[The problem of long/post-COVID in expert assessments]

Assessing long/post-COVID syndrome (PCS) following an infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a multidisciplinary challenge due to the diverse and complex symptoms. Besides discipline-specific evaluation of infection-related organ damage, the main issue is expert objectivity and causality assessment regarding subjective symptoms. The consequences of long/PCS raise questions of insurance rights in all fields of law. In cases of persistent impairment of performance, determining reduction in earning capacity is crucial for those affected. Recognition as an occupational disease (BK no. 3101) is vital for employees in healthcare and welfare sectors, along with occupational accident recognition and assessing the illness's consequences, including the reduction in earning capacity (MdE) in other sectors or work areas. Therefore, expert assessments of illness consequences and differentiation from previous illnesses or damage disposition are necessary in all areas of law, individually based on corresponding organ manifestations in medical fields and interdisciplinarily for complex late sequelae, for instance, by internists with appropriate qualifications for pulmonary or cardiac manifestations and neurologists, psychiatrists, and neuropsychologists for neurological and psychiatric manifestations, etc.

Increased frequency of TIGIT+CD73-CD8+ T cells with a TOX+ TCF-1low profile in patients with newly diagnosed and relapsed AML

The inhibitory receptor TIGIT, as well as theectonucleotidases CD39 and CD73 constitute potential exhaustion markers for T cells. Detailed analysis of these markers can shed light into dysregulation of the T-cell response in acute myeloid leukemia (AML) and will help to identify potential therapeutic targets.  The phenotype and expression of transcription factors was assessed on different T-cell populations derived from peripheral blood (PB, n = 38) and bone marrow (BM, n = 43). PB and BM from patients with AML diagnosis, in remission and at relapse were compared with PB from healthy volunteers (HD) (n = 12) using multiparameter flow cytometry. An increased frequency of terminally differentiated (CD45R^-CCR7^-)CD8⁺ T cells was detected in PB and BM regardless of the disease state. Moreover, we detected an increased frequency of two distinct T-cell populations characterized by the co-expression of PD-1 or CD39 on TIGIT⁺CD73^-CD8⁺ T cells in newly diagnosed and relapsed AML in comparison to HDs. In contrast to the PD-1⁺TIGIT⁺CD73^-CD8⁺ T-cell population, the frequency of CD39⁺TIGIT⁺CD73^-CD8⁺ T cells was normalized in remission. PD-1⁺- and CD39⁺TIGIT⁺CD73^-CD8⁺ T cells exhibited additional features of exhaustion by decreased expression of CD127 and TCF-1 and increased intracellular expression of the transcription factor TOX. CD8⁺ T cells in AML exhibit a key signature of two subpopulations, PD-1⁺TOX⁺TIGIT⁺CD73^-CD8⁺- and CD39⁺TOX⁺TIGIT⁺CD73^-CD8⁺ T cells that were increased at different stages of the disease. These results provide a rationale to analyze TIGIT blockade in combination with inhibition of the purinergic signaling and depletion of TOX to improve T-cell mediated cytotoxicity in AML. Abbreviations: AML: Acute myeloid leukemia; pAML: newly diagnosed AML; rAML: relapse AML; lrAML: AML in remission; HD: healthy donor; PB: peripheral blood; BM: bone marrow; TIGIT: T-cell immunoreceptor with Ig and ITIM domains; PD-1: Programmed cell death protein 1; CD73: ecto-5'-nucleotidase; CD39: ectonucleoside triphosphate diphosphohydrolase 1; ATP: adenosine triphosphate; ADO: adenosine; CD127: interleukin-7 receptor; CAR-T cell: chimeric antigen receptor T cell; TCF-1: transcription factor T-cell factor 1; TOX: Thymocyte selection-associated high mobility group box protein; NFAT: nuclear factor of activated T cells; NA: Naïve; CM: Central Memory; EM Effector Memory; EMRA: Terminal Effector Memory cells; FMO: Fluorescence minus one; PVR: poliovirus receptor; PVRL2: poliovirus receptor-related 2; IFN-γ: Interferon-γ; IL-2: interleukin-2; MCF: multiparametric flow cytometry; TNFα: Tumornekrosefaktor α; RT: room temperature.

First-line immune checkpoint inhibitors for extensive stage small-cell lung cancer: clinical developments and future directions

Small-cell lung cancer (SCLC) is an aggressive and rapidly growing disease with poor prognosis. Despite intense efforts to improve clinical outcomes, platinum/etoposide chemotherapy has remained the most effective regimen for first-line extensive disease SCLC for decades. The addition of immune checkpoint inhibitors, and specifically programmed death-ligand 1 inhibitors, to standard platinum/etoposide, significantly improves survival and represents a promising advance in this field. However, identification of a predictive biomarker to refine patient selection is an area of unmet need. Further understanding of tumour immunity and mechanism of resistance is required to design novel strategies that improve survival. In this review, we describe recent developments and future directions on first-line immune checkpoint blockade for extensive disease-SCLC.

Early Antiretroviral Therapy in HIV-Infected Children Is Associated with Diffuse White Matter Structural Abnormality and Corpus Callosum Sparing

BACKGROUND AND PURPOSE

Fractional anisotropy in the frontal white matter, corpus callosum, and internal capsule is abnormal in human immunodeficiency virus-positive (HIV+) adults. We describe the distribution and nature of white matter abnormalities in a cohort of children who started antiretroviral therapy within the first year of life and the benefit of early treatment by using DTI measures (fractional anisotropy and mean, axial, and radial diffusion).

MATERIALS AND METHODS

DTI was performed on children in a neurodevelopmental substudy from the Children with HIV Early Antiretroviral trial. Voxel-based group comparisons were obtained to determine regions where fractional anisotropy and mean diffusion differed between HIV+ and uninfected children. Associations of DTI parameters with the timing of antiretroviral therapy initiation were examined.

