A randomised, multi-centre, prospective, observer and patient blind study to evaluate a non-absorbable polypropylene mesh vs. a partly absorbable mesh in incisional hernia repair.

BACKGROUND: The implantation of a polymer mesh is considered as the standard treatment for incisional hernia. It leads to lower recurrence rates compared to suture techniques without mesh implantation; however, there are also some drawbacks to mesh repair. The operation is more complex and peri-operative infectious complications are increased. Yet it is not clear to what extent a mesh implantation influences quality of life or leads to chronic pain or discomfort. The influence of the material, textile structure and size of the mesh remain unclear. The aim of this study was to evaluate if a non-absorbable, large pore-sized, lightweight polypropylene (PP) mesh leads to a better health outcome compared to a partly absorbable mesh. METHODS/DESIGN: In this randomised, double-blinded study, 80 patients with incisional hernia after a median laparotomy received in sublay technique either a non-absorbable mesh (Optilene® Mesh Elastic) or a partly absorbable mesh (Ultrapro® Mesh). Primary endpoint was the physical health score from the SF-36 questionnaire 21 days post-operatively. Secondary variables were patients' daily activity score, pain score, wound assessment and post-surgical complications until 6 months post-operatively. RESULTS: SF-36, daily activity and pain scores were similar in both groups after 21 days and 6 months, respectively. No hernia recurrence was observed during the observation period. Post-operative complication rates also showed no difference between the groups. CONCLUSION: The implantation of a non-absorbable, large pore-sized, lightweight PP mesh for incisional hernia leads to similar patient-related outcome parameters, recurrence and complication rates as a partly absorbable mesh.

Randomized clinical trial on the effect of coffee on postoperative ileus following elective colectomy.

BACKGROUND: Postoperative ileus is a common problem after abdominal surgery. It was postulated that coffee intake would decrease postoperative ileus after colectomy. METHODS: This was a multicentre parallel open-label randomized trial. Patients with malignant or benign disease undergoing elective open or laparoscopic colectomy were assigned randomly before surgery to receive either coffee or water after the procedure (100 ml three times daily). The primary endpoint was time to first bowel movement; secondary endpoints were time to first flatus, time to tolerance of solid food, length of hospital stay and perioperative morbidity. RESULTS: A total of 80 patients were randomized, 40 to each group. One patient in the water arm was excluded owing to a change in surgical procedure. Patient characteristics were similar in both groups. In intention-to-treat analysis, the time to the first bowel movement was significantly shorter in the coffee arm than in the water arm (mean(s.d.) 60·4(21·3) versus 74·0(21·6) h; P = 0·006). The time to tolerance of solid food (49·2(21·3) versus 55·8(30·0) h; P = 0·276) and time to first flatus (40·6(16·1) versus 46·4(20·1) h; P = 0·214) showed a similar trend, but the differences were not significant. Length of hospital stay (10·8(4·4) versus 11·3(4·5) days; P = 0·497) and morbidity (8 of 40 versus 10 of 39 patients; P = 0·550) were comparable in the two groups. CONCLUSION: Coffee consumption after colectomy was safe and was associated with a reduced time to first bowel action.

[Hospital cooperation models. Safeguarding optimized patient care, medical training and resource utilization]. / Krankenhaus-kooperationsmodelle. Nachhaltige Sicherung einer optimierten Patientenversorgung, Weiterbildung und Ressourcenauslastung.

