Impact of Preanalytical Factors During Histology Processing on Section Suitability for Digital Image Analysis

Digital image analysis (DIA) is impacted by the quality of tissue staining. This study examined the influence of preanalytical variables-staining protocol design, reagent quality, section attributes, and instrumentation-on the performance of automated DIA software. Our hypotheses were that (1) staining intensity is impacted by subtle differences in protocol design, reagent quality, and section composition and that (2) identically programmed and loaded stainers will produce equivalent immunohistochemical (IHC) staining. We tested these propositions by using 1 hematoxylin and eosin stainer to process 13 formalin-fixed, paraffin-embedded (FFPE) mouse tissues and by using 3 identically programmed and loaded immunostainers to process 5 FFPE mouse tissues for 4 cell biomarkers. Digital images of stained sections acquired with a commercial whole slide scanner were analyzed by customizable algorithms incorporated into commercially available DIA software. Staining intensity as viewed qualitatively by an observer and/or quantitatively by DIA was affected by staining conditions and tissue attributes. Intrarun and inter-run IHC staining intensities were equivalent for each tissue when processed on a given stainer but varied measurably across stainers. Our data indicate that staining quality must be monitored for each method and stainer to ensure that preanalytical factors do not impact digital pathology data quality.

[Natural orifice transluminal endoscopic surgery in Germany: Data from the German NOTES registry]

BACKGROUND

The German NOTES registry (GNR) was initiated by the German Society for General and Visceral Surgery (DGAV) as a treatment and outcome database for natural orifice transluminal endoscopic surgery (NOTES).

AIM

The aim of this study was the descriptive analysis of all GNR data collected over a 5-year period since its start in 2008 with more than 3000 interventions.

MATERIAL AND METHODS

The GNR is an online database with voluntary participation available to all German-speaking clinics. Demographic data, therapy details, complications and data on the postoperative course of patients are recorded. All cases in the GNR between March 2008 and November 2013 were included in the analysis.

RESULTS

From a total of 3150 data sets 2992 (95 %) were valid and suited for the analysis. Hybrid transvaginal cholecystectomy was the most frequently used procedure (88.7 %), followed by hybrid transvaginal/transgastric appendectomy (6.1 %) and hybrid transvaginal/transrectal colon procedures (5.1 %). Intraoperative complications occurred in 1.6 %, postoperative complications in 3.7 % and conversions were reported in 1.5 %. Intraoperative bladder injuries and postoperative urinary tract infections were identified as method-specific complications of transvaginal procedures. Bowel injuries occurred as a rare (0.2 %) but potentially serious complication of transvaginal operations.

CONCLUSION

The German surgical community ensures a safe and responsible introduction of the new NOTES operation techniques with its active participation in the GNR. Despite an overall low complication rate, the high number of procedures in the GNR permitted the identification of method-specific complications. This knowledge can be used to further increase the safety of NOTES in practice.

Subsyndromal depression and anxiety in older adults: health related, functional, cognitive and diagnostic implications

Subsyndromal depression in later life is common in primary care. Comorbid anxiety disorders could exacerbate the negative effect of subsyndromal depression on functioning, health-related quality of life, comorbidity and/or cognition. We examined anxiety disorders co-existing with subsyndromal depression in participants ≥ age 50 in an NIH trial of Problem Solving Therapy for Primary Care for indicated prevention of major depression. There were 247 participants, with Centers for Epidemiologic Studies - Depression scores ≥ 11. Participants could have multiple psychiatric diagnoses: 22% of the sample had no DSM IV diagnosis; 39% of the sample had only 1 DSM IV diagnosis; 28% had 2 diagnoses; 6% had 3 DSM IV diagnoses; 4% had 4 DSM IV diagnoses; and 1% had 5 diagnoses. Furthermore, 34% of participants had a current comorbid DSM IV diagnosis of a syndromal anxiety disorder. We hypothesized that those with subsyndromal depression, alone relative to those with co-existing anxiety disorders, would report better health-related quality of life, less disability, less medical comorbidity and less cognitive impairment. However, there were no differences in quality of life based on the SF 12 nor in disability based on Late Life Function and Disability Instrument scores. There were no differences in medical comorbidity based on the Cumulative Illness Scale-Geriatrics scale scores nor in cognitive function based on the Executive Interview (EXIT), Hopkins Verbal Learning Test-Revised and Mini-Mental Status Exam. Our findings suggest that about one third of participants 50 years and older with subsyndromal depression have comorbid anxiety disorders; however, this does not appear to be associated with worse quality of life, functioning, disability, cognitive function or medical comorbidity.

High frequency-low morbidity mechanical complications of tube feeding: a prospective study

Because of preferential use of the enteral route for nutritional support, a prospective study of mechanical complications was done in 109 consecutive patients. One hundred seventy-two nasogastric tubes were placed in 60 patients, 42 esophagostomies in 28 patients, 32 gastrostomies in 22 patients and 9 jejunostomies in 8 patients. Data show that the use of enteral feeding tubes is not without complications. The complications fell into two major categories. There were 15 low frequency mechanical complications, of which four (2 carotid artery blowouts, 1 gastrointestinal perforation, and 1 aspiration) were of high morbidity and 11 of low morbidity. There were 132 high frequency-low morbidity complications with the use of 255 tubes. These consisted mainly of unplanned and untimely removal of feeding tubes with interruption of feedings and necessitating tube replacement. Data indicate that the main problems related to the use of enteral nutrition are not the dramatic complications which create notoriety but those related to the ordinary mechanical complications occurring daily and which command little attention because of their low mortality. These can assume importance because of their high frequency and as such are characterized as high frequency-low morbidity complications.

