[Antibiotic prophylaxis before dental procedures in arthroplasty patients]

Antibiotic prophylaxis is commonly prescribed to patients with total arthroplasties before a dental intervention. This attitude is not evidence-based for several reasons: 1) the usual pathogens of prosthetic joint infections are not of oral origin; 2) even if given, systemic antibiotic do not completely suppress the occult bacteraemia occurring during dental intervention and 3) humans may have up to twelve episodes of occult bacteraemia of dental origin per day. Routine antibiotic prophylaxis should be clearly distinguished from the antibiotic treatment required in case of established oral cavity infection. A constant optimal oral and dental hygiene is more important in terms of prevention and should be routinely recommended to every patient carrying a joint arthroplasty.

Modifiable surgical and anesthesiologic risk factors for the development of cardiac and pulmonary complications after laparoscopic colorectal surgery

BACKGROUND

In contrast to patient-related risk factors, which are difficult to influence, factors relating to surgery and anesthesia that can be influenced have hardly been investigated. This study aimed to identify such risk factors.

METHODS

Pre- and intraoperative surgical and anesthesiologic factors of 388 colonic and 112 rectal procedures performed by a single surgeon within 50 months were recorded and analyzed for correlations with postoperative complications requiring treatment.

RESULTS

Higher American Society of Anesthesiology (ASA) emergency interventions and intraoperative factors (bleeding, long operating time) had an elevated risk for general complications. Furthermore, patients benefited from the clinical experience of the anesthesiologist, especially in terms of emergency procedures, hemorrhagic complications, and a longer operating time.

CONCLUSIONS

Standardization of the surgical technique, "bloodless" surgery, standardization of intraoperative monitoring, and the use of board-certified anesthesiologists for high-risk cases, emergency procedures, and patients with high ASA stages are able to reduce postoperative morbidity.

[Sense or nonsense of a prophylactic drainage after laparoscopic colorectal surgery - a prospective study]

INTRODUCTION

A growing number of studies do not show an advantage of prophylactic drainage in intraabdominal surgery any more. Especially against the background of "fast-track" surgery, this study aimed at an analysis of the influence of drainage on the patient's outcome in elective laparoscopic colorectal surgery.

METHOD

Within a 50-month period, 569 laparoscopic colorectal operations were carried out at the Klinikum Bremerhaven Reinkenheide, a centre for minimally invasive surgery. Of these, 505 patients were operated by one surgeon. For this prospective study, the data of 299 elective colon resections because of carcinoma or diverticulitis of the sigmoid colon in Hinchey stages 0-II, out of these 505 patients, have been analysed.

RESULTS

Before May 2006, a drainage was always used (n = 163, group A). Since May 2006, no drainage was used in 103 patients (group B). In another 33 patients (group C), drainage was used in complicated cases. The operation time was significantly reduced in patients with no drainage (99 min in group B vs. 120 min in group A) and there was a significantly reduced postoperative stay (6 days in group B vs. 11 days in group A). Furthermore, patients without drainage suffered less surgical and general complications than patients with drainage (6 vs. 10 % surgical complications; 1 vs. 6 % general complications). Infections of the wound occurred in 8.6 vs. 4.9 % of the cases when a drainage was used.

CONCLUSION

According to our experience, prophylactic drainage does not seem to be necessary in elective colon surgery. Overall, drainage was accompanied by a higher rate of surgical and general complications. Therefore it does not fit into the concept of "fast-track" surgery.

[Laparoscopic resection with primary anastomosis in Hinchey stages I and II without previous abscess drainage]

INTRODUCTION

Intra-abdominal abscesses in diverticulitis so far have been drained percutaneously until the acute inflammation subsides and colon resection can be carried out for restoration of continence. However this method is successful in only about half of patients and lavage lasts for 2 to 3 weeks. Therefore it has to be decided whether an early operation without prior interventional drainage can attain results similar to those of the elective operation.

METHODS

We performed primary laparoscopic surgery without prior interventional drainage or colon lavage in 72 patients in Hinchey stages I and II within 12 h of hospital admission. The peri- and postoperative processes were analyzed prospectively using 115 parameters.

RESULTS

There was no difference in the postoperative course of patients receiving elective surgery for recurrent diverticular disease and those undergoing surgery for acute diverticulitis (Hinchey stages I and II). The rates of surgical and general complications were identical (7.7% vs 9.6% and 9% vs 3.6%, respectively). Wound infections were noted in 7.7% and 7.2%, respectively. No case of anastomotic leakage was observed.

CONSEQUENCE

Based on our prospective data (grade of evidence II), we consider laparoscopic sigmoid resection with primary anastomosis (in continuity) in Hinchey stages I and II without prior interventional drainage and colon preparation to be justified.

