[The clinical importance of the critical view of safety in laparoscopic cholecystectomy]

BACKGROUND

Injury of the bile duct during cholecystectomy (CHE) is a severe complication. The critical view of safety (CVS) can help to reduce the frequency of this complication during laparoscopic CHE. So far, no scoring of CVS images with a grading system is available.

METHOD

The CVS images of 534 patients with laparoscopic CHE could be structurally analyzed and assessed with marks from 1 (very good) to 5 (insufficient). The CVS mark was correlated with the perioperative course. Additionally, the perioperative course of patients after laparoscopic CHE with and without a CVS image was investigated.

RESULTS

In 534 patients 1 or more CVS images could be analyzed. The average CVS mark was 1.9, whereby 280 patients (52.4%) had a 1, 126 patients (23.6%) a 2, 114 (21.3%) a 3 and 14 patients (2.6%) a 4 or 5. Younger patients with elective laparoscopic CHE had CVS images significantly more frequently (p ≤ 0.04). The statistical examination with Pearson's χ²-test and the F‑test (ANOVA) showed a significant correlation between improving CVS marks and reduction of surgery time (p < 0.01) and the hospitalization time (p < 0.01). For senior physicians the quota of CVS images ranged from 71% to 92% and the average marks from 1.5 to 2.2. The marks for the CVS images were significantly better for female than male patients (1.8 vs. 2.1, p < 0.01).

DISCUSSION

There was a relatively broad distribution of marks for CVS images. Injuries of the bile duct can be avoided with a high degree of certainty with marks 1‑2 for the CVS image. The CVS is not always adequately visualized in laparoscopic CHE.

[The COVID-19 pandemic had significant impact on duration of surgery and hospitalization time for patients after cholecystectomy]

BACKGROUND

The COVID-19 pandemic made substantial changes in medical care necessary. The aims of this study were to find out what influence the pandemic had on the perioperative course in patients with cholecystectomy (CHE) and to highlight possible residual consequences.

METHOD

From 1 July 2018 to 31 December 2021 a total of 735 patients with CHE were analyzed. Up to 21 March 2020 patients were assigned to the regular patient group (Reg, n = 430), patients after this date (first lockdown 22 March 2020) to the Cov19 patient group (Cov19, n = 305) and the 2 groups were compared.

RESULTS

The average age of all patients was 59 years and 63% were women. The average length of hospitalization (KrVD, time period between surgery and discharge) was 4.4 days. The patient groups Reg and Cov19 did not differ with respect to age, gender or KrVD. The total number of CHEs carried out was reduced by 21.4% in the Cov19 group. This affected elective and emergency CHE to the same extent. The length of surgery significantly increased in the Cov19 group from 64 min (SD 34 min) to 71 min (SD 38 min). The number of short and long hospital stays (KrVD 2 or >4 days) significantly increased in the Cov19 group from 4 % to 20 % (short stay, p < 0.01) and from 23 % to 27 % (long stay, p < 0.01). This was particularly observed for patients >70 years old with an increase in long stays from 43 % to 56 % in the Cov19 group.

CONCLUSION

The COVID-19 pandemic led to a clear reduction in CHE both for elective and emergency interventions. Furthermore, a significant lengthening of the surgery and hospitalization times could be observed for older patients. The residual consequences of the pandemic could be shortened hospitalization times after uncomplicated CHE and more interventional treatment procedures in complex cases.

Patienten* nach unauffälliger elektiver laparoskopischer Cholezystektomie können ohne Laborwertkontrollen entlassen werden – Ergebnisse einer prospektiven Studie

Hintergrund

Die Bedeutung postoperativer Laborkontrollen nach elektiver laparoskopischer Cholezystektomie (lap. CHE) ist umstritten. Das Ziel dieser prospektiven Studie war es, herauszufinden, ob Patienten* bei unauffälligem perioperativem Verlauf nach lap. CHE ohne Laborwertkontrollen sicher entlassen werden können.

Methodik

Vom 09/20 bis 03/22 wurden alle Patienten* mit einer lap. CHE gescreent und nach Erhalt des Einverständnisses in die Studie eingeschlossen. Der Verlauf wurde mit einem Scoring- (Punktewert 3–15 Punkte) und Befragungsbogen strukturiert verfolgt. Ein Scoringwert von ≤ 9 Punkten beschrieb einen unauffälligen perioperativen Verlauf. Die Ethikkommission Heidelberg hat dieser Studie zugestimmt (S-026/2020).