RESULTS

Thirty-nine HIV+ children (15 boys; mean age, 5.4 years) and 13 controls (5 boys; mean age, 5.7 years) were scanned. Two clusters with lower fractional anisotropy and 7 clusters with increased mean diffusion were identified in the HIV+ group, with symmetric distribution predominantly due to increased radial diffusion, suggestive of decreased myelination. Corticospinal tracts rather than the corpus callosum were predominantly involved. Children on early-interrupted antiretroviral therapy had lower fractional anisotropy compared with those receiving continuous treatment.

CONCLUSIONS

HIV+ children at 5 years of age have white matter abnormalities measured by fractional anisotropy, despite early antiretroviral therapy, suggesting that early antiretroviral therapy does not fully protect the white matter from either peripartum or in utero infection. In contrast to adults, the corticospinal tracts are predominantly involved rather than the corpus callosum, possibly due to early antiretroviral therapy. Continuous early antiretroviral therapy can limit white matter damage.

DMSO modifies the permeability of the zebrafish (Danio rerio) chorion-implications for the fish embryo test (FET)

Since 2007, when REACH came into force, the fish embryo test has received increasing attention as a potential alternative for the acute fish test. Due to its low toxicity and the ability to permeate biological membranes without significant damage to their structural integrity, dimethyl sulfoxide (DMSO) is a commonly used solvent in the fish embryo test. Little is known, however, about the membrane penetration properties of DMSO, the impact of different concentrations of DMSO on the potential barrier function of the zebrafish chorion and on changes in the uptake of chemicals into the embryo. Therefore, in the present study, the fluorescent dyes fluorescein (mol wt 332; Pow 3.4) and 2,7-dichlorofluorescein (mol wt 401; Pow 4.7), both substances with limited water solubility, were used to visualize the uptake into the egg as well as the accumulation in the embryo of the zebrafish depending on different concentrations of DMSO. The distribution of fluorescein within the egg compartments varied with DMSO concentration: When dissolved in 0.01% DMSO, fluorescein did not pass the chorion. In contrast, concentrations ≥ 0.1% DMSO increasingly facilitated the uptake into the perivitelline space. In contrast, the uptake of 2,7-dichlorofluorescein was not substantially increased with rising DMSO concentrations, indicating the importance of factors other than the solvent (e.g. mol wt). With respect to the fish embryo test, results indicate that DMSO may be used without complications as a solvent, however, only at a maximum concentration of 0.01% (0.1 mL/L) as already indicated in the OECD difficult substances paper (OECD, 2000).

The acute abdomen in the older person

The acute abdomen is a common condition in older people. Half of all presentations to hospital require admission, with a third requiring immediate surgery. The Royal College of Surgeons of England have reported a worryingly high mortality rate in the over 80s undergoing emergency surgery, with a 3-fold difference in mortality throughout the England, Wales and Northern Ireland. The aim of this article is to highlight the issues that older people face in relation to acute abdominal pathology.

Comparison of paper print and soft copy reading in plain paediatric radiographs

With the introduction of a Picture Archiving and Communication System, Computed (CR) and Digital Radiography (DR), reading digital images takes place from a computer screen. Laser paper print rather than laser film would be a significantly more cost-effective option for hard copy production, but would need to demonstrate acceptable diagnostic quality compared to the reference standard of screen reading. A comparative study of 51 digital paediatric CR radiographs presented in laser paper print and soft copy format to determine the diagnostic value of the paper print when compared to the reference standard of screen reading. Chest radiography had a poor sensitivity of 66.1% while musculoskeletal and abdominal radiography had acceptable sensitivities of 90% and 99%, respectively. Specificity was excellent for the different regions (98.6-99.5%). The paper print format should not be used for diagnostic purposes in paediatric chest radiography, but may still be used for demonstration when accompanied by the radiology rapport obtained from soft copy reading. Further studies would be needed to investigate the use of paper prints in abdominal and musculoskeletal radiography owing to the low number of abdominal radiographs and lack of musculoskeletal case variety in our study.

Renal vein thrombosis in transitional cell carcinoma

A rare case of renal transitional cell carcinoma (TCC) associated with bland thrombus of the renal vein extending into the inferior vena cava is described. Tumour thrombus in renal cell carcinoma is frequently encountered, but only very rarely occurs with TCC. Bland renal vein thrombosis occurring with renal TCC has not been described before. Contrast enhanced computed tomography assisted in distinguishing between bland and tumour thrombosis and aided in surgical management.

Laparoscopic antireflux surgery: long-term outcomes and quality of life

BACKGROUND

To evaluate the outcome of antireflux surgery, we assessed disease-specific symptoms and quality of life of all patients treated by laparoscopic fundoplication at our center between 1992 and 2002.

MATERIALS AND METHODS

Preoperative symptoms and details of surgery were evaluated for 186 laparoscopic fundoplications. Disease-specific symptoms and quality of life were assessed using a questionnaire. Of 186 patients, 143 returned the questionnaire.

RESULTS

The most common preoperative symptoms under medical antireflux therapy were regurgitation (54%) and heartburn (30%). Indications for surgery were refractory symptoms (88%) and the patient denying long-term medication (42%). The surgical approaches were Nissen fundoplication (98%) or Toupet fundoplication (2%, for heavy esophageal motility disorder). The conversion rate was 10%. There were no deaths, and 6 patients (3%) had to be reoperated. The questionnaire revealed that in 82% of the patients who responded, the preoperative reflux symptoms were gone, and 94% were satisfied with the result and would undergo surgery again. The average gastrointestinal quality of life index was 115 points (healthy volunteers in the literature, 120.8 points).

