[Laparoscopic "fast-track" sigmoidectomy for diverticulitis disease in Germany. Results of a prospective quality assurance program]

BACKGROUND AND OBJECTIVE

The natural course of sigmoid colon diverticulitis during conservative therapy and the assessment of the perioperative morbidity after sigmoid colon resection are differently evaluated by surgeons and gastroenterologists. The "fast-track" rehabilitation accelerates the reconvalescence and reduces the rate of postoperative general complications after colorectal surgery. The results of the laparoscopic "Fast-track" sigmoidectomy should be examined within a quality assurance program to better evaluate the perioperative risks following surgical management of diverticulitis.

PATIENTS AND METHODS

A prospective data collection within the voluntary quality assurance program "fast-track" Kolon II was performed. All participating clinics agreed on a multimodal, evidence-based standard perioperative treatment in terms of a "fast-track" rehabilitation for elective operations for sigmoid diverticulitis.

RESULTS

Data from 846 patients undergoing laparoscopic "fast-track" sigmoid colon resection in 23 surgical departments in Germany were collected and evaluated. The mean age of the patients was 63 years (range 23 - 91). 203 patients (24 %) had severe co-morbidities (ASA classification III - IV). A conversion to conventional open surgery was necessary in 51 cases (6 %). Complications occurred in 93 patients (11 %). 76 patients suffered a surgical complication (8.9 %) and 32 patients (3.8 %) a general complication. Two patients died postoperatively due to multi-organ failure following anastomotic leaks. The patients took solid food in median on day 1 after surgery (range, 0 - 5) and passed stool on day 2 (range, 0 - 22). Predefined discharge criteria (free of pain on oral medication, normal oral feeding, stool) were met on day 4 (range, 1 - 58) and the patients were discharged on day 7 (range, 3 - 72). The 30-day re-admission rate was 3.9 %.

CONCLUSION

Patients undergoing laparoscopic "fast-track" sigmoidectomy had a low rate of general complications and had a rapid reconvalescence with a short postoperative in-patient treatment as documented in a german quality assurance program.

Multimodal perioperative rehabilitation for colonic surgery in the elderly

BACKGROUND

Traditional perioperative care for colonic surgery in elderly patients is associated with increased morbidity and mortality compared to that of younger patients. Although multimodal perioperative rehabilitation has evolved as a valid concept to improve postoperative outcome, its use has not yet been established for colonic surgery in the elderly.

METHODS

Data from 24 German hospitals performing multimodal perioperative rehabilitation as the standard perioperative care for elderly patients who have undergone elective colonic resection was assessed in a prospective multicenter study between April 2005 and April 2007.

RESULTS

A total of 742 patients aged > or = 70 were examined. Overall compliance with the multimodal care protocol decreased with increasing age. Although laparoscopic colonic surgery was performed in 39.1% of the septuagenarians, the number decreased to 25.1% in the very old patients. The overall complication rate was 22.9% in the septuagenarians (18.1% surgical and 11.6% general complications) and increased in the very old patients to 38.4% (28.0% and 23.6%, respectively) The overall mortality rate was 1.0% and showed no age-specific variations.

CONCLUSIONS

Although the overall morbidity did increase with age, it was still less when compared to that of historical groups with traditional care. Therefore, multimodal perioperative rehabilitation should be recommended for the elderly.

"Fast-track" rehabilitation for elective colonic surgery in Germany--prospective observational data from a multi-centre quality assurance programme

BACKGROUND

The results of "Fast-track" colonic surgery in an unselected population outside of specialised units has been unknown yet.

MATERIALS AND METHODS

Data from 24 German hospitals performing "Fast-track" rehabilitation as the standard peri-operative care for patients undergoing elective colonic resection were collected in a prospective multi-centre study conducted between April 2005 and September 2006 to evaluate local and general morbidity.

RESULTS

One thousand and forty-seven patients undergoing elective "fast-track" colonic resection were included. Compliance to essential parts of "fast-track" rehabilitation was high (epidural analgesia 86,6%, early oral feeding and mobilisation on the day of surgery 85.5 and 85.4%). Surgical morbidity was observed in 148 patients (14.1%) and general morbidity in 95 patients (9.1%), while mortality was 0.8%. Predefined discharge criteria were met within 5 (1-83) days after surgery, but because of economical restraints in the German DRG system, patients were discharged only after 8 (3-83) days. Re-admission rate was 3.9%.

CONCLUSION

"Fast-track" rehabilitation for elective colonic resection was safe and feasible in German hospitals of all sizes and yielded a low general morbidity and re-admission rate. Post-operative recovery was enhanced, but discharge from hospital was delayed because of economical reasons.

Feasibility and accuracy of TRUS in the pre-treatment staging for rectal carcinoma in general practice

AIMS

Transrectal ultrasonography (TRUS) is the diagnostic tool of choice for local staging of rectal carcinoma. The accuracy in determining of tumour infiltration depth has been reported to reach 95% (on average, 85%). The aim of the study was to analyse the diagnostic accuracy of the TRUS in the clinical routine.