Ergebnisse

Es wurden 275 Patienten* mit Gallenblasenoperation erfasst. Davon unterzogen sich 80 % einer elektiven lap. CHE. 56 Patienten* (25 %) wurden in die Studie eingeschlossen, 51 Patienten* wurden bei einem Scoringwert ≤ 9 Punkten ohne Blutentnahme entlassen. Das Durchschnittsalter der 51 Patienten* war 50,8 Jahre, der durchschnittliche Krankenhausaufenthalt betrug 2,6 Tage. 40 von 51 Patienten* (78,4 %) konnten postoperativ befragt werden. Bei keinem der Patienten* kam es nach Entlassung zu relevanten Komplikationen. 27 der 40 Patienten* (67,5 %) sind postoperativ noch einmal zum Hausarzt gegangen. Aufgrund anderer Operationen und einer endoskopischen Intervention sind 4 Patienten* erneut stationär behandelt worden. Alle Patienten* waren mit dem chirurgischen Verlauf zufrieden.

Diskussion

Patienten* mit unauffälligem perioperativem Verlauf nach elektiver lap. CHE (Scoringwert ≤ 9 Punkten) können ohne postoperative Laborwertkontrolle entlassen werden.

Geriatric traumatology (e. g. "Alterstraumatologie") is more than orthogeriatrics-Experiences of a physician in advanced training

This article reporting the view of an early career physician focuses on the diverse components of orthogeriatric co-management in a clinical setting. Geriatric trauma patients require a multimodal and interdisciplinary management, which includes individual and age-specific aspects, such as intensified physiotherapy, trauma surgery and geriatric expertise as well as social support. In Germany this surgical and geriatric co-treatment is provided by the program geriatric traumatology (Alterstraumatologie), which is implemented and certified at special institutions called geriatric trauma centers (Alters-Trauma-Zentrum). This special care is accomplished by an orthogeriatric co-management, which combines the efforts of both modern state of the art trauma surgery and geriatric medicine, preferable by using the procedure of the so-called geriatric early rehabilitative complex treatment (geriatrische frührehabilitative Komplexbehandlung) according to the diagnosis-related group (DRG) procedure OPS 8550. This is administered in 3 periods: the preoperative period, perioperative period and postoperative period and if indicated followed and completed by a geriatric rehabilitation. According to recent studies this approach has proved to be beneficial especially with respect to a reduction of posttraumatic morbidity rates and avoiding loss of function.

[Which patient needs controls of laboratory values after elective laparoscopic cholecystectomy?-Can a score help?]

BACKGROUND

Laparoscopic cholecystectomy is nearly exclusively carried out as an inpatient operation in Germany. The aim of the study was to evaluate for which patients postoperative laboratory control values are necessary.

METHODS

This retrospective analysis included 100 patients who underwent elective laparoscopic cholecystectomy. A scoring and data collection sheet was developed, which enables a risk stratification. Using the scoring system patients can achieve between 3 and 15 points.

RESULTS

In total 100 patients were included in the study. Of the patients 64 (group 1) had between 3 and 8 points, 29 patients (group 2) between 9 and 11 points and 7 patients (group 3) between 12 and 15 points. In comparison to group 1 the C‑reactive protein values as well as the duration of hospital stay were significantly increased in group 2 and group 3 (p > 0.05). In group1 a total of 60 patients (93.7%) were discharged regularly on postoperative days 1-3. In group 2 there were 17 patients (58.6%) who could be discharged with unremarkable blood values and in group 3 there were 3 patients (42.8%). In the total collective hospital discharge without a laboratory control of blood values would have been justified in 80% of the patients.

CONCLUSION

A postoperative control of laboratory blood values is not routinely necessary for patients after elective laparoscopic cholecystectomy with a score <9 points.

CHARACTERISATION OF RADIOPHOTOLUMINESCENCE DOSIMETRY SYSTEM FOR INDIVIDUAL MONITORING

Performance evaluation is typically assessed as part of the approval procedure to verify that a dosimetry system fulfils specified national or international type-test requirements under representative exposure conditions that are expected to mimic workplace fields from the radiological activities being monitored. The International Atomic Energy Agency Radiation Safety Technical Services Laboratory has recently implemented an integrated radiophotoluminescence (RPL) personal dosimetry system developed by Chiyoda Technol Corporation. This paper reports on the successful verification of dosimetric performance properties of the RPL dosimetry system to IEC 62387:2020, in which the badges were exposed to a range of radiation energies and angles of incidence as well as other influence parameters. Characteristics under test included the coefficient of variation, non-linearity of response due to dose dependence as well as the energy and angular response to photon and beta radiation.

