Effects of field contamination by metals (Cd, Cu, Pb, Zn) on biometry and mechanics of echinoderm ossicles.

Echinoderms are known to readily incorporate metals in their calcified endoskeleton. It is currently unclear if this has an impact on the skeleton function or if this can be considered as a detoxification mechanism. In the present work, populations of the sea urchin Echinus acutus and the starfish Asterias rubens were studied in stations distributed along a metal contamination gradient in a Norwegian fjord (Sørfjord). Ossicles involved in major mechanical functions - sea urchin spine and starfish ambulacral plate - were analyzed for their metal concentration (Cd, Cu, Pb and Zn) and their biometric and mechanical properties. Starfish plates were more contaminated by Cd, Pb and Zn than sea urchin spines. Cu concentrations were at background levels. In E. acutus, metals principally affected size. In A. rubens, material stiffness and toughness were decreased in the most contaminated station. This reduction is attributed either to the direct incorporation of metals in the calcite lattice and/or to deleterious effects of metals during skeleton ontogenesis. The contrasting incorporation of metals in the skeleton of the two investigated species accounts for the different impact of the metals, including in terms of fitness. The present results clearly indicate that, at least in A. rubens, incorporation of metals in the skeleton cannot be considered as a detoxification mechanism.

Long-term survival after perforated diverticulitis.

AIM: Short-term survival after emergency surgery for perforated diverticulitis is poor. Less is known about long-term survival. The aims of this study were to evaluate long-term survival after discharge from hospital and to identify factors associated with prognosis. METHOD: All patients who underwent emergency surgery for perforated diverticulitis in five hospitals in Rotterdam, the Netherlands, between 1990 and 2005, were included. The association between type of surgery (Hartmann's procedure or primary anastomosis) and long-term survival was analysed using multivariate Cox regression analysis, taking into account age American Society of Anesthesiology (ASA) classification, Hinchey score, Mannheim Peritonitis Index (MPI) and surgeon's experience. In addition, survival of the patients was compared with that of the matched general Dutch population. RESULTS: Of 340 patients included in the study, 250 were discharged alive from hospital. The overall 5-year survival was 53%. Survival was significantly impaired compared with the expected matched gender-, age- and calendar time-specific survival. Overall survival was significantly related to age and ASA classification. Hinchey score, MPI, number of re-interventions, the surgeon's experience and type of procedure did not influence long-term survival, although a trend was found for Hartmann's procedure to be a risk factor for poorer survival compared with primary anastomosis (hazard ratio for mortality: 1.88; 95% confidence interval, 0.96-3.67; P = 0.07). CONCLUSION: Long-term survival of patients after perforated diverticulitis is limited and mainly caused by the poor general condition of the patients, rather than by the severity of the primary disease or calendar-time and type of procedure.

Reversal of Hartmann's procedure after perforated diverticulitis through the stomal side without additional incisions: the SIR procedure.

AIMS: Reversal of Hartmann's procedure (HP) is a complex operation and only performed in 50-60% of the patients. Stomal incision reversal (SIR), a new minimally invasive procedure for HP reversal, was assessed and compared to the standard surgical approach. METHODS: 16 patients who had undergone HP for perforated diverticulitis underwent HP reversal by SIR. The only incision in SIR is the one to release the end colostomy. Intra-abdominal adhesiolysis is done manually. A stapled end-to-end colorectal anastomosis is created. The 16 patients who underwent SIR were compared with 32 control patients who were matched according to gender, age, American Society of Anesthesiologists (ASA) classification and Hinchey stage. RESULTS: The operation time was shorter after SIR than after reversal by laparotomy [75 min (58-208) vs. 141 min (85-276); p < 0.001]. Patients after SIR had a shorter hospital stay than patients after laparotomy [4 days (2-22) vs. 9 days (4-64); p < 0.001]. The numbers of total postoperative surgical complications (early and late) were not different (p = 0.13). The anastomotic leakage rate was similar in both groups (6%). The conversion rate in the SIR group was 19% (n = 3). CONCLUSION: SIR compared favorably with HP reversal by laparotomy in terms of operation time and hospital stay, without increasing the number of postoperative complications.

Easy cleaning of the scope's lens in a syringe to prevent condensation during laparoscopic surgery.

BACKGROUND: Condensation on the scope's lens resulting from differences between room temperature and intraabdominal temperature is a disturbing problem for laparoscopic surgeons. Anti lens condensation solutions prevent fogging in the intraabdominal environment but are troublesome to apply to the scope. METHODS: A simple method of cleaning the lens with a syringe is reported. RESULTS: The described procedure appears to be a very simple, cheap, and effective technique for preventing condensation on the scope lens. CONCLUSION: The use of a simple syringe can prevent bothersome condensation on the scope lens during laparoscopic surgery.

Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure?

OBJECTIVE: Hartmann's procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis. METHOD: All 158 patients who had survived emergency surgery for acute perforated diverticulitis in five teaching hospitals in The Netherlands between 1995 and 2005 and underwent HP or PA with DI were retrospectively studied. Age, gender, ASA-classification, severity of primary disease, delay of stoma reversal, surgeon's experience, surgical procedure and type of anastomosis were analysed in relation to outcome after stoma reversal. RESULTS: Of the 158 patients, 139 had undergone HP and 19 PA with DI. The reversal-rate was higher in patients with DI (14/19; 74%) compared to HP (63/139; 45%) (P = 0.027) Delay between primary surgery and stoma reversal was shorter after PA with DI compared with HP (3.9 vs 9.1 months; P < 0.001). Cumulative postreversal morbidity after HP was 44%. Early surgical complications occurred in 22 of 63 patients. Morbidity after DI reversal was 15% (P < 0.001). Three patients died after HP reversal, none died after DI reversal. Anastomotic leakage was observed in 10 patients after HP reversal. This was less frequently observed when the operation was performed by a specialist colorectal surgeon (10%vs 33%; P = 0.049) and when a stapled anastomosis was performed (4%vs 24%; P = 0.037). CONCLUSIONS: Reversal of HP should only be performed by an experienced colorectal surgeon, preferably performing a stapled anastomosis, or probably not be performed at all, as it is accompanied by high postoperative morbidity and even mortality. It is important that these findings are taken in account for when performing primary emergency surgery for acute perforated diverticulitis.

Proposal for a multidisciplinary approach to the patient with morbid obesity: the St. Franciscus Hospital morbid obesity program.

Morbid obesity is a serious disease as it is accompanied by substantial co-morbidity and mortality. The prevalence is increasing to an alarming extent, in Europe as well as in the United States. In the past few decades, bariatric surgery has developed and gained importance. It currently represents the only long-lasting therapy for this group of patients, resulting in an efficient reduction in body weight and obesity-related medical conditions, mostly cardiovascular in nature. The importance of a standardized protocol, the use of selection criteria, and a multidisciplinary approach have been stressed but not yet described in detail. Therefore, in this article, the multidisciplinary approach and the treatment protocol that have been applied in our hospital for more than 20 years are set out in a detailed manner. The application of a strict protocol may help to select and follow-up motivated patients and to organize multidisciplinary research activities.

[Diagnostic image (341). A man with left thoracic pain. Incarcerated diaphragmatic hernia of the transverse colon]. / Diagnose in beeld (34I). Een man met pijn in de linker thoraxhelft. Traumatische, geïncarcereerde hernia diapharagmatica.

A 28-year-old man with a previous (old) left thoracic stab wound, developed an incarcerated diaphragmatic hernia of the transverse colon which was repaired laparoscopically.

The role of 2-hydroxyacyl-CoA lyase, a thiamin pyrophosphate-dependent enzyme, in the peroxisomal metabolism of 3-methyl-branched fatty acids and 2-hydroxy straight-chain fatty acids.

2-Hydroxyphytanoyl-CoA lyase (abbreviated as 2-HPCL), renamed to 2-hydroxyacyl-CoA lyase (abbreviated as HACL1), is the first peroxisomal enzyme in mammals that has been found to be dependent on TPP (thiamin pyrophosphate). It was discovered in 1999, when studying alpha-oxidation of phytanic acid. HACL1 has an important role in at least two pathways: (i) the degradation of 3-methyl-branched fatty acids like phytanic acid and (ii) the shortening of 2-hydroxy long-chain fatty acids. In both cases, HACL1 catalyses the cleavage step, which involves the splitting of a carbon-carbon bond between the first and second carbon atom in a 2-hydroxyacyl-CoA intermediate leading to the production of an (n-1) aldehyde and formyl-CoA. The latter is rapidly converted into formate and subsequently to CO(2). HACL1 is a homotetramer and has a PTS (peroxisomal targeting signal) at the C-terminal side (PTS1). No deficiency of HACL1 has been described yet in human, but thiamin deficiency might affect its activity.

[Diagnostic image (289). A woman with the sensation that an internal air bubble comes up]. / Diagnose in beeld (289). Een vrouw met het gevoel dat bij haar een luchtbel naar boven komt.

A 35-year-old woman was analysed because she had the recurrent sensation of an internal air bubble coming up. She was suffering from a gastric leiomyoma in the cardia-fundus area, which was removed laparoscopically.

