25 Jahre Erfahrung mit dem Anastomosenstoma

The anastomotic stoma is used since more than 25 years in emergency surgery of the bowel. To avoid a high risk primary anastomosis or a second laparotomy for reconstruction of the continuity, this procedure is performed, if sufficient bowel loop mobilization is possible. After resection of the diseased bowel segment, the proximal and distal loop are brought together and the posterior wall is then anastomized. The anterior wall of the anastomosis remains open and is fixed to the abdominal wall as a stoma. So far we have used this method in 136 patients. In 117 cases this technique was performed during emergency operations. No patient died as a result of complications of the method; 48 patients, however died due to the primary disease. Bowel continuity could be restored in 100 cases. The anastomotic stoma protects the posterior wall from elevated pressure and allows daily control of the anastomosis. In the case of extraperitoneal closure, a secondary laparotomy for reconstruction of the continuity is not necessary. The anastomotic stoma can be performed in most regions of the small and large bowel.

[Revision of guidelines for the management of patients with congenital heart failure in Germany]

The German Society for Thoracic and Cardiovascular Surgery (GSTCVS) regards 250 operations on patients with congenital heart disease per institution as an optimal number (Thorac Cardiov Surg 2006; 54: 73 - 77). In addition, all German institutions ought to participate unequivocally on data transfer to the European Association for Cardiothoracic Surgery. However, these "optimal German structures" need to be translated into action now. It will have to be the GSTCVS to ask for a hearing at the Federal Joint Committee (G-BA) (www.g-ba.de). This medical self-governing body, formed from the national associations of doctors and dentists, the German Hospital Federation and the health insurance funds, gives concrete definition to the legal requirements and implements them. Recently, the Federal Joint Committee released concrete measures for the care of newborns (Press release 21. 9. 2005, section sign 91 Abs. 7 SGB V). The obvious thing to do now would be considering measures for care of patients with congenital heart disease. We conclude, that whereas treatment and results should be further improved by quality control and quality transparency, structures of institutions involved in the care of patients with congenital heart disease can only be implemented by the Federal Joint Committee.

Role of bladder neck mobility and urethral closure pressure in predicting outcome of tension-free vaginal tape (TVT) procedure

OBJECTIVE

To investigate how urethral mobility and urethral closure pressure affect the outcome of tension-free vaginal tape (TVT) insertion for stress incontinence.

METHODS

A total of 191 consecutive women with genuine stress urinary incontinence with or without intrinsic sphincter deficiency were evaluated prospectively with multichannel urodynamics, 24-h voiding diaries, clinical stress tests and introital ultrasound measurements preoperatively and 6 months after surgery. Additional introital ultrasound examinations were performed immediately after the operation, at 12 months and annually thereafter. 177/191 patients had completed a 36-month follow-up at the time of writing. Urethral mobility was described as linear dorsocaudal movement (LDM), with hypermobility being defined as LDM > 15 mm on sonography. Intrinsic sphincter deficiency was defined by a maximum urethral closure pressure (MUCP) of <20 cm H(2)O.

RESULTS

The overall cure rate at the 36-month follow-up was 89.5% (Kaplan-Meier estimator), with secondary cure (within 6 months of surgery) in 10.5% of these patients. The operation failed in 4.2% of the women and recurrence was seen in 6.3% of the cases. Bladder neck mobility was significantly reduced at the 6-month follow-up (P < 0.001). Compared with primary cure, therapeutic failure and secondary cure were associated with a significantly lower postoperative bladder neck mobility (P < 0.05). Postoperative hypermobility reduced the risk of therapeutic failure. In addition, women with therapeutic failure or secondary cure had a significantly lower MUCP than did those with primary cure (P < 0.01).

CONCLUSION

The effectiveness of the TVT sling appears to depend on adequate postoperative urethral mobility and urethral closure pressure.