CONCLUSION

Laparoscopic fundoplication is a safe antireflux therapy resulting in high levels of patient satisfaction and near-normal quality of life in the long term.

Long-term results after stapled hemorrhoidopexy: high patient satisfaction despite frequent postoperative symptoms

PURPOSE

Stapled hemorrhoidopexy has been demonstrated to be advantageous in the short term compared with the traditional techniques. We aimed to evaluate long-term results after stapled hemorrhoidopexy and to assess patient satisfaction in association with postoperative hemorrhoidal symptoms.

METHODS

This prospective study included 216 patients with Grade 2 or 3 hemorrhoids, who had stapled hemorrhoidopexy using the circular stapled technique. The results were evaluated by a standardized questionnaire at least 12 months after the operation. The primary end point was patient satisfaction; secondary end points included specific hemorrhoidal symptoms.

RESULTS

Followup data were obtained for 193 of 216 patients (89 percent) with a median follow-up of 28 (range, 12-53) months, most of whom (89 percent) were satisfied or very satisfied with the surgery. The main preoperative symptom was no longer present postoperatively in 66 percent of patients, was relieved in 28 percent, and had worsened in 2 percent. Postoperative complaints included symptoms of hemorrhoidal prolapse (24 percent of patients), anal bleeding (20 percent), anal pain (25 percent) fecal soiling/leakage (31 percent), fecal urgency (40 percent), and local discomfort (38 percent). Bivariate analysis showed significant associations between each of these symptoms and patient satisfaction. Nine patients (5 percent) were reoperated on during the follow-up period.

CONCLUSIONS

Long-term patient satisfaction was high in most of patients after stapled hemorrhoidopexy for second-degree and third-degree hemorrhoids. However, an unsatisfactory outcome was significantly related to postoperative hemorrhoidal symptoms such as prolapse, fecal soiling/leakage, and new onset of fecal urgency.

Outcome and quality of life after open surgery versus endoscopic stapler-assisted esophagodiverticulostomy for Zenker's diverticulum

Two techniques for treatment of Zenker's diverticulum, endoscopic stapler-assisted esophagodiverticulostomy and open cricopharyngeal myotomy by transcervical approach, were compared with regard to patient satisfaction and quality of life. Between January 1994 and December 2004 a total of 47 patients with Zenker's diverticulum underwent surgery in our department. Besides the usual retrospective evaluation of details of surgery, all patients were sent a questionnaire on their actual complaints and quality of life according to the Gastrointestinal Quality of Life Index (GIQLI). Twenty patients had the endoscopic procedure (Group A), and 27 the open procedure (Group B). The preoperative symptoms were dysphagia in 96%, regurgitation of undigested food in 60%, cough in 19%, and pneumonia caused by recurrent aspiration in 9%. The length of surgery was on average 32 min (range 5-70 min) in Group A and 106 min (range 45-165 min) in Group B, and the length of hospital stay was 5.5 days (range 1-10 days) and 12.3 days (range 7-25 days), respectively. The results of the questionnaire showed that the preoperative symptoms had disappeared in up to 83%, and 91% in Group A and 100% in Group B would be willing to undergo surgery again. The mean GIQLI was 123 points in Group A and 118 points in Group B (healthy volunteers in the literature, 125 points). Both techniques showed good results in a long-term follow-up with regard to relief of symptoms and patient satisfaction. Both groups had an excellent Gastrointestinal Quality of Life Index, comparable to that of a healthy standard population.

Reduction in Slippage with 11-cm Lap-Band® and Change of Gastric Banding Technique

BACKGROUND

Slippage occurs after 2-18% of gastric bandings performed by the perigastric technique (PGT). We investigated the slippage-rate before and after the introduction of the pars flaccida technique (PFT) and the 11-cm Lap-Band, and the long-term results of the re-operated patients.

METHODS

Between Dec 1996 and Feb 2004, 360 patients with a mean BMI of 44 kg/m2 were operated. The PGT (n=168) and PFT9.75 (n=15) groups received the 9.75-cm Lap-Band, and the PFT11 group (n=177) received the new 11-cm Lap-Band. Follow-up rate was 99%.

RESULTS

Slippage occurred in a total of 31 patients from all groups (PGT, n=28, or 17%; PFT9.75, n=1, or 7%; PFT11, n=2, or 1%). Average yearly re-operation rate for slippage in the first 3 years postoperatively was 3.8%, 2.2% and 0.9%, respectively. Laparoscopic re-banding was necessary for posterior (n=19) or lateral (n=12) slippage. The late postoperative course after re-banding was: uneventful 58%, weight regain 35% and/or esophageal motility disorder 23%, secondary band intolerance 20%, and one persistent posterior slippage. 8 patients (26%) needed biliopancreatic diversion.

CONCLUSION

Since the introduction of the PFT and the 11-cm Lap-Band, we observed a significant reduction in slippage rate and no posterior slippage. Re-banding had a less favorable long-term result than did first-procedure banding.

[Twelve years of laparoscopic cholecystectomy]

We studied developments in indication, operation time, conversion rate, morbidity, and mortality from the beginning of laparoscopic cholecystectomy. Between 1990 and 2002 we prospectively evaluated 4498 patients undergoing cholecystectomy (CE), of whom 79% were treated laparoscopically (lap). In 6.6%, the procedure had to be converted from laparoscopic to open cholecystectomy (con), and 14% were performed open from the beginning (open). During the above time period, the rate of open CE decreased steadily (49% in 1990 to 7.2% in 2002). The average operation time of lap CE remained constant with an average of 74 min (range 20-330). The conversion rate decreased in spite of broader indication for lap CE in even more complicated gallstone diseases, from an initial 9.4% to 2.5%. Among intraoperative complications in lap and con, bile duct lesions remained constant with 5/3856 (0.1%), bleeding which led to conversion decreased from 1.9% to 0.3%, and the rate of gall bladder perforation increased from 12% to 20.5%. Thirty-day morbidity was 2% in lap CE, 5% in con, and 11.5% in open. The mortality was 0% in lap, 0.7% in con, and 1% in open.