Effects of the dopaminergic agent and NMDA receptor antagonist amantadine on cognitive function, cerebral glucose metabolism and D2 receptor availability in chronic traumatic brain injury: A study using positron emission tomography (PET)

PRIMARY OBJECTIVE

This study was performed to assess effects of amantadine (AMH), a dopaminergic agent and NMDA antagonist, on chronic traumatic brain injury (TBI). The primary hypotheses were that amantadine treatment would result in executive function improvement and increased activity in pre-frontal cortex.

RESEARCH DESIGN

An open-label design was used.

METHODS

Twenty-two subjects underwent neuropsychological testing pre- and post-12 week treatment. Six subjects also underwent PET scanning.

INTERVENTION

Amantadine 400 mg was administered per day.

RESULTS

Significant improvements on tests of executive function were observed with treatment. Analysis of PET data demonstrated a significant increase in left pre-frontal cortex glucose metabolism. There was a significant positive correlation between executive domain scores and left pre-frontal glucose metabolism.

CONCLUSIONS

This is the first known study to assess amantadine in chronic TBI using PET and the data are consistent with the hypotheses. The conduction of further studies is warranted.

Iodocyclization Reactions for the Desymmetrization of Cyclohexa-1,4-dienes

Fifteen examples are presented showing that various modes of cyclization (5-endo, 5-exo, 6-endo, 6-exo, and 7-endo) can be used for the desymmetrization of cyclohexa-1,4-dienes. All take place with complete diastereocontrol and good yield.

Long-term results of a randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs

INTRODUCTION

There is an ongoing debate about the preferred technique for inguinal hernia repair. In this randomized study the long-term results of Shouldice, Lichtenstein and transabdominal preperitoneal (TAPP) hernia repair were compared.

METHODS

Some 280 men with a primary hernia were randomized prospectively to undergo Shouldice, tension-free Lichtenstein or laparoscopic TAPP repair. Patients were examined after 52 months to assess hernia recurrence, nerve damage, testicular atrophy and patient satisfaction.

RESULTS

Hernia recurrence occurred in six patients after Shouldice repair, and in one patient each after Lichtenstein and TAPP repairs. All recurrences after tension-free repairs were diagnosed within the first year after surgery. Nerve injuries were significantly more frequent after open Shouldice and Lichtenstein repairs. Patient satisfaction was greatest after laparoscopic TAPP repair.

CONCLUSION

Tension-free repair was superior to the non-mesh Shouldice technique. The open anterior approach to the groin was associated with demonstrable nerve injury, and laparoscopic TAPP repair was the most effective approach in the hands of an experienced surgeon.

Evacuation of neorectal reservoirs after TME

Colon pouch reconstruction after deep rectal resection is functionally superior to straight colorectal/anal anastomosis. However, stool evacuation difficulties could jeopardize the functional benefit of neorectal reservoirs. Beside the well proven colon J-pouch, the transverse coloplasty pouch may represent a viable alternative. We examined evacuation and functional outcome after total mesorectal excision and transverse coloplasty pouch reconstruction. Thirty consecutive patients with cancer of the middle and distal third of rectum underwent a total mesorectal excision. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin enema postoperatively. Eight months after surgery, video defecography, anal manometry and pouch volumetry were performed and the patients were interviewed according to a standardized continence questionnaire. Rectal resection and reconstruction with transverse coloplasty pouch anastomosis could be performed in all patients. No insufficiency of the pouch occurred. In the follow-up, no patient had difficulties to evacuate the pouch, none of these patients needed enemas or suppositories to facilitate defecation. All patients were continent for solid stools. Twenty-five of 27 patients had up to three bowel movements per day. Patients with reduced pelvic floor movement in the defecography proved more likely to suffer from urgency, fragmented evacuation and incontinence. Transverse coloplasty pouch reconstruction after total mesorectal excision is not associated with stool evacuation problems. Urgency and incontinence, which are rarely seen after this type of reconstruction, correlate with impaired pelvic floor movement rather than with pouch size or anal sphincter tonus.

The neurobehavioural rating scale-revised: sensitivity and validity in closed head injury assessment

OBJECTIVES

To investigate the factor structure and psychometric properties of the neurobehavioural rating scale-revised (NRS-R) and to determine its usefulness in clinical trials.

METHODS

A consecutive series of patients sustaining severe closed head injury were evacuated to one of 11 large regional North American trauma centres and entered into a randomised, phase III, multicentre clinical trial investigating the therapeutic use of moderate hypothermia. Acute care personnel were blinded to outcome and outcome personnel were blinded to treatment condition. The Glasgow outcome scale (GOS) was the primary outcome measure. Secondary outcome measures included the disability rating scale (DRS) and the NRS-R.

