[Intraoperative fluorescence angiography in colorectal surgery]

BACKGROUND

Fluorescence angiography with indocyanine green (ICG-FA) is frequently used in colorectal surgery to assess the blood perfusion in the region of an anastomosis. Previous studies with ICG-FA in both open and laparoscopic surgery could show a low rate of anastomotic leakage, e.g. the PILLAR II study with a leakage rate of 1.4%. This article presents own results, the current status of ICG-FA and the fields of application.

OBJECTIVE

The aim of the study was to analyze whether the results obtained so far with ICG-FA are sufficient to recommend an extended use of this relatively new method in colorectal surgery.

MATERIAL AND METHODS

From July 2009 to June 2019 a total of 378 colorectal resections (280 colon resections and 98 rectal resections) with intraoperative examination of the anastomosis using ICG-FA were performed. In 13 patients (3.4%) there was reduced intraoperative perfusion, which led to a change in the operative procedure (resection of the anastomosis and new anastomosis, colostomy).

RESULTS

The total anastomotic leakage rate was 3.7% with 8 leaks in the colon (2.9%) and 6 in the rectum (6.1%). Without the intraoperative change in 13 patients the rate of leakages could have increased to 7.1% (27/378). The use of ICG-FA in the group of patients studied potentially led to a reduction of the leakage rate by 48%. Current publications show similar results with a potential decrease in the rate of anastomotic leaks in colorectal surgery.

CONCLUSION

The results show a very low rate of anastomotic leakage when using ICG-FA. These results are promising in colorectal surgery but controlled randomized studies are lacking and should be carried out before final recommendations can be given.

Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature

BACKGROUND

Since January 1st, 2005, the current situation for bariatric surgery has been examined by means of a voluntary quality assurance study in Germany with a multicenter design in which 38 hospitals and surgical departments participated. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

Data describing peri-interventional characteristics were prospectively documented in an internet online data registry. All primary bariatric procedures performed since January 1st, 2005, were registered. In addition, reoperations in patients who had previously undergone primary surgical intervention were included. As a representative excerpt from the overall prospective multicenter observational study on obesity surgery, data on the type, regimen, and time course of deep venous thrombosis (DVT) prophylaxis were documented. From the number and spectrum of complications, the incidences of clinically manifest DVT or pulmonary embolism (PE) were derived during the in-hospital course and follow-up in conjunction with the type of surgical procedure and body mass index (BMI).

RESULTS

Overall, 3,122 bariatric procedures were performed at 38 German hospitals between January 2005 and December 2007. These procedures were subdivided into 2,869 primary operations and 253 revisions (sex ratio, male to female = 25.6:74.4%). The average BMI of all patients was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. In 2005 and 2006, gastric banding (GB) was the most commonly performed operation, followed by Roux-en-Y gastric bypass (RYGBP). In 2007, RYGBP was carried out in 42.1% of all bariatric procedures. Interestingly, the incidence of deep venous thrombosis (DVT) was only 0.06%, whereas PE occurred in 0.06% of patients only after hospital discharge. The DVT prophylaxis protocol used has been changed for the last 2 years: the majority of patients with a BMI above 50 kg/m(2) received low-molecular-weight heparin twice a day.

CONCLUSION

In Germany, a trend from GB to sleeve gastrectomy (SG) and malabsorptive approach has been evaluated. This trend is associated with differences of the DVT prophylaxis regimen in the profile of bariatric surgical patients depending on BMI and the type of bariatric procedure. Despite the low incidence of DVT and pulmonary embolism (PE) detected, there is a lack of evidence on a reasonable regimen for sufficient DVT prophylaxis in bariatric surgery; instead, there are only recommendations from the guidelines and statements of a specific medical society. Therefore, prospective studies are necessary to determine the optimal DVT prophylaxis for bariatric surgical patients as well as obese patients undergoing surgery.

A nationwide survey on bariatric surgery in Germany--results 2005-2007

BACKGROUND

Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined since January 1st, 2005 with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an Internet online data registry. In particular, perioperative characteristics, such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes, were investigated.