INTRODUCTION: In the face of continuous medical progress on the one hand and the increasing cost pressure through the diagnosis-related groups (DRG) system with concomitant hospital privatization on the other, pioneering and economical models for modern and competent patient care are required. METHODS: The cooperation model of the surgical department of the Heidelberg University Hospital is based on patient selection according to the grade of disease complexity and has been successfully developed in Heidelberg since 2005. The long-term results on the basis of actual proceeds are presented. RESULTS: Cooperation with the Salem Hospital chaired by the director of the University surgical department has been ongoing for 6 years. General visceral surgery cases with low complexity are treated at the secondary cooperation hospitals whereas complex oncological operations of the esophagus, liver, pancreas, rectum or multivisceral resections and transplantations are performed at the University hospital. Optimal utilization of the operative and infrastructural resources of both cooperation partners lead to an improvement in surgical training and proceeds. Likewise, another cooperation with the secondary hospital in Sinsheim, which started 2 years ago, has shown similar positive results. Clinical rotation for surgical residents and attending surgeons guarantee a complete and competent surgical training in the field of general surgery. CONCLUSIONS: The long-term results indicate that the cooperation model functions to achieve an optimized treatment of patients and an economical win-win situation for all cooperation partners by differential utilization of the available resources in the hospital network.

[Diagnosis and definition of anastomotic leakage from the surgeon's perspective]. / Diagnostik und Definition der Nahtinsuffizienz aus chirurgischer Sicht.

The leak rates of different gastrointestinal anastomoses vary considerably but despite this there are common and general concepts for diagnosis and management. Early diagnosis and timely consistent therapy must guide management to prevent harm to the patients. Diagnosis of anastomotic leaks is coupled to clinical signs of the patients and should be initiated promptly. Dependent on the localization of the leak, computed tomography with administration of oral or rectal contrast dye and endoscopy are of high diagnostic value. Both procedures guarantee the option of drainage or stenting through interventional drains or stent placement. Only the implementation of uniform definitions of anastomotic leaks enables surgeons to compare and to improve surgical treatment. Over recent years consensus definitions of postoperative complications including bile leak, pancreatic fistula and colorectal leak have been formulated. These definitions are based on a 3-fold increase of bilirubin (bile leak) or amylase levels (pancreatic fistula) in abdominal drainage fluid compared to serum levels or on an intestinal wall defect with communication of the intraluminal and extraluminal compartments (colorectal anastomosis). The definitions each describe three severity grades A-C. A change of clinical management is required in grade B whereas grade C usually requires a re-operation. Comparable consensus definitions for anastomotic leaks following esophagogastrostomy or esophagojejunostomy or following small bowel anastomosis have not been established. The authors strongly recommend implementation of the presented consensus definitions into clinical and academic daily practice.

[Surgical treatment of liver trauma: resection--when and how?]. / Chirurgische Therapie des Lebertraumas: resektion--wann und wie?

Liver resection as an emergency procedure in patients with liver injury due to abdominal trauma has become a rare procedure. In most cases liver trauma can be managed conservatively. Currently surgery is only indicated in hemodynamically instable patients and in cases of progredient haematoma where the main aim is control of bleeding. Anatomical liver resection should be avoided and may only be performed in cases of total vascular avulsion. Debridement of devascularized tissue can also be carried out in terms of an atypical liver resection. This article elucidates the current indications for liver resection after traumatic liver injury.

[Open appendectomy. When do we still need it?]. / Offene Appendektomie. Wann wird sie noch gebraucht?

Acute appendicitis is the most common emergency visceral surgical procedure in Germany with 130,000 appendectomies. The question of which operational procedure should be used must therefore be discussed at regular intervals. In many centers of minimal invasive surgery, laparoscopic appendectomy (LA) is the standard procedure. Nearly 30 years after introduction of LA, it is believed that open appendectomy (OA) is needed only on rare occasions, but the actual percentage of OAs carried out in 2006 was 46% of all appendectomies. This high percentage documents that OA is still the standard procedure in many German hospitals. A review of the literature shows that there are still some situations in which OA is superior to LA. Infants younger than 5 years old have a more difficult basic requirement for LA due to the small abdominal cavity, therefore OA is the procedure of choice in most cases. During pregnancy OA has a lower risk for the fetus than LA. Cost analyses show that OA is less expensive for the hospital in material costs, whereas LA is the better economic choice due to an earlier return to work. In summary, there are only marginal differences between the two procedures since both offer a fast patient recovery. Advantages in favor of both LA and OA exist in subgroup analyses and the possible subgroups that can benefit from OA are discussed in this article.

Cyclosporin A causes a hypermetabolic state and hypoxia in the liver: prevention by dietary glycine.

