Sustainability in humanitarian surgery during medical short-term trips (MSTs): feasibility of inguinal hernia repair in rural Nigeria over 6 years and 13 missions.

PURPOSE: Surgical teaching missions are known to contribute significantly in reducing the local burden of disease. However, the value of short-term medical service trips (MSTs) remains under debate. Humanitarian surgery is highly dependent on funding, and consequently, data evaluation is needed to secure funding for future projects. The aim of this trial is to evaluate the results of 6-year MSTs to rural Nigeria with a specific emphasis on hernia repairs. METHODS: Retrospective series of consecutive operations performed between 2011 and 2016 in rural Nigeria during 13 MSTs. Operations were categorized into type and number of procedures and origin of the surgeon. In terms of inguinal hernia repairs additional data was evaluated such as frequency of local anaesthesia (LA) and the type of hernia. The total amount of disability-adjusted life years (DALYs) averted during each mission are presented and discussed with regard to sustainability of these missions. RESULTS: From 2011 to 2016, a total of 1674 patients were operated. Of these, 1302 patients were operated for 1481 hernias of which 36.7% accounting as inguinoscrotal hernias. The percentage of operations performed by Nigerian staff increased from 31 to 55%. Overall, eighteen percent of the operations was solely performed by Nigerians. Totally, we averted 8092.83 DALY's accounting for 5.46 DALY's per hernia. CONCLUSION: The presented missions contribute significantly to an improvement in local healthcare and decrease the burden of disease. We were able to show the sustainable character of these surgical missions. As a next step, we will analyse the cost-effectiveness of MSTs.

Lower shedding of strongylid eggs by Warmblood horses with recurrent airway obstruction compared to unrelated healthy horses.

An association between equine recurrent airway obstruction (RAO) and increased resistance to intestinal parasites has been demonstrated in descendants of an RAO-affected stallion. It was hypothesised that members of another high-incidence RAO family (F) and unrelated RAO-affected Warmblood horses (UA) would shed fewer strongylid eggs than unrelated RAO-unaffected pasture mates (PM) under the same environmental conditions. Faecal worm egg counts were performed on faecal samples (63 F, 86 UA, 149 PM) and classified into three categories: 0, 1-100 and >100 eggs per gram. While results for F did not differ from PM, UA were 2.5-times less likely to shed strongylid eggs than PM. RAO-affected Warmblood horses may be more resistant to strongylid nematodes than unrelated unaffected pasture mates and a family history of RAO does not necessarily confer protection against helminth infections.

[Genetics of recurrent airway obstruction (RAO)]. / Genetik der rezidivierenden Atemwegsobstruktion (RAO).

Recurrent airway obstruction (RAO) is a multifactorial and polygenic disease. Affected horses are typically 7 years of age or older and show exercise intolerance, increased breathing effort, coughing, airway neutrophilia, mucus accumulation and hyperreactivity as well as cholinergic bronchospasm. The environmental factors responsible are predominantly allergens and irritants in haydust, but the immunological mechanisms underlying RAO are still unclear. Several studies have demonstrated a familiar predisposition for RAO and it is now proven that the disease has a genetic basis. In offspring, the risk of developing RAO is 3-fold increased when one parent is affected and increases to almost 5-fold when both parents have RAO. Segregation analysis in two high-prevalence families demonstrated a high heritability and a complex inheritance with several major genes. A whole genomescan showed chromosome-wide significant linkage of seven chromosomal regions with RAO. Of the microsatellites, which were located near atopy candidate genes, those in a region of chromosome 13 harboring the IL4R gene were strongly associated with the RAO phenotype in the offspring of one RAO-affected stallion. Furthermore, IgE-levels are influenced by hereditary factors in the horse, and we have evidence that RAO-affected offspring of the same stallion have increased levels of specific IgE against moldspore allergens. The identification of genetic markers and ultimately of the responsible genes will not only allow for an improved prophylaxis, i.e. early identification of susceptible individuals and avoidance of high-risk matings, but also improve our ability to find new therapeutic targets and to optimize existing treatments.

Submassive pulmonary embolism and muscular calf vein thrombosis after complicated hip fracture.

