Aneurysmaausschaltung am Iliakalarterienstumpf nach Bifurkationsprothesen-Implantation

Die interventionelle Radiologie zeigt bei gefäßmedizinischen Fragestellungen ein Spektrum von Indikationen. Mittels Punktion der A. femoralis dextra in Seldinger-Technik wurde interventionell-radiologisch unter Fluoroskopie- Führung suffizient ein Aneurysma des A.-iliaca-communisdextra- Stumpfes mittels Coil-Embolisation exkludiert. Die Komplikation einer iatrogen induzierten Blutung aus dem Aneurysmahals wurde mit Okklusionsemulsion gestoppt. Interventionell-radiologische Maßnahmen erlauben ein minimal-invasives Herangehen an einst klassische gefäßchirurgische Operationen. Ebenso werden Komplikationen der bildgeführten interventionellen Radiologie beherrschbar.

Impact of anastomotic leakage on oncological outcome after rectal cancer resection

BACKGROUND

: Anastomotic leakage has a major impact on morbidity and mortality in rectal cancer surgery. Its relevance to oncological outcome is controversial. This observational study investigated the influence of anastomotic leakage on oncological outcome.

METHODS

: Data for 1741 patients undergoing curative resection of rectal cancer (located less than 12 cm from the anal verge) with normal healing were compared with those for 303 patients who experienced anastomotic leakage. Morbidity, mortality and long-term oncological outcomes were analysed.

RESULTS

: Median follow-up was 40 months. Patients with anastomotic leakage had a higher postoperative mortality rate than those with no leakage (4.3 versus 1.2 per cent; P < 0.001). Patients with leakage necessitating surgical treatment had a higher 5-year local recurrence rate (17.5 versus 10.1 per cent; P = 0.006) and a lower 5-year disease-free survival rate (70.9 versus 75.4 per cent; P = 0.020) than those without leakage. Patients with anastomotic leakage not requiring surgical intervention did not have a worse oncological outcome.

CONCLUSION

: A negative prognostic impact of anastomotic leakage on local recurrence and disease-free survival was found only for patients with leakage needing surgical revision.

[Magnitude and strategies of cataract management in the world]

Although cataracts cause 47% of global blindness, their epidemiologic impact in different countries is notoriously uneven and the world can be divided into two zones according to economic conditions. In advanced countries where care is good, cataracts account for only 5% of blindness while cataracts still account for 50% of blindness in developing countries. After a brief overview of historical, clinical and therapeutic aspects, this article updates epidemiological data on cataracts in the world. It also provides insight into political, socio-economic, and cultural factors adversely affecting care availability in developing countries thus making cataracts a major public health problem and an obstacle for development. Finally this article offers a few recommendations for reducing the backlog of cataracts in the world and for consolidating advances made over the last two decades thanks to experience gained in various National Blindness Prevention Programs (NBPP).

[Conjunctival melanoma at corneoscleral limbus on primary acquired melanosis. A case report]

A 51-year-old Caucasian man consulted for a visual loss in the left eye due to corneal extension of a conjunctival melanoma. This conjunctival melanoma arose from primary acquired melanosis with atypia at the temporal corneoscleral limbus. The patient was treated using a combination of surgical excision with physical treatment by ocular proton therapy. Progression remained under control 11 months after treatment: no local tumour recurrence or metastasis was observed. Primary acquired melanosis with atypia must be regarded as a premalignant melanocytic lesion. Based on this case report, the authors focus on primary acquired melanosis and its risk of transformation to a conjunctival malignant melanoma.

Neonatal functional blockade of the entorhinal cortex results in disruption of accumbal dopaminergic responses observed in latent inhibition paradigm in adult rats

Latent inhibition (LI) has been found to be disrupted in non-treated patients with schizophrenia. Dopaminergic (DAergic) dysfunctioning is generally acknowledged to occur in schizophrenia. Various abnormalities in the entorhinal cortex (ENT) have been described in patients with schizophrenia. Numerous data also suggest that schizophrenia has a neurodevelopmental origin. The present study was designed to test the hypothesis that reversible inactivation of the ENT during neonatal development results in disrupted DA responses characteristic of LI in adult rats. Tetrodotoxin (TTX) was microinjected locally in the left ENT at postnatal day 8 (PND8). DA variations were recorded in the dorsomedial shell and core parts of the nucleus accumbens (Nacc) using in vivo voltammetry in freely-moving grown-up rats in a LI paradigm. In the first session the animals were pre-exposed (PE) to the conditional stimulus (banana odour) alone. In the second they were aversively conditioned to banana odour. In the third (test) session the following results were obtained in PE animals subjected to temporary inactivation of the ENT at PND8: (1) aversive behaviour was observed in TTX-PE conditioned animals; (2) DA variations in the dorsomedial shell and core parts of the Nacc were similar in TTX-PE and non-pre-exposed conditioned rats. These findings strongly suggest that neonatal disconnection of the ENT disrupts LI in adult animals. They may further our understanding of the pathophysiology of schizophrenia.

