[Laparotomy closure and incisional hernia prevention - what are the surgical requirements?]

In the light of an incisional hernia incidence of between 10 and 20 % that remains constantly high in spite of modifications of suture materials and suture techniques, intensified scientific efforts aiming at incisional hernia prevention are -required. This article reviews the scientific results dealing with incisional hernia incidence, time of manifestation, risk factors and the influence of suture material and suture technique. A lack of evidence-based data and no current consensus concerning the ideal material and technique to close laparotomies has to be mentioned. To encourage a novel approach to incisional hernia -prevention, the results of experimental studies which demonstrate the negative effects of conventional laparotomy closure on the abdominal wall are discussed. Histology and additionally -laser-fluorescence angiography reveal the weak-en-ing of abdominal wall structures and abdominal wall perfusion after directly suturing the -incisional edges. Additionally, inadequate suture -tension has an influence on collagen quantity and quality in the healing incision. Further investigations with a suture simulator have made clear that surgical sutures vary widely in precision and reproducibility of suture tension when completed only under visual and tactile control. As suture tension dynamics cannot be measured due to the lack of adequate devices, an implantable sensor has been developed that reveals a loss of suture tension of up to 60 % of the initial tension in the first 2 hours after completion of laparotomy closure. These results have led to the development and experimental use of a bridging closure with a tension-banding technique. This technique has almost no influence on abdominal wall per-fusion, leaves the architecture and dynamics of the abdominal wall intact, and results in a favour-able ultra-structural composition of collagen and a mechanically stable laparotomy healing after 15 months. Measures to prevent incisional hernia formation - which is in fact the post-operative complication in surgery most frequently leading to re-operation - require intensified research activities. Success will only be achieved if the development of -unconventional closure techniques is encouraged and the beaten path of suturing the incisional edges is discarded.

Once-daily prolonged-release tacrolimus (ADVAGRAF) versus twice-daily tacrolimus (PROGRAF) in liver transplantation

The efficacy and safety of dual-therapy regimens of twice-daily tacrolimus (BID; Prograf) and once-daily tacrolimus (QD; Advagraf) administered with steroids, without antibody induction, were compared in a multicenter, 1:1-randomized, two-arm, parallel-group study in 475 primary liver transplant recipients. A double-blind, double-dummy 24-week period was followed by an open extension to 12 months posttransplant. The primary endpoint, event rate of biopsy-proven acute rejection (BPAR) at 24 weeks, was 33.7% for tacrolimus BID versus 36.3% for tacrolimus QD (Per-protocol set; p = 0.512; treatment difference 2.6%, 95% confidence interval -7.3%, 12.4%), falling within the predefined 15% noninferiority margin. At 12 months, BPAR episodes requiring treatment were similar for tacrolimus BID and QD (28.1% and 24.7%). Twelve-month patient and graft survival was 90.8% and 85.6% for tacrolimus BID and 89.2% and 85.3% for tacrolimus QD. Adverse event (AE) profiles were similar for both tacrolimus BID and QD with comparable incidences of AEs and serious AEs. Tacrolimus QD was well tolerated with similar efficacy and safety profiles to tacrolimus BID.

Coincidence of immune thrombocytopenia, intracranial hemorrhage and graft-versus-host disease in an 11-year-old girl

Primary immune thrombocytopenia (ITP) in children is usually self-limiting and harmless but can, rarely, result in life-threatening complications. The case of an 11-year-old girl with ITP is presented who developed recurrent intracranial hemorrhages followed by cerebral infarctions. The clinical course was complicated by a graft-versus-host disease involving several organs. Treatment was performed according to the current international consensus report of 2010 with glucocorticoids, immunoglobulin G, anti-D-immunoglobulin and additionally embolisation of the splenic artery. The girl survived. Reliable predictors, preventive measures for life-threatening complications in ITP and more information about the effectiveness and side-effects of the recommended treatment are urgently needed.

Recent and future warm extreme events and high-mountain slope stability

The number of large slope failures in some high-mountain regions such as the European Alps has increased during the past two to three decades. There is concern that recent climate change is driving this increase in slope failures, thus possibly further exacerbating the hazard in the future. Although the effects of a gradual temperature rise on glaciers and permafrost have been extensively studied, the impacts of short-term, unusually warm temperature increases on slope stability in high mountains remain largely unexplored. We describe several large slope failures in rock and ice in recent years in Alaska, New Zealand and the European Alps, and analyse weather patterns in the days and weeks before the failures. Although we did not find one general temperature pattern, all the failures were preceded by unusually warm periods; some happened immediately after temperatures suddenly dropped to freezing. We assessed the frequency of warm extremes in the future by analysing eight regional climate models from the recently completed European Union programme ENSEMBLES for the central Swiss Alps. The models show an increase in the higher frequency of high-temperature events for the period 2001-2050 compared with a 1951-2000 reference period. Warm events lasting 5, 10 and 30 days are projected to increase by about 1.5-4 times by 2050 and in some models by up to 10 times. Warm extremes can trigger large landslides in temperature-sensitive high mountains by enhancing the production of water by melt of snow and ice, and by rapid thaw. Although these processes reduce slope strength, they must be considered within the local geological, glaciological and topographic context of a slope.