RESULTS

Exploratory factor analysis of NRS-R data collected at 6 months after injury (n=210) resulted in a five factor model including: (1) executive/cognition, (2) positive symptoms, (3) negative symptoms, (4) mood/affect, and (5) oral/motor. These factors showed acceptable internal consistency (0.62 to 0.88), low to moderate interfactor correlations (0.19 to 0.61), and discriminated well between GOS defined groups. Factor validity was demonstrated by significant correlations with specific neuropsychological domains. Significant change was measured from 3 to 6 months after injury for the total score (sum of all 29 item ratings) and all factor scores except mood/affect and positive symptoms. The total score and all factor scores correlated significantly with concurrent GOS and DRS scores.

CONCLUSIONS

The NRS-R is well suited as a secondary outcome measure for clinical trials as its completion rate exceeds that of neuropsychological assessment and it provides important neurobehavioural information complementary to that provided by global outcome and neuropsychological measures.

Factor analysis of an outcome interview for use in clinical trials of traumatically brain-injured patients: a preliminary study

OBJECTIVE

To study the factor structure, internal consistency, concurrent validity, and sensitivity to detect change in patient report of problems of a structured interview in relationship with accepted outcome measures.

DESIGN

Outcome status of patients with severe traumatic brain injury participating in a randomized, phase III, multicenter clinical trial was assessed at 6 mo postinjury using the Glasgow Outcome Scale, the Disability Rating Scale, and the Severe Traumatic Brain Injury Outcome Interview.

RESULTS

Exploratory factor analysis of the Severe Traumatic Brain Injury Outcome Interview produced a meaningful five-factor model: (1) activities of daily living; (2) cognitive; (3) affective; (4) behavioral; and (5) instrumental activities of daily living. The internal consistency of the factors ranged from moderate (0.61 instrumental activities of daily living) to high (0.94 activities of daily living); the interfactor correlations were moderate. The summed factor scores were significantly correlated with measures of global outcome: the Glasgow Outcome Scale (r = 0.66; P < 0.0001) and the Disability Rating Scale (r = 0.61; P < 0.0001). Patient report of cognitive problems correlated moderately with the neuropsychological tests. The summed factor scores were sensitive to change over time.

CONCLUSIONS

Overall, the interview assessed the major important features of outcome pertinent to traumatic brain injury and demonstrated greater sensitivity to subtle changes over time than the unidimensional approaches, such as the Glasgow Outcome Scale and Disability Rating Scale.

[Postoperative wound healing in wound-water contact]

The avoiding of water-contact to the freshly closed operation-wound is an unwritten law in surgery. In general, taking a bath or shower is not allowed before wound stitch removal under the idea that early water-contact may lead to a higher wound-infection rate. In a prospective trial 170 patients, operated in our short-stay surgery-unit, were allowed to take a shower 24 hours after surgery. Full water contact of the fresh uncovered wound was accepted. The wound-infection rate in this group was compared with the infection-rate of an historical group from our department (n = 956).

RESULTS

In the water-contact group no case of wound-infection was observed while we were observing a wound-infection-rate of 0.6% in the other group. The difference between the two groups wasn't statistically significant (p = 0.125).

CONCLUSION

Water-contact of the fresh operation wound 24 hours after surgery did not increase the post-operative wound infection risk in this study.

[Management of inguinal hernia--a comparison of current methods]

Between July 1995 and June 1996, 280 patients were operated on for inguinal hernia within the scope of a prospective, randomized study. The aim of the study was to compare the Shouldice technique with tension-free hernioplasty (Lichtenstein, TAPP). The operation time was comparable in all three groups. There was less need for analgesics and postoperative morbidity was less after the tension-free technique. No severe complications such as deep wound infection or infection of the implant were seen in any of the groups. After a follow-up period of 18 months, we found two recurrences after the Shouldice operation and one recurrence in each of the tension-free groups. Treatment satisfaction after tension-free hernioplasty was high. One year after the Shouldice operation, about 10% of the patients were dissatisfied because of persistent discomfort and pain. Because of lower morbidity, less pain, and low recurrence rates after tension-free hernioplasty, we find the tension-free techniques to be superior to conventional hernioplasty.

[Anal gland carcinoma with osteoblastic metastases]

HISTORY AND CLINICALLY FINDINGS

A 52-year-old woman was admitted because of anal pain of 6 weeks duration. Physical examination was unremarkable except for a cherry-sized swelling, painful to pressure, on rectal examination. As the erythrocyte sedimentation rate and C-reactive protein were increased (69/115 and 12.1 mg/dl, respectively) and abscess was diagnosed. Carcinoembryonic antigen was within normal limits.

INVESTIGATIONS

At rectoscopy a fluctuating abscess-linked swelling was found at 3 cm and a submucous tumour at 5 cm from the anus.

TREATMENT AND COURSE

The abscess was cut open and at the level of the dentate line a submucous adenocarcinoma about 3 cm in diameter was resected. A small residual tumour was removed by abdomino-perineal rectal extirpation. As histologically it was an adenocarcinoma not of colorectal type, without relationship to rectal mucosa but in close contact to the anal glands, and the further course did not indicate a metastasis from another primary tumour, the diagnosis of anal gland adenocarcinoma was established. A local recurrency was resected 6 months later, followed by combined radio- and chemotherapy. A diffuse osteoblastic metastasis was discovered later and the patient died 21 months after diagnosis.

