature.

BACKGROUND: There are numerous causes of hepatic gas formation that range from serious pathologies to incidental findings, including mesenteric infarction, liver abscess, inflammatory bowel disease or minimally invasive hepatic interventions. CASE PRESENTATION: We report a case of a 50-year-old man who was admitted to the emergency room after a car accident. The clinical examination and further diagnostics revealed a craniocerebral injury with a fracture of the skull, concomitant soft tissue lesions and subarachnoidal bleeding. Furthermore, a blunt thoracic trauma with hemopneumothorax due to rib fractures was treated with a chest tube. No obvious abdominal pathology was seen. While in the operating theatre for the surgical revision of the cranial soft tissue lesions, a femoral venous catheter was inserted without any complications. A routine ultrasound of the abdomen six hours after the trauma revealed unclear hepatic gas formation. A contrast-enhanced computer tomography (CT) scan of the abdomen was performed, and the gas formation was found to be localized within the left hepatic vein. Afterwards, there was no specific treatment of the hepatic venous gas formation, as no alterations of liver function or liver enzymes were seen. The further course of the patient was uneventful regarding the gas formation in the liver, and another ultrasound two days later revealed no further gas in the liver. CONCLUSIONS: The placement of a femoral venous catheter is a risk factor for gas formation in liver veins. No further treatment is needed in cases with stable liver function. To rule out serious pathologies, diagnostic findings (e.g., ultrasound, CT), clinical history and underlying diseases need to be analyzed carefully after the detection of intrahepatic gas formation. With contrast-enhanced CT, the localization of the gas and its potential causes might be detectable.

Microbiology of the infected recurrent sacrococcygeal pilonidal sinus.

The aim of the present retrospective single centre study was to define the changes in the microbiological flora of the recurring sacrococcygeal pilonidal sinus (PS). Microbiological findings of swab samples of abscess-forming PS from 2000 to 2010 were evaluated. Within this time span, 73 swab samples were taken from primary sacrococcygeal pilonidal sinus (pPS) and 23 swab samples of patients with recurring sacrococcygeal pilonidal sinus (rPS). Our results show a statistically significant shift of the bacterial flora towards the gram-positive range (P = 0·029) and a shift with tendency towards the aerobic range (P = 0·090). Pathogens of pPS are not always solely anaerobic or gram-negative, and those of rPS not always aerobic or gram-positive. Therefore, antibiosis preceding microbiological examination should cover both the aerobic and anaerobic bacteria as well as the gram-positive and the gram-negative spectrum.

Predictive factors for survival and recurrence rate in patients with node-negative gastric cancer--a European single-centre experience.

PURPOSE: Gastric cancer is a common disease with poor prognosis. Lymph node involvement is the strongest prognostic factor regarding survival in curatively (R0) resected patients. The aim of this study was to determine if a subgroup with higher risk for tumour recurrence exists in patients with node-negative gastric cancer. Furthermore, we aimed to identify prognostic factors and recurrence patterns for this subgroup. METHODS: We collected demographical, clinical, pathohistological and follow-up data from 1,074 patients with gastric cancer in a prospectively maintained database. In 228 cases, R0 resections for node-negative gastric cancer were performed. The median follow-up period was 59 months. Statistical analysis was performed using SPSS 19.0. RESULTS: The 5- , 10- and 15-year overall survival was 83, 75.5 and 73 %, respectively, with a disease-free survival of 78, 73 and 73 %. Tumour recurrence was observed in 18.9 % (43 cases), 14 % of which were diagnosed after more than 5 years. Gender, T-category , lymphangioinvasion, tumour differentiation, serosal infiltration, histological growth pattern, tumour size and classification according to Lauren were significant prognostic factors for overall survival in univariate analysis. Multivariate analysis showed tumour size and female sex to be independent prognostic factors. Non-exophytic tumour growth was a relevant factor for the development of local recurrence. Diffuse type gastric cancers as well as signet ring cells were significantly associated with the development of peritoneal carcinomatosis, and male gender with hematogenous metastases. CONCLUSIONS: Multimodal treatment and individual follow-up might be beneficial in patients with higher risk of recurrence after R0 resection of node-negative gastric cancer.

Suture granuloma mimicking a recurrent sacro-coccygeal pilonidal sinus after Limberg flap.