CONCLUSION

Since the introduction of laparoscopic cholecystectomy the indication for this minimal-invasive operation steadily increased, the conversion-rate decreased and the complication-rate could be held low. Even with fast laparoscopic experience 7% of all cholecystectomies are technically difficult and remain to be carried out primarily in an open technique. The laparoscopic cholecystectomy has become the gold standard in the therapy of gallstone disease.

Relationship of hairless mouse skin surface temperature to wound severity and maturation time

Skin surface temperature (SST) changes measured on live hairless mice are presented as a simple means of following wound healing. SST is generally determined by 3 factors which are the ambient temperature, the rate of water loss from the surface of the skin and the diffusion of thermal energy from the body's core. The SST increase immediately after a burn injury reflects the amount of thermal energy absorbed by the skin surface. For burns and other injuries, the drop in SST following injury, but after thermal equilibrium has been established, provides an early indication of the degree of impairment of the skin's barrier. Three kinds of mouse skin wounds, mechanical (tape stripping), thermal and chemical (phenol application), were investigated. SST nadirs ranged from 2.1 to 4.4 degrees C with mild to full-thickness burns, respectively. Except for the earliest moments after wounding, striking parallels were noted between SST and transepidermal water loss profiles for these injuries. The SST profile over the full course of wound healing clearly indicates the severity of the injury, the stages of wound maturation and the time to complete skin healing.

Novel Notch alleles reveal a Deltex-dependent pathway repressing neural fate

BACKGROUND

The Notch receptor triggers a wide range of cell fate choices in higher organisms. In Drosophila, segregation of neural from epidermal lineages results from competition among equivalent cells. These cells express achaete/scute genes, which confer neural potential. During lateral inhibition, a single neural precursor is selected, and neighboring cells are forced to adopt an epidermal fate. Lateral inhibition relies on proteolytic cleavage of Notch induced by the ligand Delta and translocation of the Notch intracellular domain (NICD) to the nuclei of inhibited cells. The activated NICD, interacting with Suppressor of Hairless [Su(H)], stimulates genes of the E(spl) complex, which in turn repress the proneural genes achaete/scute.

RESULTS

Here, we describe new alleles of Notch that specifically display loss of microchaetae sensory precursors. This phenotype arises from a repression of neural fate, by a Notch signaling distinct from that involved in lateral inhibition. We show that the loss of sensory organs associated with this phenotype results from a constitutive activation of a Deltex-dependent Notch-signaling event. These novel Notch alleles encode truncated receptors lacking the carboxy terminus of the NICD, which is the binding site for the repressor Dishevelled (Dsh). Dsh is known to be involved in crosstalk between Wingless and Notch pathways.

CONCLUSIONS

Our results reveal an antineural activity of Notch distinct from lateral inhibition mediated by Su(H). This activity, mediated by Deltex (Dx), represses neural fate and is antagonized by elements of the Wingless (Wg)-signaling cascade to allow alternative cell fate choices.

Prevalence of postcholecystectomy symptoms: long-term outcome after open versus laparoscopic cholecystectomy

After cholecystectomy a certain number of patients continue to suffer from abdominal symptoms or develop such symptoms postoperatively. The aim of this study was to compare the prevalence of postcholecystectomy symptoms with open cholecystectomy during the prelaparoscopic era and those with laparoscopic cholecystectomy 4 years after introduction of the laparoscopic technique. Between July 1988 and June 1989 a total of 163 consecutive patients with elective open cholecystectomy and between September 1994 and August 1995 a total of 234 consecutive patients with elective laparoscopic cholecystectomy were prospectively evaluated using a standard questionnaire about preoperative symptoms, diagnostic modalities, and intraoperative findings. After a minimum of 12 months the patients were interviewed by telephone. Since the introduction of the minimal invasive technique the number of cholecystectomies performed at our institution increased. There was no significant difference in the prevalence of postcholecystectomy symptoms found after the open procedure compared with laparoscopic cholecystectomy: 90% of patients after open and 94% after laparoscopic cholecystectomy had no or only minor symptoms.

Interactions between chip and the achaete/scute-daughterless heterodimers are required for pannier-driven proneural patterning

The GATA factor Pannier activates the achaete-scute (ASC) proneural complex through enhancer binding and provides positional information for sensory bristle patterning in Drosophila. Chip was previously identified as a cofactor of the dorsal selector Apterous, and we show here that both Apterous and Chip also regulate ASC expression. Chip cooperates with Pannier in bridging the GATA factor with the HLH Ac/Sc and Daughterless proteins to allow enhancer-promoter interactions, leading to activation of the proneural genes, whereas Apterous antagonizes Pannier function. Within the Pannier domain of expression, Pannier and Apterous may compete for binding to their common Chip cofactor, and the accurate stoichiometry between these three proteins is essential for both proneural prepattern and compartmentalization of the thorax.

The learning curve of laparoscopic cholecystectomy and changes in indications: one institutions's experience with 2,650 cholecystectomies

PURPOSE

In a prospective series of 2,650 consecutive patients undergoing cholecystectomy, we analyzed the learning curve since the introduction of laparoscopic cholecystectomy (LC) in terms of operating time, conversion rate, morbidity, mortality, and consequent changes in indications for either laparoscopic or open cholecystectomy (OC).

PATIENTS AND METHODS

Between July 1990 and June 1997, LC was performed in 1,929 patients (73%), 203 of whom (7.5%) had to be converted to OC, while 518 patients (19.5%) had primary OC. Patients having LC were predominantly female, younger, with less comorbidity and less complicated gallstone disease than patients having OC.