CONCLUSION

An osteoblastic metastasis from an anal gland carcinoma, as occurred in this case, has not been previously reported.

Parental report of sleep problems in children with attentional and learning disorders

This study examined whether parents of children diagnosed with neurodevelopmental disorders (n = 79) report greater sleep-related problems in their offspring than do parents of normal community-based children (n = 86) on a research questionnaire developed to assess sleep and breathing problems, sleepiness, and behavioral problems. Clinical subgroups included: attention deficit/hyperactivity disorder (ADHD) (n = 43), learning disabilities (LD) (n = 11), and combined ADHD/LD (n = 25). Analyses revealed that parents of children with neurodevelopmental disorders report greater problems along all three dimensions than parents of normal control children. Sleep-related difficulties were reported at the same frequency across all three clinical subgroups. No significant difference between clinical and control groups was noted, however, in the reported length of sleep on weeknights. These preliminary findings suggest that sleep-related problems need to be routinely reviewed as part of the clinical evaluation of neurodevelopmental problems, because they may contribute to and/or exacerbate the behavioral manifestation of these disorders.

[Aneurysms of the iliac artery in fibromuscular dysplasia as differential diagnostic consideration in acute lower abdominal pain]

A 48 year old woman was admitted to our department with sudden onset of pain in the left lower abdominal quadrant and the initial diagnosis of diverticulitis or left sided adnexitis was made. On physical examination she was found to have pain and localized peritonism in the left lower abdominal quadrant. Ischemic signs in the same sided lower limb could not be observed. Further diagnostics (abdominal ultrasonography, transvaginal ultrasonography, angiography and computed tomography) showed a covered perforated aneurysm in the left common or internal iliac artery as the reason for the abdominal pain. Coincidental focal aneurysms were seen in the middle segment of both renal arteries and also in the right common iliac artery. The patient was treated with an aorto-iliac-bypass (Impra-prosthetic graft). Histological examination showed features of fibromuscular dysplasia. We are reporting this case due to the unusual localisation, the atypical symptoms and the difficult diagnostics.

[Hemorrhoids--etiology, symptoms and therapy]

Hemorrhoids are a very widespread disease causing pain by thrombosis, fear by bleeding and be a burden by weeping and pruritus. The different treatments show the different interpretations of physicians and patients. This paper will give a view of the most common and standardized procedures. Rubber band ligation is the most effective procedure in treating 1st and 2nd grade hemorrhoids. Surgical procedure is best in 2nd and 3rd grade disease. Recurrency is between 0.5 and 5% only. Technical development in surgical practice was leading to less pain in postoperative period by using diathermy, non-traumatic technique and avoiding of tampons. Using these principles hemorrhoidectomy allows a short hospital stay according to the individual needs of the patient. Special care should be given on urinary retention, the most common complication in anorectal surgery.

[Laparoscopic cholecystectomy in therapy of acute cholecystitis: immediate versus interval operation]

From January 1991 to May 1996 a total of 3,010 cholecystectomies was performed for cholelithiasis. Pathohistologically an acute cholecystitis was found in 483 patients (16%). The overall proportion of laparoscopic operations has increased from 12.5% in 1991 to 96.6% at present. In patients with acute cholecystitis the proportion of laparoscopic operations has increased from initially only 1.87% up to 83.3%. The duration of surgery (81 min versus 54 min), rate of conversion (12% versus 1.07%) and rate of complications (7.76% versus 2.2%) were all significantly higher in cases of acute cholecystitis than in those without inflammation. There was no mortality in either group. Furthermore no significant difference was found between patients with histopathologically proven acute inflammation and patients with an acute episode of chronic cholecystitis. The duration of complaints, however, had a significant influence on surgical results. In patients that were either operated on within 48 h after the onset of disease or more than 10 days later, the length of the operation was shorter and the rates of conversion and complications were lower. Our results prove that laparoscopic cholecystectomy is also very successful in cases of acute cholecystitis, though a long learning curve has to be expected. Taking efficiency and economy into consideration, surgery within a few days of the onset of disease must be recommended.

Total gastrectomy. Updated operative mortality and long-term survival with particular reference to patients older than 70 years of age

OBJECTIVE

The authors conducted a study of patients who underwent total gastrectomy for gastric malignancy to elucidate contributing factors that lead to successful management of this disease in geriatric patients.

SUMMARY BACKGROUND DATA

The average mortality rate for patients undergoing stomach surgery due to carcinoma is 7.8% according to the literature overview, still relatively high. Even higher mortality rates are observed for geriatric patients after a total gastrectomy. Because of epidemiologic changes, a total gastrectomy is required with growing frequency in these high-risk patients.

METHODS

The study involved 380 patients with a gastric malignancy. Risks and benefits of a total gastrectomy with radical lymphadenectomy at an advanced age were analyzed retrospectively in 163 patients older than 70 years of age. The results achieved in these patients were compared with those observed in 217 younger patients.

RESULTS

The 30-day mortality and morbidity rates for the elderly patients were 3% and 33.7%, respectively; for the younger patients, they were 0.46% and 21.2%, respectively. A statistically significant correlation was found between the presence of risk factors, the occurrence of complications, and the mortality rate. No difference was seen between the two age groups when risk factors were absent. The 5-year survival rate was 30%, with no difference between young and elderly patients.