Sacro-coccygeal pilonidal sinus disease is classified as an asymptomatic, acutely abscess-forming or chronic subcutaneous inflammation in the sacro-coccygeal region featuring characteristic pits in the bottom cleft. Due to high rates of recurrence, two flap techniques have been established in the course of the past three decades. One of them is the Karydakis operation, the other option is a rotation flap named Limberg procedure. We report about a case of suture granuloma in the area of a Limberg flap after recurrent pilonidal sinus with extrusion of the suture material, thus mimicking recurrence. In case of recurrent pilonidal sinus following plastic coverage or primary closure, respectively, the differential diagnosis of suture granuloma should be considered.

Clinical symptoms and sonographic follow-up after surgical treatment of nonparasitic liver cysts.

BACKGROUND: The optimal treatment of nonparasitic liver cysts is still a topic of debate. Only symptomatic cysts are being considered as requiring treatment. Aim of this study is to evaluate our experience with this disease over the past ten years with a structured follow-up program. METHODS: From January 2000 to August 2010, 56 consecutive patients with nonparasitic liver cysts were treated at our institution. We assessed morbidity, recurrence and complication rates, quality of life as well as pre- and post-operative sonographic status of the cysts and course of clinical symptoms. RESULTS: In 84% of the patients surgery was started as a laparoscopic procedure. Conversion rate was 6.4%. Average diameter of deroofed cysts was 12 cm. Overall complication rate was 16% and overall recurrence rate 28.3% (8.7% recurrences at the surgical site, 19.6% new or enlarged cysts). One half of the patients were symptom-free after surgery and the other half had at least one persisting symptom post-operatively. In one half of these patients with persisting symptoms, symptoms were ameliorated by surgery. In the other half of patients the number of symptoms increased after surgery. Two thirds of the overall patients reported their post-operative health as being good or very good. CONCLUSIONS: Surgical deroofing is the most effective treatment option for symptomatic liver cysts. Half of our patient population retained at least one symptom from a group of more than ten abdominal symptoms.Only the minority of these cases may be attributed to true recurrence, de-novo cysts or growing pre-existing cysts. The analysis of our cases suggests that the persistent symptoms in our patients may in part be due to the fact that the association between clinical complaints and the liver cysts was not sufficiently established. A more rigid patient selection should be implemented in order to achieve better results from the treatment of cysts. Because even large cysts are frequently asymptomatic, patient selection should not primarily be based on the cyst size only. The decision should be based strictly on the correlation between cyst / cyst location and symptoms / clinical complaints. In our opinion, further diagnostic procedures may be necessary in individual cases to clarify such a correlation.

Resection of liver metastases is beneficial in patients with gastric cancer: report on 15 cases and review of literature.

BACKGROUND: Although up to 9% of patients with gastric cancer develop liver metastases, liver resection is rarely performed because of co-existing non-curative factors. Furthermore, the benefit of liver resection is still controversially discussed. Our goal was to investigate the outcome of patients who underwent liver resection or radiofrequency ablation (RFA) for hepatic metastasized gastric cancer. METHODS: Retrospectively collected data from a prospectively maintained database were analyzed from 15 patients who underwent liver resection or RFA for liver metastases from gastric cancer. RESULTS: Overall 5-year survival and median survival were 27% and 48 months for resected/RFA patients. The peri-operative complication rate was low. One patient has been tumor-free for 90 months now. CONCLUSIONS: Liver resection in patients with hepatic metastasized gastric cancer is beneficial and safe if an R0 situation can be achieved. RFA might be a useful alternative in those patients where surgery is not feasible.

Impact of clinical and pathohistological characteristics on the incidence of recurrence and survival in elderly patients with gastric cancer.