Treatment of biliary obstruction in selected patients by endoscopic ultrasonography (EUS)-guided transluminal biliary drainage

BACKGROUND AND STUDY AIMS

Endoscopic retrograde cholangiopancreatography (ERCP)-guided implantation of a biliary endoprosthesis or stent is the gold standard treatment for biliary obstructions. When the papilla cannot be traversed because there is pyloric or duodenal stenosis, or the catheter cannot be introduced, or because of previous gastrointestinal surgery (Billroth II gastric resection, Whipple procedure, gastrectomy with Roux-en-Y reconstruction), the alternative treatment is considered to be percutaneous transhepatic cholangiography and drainage (PTCD). The aim of the study was to investigate the further alternative of endoscopic ultrasound (EUS)-guided transgastric or transjejunal biliary drainage where PTCD failed or was declined, and particularly, the feasibility and outcome of this option.

PATIENTS AND METHODS

Over 3 years all appropriate consecutive patients (as defined above) were enrolled in this prospective, observational, single-center, case series study, and patient and intervention data were recorded. Feasibility was characterized by success rate (regression of cholestasis), and outcomes by complication rate, mortality, and follow-up findings.

RESULTS

Between November 2002 and December 2005, eight patients (in 10 interventions) underwent this new biliary drainage procedure. The routes were transesophageal (n = 1), transgastric (n = 4), and transjejunal (n = 3, including a rendezvous technique with ERCP [n = 1]). The indications were cholestasis, arising from recurrent tumor growth (n = 5, 62.5%), that included gastric carcinoma after previous gastrectomy (n = 4) and a periampullary carcinoma after previous Whipple procedure (n = 1); arising from Klatskin tumor (n = 2, 25%); and from benign stenosis of a hepaticojejunostomy (n = 1, 12.5%). Five patients (62.5%) received a metal stent, and three (37.5%) had a plastic prosthesis (8.5-Fr double-pigtail). The technical success rate was 90% (9/10) and the clinical success rate was 88.9% (8/9). There was only one case of cholangitis (12.5%) and slight postinterventional pain, but no severe complications such as bleeding or perforation, and no mortality. During follow-up (range 4 weeks to 3 years) re-interventions were needed in two patients (20%) because of increasing cholestasis; these resulted in technical success and clinical improvement.

CONCLUSION

EUS-guided transgastric or transjejunal biliary drainage is a reasonable, feasible and encouraging treatment option in selected patients as indicated, with a low peri-interventional risk. It broadens the therapeutic spectrum but still needs further evaluation and follow-up investigation.

Low prevalence of Helicobacteraceae in gall-stone disease and gall-bladder carcinoma in the German population

Colonisation of the hepatobiliary system with bile-resistant Helicobacter spp. has been proposed as a novel risk-factor in the pathogenesis of gall-bladder carcinoma (GBC). There are reports that biliary Helicobacter colonisation is frequent in countries with a high incidence of gall-bladder carcinoma. However, the prevalence of Helicobacteraceae in the gall-bladders of patients with GBC in Germany, a region with a low incidence of GBC, is unknown. Therefore, gall-bladder tissue from 99 patients who had undergone cholecystectomy was tested, including 57 cases of gall-stone disease (GSD), 20 cases of GBC, and 22 control patients. The presence of Helicobacter spp. was investigated by culture, immunohistochemistry and a group-specific PCR targeting the 16S rRNA gene of all currently known Helicobacteraceae. Of the 99 cases investigated, only one patient with GSD was PCR-positive for Helicobacteraceae. For this individual, sequence analysis of the 16S rRNA gene showed that it had homology closest to the 16S rRNA sequence of Helicobacter ganmani. Helicobacteraceae were not detected by culture or immunohistochemistry. The low prevalence of Helicobacteraceae in the gall-bladders investigated suggests that Helicobacteraceae do not play a predominant role in the pathogenesis of GSD and GBC in the German population. The low prevalence could be a possible explanation for a relatively low incidence of GBC in the German population, despite the fact that GSD, the major risk-factor for GBC, is highly prevalent.

Bone formation using human demineralised bone matrix (Grafton) for the treatment of bone cysts in children

Bone cysts, in particular solitary bone cysts, are the most frequent cause of pathological fractures in children. However, there is still a great variety of regimens used to treat these lesions. Since demineralised bone matrix (DBM) is commercially available, we aimed to use this material for the consolidation of bones diagnosed as fragile because of cyst formation. Each of the 7 bone cysts as well as one enchondroma filled with DBM showed a continuous decrease in bone transparency over a period of two years (mean 8 months). A significant decrease in bone transparency and simultaneous cortical remodelling was radiographically detected in these cases as the specific hallmark of an initiated graft incorporation after 3 to 4 months. It was demonstrated that it is possible to heal children within an acceptable period of time using DBM to fill the cystic lesion. DBM appears to be a reasonable and beneficial alternative for the treatment of bone cysts offering both osteoinduction and osteoconductive features.