Technique for instant stapling of the sigmoid mesentery and mesorectum in laparoscopic colorectal surgery.

BACKGROUND: Dissection of the mesentery of the distal sigmoid or rectum before transection with a linear stapler in laparoscopic colorectal surgery is time consuming, can cause irritating bleeding, and can harm the vascularization of the distal part of the bowel anastomosis. METHODS: A new linear stapling technique in laparoscopic colorectal surgery is presented. This technique is used to perform transection of the distal sigmoid or proximal rectum with a linear stapler by instant stapling of both the mesentery/mesorectal fat and the intestine instead of standard preliminary dissection. This technique was performed in a pilot study of 27 laparoscopic colorectal operations for benign or malignant disease. RESULTS: In none of the 27 patients was leakage of the anastomosis observed. CONCLUSIONS: This new technique is safe and effective. It saves time, avoids troublesome dissection of the mesentery/mesorectum, which can cause bleeding or damage to the bowel, and preserves vascularization of the distal part of the anastomosis.

[Introduction of laparoscopic colorectal surgery in the Sint Franciscus Gasthuis, Rotterdam, 2002/2005]. / Introductie van laparoscopische colorectale chirurgie in het Sint Franciscus Gasthuis, Rotterdam, 2002/'05.

OBJECTIVE: Analysis of the introduction of laparoscopic colorectal surgery in practice DESIGN: Retrospective and descriptive. METHOD: The introduction process of laparoscopic colorectal surgery in the Sint Franciscus Gasthuis (hospital) in Rotterdam, The Netherlands, was divided into 3 phases: the pioneers phase (1 August 2002 to 31 August 2004), the course phase (1 September 2004 to 31 December 2004) and the implementation phase (1 January 2005 to 31 August 2005). All patients who received elective laparoscopic colorectal resection (n = 88) of the total 255 patients who, according the current standard could be treated laparoscopically, were analysed for iatrogenic complications, operation time and the percentage that was performed by surgical residents. RESULTS: The percentage of elective colorectal procedures that were performed laparoscopically increased significantly in the 3 phases from 17% (27/163), to 50% (18/36) and 77% (43/56). Of these procedures, 30% (8/27), 17% (3/18) and 16% (7/43) were converted to an open procedure respectively. During the pioneers phase, 5 iatrogenic complications occurred: 2 ureter stenoses, 1 colon lesion, 1 inferior mesenteric artery bleeding lesion and 1 renal vein bleeding resulting in secondary splenectomy. During the course and implementation phases, no iatrogenic complication lesion occurred. The average operation time decreased from 191 via 186 to 182 minutes, despite the fact that the percentage of procedures performed by surgical residents increased from 15% (4/27), to 22% (4/18) and to 44% (19/43) in the respective phases and despite the fact that the amount of rectum resections increased from 19% (5/27) via 44% (8/18) to 37% (16/43). CONCLUSION: Specific training in laparoscopic colorectal surgery was combined with a safe and fast introduction of this technique in practice and the training program of surgical residents. This training could therefore avoid iatrogenic complication.

Thiamine pyrophosphate: an essential cofactor for the alpha-oxidation in mammals--implications for thiamine deficiencies?

The identification of 2-hydroxyphytanoyl-CoA lyase (2-HPCL), a thiamine pyrophosphate (TPP)-dependent peroxisomal enzyme involved in the alpha-oxidation of phytanic acid and of 2-hydroxy straight chain fatty acids, pointed towards a role of TPP in these processes. Until then, TPP had not been implicated in mammalian peroxisomal metabolism. The effect of thiamine deficiency on 2-HPCL and alpha-oxidation has not been studied, nor have possible adverse effects of deficient alpha-oxidation been considered in the pathogenesis of diseases associated with thiamine shortage, such as thiamine-responsive megaloblastic anemia (TRMA). Experiments with cultured cells and animal models showed that alpha-oxidation is controlled by the thiamine status of the cell/tissue/organism, and suggested that some pathological consequences of thiamine starvation could be related to impaired alpha-oxidation. Whereas accumulation of phytanic acid and/or 2-hydroxyfatty acids or their alpha-oxidation intermediates in TRMA patients given a normal supply of thiamine is unlikely, this may not be true when malnourished.

Farnesylation of Pex19p is not essential for peroxisome biogenesis in yeast and mammalian cells.