Effect of antithrombotic drugs on bone health

With the increasing consumption of antithrombotic drugs among old people, expected as well as unexpected side effects on bone health are considerable, e.g. osteoporosis, fragility fractures, etc. This review focuses on antithrombotic drugs and their effects on bone health. The following groups were reviewed: parenteral long-term use of unfractionated heparin (UFH) is associated with osteopenia. The oral intake of vitamin K antagonists (VKA) makes them more convenient than UFH but chronic use also results in osteopenia. Limited reports of bone loss have been associated with low molecular weight heparins (LMWH) and indirect factor Xa inhibitors but in contrast to VKA and UFH they are less associated with osteopenia. There have been limited studies evaluating the effect of new oral anticoagulants (NOACs) on bones. Overall, they are considered safer than other drugs. There have been no reports about acetylsalicylic acid (ASA) and clopidogrel causing osteopenia but their metabolism by the kidneys and liver can cause reduced 25-hydroxy-vitamin D levels and can theoretically contribute to osteoporosis. Some reports suggested that high dosage clopidogrel can also negatively affect bones. After a detailed literature review long-term use of antithrombotic drugs can negatively affect the bones. Their role in bone health needs to be studied in detail and the clinical use in geriatric patients should be prudent.

Kinetics of Pulmonary Leukocyte Sequestration in Man during Hemodialysis with Different Membrane-Types

Although it has been suggested that pulmonary sequestration of leukocytes could account for membrane-dependent white blood cell depletion in HD, direct evidence in patients is still lacking. Therefore a study was initiated to test whether and how leukocytes distribute in the lung circulation during HD with different membranes. Thirteen patients suffering from chronic renal failure underwent lung scintigraphy during HD with cuprophane (n = 3), hemophane (n = 8) and polysulfone (n = 2) lowflux capillary dialyzers. Isolated autologous leukocytes were labelled with 99m-Technetium and reinfused before starting HD. Distribution of leukocyte related activity was registered by lung scintigraphy. In comparison to normal lung scintigraphy performed without HD, an impressive redistribution peak was demonstrated 10-20 min after the start of HD with cuprophane and also to a lesser extent with hemophane. When HD was performed with polysulfone the decrease in activity was delayed but no real redistribution was obtained.

In accordance with other phenomena, such as peripheral leukopenia and changes in granulocyte oxidative metabolism, pulmonary sequestration of leukocytes takes place in man in the initial phase of HD and appears to be strongly dependent on the type of membrane. (Int J Artif Organs 1990; 13: 729-36)

State of the art in aspiration assessment and the idea of a new non invasive predictive test for the risk of aspiration in stroke

BACKGROUND

Dysphagia is a common but severe complication in acute stroke. New bedside tests are necessary to assess the risk of aspiration and avoid unnecessary alimentary restrictions but they must be completed by evaluated instruments.

OBJECTIVE

We evaluated the prognostic validity of the recognition of forms (rf) test related to the assessment by speech and language therapists (SLT).

DESIGN

Double blinded screening tests.

SETTING

Geriatric department of general hospital.

SUBJECTS

50 patients with acute stroke admitted consecutively.

METHODS

All patients were assessed by SLT, mini mental status test, short test for assessing deficits of memory and attention and abilities of daily living-test. The rf-test was performed twice with a two week interval.

RESULTS

Assessment by SLT demonstrated aspiration in 29 of 50 patients. 18 patients failed the rf-test, giving a specificity of 90% (positive predictive value 89%), a sensitivity of 55% (negative predictive value 59%). 5 of 7 patients with aspiration pneumonia failed the test. Test-retest-correlation was 0,827. Performance in the rf-test was related significantly to results of the activities of daily living-test.

CONCLUSIONS

Bedside tests to exclude aspiration in patients with acute stroke are necessary. No test so far combines high sensitivity with acceptable specificity. Compared to other bedside tests the rf-test has a high specificity while sensitivity is low. On behalf of good predictivity rf-test may be an interesting supplement to swallow tests in case of stroke and seems to be a candidate for more extended studies.

Comprehensive geriatric assessment in the elderly cancer patient

The proportion of older cancer patients is increasing due to demographic and disease-specific reasons. However, this group of patients is severely underrepresented in research and clinical therapy. Limitation in physical and functional capacity with considerable interindividual heterogeneity remains one of the important problems in the treatment decision process. One approach to this problem is the use of a Comprehensive Geriatric Assessment (CGA) to describe and classify these deficits with high validity and reliability. The different domains of CGA are described with special respect to the instruments applied, as CGA has also a key role in the decision process.