The role of actin isoforms in somatic embryogenesis in Norway spruce

BACKGROUND

Somatic embryogenesis in spruce is a process of high importance for biotechnology, yet it comprises of orchestrated series of events whose cellular and molecular details are not well understood. In this study, we examined the role of actin cytoskeleton during somatic embryogenesis in Norway spruce line AFO 541 by means of anti-actin drugs.

RESULTS

Application of low doses (50-100 nM) of latrunculin B (Lat B) during the maturation of somatic embryos predominantly killed suspensor cells while leaving the cells in meristematic centres alive, indicating differential sensitivity of actin in the two cell types. The treatment resulted in faster development of more advanced embryos into mature somatic embryos and elimination of insufficiently developed ones. In searching for the cause of the differential actin sensitivity of the two cell types, we analysed the composition of actin isoforms in the culture and isolated four spruce actin genes. Analysis of their expression during embryo maturation revealed that one actin isoform was expressed constitutively in both cell types, whereas three actin isoforms were expressed predominantly in suspensor cells and their expression declined during the maturation. The expression decline was greatly enhanced by Lat B treatment. Sequence analysis revealed amino-acid substitutions in the Lat B-binding site in one of the suspensor-specific actin isoforms, which may result in a different binding affinity for Lat B.

CONCLUSIONS

We show that manipulating actin in specific cell types in somatic embryos using Lat B treatment accelerated and even synchronized the development of somatic embryos and may be of practical use in biotechnology.

Peripheral estradiol induces temporomandibular joint antinociception in rats by activating the nitric oxide/cyclic guanosine monophosphate signaling pathway

Recently, we have reported that high physiological estradiol level during the proestrus phase of the estrous cycle or systemic estradiol administration in ovariectomized rats decreases formalin-induced temporomandibular joint nociception. However, the mechanisms underlying the antinociceptive effect of estradiol are presently unknown. In this study, we used the temporomandibular joint formalin model in rats to investigate whether estradiol decreases nociception by a peripheral non-genomic mechanism, and if so, whether this mechanism is mediated by the activation of the nitric oxide-cyclic guanosine monophosphate signaling pathway and of opioid receptors. The administration of estradiol into the ipsilateral, but not into the contralateral temporomandibular joint significantly reduced formalin-induced temporomandibular joint nociception in ovariectomized and diestrus but not in proestrus females. However, the administration of the estrogen receptor antagonist ICI 182780 into the ipsilateral, but not into the contralateral temporomandibular joint blocked the antinociceptive effect of serum estradiol in proestrus females, suggesting that the physiological effect of estradiol in nociception is mediated, at least in part, by a peripheral mechanism. The administration of estradiol into the ipisilateral temporomandibular joint did not affect formalin-induced nociception in male rats. The antinociceptive effect of temporomandibular joint estradiol administration in ovariectomized and diestrus females was mimicked by estradiol conjugated with bovine serum albumin, which does not diffuse through the plasma membrane, and was blocked by the estrogen receptor antagonist ICI 182780. The administration of the nitric oxide synthase inhibitor (nitro-l-arginine) or of a guanylate cyclase inhibitor (1H-(1,2,4)-oxadiasolo (4,2-a) quinoxalin-1-one) into the ipsilateral, but not into the contralateral temporomandibular joint blocked the antinociceptive effect of estradiol and of estradiol conjugated with bovine serum albumin, while the opioid receptor antagonist naloxone had no effect. These findings suggest that estradiol decreases temporomandibular joint nociception in female rats through a peripheral non-genomic activation of the nitric oxide-cyclic guanosine monophosphate signaling pathway.

CXCL13 and CXCL12 in central nervous system (CNS) lymphoma patients

2071

Background: Homing of malignant lymphocytes to the CNS may play a role in the pathogenesis of CNS lymphoma. Recently, the expression of the chemokine receptors CXCR4 and CXCR5 as well as their chemokine ligands CXCL12 and CXCL13 by tumor cells in primary CNS lymphoma (PCNSL) has been demonstrated. In this study, we evaluated CXCL12 and CXCL13 in cerebrospinal fluid (CSF) and serum of patients with CNS lymphoma. Methods: Samples from 30 patients with CNS lymphoma (23 with PCNSL and seven with secondary CNS lymphoma) and 40 controls (10 patients with other CNS malignancies and 30 without a malignant CNS disease) were examined. CXCL12 and CXCL13 concentrations were measured using enzyme-linked immunosorbent assays. The grade of blood brain barrier (BBB) disruption was estimated by the CSF/serum albumin ratio. Results: CNS lymphoma patients and controls did not differ in CXCL12 serum and CSF levels. Serum levels of CXCL13 were generally low. CXCL13 CSF levels, however, were high only in CNS lymphoma patients but not in controls (p < 0.0001). Chemokine levels in CSF and serum did not correlate. In CNS lymphoma CXCL13 concentration in CSF correlated with BBB disruption (R = 0.66, p = 0.003). Elevated CSF levels of CXCL12 and CXCL13 measured in seven CNS lymphoma patients decreased in five patients which responded to chemotherapy, and increased in two with lymphoma progression. Conclusions: Our results suggest a production of CXCL13 within the CNS of CNS lymphoma patients which decreases with response to therapy. Thus, CXCL13 may represent a marker for further diagnostic and prognostic studies.