RESULTS

Barring a learning curve during the first 6 months of LC, operating time remained constant at an average of 71 minutes while operating on ever more complex pathologies. The conversion rate decreased from 9.4% to 6.7% during the 7-year period. A relatively constant team of surgeons with growing experience as well as constantly improving technical equipment allowed the complication rate to remain low. The total morbidity of LC was 2.5% (0.1% bile duct injury), that of conversions 5%, and that of OC 12.5%. The mortality was 0 for LC, 0.5% for conversions, and 1% for OC.

CONCLUSION

The indications for primary OC decreased from 50% to 8.5% and the indications for LC could be broadened over the years.

[Increasing frequency of bariatric surgery interventions since replacement of gastroplasty by laparoscopic gastric banding in the treatment of morbid obesity]

Between 1984 and 1996 we performed a Mason gastroplasty for the treatment of morbid obesity: 14 patients (average age 40 (26-48) years, body mass index (BMI) 48 (37-71) kg/m2, excessive body weight 67 (41-116) kg). Since the end of 1996 we now apply adjustable laparoscopic gastric banding (lab band): 73 patients (average age 39 (22-64) years, BMI 45 (32-69) kg/m2, excessive body weight 66 (41-116) kg). We compared the early and late results of both methods. Early results: no relevant morbidity or mortality for neither method. Late/intermediate results: reoperation rate for both methods 15%. After an average of 3.7 years the excessive body weight loss (EWL) for gastroplasty was 54 (22-96)%. The EWL after lab band for 24 patients after 12 months was 47 (11-127)% and for 8 patients after 18 months 51 (28-139)%. Since the introduction of the lap band the number of bariatric operations has greatly increased. Nevertheless, the perioperative complication rate has remained low, and the long-term outcome is similar for both methods.

Simultaneous detection of high energy phosphates and metabolites of glycolysis and the Krebs cycle by HPLC

For the detailed analysis of energy metabolism, a HPLC method is described allowing the single-run separation and quantification of most metabolites from glycolysis and the Krebs cycle including the high energy phosphates. With a detection limit in the picomolar range this method is even applicable when only small sample sizes of tissue are obtained.

[Postcholecystectomy complaints one year after laparoscopic cholecystectomy. Results of a prospective study of 253 patients]

AIMS

We studied the nature and frequency of symptoms 1 year after laparoscopic cholecystectomy in order to define pre- and perioperative factors that influence the long-term outcome.

METHOD

Between September 1994 and August 1995 we prospectively evaluated 268 patients undergoing laparoscopic cholecystectomy using a standard questionnaire. After an average of 16 months (12-25 months) the patients were asked about their symptoms using a similar questionnaire by telephone or were followed up clinically if necessary.

RESULTS

In the long-term follow-up the severity of the symptoms according to the Visick score were: Visick I (no symptoms): 164 patients (65%); Visick II: 72 (28%); Visick III: 12 (5%); Visick IV: 5 (2%). The aetiologies of the postcholecystectomy syndrome were: residual stones 1%, subhepatic liquid formation 0.8%, incisional hernia 0.4%, peptic diseases 4%, wound pain 2.4%, functional disorders 26%. Patients with typical or atypical symptoms preoperatively showed no difference in the outcome 1 year after laparoscopic cholecystectomy. Neither did the number and location of laparotomies prior to cholecystectomy or the gallbladder perforation or loss of stones intraoperatively influence the severity of the postcholecystectomy symptoms.

CONCLUSIONS

One year after laparoscopic cholecystectomy 93% of the patients have no or only minor abdominal symptoms. Neither the number and location of the laparotomies prior to cholecystectomy nor the loss of gallstones intraoperatively have an impact on the long-term result.

[Results of anal sphincteroplasty in fecal incontinence--significance of intra-anal ultrasound imaging]

The aim of the study was to evaluate the clinical, manometric and endosonographic results of overlapping sphincteroplasty for traumatic sphincter defects documented by endosonography.

PATIENTS AND METHOD

We performed an overlap repair in 10 women aged 34 to 68 with fecal incontinence due to sphincter defects after obstetric (n = 8) or iatrogenic (n = 2) trauma. The fecal incontinence was graded using the Miller Score (0-18 points). Manometry and endosonography were done pre- and postoperatively. The mean follow-up time was 17 months (6-25 m.).

RESULTS

Perioperative morbidity was low: one temporary colostomy was necessary due to an anal fistula. Eight out of 10 patients were satisfied with the result. The incontinence grade fell from an average of 14 points (8-17 points) preoperatively to 5 (0-12 points) postoperatively. The mean resting pressure increased from 36 to 41 mmHg, the voluntary contraction from 48 to 59 mmHg. Endosonography allowed the precise localization of the defect before operation and the sphincteroplasty could be visualized after operation in all the patients.

CONCLUSIONS

The overlapping sphincteroplasty improved fecal incontinence successfully in 9 of 10 patients with posttraumatic sphincter defects. Endosonography is very useful in localization of the sphincter defect and documentation of the performed sphincteroplasty.

[Incarcerated diaphragmatic hernia as a sequela of iatrogenic diaphragmatic defect. 2 case reports]

We describe two cases of iatrogenic adult diaphragmatic hernias with incarceration which occurred postoperatively and led to an acute abdomen. The pathogenesis, clinical findings, the often challenging diagnostics and the therapeutic management of this rare condition are discussed.