RESULTS

During the study period, 629 surgical procedures were performed at 21 hospitals in 2005, 828 procedures at 32 hospitals in 2006, and 1,666 procedures at 35 hospitals in 2007. In 2005 and 2006, gastric banding was the most frequently performed operation, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean body mass index (BMI) was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. Follow-up data after 12 months were available for 63.8% of the patients in 2005 and 2006; these data showed greater reduction of BMI after malabsorptive rather than restrictive bariatric procedures. The mortality was 0.1% (30 days) and 0.16% (overall).

CONCLUSION

As indicated by the worldwide trend, there is an ongoing change from restrictive bariatric procedures to malabsorptive procedures and sleeve gastrectomy. Although the BMIs of German patients undergoing bariatric surgery appear to be substantially higher than those of patients from most other countries, there were no differences in intraoperative and short-term complications or in overall outcomes during follow-up when compared with published studies.

[Quality assurance in bariatric surgery in Germany--results of the German multicentre trial 2005 and 2006]

BACKGROUND

Since January 1st 2005, the situation of bariatric surgery in Germany has been examined. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke-University Magdeburg.

METHODS

The data registration took place prospectively in an internet online data base. All primary bariatric procedures performed since January 1st 2005 were detected as well as re-operations in patients who had been operated before.

RESULTS

629 patients underwent bariatric surgery in 21 hospitals in 2005 and 828 patients were operated in 32 hospitals in 2006. The mostly performed operation was gastric banding with 46.8 %, followed by Roux-Y gastric bypass with 38.5 %. 74.4 % of the patients were female. The medium BMI of all patients was 48.5 kg/m2 in 2005 and 48.4 kg/m2 in 2006. Follow-up data were available for 71.2 % of the patients operated in 2005. These data show a higher reduction of BMI after malabsorptive than after restrictive bariatric procedures.

CONCLUSION

A trend from restrictive bariatric procedures to a malabsorptive approach could be observed. In Germany the BMI of patients undergoing bariatric surgery is higher than in most countries world-wide. No differences could be detected in intraoperative and short-term complications as well in the complication rate in the first year of follow-up in comparison with the literature.

Experiences of two centers of bariatric surgery in the treatment of intragastrale band migration after gastric banding-the importance of the German multicenter observational study for quality assurance in obesity surgery 2005 and 2006

BACKGROUND

Adjustable silicone gastric banding (ASGB) is an effective treatment in morbid obesity. Band migration is a long-term complication. Causes, clinical symptoms, timing and incidence are investigated in single centres only. In Germany, since January 1st, 2005, practice in bariatric surgery has been investigated in German prospective multicenter trial for quality assurance in obesity surgery.

MATERIALS AND METHODS

All patients underwent ASGB in two centres of bariatric surgery in Germany were prospectively registered using a computer-based data form. Patients with band migration were retrospectively evaluated, in particular, causes and characteristics of its management. The results were correlated with data obtained from the German prospective multicentre trial.

RESULTS

In total, 493 patients were enrolled in the study from February 1995 to February 2007. The follow-up rate was 79.9% (mean follow-up time period, 78.7 months; range, 2-148 months). Fifteen patients (3.0%) developed migration. In 14 cases, migration occurred within the range of 30-86 months after implantation. In one case, migration occurred 10 months after repositioning of the band. In the German multicentre trial, 629 patients underwent surgery during 2005 and 827 patients in 2006. In both periods, 74.4% of the patients were female and 25.6% male. The most frequently performed operation was ASGB (46.8%) followed by Roux-en-Y gastric bypass (38.5%).

CONCLUSION

Band migration requires band removal. Different symptoms and complications influence the kind of band removal. Multicentre data were evident in the case of high long-term complication rate after ASGB. Data of the German multicentre trial show the trend from restrictive bariatric procedures to malabsorptive approach.

Perspektiven der Pflegeversicherung

Twelve years after its introduction, long-term care insurance is back on the agenda and up for political reform. This paper shows why long-term care insurance needs to be reformed. The two central aspects on which reform projects focus are addressed: firstly, the structural improvement of nursing care and long-term care insurance and, secondly, the creation of a sustained financing. The principal conclusion is that, while there is a broad consensus about the structural improvement of long-term care insurance, opinions differ widely in the matter of its sustained financing. As a consequence, a coherent financing concept has yet to emerge.