No significant financial relationships to disclose.

Initial experience with transvaginal incisional hernia repair

INTRODUCTION

Natural orifice surgery has evolved from a preclinical setting into a common occurrence at the University of California San Diego (UCSD). With close to 40 transvaginal cases, we have become comfortable with this technique and are exploring other indications. One of the perceived advantages in natural orifice surgery is the potential reduction in the incidence of hernia formation. Patients with abdominal wall hernias may be at increased risk of forming additional hernias at incision sites. In addition, patients with recurrent incisional hernias may, likewise, be at increased risk. We believe that reducing or eliminating abdominal wall incisions may be of benefit in the repair of abdominal wall hernias. Here, we describe what we believe to be the first natural orifice transluminal endoscopic surgical (NOTES) approach to the repair of an abdominal wall hernia.

METHODS

The patient is a 38-year-old female with a painful recurrent umbilical hernia, previously repaired 8 years prior with a polypropylene-based mesh. The patient underwent a transvaginal recurrent umbilical hernia repair with one other 5-mm port in the abdomen for safety.

RESULTS

The patient had no intraoperative or postoperative complications. At 5 months follow up, the patient had no complaints, no evidence of hernia recurrence, and was very pleased with her result.

CONCLUSIONS

The repair of primary and incisional hernias of the ventral abdominal wall via a transvaginal approach is technically feasible, and the result of our initial case was exceptional. However, there are still significant obstacles which must be addressed before this approach can be widely utilized. These obstacles include safe entrance into the abdominal cavity via a transvaginal approach, the proper mesh to be placed during the repair, and the risk of infection.

Randomized clinical trial of a modified Seldinger technique for open central venous cannulation for implantable access devices

INTRODUCTION

Totally implantable access ports (TIAPs) are often used for patients who need permanent venous access. The primary success rate using direct open insertion is about 80 per cent, so rescue strategies are needed. This study compared the primary success rates of standard open insertion and a modified Seldinger technique.

METHODS

This randomized trial recruited 164 patients scheduled for primary implantation of a TIAP and compared two interventions. The primary endpoint was the success rate of the implantation technique.

RESULTS

The primary success rates were similar: 66 (80 per cent) of 82 patients who had standard open insertion versus 69 (84 per cent) of 82 patients undergoing the modified Seldinger method (P = 0.686). A logistic mixed regression analysis including treatment group, age, Karnofsky index, body mass index and surgeon's experience showed no advantage for the Seldinger method: odds ratio 1.30 (95 per cent confidence interval 0.62 to 2.70). TIAPs were eventually implanted successfully in 163 (99.4 per cent) of 164 patients. In 11 patients randomized to standard surgery, the Seldinger method was a successful rescue strategy.

CONCLUSION

The primary success rate was similar for both open insertion methods. The modified Seldinger method is useful if standard open insertion fails.

REGISTRATION NUMBER

ISRCTN 52368201 (http://www.controlled-trials.com).

[The Treatment of the Complex Regional Pain Syndrome (CRPS 1 and CRPS 2) of the Upper Limb with Repeated Local Anaesthesia to the Stellate Ganglion.]

Two female patients were referred to us with a complex regional pain syndrome (CRPS) of the upper limb. One patient developed a CRPS type 1 after a radius fracture, the other presented a CRPS type 2 after a wrist trauma with a nerve injury of N. ulnaris. Both patients had progressive pain in spite of medical treatment (NSAID, Gabapentine, Calcitonine), physiotherapy, occupational therapy and osteopathy. In addition to pain they also showed the typical autonomic symptoms like oedema, hyperhidrosis, disturbances of skin colour and temperature and a severely limited motility of wrist and fingers. The clinical symptoms of both types of CRPS are identical and not restricted to the peripheral nerve distribution. The sympathetic nerve system is not only involved in the pain mechanism with reflectory processes in the segment and with the sympathetic afferent coupling, it also takes part in the neuroplasticity and in the neurogenic inflammation. The logical therapeutic intervention is therefore to normalize the hyperactivity of the sympathetic nerve systems with local anaesthetics. This regulation is done with injections to the stellate ganglion if upper limbs are affected (affections of lower limbs are treated with injections to the lumbar sympathetic trunk). Repeated injections to the stellate ganglion caused immediate improvement of pain and other symptoms in both patients.