[11 cases of anal Bowen's disease]

Bowen's disease of the anal region is a rare, slow-growing, intraepidermal squamous-cell carcinoma (carcinoma in situ). If surgical excision is incomplete, there is a risk of subsequent development of malignancy and metastasis. Between 1980 and 1995 we treated 11 patients (8 female, 3 male) with anal Bowen's disease. The mean age was 55 (34-75) years. The main reason for excision was: pain (4), itching (3), bleeding (3) and a disturbing lump (3). The intraoperative findings were in all cases a lesion at the anocutaneous line: perianal or intra-anal tumor (6), erosion (2) or ulceration (2) as well as lichenoid lesion (4) or hyperpigmentation (3). The procedure was excision of the lesion in 10 cases. Only in one case was a biopsy taken. 3 patients had to be operated on a second time for reasons of radicality. 5 years after primary diagnosis, one patient developed a recurrent invasive squamous-cell carcinoma and had to undergo perineo-abdominal rectum amputation with postoperative radiotherapy (2 years after operation). Only one patient underwent a biopsy, which produced the diagnosis of invasive squamous-cell carcinoma. He underwent combined chemo-radiotherapy. The symptoms of anal Bowen's disease are unspecific and the clinical findings are uncharacteristic. The recommended therapy is complete surgical excision. With complete excision no recurrences do occur.

[Preperitoneal prosthesis implantation in surgical management of recurrent inguinal hernia. Retrospective evaluation of our results 1989-1994]

Recurrent inguinal hernia represents a great problem in surgery given the frequency of this operation, with a recurrence rate of 0.5-8%. Re-recurrence after repair without implantation of a prosthesis occurs in 1-23% of cases. We analyzed our results of patients with recurrent inguinal hernia, operated according to the method of Stoppa. Between 1989 and July 1994 there were 58 operations upon 55 patients with an average age of 65 years, 79% of whom had unilateral and 21% bilateral hernias. 89% of all patients underwent surgery because of a recurrent inguinal hernia. A Marlex mesh was used in 79% of the case. All patients were followed up (mean 35 months, minimum 12 months). Early complications consisted in one hematoma (1.7%), which had to be drained, as well as one early recurrence (1.7%). No infections were observed. The overall recurrence rate was 12%. However, 60% of all recurrences occurred in the few first years after introduction of this technique at our clinic; with growing number of operations and experience with Stoppa's technique, we obtained a recurrence rate of 6-7% per year. In our opinion, supported by the results of other studies, Stoppa's technique is a successful method in the treatment of recurrent inguinal hernia.

[Initial results with laparoscopic fundoplication]

17 patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease not responding to medical treatment. Conversion to laparotomy was necessarily due to large paraesophageal hiatus hernia (3) or severe peri-esophagitis (1) in 4 patients. There was no perioperative morbidity or mortality. At 3 months all patients were symptom-free. Esophageal manometry revealed a rise in mean lower esophageal sphincter pressure from 4 mm Hg preoperatively to 11 mm Hg postoperatively, and lengthening of the high pressure zone from 2.3 to 3.3 cm. One patient needed reoperation one year after fundoplication due to wrap disruption with recurrent reflux disease. Laparoscopic fundoplication involves low perioperative morbidity and shortens the postoperative recovery time in selected patients.

[Reflux disease following gastropexy for para-esophageal hiatal hernia]

From 1984 to 1992 28 patients with paraesophageal hiatus hernia underwent elective operation with crural repair and gastropexy. In the absence of severe reflux disease (6 patients had mild to moderate reflux symptoms) and of esophagitis at endoscopy, no antireflux repair was performed in these patients. Follow-up of 19 patients after 3 years (12-72 months) revealed reflux symptoms in 11 patients (58%) and moderate or severe reflux disease (need for medical treatment) in 6 (32%). 6 patients developed new reflux symptoms after operation. 3 patients had esophagitis at endoscopy. In elective cases, the repair of paraesophageal hernia should, regardless of the presence of reflux esophagitis, be combined with an antireflux procedure to avoid the high risk of postoperative reflux disease.

Maternal sensitivity as an external organizer for biobehavioral regulation in infancy

Recent findings from both animal and human research have clearly demonstrated connections between behavioral coping mechanisms and adrenocortical function. The aim of this study was to address the role of maternal sensitivity as an external organizer of psychobiological function in infants during the first year of life. Forty-one infants and their mothers were observed during play at 3, 6, and 9 months of age. Age-specific patterns of relation between maternal sensitivity and infant behavioral organization were found indicating contextual dependence of infant behavior at 3 months and experience-related behavioral function at 9 months. An affect of maternal sensitivity on adrenocortical function during the free play was demonstrated at 3 and 6 months, because an increase in cortisol was most frequently observed in infants of highly insensitive mothers. The findings indicate the importance of maternal behavior for infant biobehavioral organization.

[Results of surgical therapy in esophagus and cardia carcinoma]

Surgery for carcinoma of the esophagus and cardia represents potentially curative therapy in early stage of tumor. In the advanced stage of tumor palliation is the only remaining therapeutic aim. In a retrospective study covering the period 1984-1992 we analyzed 51 patients who underwent surgery for esophageal or cardia cancer to determine whether palliation by surgery is feasible. We also analyzed morbidity and mortality of peri- and postoperative complications. In 88% we carried out standard esophagectomy consisting of abdomino-thoracic access, gastric interposition with thoracic anastomosis and extramucous pyloromyotomy. In the light of postresection histology, 53% of the operations were potentially curative (UICC stage I and II) [1], 47% palliative (UICC stage III and IV) [1]. Perioperative 30-days mortality was nil, perioperative 30-days morbidity 11% (3 patients developed pneumonia postoperatively, 2 patients with cervical anastomosis developed dehiscence of anastomosis which in both cases healed completely with conservative therapy, while a further patient with cervical anastomosis suffered persistent paralysis of the recurrent nerve. All patients were fully able to feed themselves at the time of discharge. 43% of patients had recurrent dysphagia and 24% underwent endoscopic dilatation. Three-year survival was 26%. From these results it may be concluded that esophageal resection represents either good palliation with low morbidity for the majority of patients with non-resectable carcinoma of the esophagus or potentially curative therapy with low morbidity in early stage of tumor.