The clinical relevance of distal deep vein thrombosis is discussed controversly. A 26-year-old man presented with dyspnea on exertion and pleuritic pain since the day before. Five weeks ago, he sustained multiple fractures at an accident--among others a complicated hip fracture needing screw fixation. He stopped the antithrombotic prophylaxis three days before admission. Our examinations showed calf muscle vein thrombosis and submassive bilateral pulmonary embolism. Due to our own clinical experiences, we support an anticoagulation treatment with compression therapy for isolated calf muscle vein thrombosis in patients with coexisting risk factors for venous thromboembolism.

[Acute vascular occlusion of the upper extremity after blunt trauma]. / Akuter Gefässverschluss der oberen Extremität nach stumpfem Trauma.

Intimal ruptures after blunt trauma without joint dislocation are rare. We report the case of a 62 year old male patient presenting with paraesthesia in the fingers I to III and a cool left hand after a blunt trauma of the upper arm. Non-invasive examination documented the thrombotic occlusion of the axillary artery. Due to a circular rupture of the intima surgical revascularization was performed with a vein graft.

Percutaneous embolization of renal arteriovenous fistula.

Acquired renal arteriovenous fistula is a rare complication following a nephrectomy and its diagnosis may be made many years after the intervention. The closure of the fistula is advisable in most cases, since it represents a risk for heart failure and rupture of the vessel. There are an increasing number of publications describing different techniques of occlusion. The case of a 70-year-old woman with abdominal discomfort due to a large renal arteriovenous fistula, 45 years after nephrectomy, is presented and current literature is reviewed. Percutaneous embolization was performed by placing an occluding balloon through the draining vein followed by the release of nine coils through arterial access. One day after successful occlusion of the fistula, clinical symptoms disappeared.

[First experience with a critical incident reporting system in surgery]. / Critical incident reporting system. Erste Erfahrungen in der Chirurgie.

Systems that record critical incidents were initially developed for aeronautics and are being increasingly applied in medicine. The objective is to detect problems inherent to systems and system errors before they lead to complications or do harm to patients. We report our preliminary experience with a critical incident reporting system (CIRS). Since February 1 2001, all employees of our surgical department have been able to report incidents, anonymously or candidly, to a central board using a standardized documentation form. The results are presented at monthly internal quality meetings, where two to three crucial incidences are thoroughly discussed. New information is communicated and put into practice as quickly as possible. A total of 424 incidents were reported from February 1, 2001 to December 31, 2003. Reversible damages, some of which resulted in prolonged hospitalization, were consequential to 22% of the cases. Thirteen percent were classified as "near miss" (almost incidents), whereas 65% had no consequences for patients. As expected, doctors and nurses were most frequently involved, as 36% of the reported incidents occurred in connection with the prescription and administration of medication. In particular, the near miss category revealed system errors which in 85% of cases had immediate consequences for therapeutic procedures. Based on our initial experiences, working with CIRS may be evaluated as positive. The open discussion of incidents and errors also revealed minor but often significant system errors, which resulted in alteration of our internal proceedings and thus improved the quality and safety of treatment.

[The role of video-thoracoscopy in thoracic surgery]. / Video-thorakoskopische Eingriffe--was hat sich durchgesetzt.

The widespread acceptance of minimal invasive techniques has revolutionized the practice of surgery including, thoracic surgery. Within a short period of time, video-assisted thoracic surgery (VATS) has become an acceptable approach to a wide range of thoracic procedures. The use of VATS as a diagnostic modality is now well established. For therapeutic procedures, VATS has also been generally accepted as the treatment for spontaneous pneumothorax, thoracic sympathectomy, treatment of loculated effusions and resection of simple mediastinal cysts and benign tumors. Its role in major procedures, e.g. anatomic lung resections and thymectomy, however, remain poorly defined at present although some of the existing intermediate results are encouraging. The technique continues to evolve, with further miniaturization to reduce access-induced trauma. No matter how attractive the new techniques may appear, carefully conducted clinical trials should precede the general acceptance and widespread use.