BACKGROUND: Gastric cancer is one of the most frequent malignant tumors worldwide. Despite improvements in diagnostic procedures, as well as the introduction of multimodal treatment strategies, the overall prognosis remains poor. The role of gastric resection in elderly patients with gastric cancer has not been clearly defined as yet. The goal of the present study was to assess whether specific pathohistological features result in different outcomes for younger patients and elderly patients. METHODS: A total of 272 patients with advanced gastric cancer treated surgically in our hospital between 1998 and 2009 were included in the study. Data were analyzed from a prospectively maintained database. RESULTS: Median overall survival was 84 months in the younger subgroup and 37 months in the elderly subgroup (P = 0.038), whereas local recurrence occurred more frequently in younger patients (33% vs. 23%). We identified positive lymph nodes at the contralateral curvature, perilymphonodular tumor cells, and positive lymph node conglomerates as strong negative prognostic factors. There were few pathohistological characteristics that affected survival and the incidence of tumor recurrence differently in elderly and younger patients. Although only a few elderly patients underwent chemotherapy plus gastric resection (7% vs. 28% of the younger patients), there was a trend toward longer survival for those who received multimodal treatment. CONCLUSIONS: Our results suggest that there is no tumor-related prognostic difference between young and elderly patients that would preclude radical surgery in elderly patients, as long as they are generally fit for surgery.

New methods for clinical pathways-Business Process Modeling Notation (BPMN) and Tangible Business Process Modeling (t.BPM).

PURPOSE: Clinical pathways (CP) are nowadays used in numerous institutions, but their real impact is still a matter of debate. The optimal design of a clinical pathway remains unclear and is mainly determined by the expectations of the individual institution. The purpose of the here described pilot project was the development of two CP (colon and rectum carcinoma) according to Business Process Modeling Notation (BPMN) and Tangible Business Process Modeling (t.BPM). METHODS: BPMN is an established standard for business process modelling in industry and economy. It is, in the broadest sense, a computer programme which enables the description and a relatively easy graphical imaging of complex processes. t.BPM is a modular construction system of the BPMN symbols which enables the creation of an outline or raw model, e.g. by placing the symbols on a spread-out paper sheet. The thus created outline can then be transferred to the computer and further modified as required. CP for the treatment of colon and rectal cancer have been developed with support of an external IT coach. RESULTS: The pathway was developed in an interdisciplinary and interprofessional manner (55 man-days over 15 working days). During this time, necessary interviews with medical, nursing and administrative staffs were conducted as well. Both pathways were developed parallel. Subsequent analysis was focussed on feasibility, expenditure, clarity and suitability for daily clinical practice. The familiarization with BPMN was relatively quick and intuitive. The use of t.BPM enabled the pragmatic, effective and results-directed creation of outlines for the CP. The development of both CP was finished from the diagnostic evaluation to the adjuvant/neoadjuvant therapy and rehabilitation phase. The integration of checklists, guidelines and important medical or other documents is easily accomplished. A direct integration into the hospital computer system is currently not possible for technical reasons. CONCLUSION: BPMN and t.BPM are sufficiently suitable for the planned modelling and imaging of CP. The application in medicine is new, and transfer from the industrial process management is in principle possible. BPMN-CP may be used for teaching and training, patient information and quality management. The graphical image is clearly structured and appealing. Even though the efficiency in the creation of BPMN-CP increases markedly after the training phase, high amounts of manpower and time are required. The most sensible and consequent application of a BPMN-CP would be the direct integration into the hospital computer system. The integration of a modelling language, such as BPMN, into the hospital computer systems could be a very sensible approach for the development of new hospital information systems in the future.

Non-curative gastric resection for patients with stage 4 gastric cancer--a single center experience and current review of literature.

PURPOSE: The majority of patients with gastric cancer present with an advanced stage and, therefore, may not be eligible for curative treatment. The role of non-curative gastric resection in situations other than emergency treatment for life threatening tumor-related complications is still under discussion. METHODS: Data from 290 consecutive patients with advanced gastric cancer who were treated in our hospital were analyzed. A total of 48 patients underwent primary non-curative gastric resection. RESULTS: The overall survival in the non-curatively resected group was 15 months and 6 months for non-resected patients, respectively (p < 0.001). The incidence of tumor-related complications which required intervention was 63% in non-resected patients as compared to 12% in patients who underwent primary non-curative resection. Younger age, less than three tumor locations, and chemotherapy have been identified as prognostic factors for improved survival by univariate analysis. D3 lymph node involvement and chemotherapy were independent prognostic factors in the multivariate analysis. Peritoneal carcinosis did not significantly influence survival in resected patients. Non-curative resection in combination with chemotherapy resulted in longer overall survival than resection alone. CONCLUSIONS: Primary non-curative gastric resection can reduce the incidence of severe tumor-related complications and can prolong overall survival in selected subgroups. In particular, younger patients with no more than two tumor locations should be considered for this procedure.