CONCLUSIONS

The data prove that a total gastrectomy with a radical lymphadenectomy can be carried out safely in older patients, with long-term results comparable to those achieved in younger patients.

Studies on nutritional status in general surgery patients by clinical, anthropometric, and laboratory parameters

We assessed the nutritional status of general surgery patients with and without cancer from a western European population in this prospective study. Anamnestic (weight development, abdominal complaints) and anthropometric (fat tissue measurements) data were collected on six groups of patients: cancer of the stomach (n = 13), pancreas (n = 13), colorectal (n = 23), breast (n = 12), and two control groups with benign diseases, ages 20-45 and 50-75 y. From these data, body mass index and ideal body weight were calculated. Concentrations of albumin, transferrin, retinol-binding protein, prealbumin, and creatinine height index were determined by biochemical tests. A weight loss of more than 10% was found in only 31% of gastric and 61% of pancreatic cancer patients. Significant values from anthropometric data were also found only in these groups. In biochemical tests, only the creatinine height index was reduced in all patients with pancreatic cancer. The remaining laboratory changes were so unspecific in all other parameters that no conclusions could be drawn as to the status of the patient's nutritional condition. For the evaluation of nutritional status, only relatively simple and inexpensive anamnestic and anthropometric measurements are necessary.

[Quality assurance in goiter surgery by rate of recurrent nerve paralysis]

We analyzed the results of 1147 thyroid operations performed at a teaching hospital over a period of 3 years. These results were submitted to an internal quality control. We studied the factors that influenced the surgical complication rate and particularly the rate of a palsy of the recurrent laryngeal nerve. Operations of 'simple' goitres showed only a very low risk of post-operative complications whereas the risk for patients with Graves' disease, a carcinoma or a recurrent goitre was a markedly higher. The rate of a permanent palsy of the recurrent laryngeal nerve was just 0.5% for a simple goitre but as high as 7.8% for a relapse. Not just the underlying disease but the surgeon and his surgical technique play an important role in the incidence of a palsy of the recurrent laryngeal nerve. If a sophisticated surgical technique is applied without exposing the recurrent laryngeal nerve but leaving the fascial layer that covers the nerve and the vessels of the throat intact, there are no differences between the results of these operations and such where the nerve is routinely demonstrated. The follow-up of the patients with recurrent nerve palsy showed a medium recovery time of half a year. In one of six patients with temporary palsy the restitution was seen after more then one year.

[Surgical and drug therapy of metastatic gastrinoma. Successful palliation over the course of 2 1/2 years]

A midaged lady suffering from ulcer disease for about seven years had undergone several surgical and drug therapies without any satisfying success. Then the diagnosis of a gastrinoma was made. By this time there were already multiple liver metastases. First the large supposed primary tumor of the pancreas was resected and within six months later the resection of the progressing liver metastases became necessary because of local tumor complications. The additional drug therapy with octreotide (Sandostatin) given three times daily subcutaneously prevented further tumor progress. Until now this combination of surgical and medical treatment has proved to be a successful palliative method of treating the malignant gastrinoma for 2.5 years.

[Juxtapapillary intraduodenal lipoma as a rare cause of jaundice and acute pancreatitis]

A 52-year-old man was admitted to hospital with acute pancreatitis and jaundice. The patient's medical history showed a case of hospitalization due to acute pancreatitis about three years before. Diagnostic examinations (abdomen sonography, CT, contrast medium radiography of the small intestine, ERCP) revealed a juxtapapillary lipoma, approximately 1 by 6 cm, obstructing the papilla Vateri. After the examinations had been completed and the pancreatitis had largely eased off, the lipoma was removed by transduodenal surgery. There were no postoperative complications.

[The lost gallstone--complication after laparoscopic cholecystectomy]

In this case report a persisting fistula between the right flexure of the colon and the abdominal wall was observed after a laparoscopic cholecystectomy. This was caused by a lost gallstone and eventually resulted in the resection of a colon segment. As a consequence of this case it can be said that intra-abdominally lost gallstones--especially larger ones--have to be recovered completely. In risky cholecystectomies we should consider the use of a laparoscopic bag or the installation of additional working cannulas.

Glucose homeostasis and endocrine pancreatic function in patients with chronic pancreatitis before and after surgical therapy

In a prospective clinical-experimental study, 15 consecutive patients with chronic pancreatitis, operated on because of severe pain, were examined for the effects of a duodenum-preserving resection of the pancreas head on endocrine pancreas function. This was done by means of oral and intravenous glucose tolerance testing before the operation, on the 10th or 11th day postoperatively, and 3 months after the operation. In addition to glucose levels in the peripheral venous blood, levels of insulin, C-peptide, glucagon, and pancreatic polypeptide were determined. As indicated by the k value, glucose tolerance improved postoperatively in 10 patients (66.6%); three patients (19.9%) showed no change, and one patient (6.6%) was worse. Only one patient (6.6%) developed evident diabetes mellitus immediately postoperatively. Pre- and postoperative levels of insulin and C-peptide showed no significant differences. The fasting levels of glucagon were significantly lower postoperatively than before the operation (p < 0.01). The stimulation of pancreatic polypeptide after oral glucose was significantly lower postoperatively (p < 0.01). Duodenum-preserving pancreas head resection does not lead to an impairment of glucose tolerance in the majority of patients; a deterioration was observed only in few cases (13.3%).