[Sphincter-preserving surgery of trans-sphincteric anal fistulas]

The "laying open" technique is the standard method of treating fistulas-in-ano. Laying open transsphincteric (high anal) fistulas involves division of a part of the external anal sphincter and may result in incontinence. In 12 patients with high transsphincteric fistula (7 with previous surgery to attempt fistula healing) we have used a sphincter-saving surgical method: excision of the fistula tract and closure of the internal opening by suture of the internal anal sphincter. Fistulas were eradicated in 8 patients (67%) without incontinence. In 4 patients the fistulas persisted. It is concluded that transanal closure of the internal opening and perianal fistula excision can be an effective method of treating transsphincteric fistulas without sphincterotomy, thus avoiding the risk of incontinence.

[Cholecystectomy today. A prospective study]

Between 13 June 1990 and 12 June 1993, we performed 1145 consecutive cholecystectomies. 127 patients who had undergone additional surgery were excluded from the prospective study. Of the remaining 1018 patients, 806 (78.2%) underwent laparoscopic cholecystectomy. The conversion rate to open procedure was 11.2% (90/806). The operative morbidity associated with laparoscopic cholecystectomy was 2.1% (17/806) and with open surgery 1.9% (4/212); mortality was 0.12% (1/806) and 0.47% (1/212) respectively. The reoperation rate after laparoscopic cholecystectomy was 0.6% (5/806). Reoperation was performed for lesions of the common bile duct, bleeding, and abscess formation. If the indications for open cholecystectomy are respected the morbidity and mortality were low for both laparoscopic and conventional cholecystectomy.

Acute and chronic presentation of intestinal nonrotation in adults

Intestinal nonrotation has been recognized as a cause of obstruction in neonates and children and may be complicated by volvulus and intestinal necrosis. It is very rarely seen in the adult and may present acutely as a bowel obstruction and intestinal ischemia associated with midgut or ileocecal volvulus, or chronically as vague intermittent abdominal pain. The purpose of this communication is to reveal the pathogenesis and the surgical significance of intestinal nonrotation in adults and to review the English and German language literature since 1923 to establish the optimal therapeutic management. Between 1983 and 1992, we have managed and observed prospectively 10 adults with intestinal nonrotation. In four patients the nonrotation has been detected at emergency laparotomy owing to midgut or ileocecal volvulus. Four patients suffered from chronic symptoms of intermittent volvulus or small bowel obstruction and in two patients the nonrotation has been noted as an incidental finding at laparotomy for another condition. A survey of the literature from 1923 to 1992 revealed 40 adults with symptomatic intestinal nonrotation to which we contribute nine patients. We establish that in the acute symptomatic pattern, only emergency laparotomy can provide the correct diagnosis and decrease the risk of bowel disturbance. In the chronic situation, barium studies of the upper and lower gastrointestinal tract reveal varying degrees of midgut malrotation and confirm the nonrotation in each case. Also, in these forms the explorative laparotomy with a consequent staging of the abdominal situs is to be recommended. All reported cases at our institutions are without complaints after surgery. Adult patients with intestinal nonrotation and acute or chronic obstructive symptoms or those detected incidentally at laparotomy for other conditions should undergo a Ladd procedure because of the risk of midgut volvulus. In this operation, the nonrotation is left in place and the ascending colon is sutured at the colon descendens and sigmoideum. After this procedure the mesenteric pedicle is fixed and the risk of midgut torsion remains minimal.

[Native radiologic staging of osteoporosis--CT densitometry of lumbar vertebral spongiosa. A correlation study]

Lumbar spine radiographs in 47 patients with manifest or clinically suspected osteoporosis were evaluated, using a staging system, and correlated to quantitative computed tomography (QCT) of lumbar vertebrae. The accuracy of osteoporosis assessment, obtained with plain film analysis, was 60%, the sensitivity 67%, the specificity 56%. Statistical correlation showed high standard deviation of each of the QCT-mean values according to the respective stage groups, and altogether poor linear correlation between increasing morphological stages of osteoporosis and decreasing QCT-values. As our results show plain film differentiation of normal from reduced trabecular bone mineral content is unreliable, even by use of a staging system. The diagnostic value of spine radiographs therefore remains limited to demonstration of advanced osteoporotic changes.

[Perioperative morbidity and mortality in colon resection for colon cancer]

The operative risk of colon resections was evaluated by a retrospective analysis of 231 according patients who were operated on between 1984 and 1988. Mean age of the patients was 70 years with a range from 37 to 91 years. Colonic resection consisted of ileocecal resection in 3 cases, right hemicolectomy in 144 cases, segmental resection of transverse colon in 10 cases, left hemicolectomy in 22 cases, resection of sigmoid colon in 77 cases and 5 times a subtotal colectomy was performed. In two patients (0.9%) an anastomotic leak occurred. Three patients were reoperated on: one due to an anastomotic disruption, two others due to a mechanical small bowel obstruction. Two patients (0.9%) died due to systemic complications without any evidence of anastomotic or wound problems. Thus a low morbidity and mortality of colonic resection is documented in our study. Factors contributing to these results are a standardized bowel preparation, perioperative antibiotics and modern anaesthetic techniques.