[The nursing care insurance law]

By establishing an independent statutory nursing care insurance, the security of patients in need of nursing care and the organisation of nursing care will be placed on a new basis. For instance, the bill provides for substantially extended benefits for home care and also includes benefits for long-term care in nursing homes into the general risk pool. The nursing care funds yet to be founded will receive the service guarantee for the organisation of nursing care, negotiate contracts with the respective nursing institutions and monitor their quality. Although the envisaged range of benefits covered by the statutory nursing care insurance has been noticeably extended it remains doubtful whether these benefits will be sufficient or whether there will still be the need for supplemental income support payments for nursing care. Moreover, the set of tools for regulation remains contradictory as the regulating competences of the Federal Government and those of the nursing care funds overlap. The Medical Service of the Statutory Health Insurance will be given extended responsibilities regarding the examination of individual cases, including the determination of the degree of a patient's need for nursing care, checking the possibility of rehabilitation and giving advice for individual care. Apart from that, it will assume new duties in the fields of quality assurance of the nursing care institutions and consulting the nursing care funds.

[Health care structure legislation--reform of health insurance]

On January 1st, 1993, the German Health Care Structure Reform Act has come into effect. It will fundamentally change the system of health insurance as well as the health care system. By the reform act, new structural and controlling elements have been installed in all central branches of health care, and, at the same time, a new order for the competition between the sickness funds has been established. Far-reaching structural alterations affect the hospital sector, the drug market and the system of ambulatory care. In the hospital sector, there will be a change-over to a price system consisting of special payments, payment according to diagnostic-related groups, and differentiated per-diem rates. On the drug market there will be introduced, besides a drug budget for doctors, a positive list for pharmaceuticals which will be worked out jointly by representatives of the medical profession and the sickness funds. In the ambulatory sector, licensing restrictions for doctors intending to set up practice will be introduced and the importance of the general practitioner or family doctor will be enhanced. The Health Care Structure Reform Act provides for self-government of the sickness funds and the medical profession with a wide range of controlling and shaping instruments. It also places the Ministry of Health in a better position to take influence. After the expire of the budgeting phase, competitive elements resp. extended controlling measures in the contracts sector will become more and more important features of the health care system. It remains to be seen whether the new controlling instruments will suffice to cause the intended limitation of expenditure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of chronic proliferative glomerulonephritis using acetylsalicylic acid and dipyridamole]

Fourteen patients with chronic proliferative glomerulonephritis were given for the period of one year 400 mg acetylsalicylic acid and 225 mg dipyridamole per day. During this treatment the thrombocyte aggregation became normal, however, the mean reduction of antiheparin plasma activity was not statistically significant. Normal synthesis of renal prostacyclin declined significantly as a result of treatment, while the renal thromboxane A2 synthesis remained normal even during treatment. Treatment did not influence proteinuria. The mean annual decline of glomerular filtration was greater during the investigation period than the mean annual decline in previous years, the difference was, however, only at the borderline of statistical significance. The authors did not prove a favourable effect of this treatment in patients with chronic proliferative glomerulonephritis.

[Prostaglandins and chronic proliferative glomerulonephritis]

In 14 patients with chronic proliferative glomerulonephritis, corrected arterial hypertension and normal or marginal glomerular filtration the authors assessed plasmatic and urinary metabolites of PGI2 and TXA2. They found that the production of both PGI2 and TXA2 was raised in the organism and they assume that in the stimulated synthesis hypertension and its treatment participated. The production of both prostaglandins in the kidneys was, however, normal.