[The effect of duodenum-preserving pancreatic head resection on the endocrine pancreas function in patients with chronic head pancreatitis]

In a prospective clinical-experimental study, 15 patients with chronic pancreatitis operated consecutively due to severe pain were examined for the effects of a duodenum-preserving resection of the pancreas head on endocrine pancreas function. This was done by means of oral and intravenous glucose tolerance testing before the operation, on the 10th or 11th postoperative day, and three months after the operation. In addition to glucose levels in the peripheral venous blood, levels of insulin, C-peptide, glucagon, somatostatin, and pancreatic polypeptide were determined. As indicated by the k-value, glucose tolerance improved postoperatively in 11 patients; two patients showed no change, and one patient was worse. Only one patient developed evident diabetes mellitus immediately postoperatively. The pre- and postoperative levels of insulin and C-peptide showed no significant differences. The fasting levels of glucagon were significantly lower postoperatively than before the operation (2p less than 0.01). Duodenum-preserving pancreas head resection led to improvement of the glucose tolerance in the majority of patients; a deterioration was observed only in two cases.

[Effect of enteral and parenteral nutrition on glucose tolerance in the early postoperative phase]

In a randomized clinical trial in 24 patients with colorectal resections the different behaviour of glucose tolerance (GT) in the early post-operative period was investigated. Especially, we were concerned with the way nutritional substrate were applicated. Therefore 2 groups were randomly formed for a six day period of enteral versus parenteral nutrition. To check the GT enteral tolerance-tests were done preoperatively, and on day 1, 3 and 6 postoperatively. Our results show a significant improvement of GT in the enteral group on 3, and 6, postoperative days, as well as a significantly higher insulin secretion on 3, postoperative day. C-Peptide displays similar high concentrations as a sign of elevated insulin secretion. These results prove, that enteral glucose application is superior to the parenteral way in early postoperative nutrition.

[Effect of liver passage on peripheral glucose and hormone concentrations in early postoperative enteral nutrition]

Early postoperative disorders of blood glucose homeostasis and its hormonal regulation do not allow a normal caloric enteral or parenteral substrate supply in this period. Eleven land pigs were investigated to find out how the surgical trauma of a partial gastrectomy influences the absorptive capacity of the small intestine and the hormonal regulation after intraduodenal administration of a glucose solution. We therefore conducted portal vein measurements to correlate the influence of the liver passage of early postoperative changes in blood glucose and hormonal levels. Our data show that neither the porto-arterial differences in blood glucose nor those in hormonal concentrations are significant. Therefore, we conclude that peripheral measurements can be used as good and reliable parameters for such investigations of absorption or hormonal regulation in the early postoperative period.

Home enteral nutrition via gastrostomy in advanced head and neck cancer patients

We investigated whether home enteral feeding via a tube gastrostomy would enable patients with advanced malignant disease, who were unable to maintain themselves nutritionally via the oral route, to be independent of the hospital setting. Thirty-nine patients with advanced upper gastrointestinal and head and neck cancer had a tube gastrostomy placed. Before discharge, the patient was trained in the care and use of the gastrostomy feeding tube. Ten patients died of their disease before they could be discharged. During the 6-month period before gastrostomy insertion, the mean weight loss of the remaining 29 patients was 12.8%, and the mean body weight was less than 90% of ideal body weight. Prior to operation, the mean serum albumin and total lymphocyte count were 3.7 g/L and 1,087/mL, respectively. At discharge the mean caloric intake was 1.48 times resting energy expenditure. Home enteral nutrition was provided for a median of 94 days and resulted in stabilization of nutritional indices. During their median survival of 176 days, the 29 patients were admitted a total of 52 times. Twenty-eight percent of the patients were never re-admitted after gastrostomy and were adequately maintained at home, whereas 24% needed to be re-admitted once. Only 48% were re-admitted twice to assist in their nutritional management. Twenty patients received temporary home nursing services to aid in their transition. Four patients eventually resumed oral intake, and their feeding gastrostomies were removed.(ABSTRACT TRUNCATED AT 250 WORDS)

Der Einfluß einer enteralen und parenteralen Ernährung auf die Glukosetoleranz in der frühpostoperativen Phase

Wir untersuchten die unterschiedliche Erholung der gestörten Glukosetoleranz in der frühen postoperativen Phase in Abhängigkeit vom Weg der Substratzufuhr. Dazu wurden in einer randomisierten Studie 24 Patienten, die sich kolorectalen Resektionen unterziehen mußten, 2 Gruppen zugeteilt, die wir dann postoperativ jeweils 6 Tage enteral bzw. parenteral ernährten, Zur Prüfung der Glukosetoleranz führten wir einen enteralen Toleranztest präoperativ, am 1., 3. und 6. postoperativen Tag durch. Die Ergebnisse zeigen eine signifikante Verbesserung der Glukosetoleranz in der enteral ernährten Gruppe am 3. und 6. postoperativen Tag. Die Insulinkonzentrationen sind in dieser Gruppe am 3. postoperativen Tag signifikant, am 6. postoperativen Tag noch deutlich gegenüber der parenteralen Gruppe erhöht. Ähnlich verhalten sich auch die C-Peptid-Konzentrationen, die als Maß für die gesteigerte Insulinfreisetzung gelten können. Nach diesen Ergebnissen ist eine enterale Applikation von Glukose der parenteralen in der frühpostoperativen Phase signifikant überlegen.