Pex19p exhibits a broad binding specificity for peroxisomal membrane proteins (PMPs), and is essential for the formation of functional peroxisomal membranes. Pex19p orthologues contain a C-terminal CAAX motif common to prenylated proteins. In addition, Saccharomyces cerevisiae and Chinese hamster Pex19p are at least partially farnesylated in vivo. Whether farnesylation of Pex19p plays an essential or merely ancillary role in peroxisome biogenesis is currently not clear. Here, we show that (i) nonfarnesylated and farnesylated human Pex19p display a similar affinity towards a select set of PMPs, (ii) a variant of Pex19p lacking a functional farnesylation motif is able to restore peroxisome biogenesis in Pex19p-deficient cells, and (iii) peroxisome protein import is not affected in yeast and mammalian cells defective in one of the enzymes involved in the farnesylation pathway. Summarized, these observations indicate that the CAAX box-mediated processing steps of Pex19p are dispensable for peroxisome biogenesis in yeast and mammalian cells.

[Surgical treatment of rectal prolapse]. / Chirurgische behandeling van de rectale prolaps.

Rectal prolapse must be distinguished from anal prolapse or mucosal prolapse since the treatment differs. The only effective treatment for rectal prolapse is surgery. The fact that rectal prolapse causes severe disability and that the morbidity of the current surgical treatment is low justifies surgery even at advanced age. Moreover, the success rate is high. Ventral rectopexy seems to be the surgical technique of choice on the grounds of the anatomical advantages (preservation of rectal innervation and lifting of the middle compartment) and the results (low recurrence rates and reduction of constipation). The laparoscopic approach is just as effective as an open procedure and results in less morbidity, quicker recovery and lower medical costs.

A new device for bone anchor fixation in laparoscopic sacrocolpopexy: the Franciscan laparoscopic bone anchor inserter.

BACKGROUND: A laparoscopic modification of the sacrocolpopexy procedure with mesh and bone anchor fixation with the Franciscan laparoscopic bone anchor inserter was developed. METHODS: We developed a laparoscopic bone anchor inserter for the placement of a titanium bone anchor in sacral segment 3 as fixation for the mesh in laparoscopic sacrocolpopexy procedures performed in women with posthysterectomy vault prolapse. RESULTS: Surgery successfully corrected vaginal vault prolapse. Laparoscopic bone anchor insertion with this new and simple device took 2 minutes and provided a firm anchor for mesh fixation. MRI demonstrated an anatomically preferable vaginal axis toward the hollow of the sacrum. CONCLUSION: Application of the newly developed Franciscan laparoscopic bone anchor inserter in laparoscopic sacrocolpopexy is an easy and safe procedure that provides firm fixation and excellent anatomical results.

Prevention of lens condensation in laparoscopic surgery by lens heating with a thermos flask.

Condensation on the scope lens as a result of differences between room and intraabdominal temperatures is a disturbing problem for laparoscopic surgeons. Despite the use of anti-lens condensation solutions, this cannot be entirely avoided. The authors report a simple, cheap, and effective method for preventing lens condensation by lens heating using a sterilized thermos flask filled with hot water.

[Intestinal incarceration due to a Bochdalek's hernia]. / Darmincarceratie door een hernia van Bochdalek.

A 67-year-old male presented with abdominal pain followed by respiratory distress. Imaging revealed a right-sided Bochdalek's hernia. At thoracotomy two days later, an incarcerated small bowel segment was removed, with a protracted post-operative course. In adults, a Bochdalek's hernia is rare and usually asymptomatic. However, when symptoms do occur, incarceration of the intestinal contents is frequent and accompanied by high mortality. The severely protracted course after delayed treatment of a symptomatic Bochdalek's hernia described here illustrates the importance of early recognition and surgical intervention.

Surgery for locally recurrent rectal cancer.

After the diagnosis of a locally recurrent rectal cancer, imaging is the first step to estimate the extent and location of the local tumour growth and the presence or absence of distant metastases. The aim of the treatment is a R0 resection (microscopically tumour free circumferential margin) by multimodality treatment consisting of pre-operative radiation, extended resection and intra-operative radiotherapy by either electron beam irradiation or with high dose rate brachytherapy. Filling the pelvic cavity with vital tissue such as an omentoplasty should considered carefully. With this treatment the overall three-year survival rate of a group of 33 patients was 60% with a local control rate of 73%. The combination of chemotherapy as a radiosensitizer resulted in an increase of R0 resections by 20%. Introduction of TME surgery and pre-operative radiotherapy has created a new situation with limited possibilities due to dose-accumulation toxicity of the radiotherapy and extensive scarring of the tissues making estimation of the extent of the tumour growth more difficult. The prevention of local recurrence by proper selection of primary cases, the training of experienced surgeons and the optimal use of pre-operative radiotherapy is the way forward to improve results.