[The incidence of ileus after resection for rectal cancer with and without radiotherapy]

Between 1984 and 1989 240 patients had radical abdominal resection of a rectal carcinoma. Out of 201 patients surviving 12 months or more postoperatively, two groups are surveyed. The first group presents patients undergoing adjunctive radiation therapy (n = 47), the second group did not undergo postoperative radiation therapy (n = 134). Mean follow-up time postoperatively is 39 months. Within the irradiation group, the incidence of ileus was found to be 23% (11/47), in the non-irradiated group 8% (11/134). Subsequent reoperations in order to clear intestinal obstruction were performed on 4% (5/134) of non-irradiated patients and on 21% (10/47) of the irradiated group. Considering the increased risk of postoperative ileus after rectal resection for rectal carcinoma, serious reflection should be given to assessing the appropriateness of adjunctive radiation therapy.

[Results of esophagectomy in carcinoma of the esophagus and cardia]

Surgery for carcinoma of the esophagus and cardia represents potentially curative therapy in the early stage of the tumor. In the advanced stage of tumor, palliation is the only remaining therapeutic aim. In a retrospective study covering the period 1984-1992 we analyzed 51 patients who underwent surgery for esophageal or cardia cancer to determine whether palliation by surgery is feasible. We also analyzed mortality and morbidity of peri- and postoperative complications. In 88% we carried out standard esophagectomy consisting of abdomino-thoracal access, gastric interposition with thoracal anastomosis and extramucosal pyloromyotomy. In the light of postresection histology, 53% of the operations were potentially curative (UICC stage I and II) and 47 palliative (UICC stage III and IV). Perioperative 30-day mortality was nil, and perioperative 30-day morbidity 11% (3 patients developed pneumonia postoperatively, 2 patients with cervical anastomosis developed dehiscence of anastomosis which in both cases healed completely with conservative therapy, while a further patient with cervical anastomosis suffered persistent paralysis of the recurrent nerve. All patients were fully able to feed themselves at the time of discharge. 43% of patients had recurrent dysphagia and 24% underwent endoscopic dilatation. Three-year survival was 26%. From these results it may be concluded that esophageal resection represents good palliation with low morbidity for the majority of patients with non-resectable carcinoma of the esophagus.

[Incidence of ileus following rectum resection in rectal carcinoma with or without radiotherapy]

Between 1984 and 1989 240 patients underwent radical abdominal resection of a rectal carcinoma. Out of 201 patients surviving 12 months or more postoperatively, two groups are surveyed. The first group presents patients undergoing adjunctive radiation therapy (n = 47), while the second group did not undergo postoperative radiation therapy (n = 134). Mean follow-up time postoperatively is 39 months. Within the irradiation group, the incidence of ileus was found to be 23% (11/47), and in the non-irradiated group 8% (11/134). Subsequent reoperations in order to clear intestinal obstruction were performed on 4% (5/134) of non-irradiated patients and on 21% (10/47) of the irradiated group. Considering the increased risk of postoperative ileus after rectal resection for rectal carcinoma, serious reflection should be given to assessing the appropriateness of adjunctive radiation therapy.

[Perioperative morbidity and mortality of colon resection in colonic carcinoma]

An analysis of the local and systemic perioperative complications is conducted to explore the risk of resection of colon cancer. In a retrospective study we analyzed 231 consecutive patients operated on between 1984 and 1988. The mean age was 70 (37-91) years. The operations consisted in 3 ileocecal resections, 144 right hemicolectomies, 10 resections of the transverse colon, 22 left hemicolectomies, 77 resections of the sigmoid colon and 5 subtotal colonic resections. 2 patients (0.9%) had a clinical leakage of the anastomosis. 3 patients were reoperated: one because of anastomotic leakage and two because of ileus due to small bowel adhesions. 2 patients with uncomplicated local healing died within 30 days after the operation from systemic complications (mortality 0.9%). It is concluded that with standardized preoperative bowel preparation, prophylactic perioperative antibiotics and modern anesthesia, the resection of colon cancer is today possible with minimal perioperative risk.

[Fundus plication with or without proximal selective vagotomy?]

The aim of this study was to determine the influence of proximal gastric vagotomy on the outcome after fundoplication. Of 141 patients operated on for reflux disease between 1972 and 1988, 53 had fundoplication alone (group A) and 88 fundoplication combined with proximal gastric vagotomy (group B). The two groups were similar with regard to the severity of the reflux disease (esophagitis: A 69%, B 73%) but had a different incidence of concomitant ulcer disease (A 2%, B 55%). After a mean follow-up of 9 years, 111 patients (79%) were evaluated by clinical examination and 57 patients (40%) by endoscopy. Perioperative morbidity was similar (A 22%, B 19%). Successful reflux control (A and B 81%) and overall clinical outcome (Visick I and II: A 78%, B 80%) were identical. The frequency of adverse side effects was approximately the same in both groups (dysphagia: A 28%, B 26%; gas-bloat: A 52%, B 37%). We conclude that the long term results after fundoplication are not improved by additional proximal gastric vagotomy. The combined procedure is therefore only justified if both reflux disease and ulcer disease are present.

[Laparoscopic cholecystectomy. Initial experiences and results in 278 patients]

Of 467 cholecystectomies (performed between 13. 6. 1990 and 12. 9. 1991) 278 were done by laparoscopy (196 women, 82 men; mean age 53 [18-86] years). Contraindications to a laparoscopic procedure were acute cholecystitis, severe chronic cholecystitis with adhesions, abnormal clotting and suspected gallbladder carcinoma. In 31 patients (11.1%) the initial laparoscopic cholecystectomy was continued as a conventional cholecystectomy, usually because of unclear conditions in severe chronic cholecystitis. Mean duration of hospital stay was 6.3 days for the laparoscopic procedure compared with 11.5 days for the conventional one. Complications occurred in four patients (in 12 with the conventional method): one occlusion (by clip) of the common bile duct, one bile leak, one bleeding and one pneumothorax, requiring re-operation in three patients. There were no deaths (compared with two in the conventional group). Assuming correct indications, laparoscopic cholecystectomy is a sparing method for the treatment of cholecystolithiasis.