Effect of age and gender on sweat lactate and ammonia concentrations during exercise in the heat

The dependence of sweat composition and acidity on sweating rate (SR) suggests that the lower SR in children compared to adults may be accompanied by a higher level of sweat lactate (Lac-) and ammonia (NH3) and a lower sweat pH. Four groups (15 girls, 18 boys, 8 women, 8 men) cycled in the heat (42 degrees C, 20% relative humidity) at 50% VO2max for two 20-min bouts with a 10-min rest before bout 1 and between bouts. Sweat was collected into plastic bags attached to the subject's lower back. During bout 1, sweat from girls and boys had higher Lac- concentrations (23.6 +/- 1.2 and 21.2 +/- 1.7 mM; P < 0.05) than sweat from women and men (18.2 +/- 1.9 and 14.8 +/- 1.6 mM, respectively), but Lac- was weakly associated with SR (P > 0.05; r = -0.27). Sweat Lac- concentration dropped during exercise bout 2, reaching similar levels among all groups (overall mean = 13.7 +/- 0.4 mM). Children had a higher sweat NH3 than adults during bout 1 (girls = 4.2 +/- 0.4, boys = 4.6 +/- 0.6, women = 2.7 +/- 0.2, and men = 3.0 +/- 0.2 mM; P < 0.05). This difference persisted through bout 2 only in females. On average, children's sweat pH was lower than that of adults (mean +/- SEM, girls = 5.4 +/- 0.2, boys = 5.0 +/- 0.1, women = 6.2 +/- 0.5, and men = 6.2 +/- 0.4 for bout 1, and girls = 5.4 +/- 0.2, boys = 6.5 +/- 0.5, women = 5.2 +/- 0.2, and men = 6.9 +/- 0.4 for bout 2). This may have favored NH3 transport from plasma to sweat as accounted for by a significant correlation between sweat NH3 and H+ (r = 0.56). Blood pH increased from rest (mean +/- SEM; 7.3 +/- 0.02) to the end of exercise (7.4 +/- 0.01) without differences among groups. These results, however, are representative of sweat induced by moderate exercise in the absence of acidosis.

Infectiological diagnostic problems in tertiary peritonitis

BACKGROUND

The tertiary peritonitis causes the highest mortality in intraabdominal infections. Surgical interventions and antibiotic therapy may only provide an incomplete impact on nosocomial infections acquired at an intensive care unit (ICU) [Nathens et al., World J Surg 22:158-163, 28]. To open up new resources in the management, in particular, in the previous infectious diagnostic, the aim was to investigate the infectious course as well as the diagnostic value of laboratory parameters and microbiological monitoring.

MATERIALS AND METHODS

In this retrospective patient cohort study from the Surgical ICU of a University Hospital (capacity, n=12), overall, 60 patients with a tertiary peritonitis were enrolled.

RESULTS

Approximately 20% of the patients with an intraabdominal infection developed a tertiary peritonitis. A tertiary peritonitis can more frequently develop in nosocomial intraabdominal infections, in particular, in case of necrotizing pancreatitis. The device-associated infection rate in the spectrum of nosocomial infections is sevenfold higher than in all ICU patients. Compared with the secondary peritonitis, its mortality is double as high: 35%. In the diagnostic characterizing the course of the nosocomial, prognosis-relevant infections, usual inflammatory parameters show a considerable loss of their sensitivity with a range from 35-57%. By the mean of a routine microbiological monitoring, 47.3% of the analysed subsequent infections could be identified at an early stage.

CONCLUSION

In patients with a severe infection, an early diagnostic and treatment of infectious "second hits" can improve the complication rate and prognosis. During the prolonged and complicated septic course of tertiary peritonitis, an additional routine microbiological monitoring contributed effectively to early detection and diagnostic of nosocomial infections. Further studies to investigate the value and efficacy of such monitoring, which have been abandoned, should be undertaken in infectious high-risk patients.

Isolated vasculitis of the stomach: a novel or rare disease with a difficult differential diagnosis

In up to 80 % of patients with vasculitis, signs of the disease are also seen in the gastrointestinal tract. However, no cases of exclusively gastric vasculitis have previously been reported. We report here the case of a 45-year-old woman with upper abdominal discomfort (no arthropathy), with gastroscopic and endoscopic ultrasound (EUS) findings that mimicked scirrhous gastric carcinoma. Gastroscopy revealed giant gastric folds and a suspicious antral ulcer (with histological findings suggesting chronic active pangastritis). EUS showed a concentric, thickened gastric wall (8 mm) with "pseudolamellation" and more than five enlarged lymph nodes in the paragastric region (lesser curvature). On the basis of suspected scirrhous gastric carcinoma, the patient underwent a four-fifths gastric resection of the altered parts of the gastric tissue. The postoperative course was uneventful. Histological examination of the specimen revealed severe obliterative panvasculitis of the stomach. During a 22-month follow-up period, no signs or symptoms of systemic primary or secondary vasculitis were found in the patient's medical history, symptoms, laboratory parameters, or imaging. This case shows for the first time that a specific gastric panvasculitis can occur, either as a preliminary stage of the condition or as a distinct manifestation of vasculitis associated with the stomach alone. Gastric resection appears to be indicated in patients with isolated obliterative gastric vasculitis, since it avoids the side effects of long-term immunosuppressive therapy and provides prognostic information that takes account of the differential diagnosis of scirrhous gastric carcinoma.