The Interplay Between Biliary Occlusion and Liver Regeneration: Repeated Regeneration Stimuli Restore Biliary Drainage by Promoting Hepatobiliary Remodeling in a Rat Model.

Background and Aims: Patients with malignant biliary obstruction do not seem to benefit from "two-stage hepatectomy" due to an impairment of liver regeneration. We designed a novel model of "repeated regeneration stimuli" in rats mimicking a "two-stage hepatectomy" with selective or complete biliary occlusion mimicking Klatskin tumors III° or IV°. Using this new model, we wanted to investigate (1) the impact of preexistent cholestasis of different extent on the time course of liver regeneration and (2) the dynamics of hepatobiliary remodeling under regeneration conditions. Materials and Methods: Rats were subjected to a sequence of three operations: surgical induction of biliary occlusion, followed by "repeated regeneration stimuli" consisting of ligation of the left branch of the portal vein (supplying 70% of the liver volume, sPVL) as first stage and a 70%-hepatectomy (70%PHx) as second stage. Biliary occlusion (1st procedure) was induced by ligating and transection of either the common (100%, tBDT) or the left bile duct (70%, sBDT). A sham operation without ligating the bile duct was performed as control (0%, Sham). Two weeks later, on day 14 (POD14), the sPVL (2nd procedure) was performed. Another week later (POD 21), the 70%PHx (3rd procedure) took place and animals were observed for 1 week (POD 28). The first experiment (n = 45 rats) was dedicated to investigating liver regeneration (hypertrophy/atrophy), proliferative activity and hepatobiliary histomorphology (2D-histology: HE, BrdU) in the future liver remnant (FLR). The second experiment (n = 25 rats) was performed to study the dynamics of hepatobiliary remodeling in livers with different regenerative pressure (tBDT only POD21 vs. tBDT only POD 28 vs. tBDT + sPVL vs. tBDT + 70%PHx vs. tBDT + sPVL + 70%PHx) using µCT scans of explanted livers. Effect of biliary occlusion: Total biliary occlusion (tBDT) led to a 2.4-fold increase in whole liver volume due to severe biliary proliferation within 14 days. In contrast, partial biliary occlusion (sBDT) caused only a volume gain of the obstructed liver lobes due to biliary proliferates, resulting in a minor increase of total liver volume (1.7-fold) without an increase in bilirubin levels. Liver regeneration and atrophy: As expected, sPVL caused substantial volume gain (tBDT: 3-fold; sBDT: 2.8-fold; Sham 2.8-fold) of FLR and a substantial volume loss (tBDT: 0.9-fold; sBDT: 0.6-fold; Sham: 0.4-fold) of the portally deprived "future resected lobes" compared to the preoperative liver volume. The subsequent 70%PHx promoted a further volume gain of the FLR in all groups (tBDT: 4-fold; sBDT: 3-fold; Sham 3-fold compared to original volume) until POD 28. Hepatobiliary remodeling: After tBDT, we identified histologically three phases of hepatobiliary remodeling in the FLR. Following tBDT, biliary proliferates developed, replacing about 15% of the hepatocellular tissue. After sPVL we found incomplete restoration of the hepatocellular tissue with a visible reduction of the biliary proliferates. The 70%PHx led to an almost complete recovery of the hepatocellular tissue in the FLR with a nearly normal liver architecture. In contrast, after sBDT and Sham we observed a near normal liver morphology in the FLR at all time points. CT-scanning of the explanted livers and subsequent 3D reconstruction visualized the development of extrahepatic biliary collaterals. Collaterals were detected in 0/5 cases 1 week after sPVL (first regeneration stimulus), and in even more cases (3/5) 1 week after the 70%PHx (second regeneration stimulus). Histological workup identified the typical biliary cuboid epithelium as inner lining of the collaterals and peribiliary glands. Conclusion: Liver volume of the FLR increased in cholestatic rats mainly due to biliary proliferates. Application of repeated regeneration stimuli in the style of a "two-stage hepatectomy" promoted almost full restoration of hepatocellular tissue and architecture in the FLR by reestablishing biliary drainage via formation of biliary collaterals. Further exploration of the dynamics in hepatobiliary modeling using this model might help to better understand the underlying mechanism.