PATIENTS AND METHODS

From 01/01/2000 to 12/31/2003, all patients with rectal carcinoma were enrolled in a prospective multicenter observational study. In case of complete findings of pre-operative TRUS and post-operative histological investigation of the surgical specimen on the tumour infiltration depth, overall accuracy of TRUS was determined.

RESULTS

Overall, 13,610 patients with rectal carcinoma were enrolled in the study. Five thousand and fifty-six subjects (37%) underwent TRUS. In 3,501 patients, TRUS finding (uT-stage) could be compared with the result of the definitive histologic investigation (pT-stage). The accuracy of TRUS in all T-stages was 65.8%. The highest sensitivity was achieved in the T3-stage (74.9%), while in T2, T1, and T4, it was 59.6, 59.0 and 31.1%, respectively. In discriminating tumour growth limited to the rectal wall vs that through the rectal wall into the neighboring tissue, TRUS-associated accuracy was 76.5%. There were no differences between various tumour locations above the anocutaneous line.

CONCLUSIONS

Diagnostic accuracy of TRUS in determining depth of tumour infiltration within or through the rectum wall in the routinuous diagnostic of rectal carcinoma does not reach the excellent published study results. A considerable improvement of the qualitative outcome in using this specific diagnostic tool appears to be recommendable to utilize its advantages such as high accuracy, efficacy, and practicability in the diagnostic process and deriving consequences for a possible neoadjuvant treatment as well as optimal planning of the surgical approach.

Metabolic catecholamine, and endurance responses to caffeine during intense exercise

This study examined the possible effects of caffeine ingestion on muscle metabolism and endurance during brief intense exercise. We tested 14 subjects after they ingested placebo or caffeine (6 mg/kg) with an exercise protocol in which they cycled for 2 min, rested 6 min, cycled 2 min, rested 6 min, and then cycled to voluntary exhaustion. In each exercise the intensity required the subject's maximal O2 consumption. Eight subjects had muscle and venous blood samples taken before and after each exercise period. The caffeine ingestion resulted in a significant increase in endurance (4.12 +/- 0.36 and 4.93 +/- 0.60 min for placebo and caffeine, respectively) and resulted in a significant increase in plasma epinephrine concentration throughout the protocol but not in norepinephrine concentration. During the first two exercise bouts, the power and work output were not different; blood lactate concentrations were not affected significantly by caffeine ingestion, but during the exercise bouts muscle lactate concentration was significantly increased by caffeine. The net decrease in muscle glycogen was not different between treatments at any point in the protocol, and even at the time of fatigue there was at least 50% of the original glycogen concentration remaining. the data demonstrated that caffeine ingestion can be an effective ergogenic aid for exercise that is as brief as 4-6 min. However, the mechanism is not associated with muscle glycogen sparing. It is possible that caffeine is exerting actions directly on the active muscle and/or the neural processes that are involved in the activity.

Toxicological findings in a fatal case of acebutolol self-poisoning

A fatal case of acebutolol self-poisoning is presented. After single-step liquid-liquid alkaline extraction, acebutolol was identified by using an HPLC/DAD screening procedure. By means of a specific HPLC method, acebutolol was then quantified in a large range of postmortem samples. The blood acebutolol concentration was 34.7 micrograms/mL. The tissue distribution of the drug is discussed in the light of the existing literature.

[Artificial respiration in a surgical intensive care unit]

An indication for respiratory treatment is given in manifest and for prophylactic mechanical ventilation in expected pulmonal insufficiency. The mortality rate can be reduced by an early respiratory treatment, therefore prophylactic mechanical ventilation should be performed liberally. Mainly patients after abdomino-thoracal operations and major vascular or upper abdominal surgery are at risk for lethal postoperative pulmonary complications.

Heterogeneous oxygenation of rectal carcinomas in humans: a critical parameter for preoperative irradiation?

Tissue oxygenation was measured in 10 patients with differentiated adenocarcinoma in a very localized region in the middle part of the rectum (grade I - II, clinical stage II) by means of a cryophotometric micromethod. The results obtained clearly show that the oxygenation of differentiated rectal adenocarcinoma is distinctly lower than that of the normal rectal mucosa; tissue hypoxia or even anoxia are a common feature in those tumors; There exist considerable inter- individual differences among tumors of the same clinical staging and histological grading; substantial intra- individual heterogeneities in the oxygenation are evident within the same tumor and even within neighbouring microareas of the tissue. These findings imply that the commonly used classifications do not allow any conclusions concerning the oxygenation status, and probably the radiosensitivity of a tumor, respectively.

[Validity of the transcutaneous PO2-measurement during pharmacologically induced changes of skin perfusion (author's transl)]

The validity of transcutaneous oxygen partial pressure (tcPO2) was tested during pharmacological vasodilatation and vasoconstriction of the skin. Measurements of transcutaneous oxygen partial pressure (tcPO2) were done on the hairless skin of the abdomen in 18 anaesthetized rabbits, when beta-pyridyl-carbonyl (Ronicol) was used as a vasodilator and vasopressin (Pitressin) as a vasoconstrictor. Vasodilation yielded no significant influence on the tcPO2-measurement. Vasoconstriction, however, resulted in a marked decrease of the tcPO2-signal (p less than 0.001). During this phase tcPO2 did no longer reflect arterial PO2 which remained nearly constant. In this experimental model vasoconstrictive drugs may cause a marked underestimation of the arterial oxygen tension. The dependence of the tcPO2-measurement on maximal local skin perfusion should be considered in intensive care patients.