[How often do surgical residents operate in a category A non-university post-graduate teaching hospital?]. / Wie oft operieren chirurgische Facharztanwärter an einer nicht-universitären Weiterbildungsstätte der Kategorie A?

INTRODUCTION: After introduction of the new postgraduate training program for general surgery the completion of the operation list still represents the most important step. Based on our number of operations we examined whether residents would carry out the requested interventions at our non-university teaching hospital (category A). METHOD: For eight tracer operations we retrospectively counted the number of cases of the non private patients from 1998-2002 and took account of the postgraduate education status of the operator. In this period the team consisted of 51 residents (71 education years), of whom 18 candidates for general surgery who carried out the interventions (35 education years, inclusive rotation in ICU, emergency room and special surgical disciplines). RESULTS: Regarding all tracer operations, the amount of interventions per year and candidate which are necessary to accomplish the goal for the first four years of education are reached: appendectomy 8.9, laparoscopic cholecystectomy 7.3, open inguinal hernia repair 9.4, varicose veins operation 12.1, open colon sigmoideum resection 3.2, hip and malleolar fracture 6.9, hemithyreoidectomy 5. CONCLUSION: Completion of the operation list as the major training goal was reached at our institution. Following our structured education program the demands regarding postgraduate education will be met also in future. Further studies however, must examine the impact of the new resident's work contracts dictating a reduction of the weekly working hours.

[Bilateral popliteal artery entrapment syndrome. Is preventive operation on the asymptomatic side indicated?]. / Das bilaterale arterielle popliteale Entrapmentsyndrom. Ist die präventive Operation der asymptomatischen Gegenseite indiziert?

Popliteal artery entrapment is a rare cause of claudication symptoms, but should always be included in the differential diagnosis of lower limb ischaemia in young patients, especially men. On an embryological basis, PAES is the result of the abnormal development of the popliteal artery or the gastrocnemius muscle. The anomaly is manifested as one of four types. Untreated, the entrapment results in the deterioration of the artery, resulting in eventual occlusion. Presenting the case of a 37 year old female patient with bilateral PAES and a review of the literature we discuss the clinical findings, diagnosis, treatment options and the management of the often asymptomatic opposite side.

[Perianal mucinous adenocarcinoma. A further reason for histological study of anal fistula or anorectal abscess]. / Das perianale mucinöse Adenocarcinom. Ein weiterer Grund für die histologische Untersuchung bei Analfistel oder Anorectalabscess.

A 39-year-old man came to us for surgical treatment of a hidradenitis suppurativa. Upon excision of a perianal abscess, the diagnosis of a rare tumor, a perianal mucinous adenocarcinoma (pT4, pN 1, MO), was made. An abdominoperineal resection was performed, followed by a combination of adjuvant radiation and chemotherapy. A year after the operation, the patient is doing well without any signs of recurrence. This carcinoma probably arises in the anal glands. It often presents as a perirectal abscess and/or an anal fistula. Therefore, the diagnosis is often delayed. At presentation, the tumor is bigger than 5 cm in diameter in 80% of the cases, and the prognosis is poor. It metastasizes mostly to the superficial inguinal or to the retrorectal lymph nodes. There are only case reports and no comparative studies in the literature. In the last 10 years, the carcinoma has mostly been treated by neoadjuvant radiation and chemotherapy, followed by abdominoperineal resection. Since then, the median survival has increased to 3 years. This is the first case report of a combination of a perianal mucinous adenocarcinoma with a hidradenitis suppurativa.

[Endoscopic bursa shaving in acute bursitis]. / Das endoskopische Bursashaving bei akuter Bursitis.

OBJECTIVES: After resection of olecranon or prepatellar bursa for bursitis there can be long-term skin complications in up to 20%. We wanted to determine the outcome after endoscopic resection, a technique first described in 1990. METHODS: In a period of three years (6/97-7/00) 13 Patients with bursitis were prospectively enclosed in the study and underwent endoscopic resection of the bursa. All patients were examined clinically three weeks and six months postoperatively. RESULTS: In nine patients a resection of the Olecranon bursa was performed, in four patients of the pre-patellar bursa. 11 cases showed a septic bursitis, two a chronic. 50% of the operations were conducted in general anesthesia. We observed no intra- or postoperative complications. The follow-up examinations showed no pain, no recurrence and no loss of joint motion. CONCLUSION: It is our opinion that the endoscopic resection of the Olecranon and pre-patellar bursa for septic bursitis is a promising technique and shows favourable results compared to the open resection.