Pressure-jump-induced kinetics reveals a hydration dependent folding/unfolding mechanism of ribonuclease A

Pressure-jump (p-jump)-induced relaxation kinetics was used to explore the energy landscape of protein folding/unfolding of Y115W, a fluorescent variant of ribonuclease A. Pressure-jumps of 40 MPa amplitude (5 ms dead-time) were conducted both to higher (unfolding) and to lower (folding) pressure, in the range from 100 to 500 MPa, between 30 and 50 degrees C. Significant deviations from the expected symmetrical protein relaxation kinetics were observed. Whereas downward p-jumps resulted always in single exponential kinetics, the kinetics induced by upward p-jumps were biphasic in the low pressure range and monophasic at higher pressures. The relative amplitude of the slow phase decreased as a function of both pressure and temperature. At 50 degrees C, only the fast phase remained. These results can be interpreted within the framework of a two-dimensional energy surface containing a pressure- and temperature-dependent barrier between two unfolded states differing in the isomeric state of the Asn-113-Pro-114 bond. Analysis of the activation volume of the fast kinetic phase revealed a temperature-dependent shift of the unfolding transition state to a larger volume. The observed compensation of this effect by glycerol offers an explanation for its protein stabilizing effect.

C1-INH and its Effect on Infarct Size and Ventricular Function in an Acute Pig Model of Infarction, Cardiopulmonary Bypass, and Reperfusion

BACKGROUND

Recent studies suggest that complement inhibition reduces reperfusion injury. A clinical setting with local application of a C1 esterase inhibitor (C1-INH) has been modeled in an animal study in order to further investigate these findings.

METHODS

In 21 pigs, the left anterior descending coronary artery (LAD) was occluded distally to the first diagonal branch for 2 hours (h), including 1 h of cardioplegic arrest during CPB. After release of the coronary snare, C1-INH or NaCl (control) was applied to the aortic root. Thereafter, the aortic cross-clamp was removed and the heart was reperfused for 30 minutes before weaning from CPB. Left ventricular pressure volume analysis was performed by a multielectrode conductance catheter and the area at risk and infarct size were determined from excised hearts.

RESULTS

The following data were observed (mean+/-SEM) for the control group and the C1-INH group, respectively, after 1-h ligation of the LAD: heart rate (HR) 86+/-3 and 93+/-6 beats/min, stroke volume (SV) 1.2+/-0.1 and 1.2+/-0.1 ml/kg, aortic pressure (AoP) 83+/-6 and 87+/-5 mmHg, left ventricular end-diastolic pressure (LVedP) 12+/-1 and 11+/-2 mmHg; two hours after weaning from CPB: HR 106+/-9 and 123+/-4 beats/min, SV 0.9+/-0.1 and 0.9+/-0.1 ml/kg, AoP 65+/-5 and 79+/-7 mmHg, LVedP 9+/-1 and 8+/-1 mmHg. Conductance catheter measurements showed no improved left ventricular performance after C1-INH application. Infarct size to area at risk ratio was 61.5+/-4.2% for controls and 61.4+/-4.8% for C1-INH.

CONCLUSIONS

Intracoronary application of complement inhibitor in an acute infarction model, which mimicked a clinical setting of urgent coronary bypass grafting after ischemia, has been shown to neither influence the area of infarction, nor the ventricular function.

Endoscopic Radial Artery Harvesting Through a Single Incision

A method of radial artery harvesting through a single 3-cm skin incision is presented. This technique is performed with an endoscope inserted into a retractor and a harmonic scalpel for dissection of the artery. Transsection of the artery is carried out with a pre-tied endoloop. The endoscopic harvesting can be done in 45 minutes, resulting in less operative trauma and an excellent cosmetic outcome.

Pressure as a tool to study protein-unfolding/refolding processes: The case of ribonuclease A

This paper gives an overview of the application of high-pressure to study the folding/unfolding processes of proteins using Ribonuclease A as a model protein. A particular focus is the study of pressure-equilibrium unfolding and folding kinetics using variants and the information obtained by comparing these with the wild-type enzyme.