[O2-uptake of the cirrhotic liver. An experimental study (author's transl)]

In 15 Beagles with cirrhosis of the liver (TAA induced) and in 22 healthy controls the flow in the hepatic artery (Q a.h.) and in the portal vein (Q v.p.) was measured by kineangiodensitometry. The oxygen content in the hepatic artery, portal and hepatic vein was determined after withdrawal by inserted catheters. Thereafter the O2-uptake (V O2) via portal vein (V pO2) and hepatic artery (V aO2) was calculated. The control animals showed Q a.h. of 175 +/- 25 ml/min and Q v.p. of 511 +/- ml/min. In the cirrhotic animals Q a.h. rose up to 205 +/- 31 ml/min, there was a decrease of Q v.p. to 260 +/- 49 ml/min. V O2 of the liver of the controls was 5,6 +/- 1 ml/100 g/min. V aO2 ws 2,0 +/- 0,4 ml/100 g/min (35%), V pO2 was 3,6 +/- 0,7 ml/100 g/min (65%). In the cirrhotic animals V O2 decreased to 4,7 +/- 0,9 ml/100 g/min, V aO2 rose up to 3,0 +/- 0,6 ml/100 g/min (64%), V pO2 was reduced to 1,7 +/- 0,6 ml/100 g/min (36%). There was a statistically significant difference of all values measured (p less than or equal to 0,01). In cirrhosis of the liver the hepatic artery carries the main oxygen supply.

Mesenterico-caval shunt in rats. Technique and results

A microsurgical technique for mesenterico-caval shunting in the rat is described. The method results in a partial blood drainage from the upper abdominal content whereas the blood of the mesenteric vein is shunted to the inferior caval vein. Controls were undertaken after 1 and 3 weeks, either visually or radiologically. Twenty-two of 26 surviving animals showed patency of the shunt. All animals had undisturbed blood supply to the portal stump.

Scattering of solar radiation by hexagonal ice crystals

The classical ray optics approximation has been applied to compute the angular scattering of light by finitesized hexagonal ice crystals in the form of columns and plates. The results are presented at a wavelength of 0.55 microm for a random orientation of the crystals either in space or in a plane. The results are also compared to those of ice spheres. For the first time the angular light scattering of platelike crystals and a quantitative description of the 46 degrees halo are given. Contrary to earlier studies, it is shown that both plate- and columnlike ice crystals show a strong backscattering. In agreement with previous studies, ice spheres are found to scatter-when compared to ice prisms-less energy at angles near 90 degrees . With regard to the effect of orientation on the light scattering, it is shown that columnlike crystals randomly oriented in a plane behave rather like spherical particles and not like columns randomly oriented in space.

[Liver blood flow studies using cineangiodensitometry]

In 12 anesthetized beagle dogs breathing spontaneously flow in the hepatic artery (168 ml/min + 10 SEM) and portal vein (576 ml/min +/- 20 SEM) was measured by means of angiodensitometry. Total hepatic blood flow (THBF) was 185 ml/100 g/min +/- 11 SEM. In our opinion this relatively high THBF depends upon the method used.

[Esophageal varices hemorrhage in portal hypertension (author's transl)]

Diagnostic and therapeutic possibilities for esophageal varices hemorrhage in portal hypertension are indicated with reference to 149 patients. In the acute phase, operative measures are to be rejected because the lethality is too high. Conservative treatment with a Blakemore-Sengstaken probe should always be introduced at first. After confirmation of the conditions in the liver, a pressure-reducing anastomosis operation (delayed emergency shunt) must be performed. For this purpose we prefer the terminolateral splenorenal anastomosis.

[Respiratory gas exchange and glucose uptake by the human spleen in situ (author's transl)]

Blood samples were taken from the splenic artery, vein and pulp of 16 patients suffering from lymphoproliferative diseases, essential thrombocytopenia or hereditary spherocytosis and undergoing early splenectomy. The relevant parameters of the respiratory gas exchange as well as glucose and lactate concentrations were determined in these samples. In no case did the thorough examination of the splenic tissue reveal any histopathologic aspects. Taking into account a mean splenic blood flow of 100 ml/100 g/min during anaesthesia, the mean oxygen consumption of the splenic tissue attains 1.1 ml/100 g/min. The glucose uptake and the lactate release show to be 9 mg/100 g/min and 5.2 mg/100 g/min, respectively. Despite high glucose uptake rates and pronounced glycolytic activities there is no evidence of the existence of low pH values, a glucose depletion or hypoxia in the normal spleen. In the normal spleen, therefore, the intrasplenic sequestration of red blood cells cannot be explained by unfavourable metabolic conditions.