Der Einfluß der Leberpassage auf die peripheren Glukose- und Hormonkonzentrationen bei frühpostoperativer enteraler Ernährung

An 11 Landschweinen wurde der Einfluß des Operationstraumas einer Magenkeilresektion auf die resorptive Kapazität des Dünndarmes und der hormonellen Regulation bei intraduodenaler Glukosegabe untersucht. Dabei wurde durch Pfortadermessungen der Einfluß der Leberpassage und die frühpostoperativen Veränderungen der Hormon- und Blutzuckerspiegel im peripheren und portalen Blut verglichen. Unsere Untersuchungen zeigen, daß sich in den portoarteriellen Differenzen weder im Blutzucker noch den Hormonkonzentrationen ein signifikanter Unterschied nachweisen läßt. Periphere Messungen dieser Größen können deshalb als verlässliche Parameter für Untersuchungen zur Resorption als auch zur hormonellen Regulation unmittelbar posttraumatisch benutzt werden.

[Duration of the preventive use of antibiotics in colorectal surgery--single administration versus short-term prevention]

The effect of a combination of 4 g mezlocillin and 0.5 g metronidazole for the prophylaxis against infections in a one-shot dose immediately preoperatively compared to a short-time dose of 2 days given to 90 patients with resection of colorectal carcinoma was investigated in a prospective and randomized study. 6 patients developed a wound infection in the early postoperative phase; 4 of these infections (3 were severe, 1 was mild) occurred in the one-shot group and 2 in the short-time prophylaxis group. After more than 20 days postoperatively 3 late infections were observed which had a mild course (2 cases in the one-shot group, 1 case in the short-time prophylaxis group). All infections were localized in the sacral wound region in patients with abdominoperineal resection. The abdominal wounds healed per primam in each case. Besides those, 26 infections of the urinary tract were observed, which occurred significantly more often after the one-shot dose (40.9%) than with the short-time prophylaxis (18.6%). Intraoperative smears of the lumen of the bowels showed a remaining bacterial settlement. Besides Bacteroides species, especially Escherichia coli were found among the isolates. Moreover in some cases Clostridium, Klebsiella, Proteus and Pseudomonas could be identified. Smears of the site of operation (sacral/peritoneal cavity) were contaminated in over 50%, above all by Bacteroides species; besides those, E. coli were found most often. The subcutaneous smears showed a growth of the germs only in a few cases. Aerobic bacteria in 93.8%, anaerobic bacteria except for thetaiotaomicron and B. asaccharolyticus in 85.1%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Perioperative glucose resorption and hormonal reaction following intraduodenal glucose administration]

Early postoperative enteral nutrition has repeatedly been described in the literature but has not found its place yet in everyday clinical life. We conducted perioperative intraduodenal glucose tolerance tests in 12 patients with a healthy metabolism who had to undergo moderately severe abdominal surgery. Our results suggest that the resorption is still markedly delayed 12 h postoperatively and that the hormonal regulation is also essentially disturbed. Therefore, we believe that enteral nutrition in the early postoperative period is beneficial only more than 24 h after surgery.

Perioperative Glukoseresorption und hormonelle Reaktion nach intraduodenaler Glukoseapplikation

Eine frühpostoperative enterale Ernährung wird in der Literatur immer wieder beschrieben, hat sich aber im klinischen Alltag nicht durchsetzen können. An 12 stoffwechselgesunden Patienten, die sich mittleren abdominalchirurgischen Operationen unterziehen muβten, führten wir perioperative intraduodenale Glukosebelastungen durch. Durch unsere Ergebnisse können wir zeigen, daβ die Resorption nach 12 h postoperativ noch deutlich verzögert und auch die hormonelle Regulation erheblich gestört ist. Eine enterale Ernährung in der frühpostoperativen Phase erscheint uns deshalb erst nach mehr als 24 h sinnvoll.

'Entero-insular axis' and surgical trauma

To study the optimal means of postoperative energy supply, three glucose loads (5 g, 15 g, 40 g) were given via the enteral or the parenteral route before and immediately after abdominal surgery. Pre- and post-operatively, glucose and insulin concentrations were strongly dose-related after both kinds of administration. But the postoperative insulin concentrations were higher than the preoperative ones. Likewise, in both test situations the 'insulinogenic index' was significantly higher postoperatively than preoperatively. After the enteral glucose load, however, the index was 3 to 10 times higher than after the parenteral one. According to these results, even in the early postoperative period the enteral route of glucose administration is not only feasible but seems also to be superior to the parenteral one.

[Esophagojejunostomy--how safe is manual suture today?]

Between 1982 and 1986 a total of 137 patients were gastrectomized for cancer of the stomach. The esophago-jejunal anastomosis was always carried out as an end-to-side anastomosis applying the conventional two layer technique. Only in 1 patient (0.7%) an insufficiency of this anastomosis was observed; 9 reoperations (6.6%) were necessary and 3 patients (2.2%) died in the postoperative course. These results confirm that with a precise, standardised conventional suture technique the esophageal anastomosis can be safely performed today.