Corrosion Cast and 3D Reconstruction of the Murine Biliary Tree After Biliary Obstruction: Quantitative Assessment and Comparison With 2D Histology.

Background: Obstructive cholestasis can lead to significant alterations of the biliary tree depending on the extent and duration of the biliary occlusion. Current experimental studies reported about advanced techniques for corrosion cast and 3D reconstruction (3D-reco) visualizing delicate microvascular structures in animals. We compared these two different techniques for visualization and quantitative assessment of the obstructed murine biliary tree with classical 2D histology. Methods: Male mice (n = 36) were allocated to 3 different experiments. In experiments 1 and 2, we injected two different media (Microfil© for 3D-reco, MV; Batson's No.17 for corrosion cast, CC) into the extrahepatic bile duct. In experiment 3 we sampled liver tissue for 2D histology (HE, BrdU). Time points of interest were days 1, 3, 5, 7, 14, and 28 after biliary occlusion. We used different types of software for quantification of the different samples: IMALYTICS Preclinical for 3D scans (MV); NDP.view2 for the digital photography of CC; HistoKat software for 2D histology. Results: We achieved samples in 75% of the animals suitable for evaluation (MV and CC, each with 9/12). Contrasting of terminal bile ducts (4th order of branches) was achieved with either technique. MV permitted a fast 3D-reco of the hierarchy of the biliary tree, including the 3rd and 4th order of branches in almost all samples (8/9 and 6/9). CC enabled focused evaluation of the hierarchy of the biliary tree, including the 4th to 5th order of branches in almost all samples (9/9 and 8/9). In addition, we detected dense meshes of the smallest bile ducts in almost all CC samples (8/9). MV and CC allowed a quantitative assessment of anatomical details of the 3rd and 4th order branches of almost every sample. The 2D histology identified different kinetics and areas of proliferation of hepatocytes and cholangiocytes. Complementary usage of 3D-reco, corrosion casting and 2D histology matched dense meshes of small bile ducts with areas of intensive proliferative activity of cholangiocytes as periportal proliferative areas of 4th and 5th order branches (∼terminal bile ducts and bile ductules) matched with its morphological information the matching assessment of areas with increased proliferative activity (BrdU) and a partial quantification of the characteristics of the 4th order branches of the biliary tree. Conclusion: The 3D-reco and corrosion casting of the murine biliary tree are feasible and provide a straightforward, robust, and reliable (and more economical) procedure for the visualization and quantitative assessment of architectural alterations, in comparative usage with the 2D histology.

Species specific morphological alterations in liver tissue after biliary occlusion in rat and mouse: Similar but different.

BACKGROUND: The selection of the appropriate species is one of the key issues in experimental medicine. Bile duct ligation is the mostly used experimental model in rodents to explore special aspects of occlusive cholestasis. We aimed to clarify if rats or mice are suitable for the same or different aspects in cholestasis research. METHODS: We induced biliary occlusion by ligation and transection of the common bile duct (tBDT) in rats and mice (each n = 25). Recovery from surgical stress was assessed by daily scoring (stress score, body weight). At five different time points (days 1, 3, 7, 14, 28 after tBDT) we investigated hepatic morphometric and architectural alterations (Haematoxylin-Eosin staining, Elastica van Gieson staining) and the proliferative activities of parenchyma cells (Bromodeoxyuridine staining); as well as established systemic markers for liver synthesis, hepatocellular damage and renal dysfunction. RESULTS: We found substantial differences regarding survival (rats: 100%, 25/25 vs. mice 92%, 22/25, p = 0.07) and body weight gain (p<0.05 at postoperative days 14 and 28 (POD)). Rats showed a faster and progressive hepatobiliary remodelling than mice (p<0.05 at POD 7+14+28), resulting in: i) stronger relative loss of hepatocellular mass (rats by 31% vs. mice by 15% until POD 28; p<0.05 at POD 7+14+28); ii) rapidly progressing liver fibrosis (p<0.05 at POD 14); iii) a faster and stronger proliferative response of parenchyma cells (hepatocytes: p<0.05 at POD 1+14+18; cholangiocytes: p<0.05 at POD 1+3+7+28); and iv) only tiny bile infarcts compared to mice (p<0.05 at POD 1+3+7+14). Both species showed comparable elevated markers of hepatocellular damage and serum bilirubin. CONCLUSION: The key difference between rats and mice are the severity and dynamics of histological alterations, possibly accounting for their different susceptibilities for (septic) complications with low survival (mice).