Optimising the use of carotid duplex sonography.

AIM: We analysed factors influencing diagnostic yield and treatment and their potential for optimising the use of carotid duplex sonography (CDS). METHOD: Patients referred for CDS were divided into three groups: 1: high likelihood of carotid symptoms, 2: suspected presence of asymptomatic carotid lesions, 3: other indications. Clinical data, the grading of stenosis and the therapeutic consequences were analysed. The efficiency of diagnosis was tested with an algorithm. RESULTS: 344 patients were included. Groups 1, 2 and 3 contained > or = 1 pathological finding in the carotid or vertebral system in 68%, 86% and 55% respectively, whereas high-grade stenoses or occlusions of the internal carotid artery (ICA) were detected in 10.8%, 16% and 3.6% respectively. Age > 50, > 1 risk factor, carotid murmur and concomitant vascular disease were associated with a significantly higher diagnostic yield. Subsequent treatment in groups 1, 2 and 3 involved carotid thromboendarterectomy in 6.4%, 2% and 0.7% respectively and the start of treatment with a platelet aggregation inhibitor in 9%, 30% and 17% respectively. The optimisation algorithm would have saved 21% of CDS scans. CONCLUSION: Clinical pre-selection criteria determine the diagnostic yield of CDS. The potential for optimisation depends on the treatment regimen chosen for asymptomatic stenoses and secondary prophylaxis.

Stimulation of MCF-7 breast cancer cell proliferation by estrone sulfate and dehydroepiandrosterone sulfate: inhibition by novel non-steroidal steroid sulfatase inhibitors.

Steroid sulfatase (STS) regulates the formation of active steroids from systemic precursors, such as estrone sulfate and dehydroepiandrosterone sulfate (DHEAS). In breast tissues, this pathway is a source for local production of estrogens, which support the growth of endocrine-dependent tumours. Therefore, inhibitors of STS could have therapeutic potential. In this study, we report on substituted chromenone sulfamates as a novel class of non-steroidal irreversible inhibitors of STS. The compounds are substantially more potent (6- to 80-fold) than previously described types of non-steroidal inhibitors when tested against purified STS. In MCF-7 breast cancer cells, they inhibit STS activity with IC(50) below 100 pM. Importantly, the compounds also potently block estrone sulfate-stimulated growth of MCF-7 cells, again with IC(50) below 100 pM. For one compound, we also observed a lack of any estrogenic effect at high concentrations (1 microM). We also demonstrate for the first time that STS inhibitors can block the DHEAS-stimulated growth of MCF-7 cells. Interestingly, this cannot be achieved with specific inhibitors of the aromatase, suggesting that stimulation of MCF-7 cell growth by DHEAS follows an aromatase-independent pathway. This gives further justification to consider steroid sulfatase inhibitors as potential drugs in the therapy of breast cancer.

Duplex sonographic registration of age and diabetes-related loss of renal vasodilatory response to nitroglycerine.