[Resorption and hormonal reaction in the perioperative phase following enteral administration of glucose]

It was the aim of this study to find out whether a postoperative enteral nutrition with glucose is possible. Therefore, an intraduodenal glucose load (15 g/7.5 min.; 20% solution) was applied in 14 patients with normal weight and no metabolic disorders before and on 4 consecutive days after a medium severe abdominal operation. The results show that the resorption of the enterally applied glucose is reduced only on the first postoperative day. After the peak values have been reached, the decrease of glucose from the blood is delayed up to the second postoperative day, although during the whole testing period the insulin secretion--calculated according to the insulinogenic index - corresponds to the glucose stimulation. Thus, an early postoperative enteral nutrition with glucose seems to be possible, but the reduced absorption over a short period has to be taken into consideration.

Desmoplastic fibroma of the rib

We present a 17-year-old male patient who had a desmoplastic fibroma. The diagnosis is histologically verified and differentiated from other tumors. The rare localization of this benign lesion in the rib is of particular interest.

Total gastrectomy. A 15-year experience with particular reference to the patient over 70 years of age

Between 1969 and 1984, a total of 186 patients underwent total gastrectomy. Seventy-four patients were more than 70 years of age. Surgical mortality was 13.4%, with only minor differences between those patients younger than 70 years and older patients--12.5% and 14.8%, respectively. Moreover, there was no major difference if surgery was curative or merely palliative. Of 27 patients with tumors at TNM stage IV, only one died. Of the 100 patients who were operated on during the five-year period between 1979 and 1984, only four died, for an operative mortality of 4%. These results suggest that this remarkable decline of mortality is due to a precise standardization of surgical technique and improvements in preoperative patient management and aftercare. The five-year survival was 15.9%; again, there was no major difference between the group of patients older than 70 years and those younger than 70 years (19.4% and 14.5%, respectively). The ten-year survival was 4.9%.

[Gastrectomy in the aged]

Between 1969 and 1983 a total of 152 patients underwent total gastrectomy. 58 patients were older than 70 years. Surgical lethality was 14.47% with only minor differences between those patients younger than 70 and the older ones: 13.8 and 15.5%, respectively. Moreover, it did not make any major difference whether surgery was curative or merely palliative. Of 27 patients with the tumor stage TNM IV, only one patient died. Of the 66, who were operated upon during the recent 5 years period between 1979 and 1983, only one patient died. These results suggest that this remarkable decline of lethality is due to a precise standardisation of surgical technique, improvements in preoperative management of the patient and aftercare. 5 years survival rate was 17.3%; again there was no major difference between the group of patients older than 70 and those being younger than 70 years (16.5% and 19.4% respectively). It is of interest that the patients having additional splenectomy presented with an essentially worse prognosis as opposed to those without splenectomy although there were no differences between the TNM-stages. Even if the small numbers of patients can not yet be definitely conclusive, these preliminary results indicate that the indication for splenectomy in the course of total gastrectomy should be critically evaluated.

[Blood glucose, ACTH, cortisol, T4, T3 and rT3 after cholecystectomy. Comparative studies of continuous peridural anesthesia and neuroleptanalgesia]

15 patients (12 women and 3 men) undergoing cholecystectomy were randomized into two groups. 8 patients were operated on under continuous thoracic epidural anaesthesia in combination with light general anaesthesia. Postoperatively they were kept painfree by continuous infusion of an 0.125% solution of bupivacaine via epidural catheter at a rate of 0.25-0.3 ml/kg X h over a period of four days. The 7 patients in the control group were operated on under neuroleptanalgesia. Piritramide was given for postoperative analgesia. All patients received 40 ml/kg X day of electrolyte solution during the period of investigation. Blood was collected at 8 am, 12 am, 4 pm, 8 pm, and 12 pm on the day of operation and on the third postoperative day, at 8 am on the first and second postoperative day, and at 8 am, 12 am, and 4 pm on the fourth postoperative day. Plasma glucose, ACTH, cortisol, T4, T3, and reverse T3 were measured. During the operation and for 12 h thereafter a mild hyperglycaemia was observed in the neuroleptanalgesia group but not in the epidural group. The differences were significant. A rise in ACTH was seen in both groups during and shortly after operation. The increase in cortisol concentration following this ACTH release was significant only in the neuroleptanalgesia, but not in the epidural group. From the first to the fourth postoperative day ACTH levels were low and cortisol concentrations within the normal range. On the third day it appeared that a diurnal variation in cortisol levels was again present. Cortisol suppression following the administration of 2 mg dexamethasone on the fourth postoperative day was detectable in both groups. Of the thyroid hormones, T4 remained unchanged and at a normal level during the investigation. T3 decreased and reverse T3 increased significantly, the maximum rise being observed on the second day. There were no differences between the groups. These changes are defined as low T3 syndrome, following caloric deprivation, injury, and stress. The metabolic and hormonal alterations caused by cholecystectomy are marked only during operation and shortly thereafter and only in this period are they influenced by epidural analgesia. From the first postoperative day onwards they are almost negligible so that a mitigation by using continuous epidural analgesia is not to be expected.