Selective biliary occlusion in rodents: description of a new technique.

Background: Modern therapy concepts are of limited success in patients with cholestasis (e.g., biliary occluding malignancies). Therefore, we established a new animal model enabling simultaneous investigation of liver regeneration and hepato-biliary remodelling in biliary obstructed and biliary non-obstructed liver lobes. Methods: Biliary occlusion of different extent was induced in 50 male rats: Ligation and transection of the common bile duct (100% of liver, tBDT, n=25); or of the left bile duct (70% of liver, sBDT, n=25). At postoperative days 1, 3, 7, 14 and 28 we assessed the hepatic histomorphological alterations, proliferative repair, progress of liver fibrosis (HE, BrdU, EvG) and signs of liver regeneration (liver lobe weight gain). In addition, we determined systemic markers of hepatocellular injury (ASAT, ALAT), cholestasis (Bilirubin) and synthetic liver function (INR). The animals were monitored daily (body weight gain, stress score, survival). Results: All animals survived until the planned date of sacrifice. sBDT induced in the biliary occluded liver lobes similar histomorphological alterations, proliferative repair and progress of liver fibrosis like tBDT. In the biliary non-ligated liver lobes in sBDT animals we noticed a temporarily enhanced biliary proliferation and a persistent low grade liver fibrosis in the periportal area. Conclusions: Our model of sBDT represents a safe and valid method to induce selective cholestasis. The model enables further comparative investigation of liver regeneration in different extents of occlusive cholestasis (e.g., mimicking biliary occluding malignancies).

Outcome Quality After Colorectal Cancer Resection in Certified Colorectal Cancer Centers­Patient-Reported and Short-Term Clinical Outcomes.

BACKGROUND: In this observational study, patient-reported outcomes and short-term clinical outcome parameters in patients with colorectal cancer were studied 12 months after the start of treatment. Outcomes were also compared across German Certified Colorectal Cancer Centres. METHODS: Data were collected from 4239 patients with colorectal cancer who had undergone elective tumor resection in one of 102 colorectal cancer centers and had responded to a quality-of-life questionnaire before treatment (EORTC QLQ-C30 and -CR29). 3142 (74.1%) of these patients completed a post-treatment questionnaire 12 months later. Correlation analyses were calculated and case-mix adjusted comparisons across centers were made for selected patient-reported outcomes, anastomotic insufficiency, and 30-day-mortality. RESULTS: At 12 months, mild improvements were seen in mean quality-of-life scores (66 vs. 62 points), constipation (16 vs. 19), and abdominal pain (15 vs. 17). Worsening was seen in physical function (75 vs. 82) and pain (22 vs. 19). Better patient-reported outcomes at 12 months were associated with better scores before treatment. Better results in at least three of the five scores were associated with male sex, higher educational level, higher age, and private health insurance. Major worsening of fecal incontinence was seen among patients with rectal cancer without a stoma. The largest differences across centers were found with respect to physical function. Anastomotic insufficiency was found in 4.3% of colon cancer patients and 8.2% of rectal cancer patients. 1.9% of patients died within 30 days after their resection. CONCLUSION: Clinicians can use these findings to identify patients at higher risk for poorer patient-reported outcomes. The differences among cancer centers that were found imply that measures for quality improvement would be desirable.

Wilhelm Waldeyer-An Important Scientific Researcher of the 19th Century in the Context of His Memoirs and Major Monographies.

Wilhelm Waldeyer was one of the most important anatomists of his time. The year 2021 marks the 100th anniversary of his death. His name not only lives on in terms such as "Waldeyer's pharyngeal ring" or "Waldeyer's fascia," he also coined the terms "neuron" and "chromosome." He produced monumental monographies such as "The Pelvis" and "Ovary and Egg". Waldeyer's legacy is a large body of lifetime work that continues to impress to this day. However, he also published works that today would be described as racist. His view of a woman's role was and is also controversial. Nevertheless, reading his autobiography (Lebenserinnerungen) today is still beneficial because it vividly illustrates the academic life and a scholarly existence of that era.