[Therapy of elderly patients with colorectal carcinoma]

Treating elderly patients with colorectal cancer is a challenging task for which many aspects have to be taken into account. Almost 70% of patients with colorectal cancer are 65 years or older and the number of elderly patients is expected to increase. As elderly patients frequently exhibit adverse physical or socio-economic conditions, a thorough geriatric assessment of the patient's suitability for therapy is essential before making a decision. The first line treatment for colorectal cancer is surgery. Complete resection of the tumor should also be attempted in elderly patients, as there are little differences in cancer--specific survival in selected elderly patients compared to younger patients. Surgery with palliative intention can be attempted for symptom control or to prevent later local complications caused by the primary tumor. At present, adjuvant 5-FU based chemotherapy (in colon cancer) and adjuvant radio-chemotherapy (in rectal cancer) in the elderly is recommended for locally advanced or node positive tumor after tumor resection, since the benefit seems to be comparable to that achieved in younger patients. There is also enough data to support the use of 5-FU based chemotherapy in elderly patients in the palliative setting. New drugs have recently been added to the armentarium for the treatment of metastatic colorectal cancer. However, there is as yet not sufficient data to guide the use of these new drugs (such as oxaliplatin or irinotecan) in elderly patients. However, first clinical studies seem to indicate a comparable efficacy and toxicity in elderly patients to that observed in younger patients. Further clinical trials of chemotherapy in elderly patients with colorectal cancer are necessary to gain information about treatment recommendations. It is the aim of this manuscript to summarize the current knowledge about the management of colorectal cancer in elderly patients.

Driving in vitro selection of anti-HIV-1 TAR aptamers by magnesium concentration and temperature

In vitro selection with either DNA or RNA libraries was performed against the TAR RNA element of HIV-1. The role of the selection conditions on the outcome of the selection was evaluated by varying the magnesium concentration and the temperature. The selection stringency was demonstrated to determine i) the affinity of the best identified aptamers for the TAR target, and ii) the type of interaction between the two partners. Selections performed with a DNA library under low (4 degrees C, 10 mM magnesium) and high stringency (23 degrees C, 3 mM magnesium) led to the emergence of "kissing aptamers"; but even if the motif interacting directly with the TAR loop were identical in the two kinds of aptamers, the consensus was extended from eight to thirteen nucleotides when the Mg(2+) concentration was decreased from 10 to 3 mM. Similar kissing aptamers were selected at 23 degrees C and 37 degrees C starting with two different RNA libraries under identical ionic conditions. In addition, selection performed at 37 degrees C yielded a significant proportion of antisense sequences. Only antisense RNAs complementary to the TAR loop competitively inhibited the association of a Tat peptide with TAR.

Use of hematopoietic growth factors in elderly patients receiving cytotoxic chemotherapy

Myelosuppression is a common side effect in elderly patients undergoing chemotherapy. Neutropenia and anemia cause considerable morbidity, may increase mortality, and can result in a worse outcome of treatment in elderly patients compared to younger patients with comparable type and stage of disease. The availability and proven efficacy of hematopoietic growth factors such as granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) and erythropoietin (EPO) have had a considerable impact on supportive care in cancer patients: Several randomized trials have demonstrated a reduction of neutropenia and the frequency of severe infections in elderly patients treated with G-CSF following myelotoxic chemotherapy compared with patients without growth factor support. Both for G-CSF and for recombinant human erythropoietin (rHu-EPO) several studies have demonstrated the safety and effectiveness of these molecules in elderly patients with regard to increasing hemoglobin concentrations, improving quality of life (rHu-EPO), and neutrophil recovery. Although a positive effect of the use of growth factors on overall survival in elderly cancer patients is not yet proven, a reduction of chemotherapy-induced side effects could clearly be shown. The National Comprehensive Cancer Network (NCCN) of cancer centers has recommended that all patients aged 70 years and older treated with CHOP or cytotoxic chemotherapy of comparable intensity should receive prophylactic G-CSF administration, and that the hemoglobin concentration be maintained at >or=12 g/dl in elderly patients undergoing chemotherapy.

[Chemotherapy of colorectal cancer--which therapy is justified for elderly patients?]

Treating elderly patients with colorectal cancer is a challenging task for which many aspects have to be taken into account. 70% of patients with colorectal cancer are 65 years or older and the number of elderly patients is expected to increase. As elderly patients frequently exhibit adverse physical or socio-economic conditions, a thorough geriatric assessment of the patient's suitability for therapy is essential before making a decision. At present, adjuvant 5-FU based chemotherapy (in colon cancer) and adjuvant radio-chemotherapy (in rectal cancer) in the elderly is recommended for locally advanced or node positive tumor after tumor resection, since the benefit may be comparable to that achieved in younger patients. There is enough data to support the use of 5-FU based chemotherapy in elderly patients in the palliative setting. New substances have recently been added to the armentarium for metastatic colorectal cancer. However, there is as yet not sufficient data to guide the use of these new drugs (such as oxaliplatin or irinotecan) in elderly patients. However, first clinical studies seem to indicate a comparable efficacy and toxicity in elderly patients to that observed in younger patients. Further clinical trials of chemotherapy in elderly patients with colorectal cancer are necessary to gain information about treatment recommendations.