BACKGROUND: Nitroglycerine effects dilatation of the vas afferens in the kidney by its active metabolite nitric oxide (NO). In diabetic nephropathy, NO appears to cause hyperfiltration and proteinuria. The aim of this study was to investigate the potential of duplex Doppler ultrasonography in recording changes in resistive indices following nitroglycerine and whether the extent of changes in diabetic nephropathy is reduced as a result of the arteriolar dilatation mediated by NO. METHODS: Fifty-three subjects made up three groups: group 1, 12 young healthy volunteers (5 male, 7 female, 28+/-6 years); group 2, 21 older healthy volunteers (7 male, 14 female, 62+/-8 years); group 3, 20 patients (13 male, 7 female, 56+/-18 years) with mild diabetic nephropathy. The resistive index (RI) was measured in the interlobar arteries before, and 1, 3 and 5 min after administration of 0.8 mg sublingual nitroglycerine. RESULTS: The initial RI of 0.592 decreased in group 1 by 10.8% (P<0. 01) after nitroglycerine, in group 2 the initial figure of 0.631 decreased by 5.9% (P<0.01), and in group 3 the initial figure of 0. 669 decreased by 3.4% (P<0.01). Initial RI values differed significantly between groups 1 and 3 (P<0.01) and groups 1 and 2 (P<0.01), as did values between all healthy volunteers (groups 1 and 2, n=33) and patients with nephropathy (P<0.005). The extent of DeltaRI differed significantly between groups 1 and 3 (P<0.01), 1 and 2 (P<0.02), and between all volunteers and group 3 (P<0.003). In groups 1 and 2 the initial RI was dependent on age (P<0.03), in group 3 on age and creatinine clearance (P<0.02 and P<0.05 respectively). DeltaRI correlated with age in the healthy subjects (P<0.01) and with duration of diabetes in diabetic nephropathy (P0. 03). CONCLUSIONS: Haemodynamic changes in renal perfusion caused by nitroglycerine can be detected using duplex ultrasonography. In healthy subjects, DeltaRI declines with increasing age. In diabetic nephropathy patients, the response to nitroglycerine is reduced. The increased initial RI in such patients suggests fixed arteriolar damage.

[Traumatic perforation of the small intestine--a rare complication of inguinal hernia]. / Die traumatische Dünndarmperforation--eine seltene Komplikation der Leistenhernie.

Groin hernias are among the most common surgical diseases. Traumatic rupture of the intestine is a rare complication compared to incarceration. We report on a 90-year old male with a left-sided hernia and a traumatic rupture of the small bowel. The treatment consisted of an emergency laparoscopy with simple closure of the perforation, repair of the hernia by herniorrhaphy and drainage of the abdomen.

New fluorogenic substrate for the first continuous steroid sulfatase assay.

The screening for new inhibitors of steroid sulfatase requires an efficient test system. To overcome the shortcomings of the available discontinuous fluorimetric assay, several coumarin-type compounds were investigated as potential new substrates. 3,4-Benzocoumarin 7-O-sulfate was found to have appropriate substrate properties for the establishment of the first direct continuous assay of steroid sulfatase.

Hairy roots of Datura candida×D. aurea: effect of culture medium composition on growth and alkaloid biosynthesis.

A transformed root clone of Datura candida×D. aurea was established following infection with Agrobacterium rhizogenes strain A4. This clone was examined for its growth and hyoscyamine and scopolamine content under various culture conditions. Among the three basal culture media tested, half-strength Gamborg's B5 medium supplemented with 5% sucrose was the best for root growth (288 mg dry weight/flask) and full-strength B5 medium for hyoscyamine and scopolamine content (0.36 and 0.17% dry weight, respectively). Experiments with exogenous nitrate added to the medium revealed that the biomass increased (353 mg dry weight/flask) and the hyoscyamine content improved remarkably (0.54% dry weight), but that the scopolamine content was significantly reduced. The addition of various precursors at two different concentrations did not significantly modify root growth. Feeding (R,S)-phenyllactic acid stimulated the biosynthesis of both alkaloids, whereas the addition of ornithine specifically reduced the scopolamine content.

[Endoscopic pre-peritoneal prolene mesh-plasty for management of inguinal and femoral hernias]. / Die endoskopische präperitoneale Prolennetzplastik zur Versorgung von Inguinal- und Femoralhernien.

From October 1994 to March 1996 158 inguinal or femoral hernias were repaired in 124 patients through a total extraperitoneal approach. The repairs were done with polypropylene mesh. The patients were seen 6 to 8 weeks postop; until today 57 patients were seen 12 months postop. This method favours an early return to work. Patients with unilateral hernias returned to work after an average of 14 days, patients with bilateral hernias after an average of 19 days. Complications were rare and mostly minor. So far we have seen no recurrences and no mesh related complications. We consider the laparoscopic extraperitoneal mesh repair a safe procedure for inguinal and femoral hernias.