In vivo assessment of the hepatic microcirculation after mesenterico-portal bypass (REX-shunt) using orthogonal polarization spectral imaging.

BACKGROUND: Extrahepatic portal vein thrombosis, not associated with cirrhosis or tumours, is the second most frequent cause of portal hypertension worldwide. Especially in children, anatomic mesenterico-portal interposition (REX-shunt) has become an established treatment. The changes in hepatic microcirculation after reperfusion of the shunt have not been investigated so far. AIMS: This study investigates the hepatic microcirculation before and after REX-shunt interposition using orthogonal polarization spectral imaging (OPS). PATIENTS AND METHODS: Since 2004, three consecutive patients with extrahepatic portal vein thrombosis underwent REX-shunt interposition. We measured the hepatic microcirculation by OPS before and directly after REX-shunt reperfusion and analysed the capillary vessel diameter, red blood cell velocity, functional capillary density and volumetric blood flow. Furthermore, we compared our values with the physiological values of the hepatic microcirculation defined previously by other investigators. RESULTS: All shunts showed an excellent function in the follow-up investigations. The intra-individual microcirculatory analysis revealed a reduction in the red blood cell velocity after shunt reperfusion in particular. CONCLUSIONS: Our results provide preliminary evidence for the reversal of the hepatic arterial buffer response following the restoration of the portal venous blood flow. This may be a short-term effect because of the restored portal venous blood flow.

Ruptured aneurysm of the ulnar artery in a woman with neurofibromatosis.

A 61-year-old woman with neurofibromatosis type 1 (Recklinghausen's disease) was referred for massive swelling of the right forearm, pain, increasing numbness, and impaired movement of the fingers. Angiography demonstrated a 13- x 11-mm aneurysm and a capped rupture of the ulnar artery. Because of the complicated soft-tissue condition, interventional treatment was indicated. Two 360 degrees coils were placed for embolization of the ruptured aneurysm. Arterial involvement in neurofibromatosis is a well known but infrequent occurrence. Stenotic lesions predominate. Aneurysmal defects are less common, and rupture of peripheral arteries is exceptional.

Biocellulose for Incisional Hernia Repair-An Experimental Pilot Study.

Ventral or incisional hernia are a common disease pattern in general surgery. Mostcommonly, a mesh repair is used for reconstruction, whereby the mesh itself might causecomplications, like infections or adhesions. Biological materials, like biocellulose, might reducethese clinical problems substantially. In this prospective rodent study, a biocellulose mesh(produced by Gluconacetobacter xylinus) was implanted either by a sublay technique or assupplementation of the abdominal wall. After an observation period of 90 days, animals weresacrificed. The adhesions after the reconstruction of the abdominal wall were moderate. Thehistologic investigations revealed that the biocellulose itself was inert, with a minimal regenerativeresponse surrounding the mesh. The explanted mesh showed a minimal shrinkage (around 15%) aswell as a minimal loss of tear-out force, which might be without clinical relevance. This is the firstin vivo study describing biocellulose as a suitable mesh for the repair of ventral hernia in twodifferent hernia models. The material seems to be a promising option for solving actual problems inmodern hernia surgery.

What Is the Current Knowledge About Sublay/Retro-Rectus Repair of Incisional Hernias?

Introduction: There continues to be very little agreement among experts on the precise treatment strategy for incisional hernias. That is the conclusion drawn from the very limited scientific evidence available on the repair of incisional hernias. The present review now aims to critically assess the data available on the sublay/retro-rectus technique for repair of incisional hernia. Materials and Methods: A systematic search of the literature was performed in May 2018 using Medline, PubMed, and the Cochrane Library. This article is based on 77 publications. Results: The number of available RCTs that permit evaluation of the role of the sublay/retro-rectus technique in the repair of only incisional hernia is very small. The existing data suggest that the sublay/retro-rectus technique has disadvantages compared with the laparoscopic IPOM technique for repair of incisional hernia, but in that respect has advantages over all other open techniques. However, the few existing studies provide only a limited level of evidence for assessment purposes. Conclusion: Further RCTs based on a standardized technique are urgently needed for evaluation of the role of the sublay/retro-rectus incisional hernia repair technique.