Deficiency of heme oxygenase-1 impairs renal hemodynamics and exaggerates systemic inflammatory responses to renal ischemia

Heme oxygenase-1 may exert cytoprotective effects. In this study we examined the sensitivity of heme oxygenase-1 knockout (HO-1(-/-)) mice to renal ischemia by assessing glomerular filtration rate (GFR) and cytokine expression in the kidney, and inflammatory responses in the systemic circulation and in vital extrarenal organs. Four hours after renal ischemia, the GFR of HO-1(-/-) mice was much lower than that of wild-type mice in the absence of changes in renal blood flow or cardiac output. Eight hours after renal ischemia, there was a marked induction of interleukin-6 (IL-6) mRNA and its downstream signaling effector, phosphorylated signal transducer and activator of transcription 3 (pSTAT3), in the kidney, lung, and heart in HO-1(-/-) mice. Systemic levels of IL-6 were markedly and uniquely increased in HO-1(-/-) mice after ischemia as compared to wild-type mice. The administration of an antibody to IL-6 protected against the renal dysfunction and mortality observed in HO-1(-/-) mice following ischemia. We suggest that the exaggerated production of IL-6, occurring regionally and systemically following localized renal ischemia, in an HO-1-deficient state may underlie the heightened sensitivity observed in this setting.

Pharmacoproteomics: advancing the efficacy and safety of regenerative therapeutics

Proteomic analyses encompass a suite of high-throughput technologies for large-scale separation and identification of proteins responsible for execution of physiological processes. As such, proteomics is ideally suited to dissecting developmental complexity and dynamics, an understanding of which is vital to the realization of regenerative therapeutic medicine. Pharmacoproteomics is increasingly targeting characterization of regenerative therapeutic strategies. A perspective on the application of proteomics to further our understanding of cardiac regenerative medicine, in concert with guided cardiogenic programming, is delineated herein.

ATP-sensitive potassium channels: metabolic sensing and cardioprotection

The cardiovascular system operates under a wide scale of demands, ranging from conditions of rest to extreme stress. How the heart muscle matches rates of ATP production with utilization is an area of active investigation. ATP-sensitive potassium (K(ATP)) channels serve a critical role in the orchestration of myocardial energetic well-being. K(ATP) channel heteromultimers consist of inwardly-rectifying K(+) channel 6.2 and ATP-binding cassette sulfonylurea receptor 2A that translates local ATP/ADP levels, set by ATPases and phosphotransfer reactions, to the channel pore function. In cells in which the mobility of metabolites between intracellular microdomains is limited, coupling of phosphotransfer pathways with K(ATP) channels permits a high-fidelity transduction of nucleotide fluxes into changes in membrane excitability, matching energy demands with metabolic resources. This K(ATP) channel-dependent optimization of cardiac action potential duration preserves cellular energy balance at varying workloads. Mutations of K(ATP) channels result in disruption of the nucleotide signaling network and generate a stress-vulnerable phenotype with excessive susceptibility to injury, development of cardiomyopathy, and arrhythmia. Solving the mechanisms underlying the integration of K(ATP) channels into the cellular energy network will advance the understanding of endogenous cardioprotection and the development of strategies for the management of cardiovascular injury and disease progression.

[Laparoscopic appendectomy as training procedure for all stages of appendicitis]

Appendectomy is one of the most common procedures in general surgery. Appendectomy is routinely performed in our department laparoscopically and as a training procedure for all stages of appendicitis. Between 1.1.2003 till 31.7.2005 642 patients underwent appendectomy. 613 of them were performed laparoscopically with a conversion rate of 0,6% in uncomplicated findings and 8,1% in complicated findings (perforated, abscess and gangrenous appendicitis). The postoperative recovery after laparoscopic appendectomy was without any significant complication in 98.2% of the patients with acute appendicitis and 89% of the patients with complicated findings. The overall morbidity rate in both situations (uncomplicated and complicated findings) did not differ from that described in literature. This supports impressively our thesis that laparoscopic appendectomy is feasible in all situations, with a high value for training young surgeons.

Minimally invasive transhiatal and transthoracic esophagectomy

BACKGROUND

Standard esophagectomy requires either a laparotomy with transhiatal removal of the esophagus or a combination of laparotomy and thoracotomy. Currently, it still is associated with a high rate of morbidity and mortality. Complications leading to greater morbidity and mortality are rarely seen after minimally invasive surgery. The authors present their experience with 25 minimally invasive esophageal resections.

METHODS

Between August 1st, 2003 and November 30th, 2005, the authors performed 25 minimally invasive esophageal resections for 4 woman and 21 men. Data were acquired prospectively.

RESULTS

In this series, a laparoscopic transhiatal approach was performed in 9 cases, a combined laparoscopic-thoracoscopic procedure in 12 cases, and laparoscopic creation of a gastric tube combined with thoracotomy in 4 cases. No conversion became necessary. The mean operation time was 165 min (range, 150-180 min) for the laparoscopic transhiatal approach and 300 min (range, 240-360 min) for both combination approaches. Using the combined laparoscopic-thoracoscopic procedure, 23 lymph nodes (range, 19-26 lymph nodes) were removed, and using the laparoscopic transhiatal approach, 14 lymph nodes (range, 12-17 lymph nodes) were removed. The median stay in the intensive care unit was 1.5 days (range, 1-22 days), and the overall postoperative stay was 10 days (range, 7-153 days). Two intraoperative complications and two cervical anastomotic leakages were observed. The 30-day mortality rate was 0%.