Quest for a reliable, valid, and sensitive in situ hybridization procedure to detect viral nucleic acids in the central nervous system

In situ hybridization (ISH) to detect and to quantitate viral nucleic acid sequences in cryopreserved central nervous system (CNS) tissue is a reliable, valid and sensitive molecular technique. On the other hand, utilization of formaldehyde fixed paraffin embedded (FFPE) tissue to improve cytomorphology requires fundamental changes in the procedure since it is necessary to cleave the elaborate protein network cross-linked by formaldehyde using elevated concentrations of proteinases in order to permit diffusion of complementary DNA probes to the targets (genomic viral nucleic acid sequences and/or viral mRNA). Adversely, this procedure hydrolyzed the proteinaceous glues generally used to fix tissue to glass slides resulting in loss of tissue sections during the ISH protocol. This report describes the application of a novel procedure utilizing a silano-organic compound to covalently bond to glass slides FFPE sections as well as cryopreserved tissue sections and cultured cells with and without virus infections. This covalent bonding procedure has permitted optimization of the ISH procedure for virus detection and quantification, especially for exploratory studies of specificity and wash stringency in relation to the Tm of the hybridized product. Progressive multifocal leucoencephalopathy (PML) caused by an opportunistic papovavirus (JC) was chosen because of the ready availability of tissue, stability of papovavirus nucleic acids, and specificity of 3H- and 35S-radiolabeled JC cloned DNA probes. Further, this laboratory is utilizing the optimized sensitive procedure to search for several virus etiologies in human diseases such as multiple sclerosis, temporal lobe epilepsy, Alzheimer's disease, schizophrenia, and Parkinson's disease, as well as normal aging.(ABSTRACT TRUNCATED AT 250 WORDS)

Acquired immune deficiency syndrome and multiple tract degeneration in a homosexual man

A 35-year-old homosexual man with acquired immune deficiency syndrome developed progressive dementia and spastic quadriparesis over a two-month period. Severe symmetrical, bilateral degeneration of the corticospinal and frontopontine fibers and cerebellar white matter were found postmortem. Several glial nodules in the brainstem and cerebellum suggested "smoldering" brainstem encephalitis. The possible association of the adenovirus that was isolated from the patient's cerebrospinal fluid to these obscure changes in the central nervous system is discussed.

Case report: acute hemorrhagic multifocal angioencephalopathy

A 53-year-old chronic alcoholic male developed an acute febrile, fulminant fatal encephalopathy which lasted 2.5 weeks. Necropsy showed focal, acute hemorrhagic necrotizing lesions of the diencephalon, cingulate gyrus, and amygdala, apparently due to a vasculopathy involving mainly small veins. The case is unique, but the pathology is somewhat similar to an idiopathic disorder described as subacute diencephalic angioencephalopathy [DeGirolami et al. 1974, Kinney et al. 1980].

Xanthogranuloma of the dura in systemic Weber-Christian disease

A 51-year-old woman who had systemic Weber-Christian disease (WCD) displayed multiple xanthomatous lesions and a large xanthogranuloma of the tentorium cerebelli with signs of brainstem and cerebellar compression. Three other cases of dural xanthomatous lesions associated with systemic WCD have been reported. These dural and leptomeningeal xanthomatous lesions in WCD, a nonsuppurative inflammatory condition, are similar to those of Hand-Schüller-Christian disease, a quasi-neoplastic process.

Effects of total fasting in obese women. II. Acid-base balance

Acetoacetate, beta-hydroxybutyrate, pyruvate and lactate in whole blood, the acid-base balance according to Astrup, SGOT and SGPT, and the serum and urinary sodium and potassium were estimated in 10 fasting obese women. Fasting led metabolic acidosis due to a tenfold increase of acetoacetate and beta-hydroxybutyrate, while pyruvate and lactate had a tendency to decrease. Serum and urinary sodium and potassium decreased; A tendency to increased SGOT and SGPT was observed. Sodium bicarbonate administered in general since the 8th or 9th day of fasting led in 4 to 5 days to an earlier correction of blood pH, while pCO2, actual HCO3, standard HCO3, base excess, buffer base, pO2, Hb saturation and total CO2 reached the prefasting values only several days after blood pH normalisation. The administration of NaHCO3 corrected the serum level of sodium while its excretion remained low. Bicarbonate had no influence on the decreasing trend of serum potassium, but the urinary output of potassium was stabilized. It is suggested that in fasting subjects 1. the correction of the metabolic acidosis by NaHCO3 does not reduce the rate of lipid catabolism and does not lead to fluid retention and 2. liver damage in fasting may be prevented by blood pH normalisation.