CONCLUSION

The findings demonstrate that laparoscopic transhiatal and combined laparoscopic/thoracoscopic esophagectomy are feasible and can be performed with low rates of morbidity and mortality. Due to an equal extent of lymph node dissection, there should be no difference in long-term survival between minimally invasive surgery and open surgery.

Nuclear transport: target for therapy

Drugs directed at plasma membrane receptors target environment-cell interactions and are the mainstay of clinical pharmacology. Decoding mechanisms that govern intracellular signaling has recently opened new therapeutic avenues for interventions at cytosol-organellar interfaces. The nuclear envelope and nuclear transport machinery have emerged central in the discovery and development of experimental therapeutics capable of modulating cellular genetic programs. Insight into nucleocytoplasmic exchange has unmasked promising anticancer, antiviral, and anti-inflammatory strategies.

Aminoglycoside-induced translational read-through in disease: overcoming nonsense mutations by pharmacogenetic therapy

A third of inherited diseases result from premature termination codon mutations. Aminoglycosides have emerged as vanguard pharmacogenetic agents in treating human genetic disorders due to their unique ability to suppress gene translation termination induced by nonsense mutations. In preclinical and pilot clinical studies, this therapeutic approach shows promise in phenotype correction by promoting otherwise defective protein synthesis. The challenge ahead is to maximize efficacy while preventing interaction with normal protein production and function.

[Laparoscopic Dor-hemifundoplication for therapy of gastroesophageal reflux disease]

INTRODUCTION

Gastroesophageal reflux disease is a major health problem in western industrial nations. Several prospective randomized studies showed the operative therapy of GERD superior to a steady medication with omeprazole regarding recurrence rate as well as rate of side effects. The today most performed 360 degrees fundoplication (Nissen-Rossetti) leads in 10-30% to a persisting postoperative dysphagia. We prefer the anterior semifundoplication by Dor. Aim of our study is to find out if our results are comparable to current literature and to open procedure.

PATIENTS

Between 1.1.03 and 30.6.05 one operator performed on 100 consecutive patients (57 female, 43 male) between 29 and 86 years of age an anterior Dor-semifundoplication with posterior hiatal repair. In 37 cases we performed a cholecystectomy simultaneously, on two patients a sigmoid resection and in one case a left pancreatic resection. 52 Patients were re-evaluated after six months (median follow up nine months).

RESULTS

Median operation time was 71 min (30-250 min). The learning curve showed a time reduction of initially 102 to 40 min in the last 10 cases. Blood loss was between 10 and 300 ml (median 40 ml). No conversion was necessary). As intraoperative complication in one case the right pleural cavity was opened. Postoperative complications were found to be wound infection in one case and urinary tract infection in another. Postoperative stay was four days (2-19 d) and eight days respectively for patients after sigmoid resection or left pancreatic resection. After median follow up of nine months 45 of 52 re-evaluated patients (86%) were free of reflux symptoms, 47 (90%) were pleased or very pleased with the result of the operation. Four patients felt at least a reduction of preoperative symptoms.

CONCLUSION

The anterior Dor semifundoplication is a technically easy and low risk procedure, which has a lower side effect rate than the 360 degrees operation and will heal 90% of the patients from their reflux disease.

Ausdehnung der Lymphknotendissektion nach minimalinvasiver Ösophagusresektion?

Esophageal resection is still today associated with a high morbidity and mortality. Minimally invasive procedures show a significantly lower rate of such complications and therefore might also be associated with a lower surgical risk. However, publications till date contain little or no data on the extent of lymph node dissection. The aim of our study was to evaluate the morbidity and mortality rate of minimally invasive esophageal resection.

MATERIAL AND METHODS

In the last two years, we carried out 25 minimally invasive esophageal resections on five women and 20 men with a median age of 63 years (range 41-74 years). All data were accrued prospectively.

RESULTS

Nine patients were operated upon transhiatally and 12 combined laparocopic-thoracoscopic. On four patients, a thoracotomy was necessary. The average surgical time for the transhiatal approach was calculated at 164 minutes (range 150-180 min) and for the combined laparoscopic-thoracoscopic procedure 285 minutes (240-360 min). The thoracoscopic esophageal resection itself lasted 105 minutes on average; the last five resections each lasting 70 minutes. A median of 24,5 lymph nodes (19-26) was calculated in the laparoscopic-thoracoscopic technique. The transhiatal procedure revealed a median of 14 lymph nodes (12-17). Postoperatively, we had three cases of anastomotic and two cases of bronchial leakages, most probably associated with the use of monopolar current; complications no longer seen since usage of the HARMONIC ACE for surgical preparation. There was no 30 day letality.

CONCLUSION

Our experience with 25 successful minimally invasive esophageal resections shows that with increasing experience and better surgical equipment, the extent of lymph node dissection does not differ from open procedure.