Acute cyclosporin A (CsA) treatment inhibits mitochondrial respiration, yet effects of chronic treatment remain unclear. Accordingly, the effects of chronic CsA on oxygen metabolism in perfused rat liver and isolated mitochondria were investigated. Basal rates of oxygen uptake of around 120 micromol/g/h in isolated perfused livers from vehicle-treated controls were elevated about 1.6-fold by chronic CsA treatment. In the presence of ammonium chloride, a substrate for urea synthesis, oxygen uptake was about 150 micromol/g/h and was increased about 1.7-fold by CsA, indicating that chronic CsA treatment causes a robust hypermetabolic state in the liver. In isolated mitochondria, state 3 rates of oxygen uptake were increased about 1.6-fold by chronic CsA treatment. Since significant increases in oxygen consumption could cause hypoxia, the hypoxia marker pimonidazole was given. Pimonidazole binding in the liver was increased about 3-fold by chronic CsA. Moreover, intracellular calcium in Kupffer cells isolated from vehicle-treated rats was not altered by CsA addition; however, in cells isolated from chronic CsA-treated rats, CsA increased intracellular calcium about 15-fold and prostaglandin E(2) (PGE(2)) production 3.5-fold. Importantly, dietary glycine (5%) largely blocked chronic CsA-induced activation of Kupffer cells, blunted production of PGE(2), prevented the hypermetabolic state, and minimized tissue hypoxia. Taken together, it is concluded that chronic CsA treatment causes a hypermetabolic state leading to hypoxia and injury to the liver. It is hypothesized that CsA activates Kupffer cells and increases production of PGE(2), which alters mitochondria leading to a hypermetabolic state. Glycine inhibits activation of Kupffer cells thus preventing liver injury.

Intramucosal pH and liver endotoxin clearance during experimental liver transplantation.

The study was designed to assess the gastrointestinal ischaemia and the influence of the specific Kupffer cell toxin gadolinium chloride (GdCl3) on the hepatic and extrahepatic endotoxin [lipopolysaccharide (LPS)] clearance during experimental orthotopic liver transplantation (OLT) in pigs. In eight pig liver transplantations, the donors received 20 mg/kg of GdCl3 24 h before explantation, while controls (n = 8) received normal saline. Gastric and sigmoid intramucosal pH (pHi), LPS and endotoxin-neutralising capacity (ENC) levels were measured in the portal vein and superior vena cava after laparatomy, at the end of the anhepatic phase and 1 h after reperfusion. During the anhepatic phase, the sigmoid pHi decreased significantly from 7.32 +/- 0.02 to 7.29 +/- 0.03 (P < 0.001) and was associated with a substantial increase of portal LPS. Following reperfusion, the systemic LPS concentrations were significantly lower in the pretreated group [39 +/- 23 pg/ml (Control); 14 +/- 7 (GdCl3); P < 0.05] suggesting an improved liver LPS clearance [86% (GdCl3); 58.2% (Control); P < 0.05]. This corresponded to an increased ENC in the pretreated group [118 +/- 52 ENU/ml (GdCl3) vs 81 +/- 45 ENU/ml (Control); P < 0.05]. The anhepatic phase induced splanchnic ischaemia which correlated with portal endotoxaemia. Donor preconditioning with GdCl3 leads to lower systemic LPS concentrations in the recipient and increases ENC values in the early phase after OLT. An improved hepatocellular LPS extraction and/or an activation of the extrahepatic reticulo-endothelial system as a result of GdCl3 treatment is discussed.

Kupffer cell-dependent reperfusion injury in liver transplantation: new clinically relevant use of glycine.

Kupffer cell-dependent reperfusion injury occurs to the liver following transplantation, most often in fatty livers which fail most frequently due to primary nonfunction. Failure was largely blocked with Carolina rinse solution, which contains glycine, and prevents the activation of Kupffer cells. Furthermore, gentle in situ organ manipulation, which cannot be prevented using standard harvesting techniques, has a detrimental effect on survival. These effects were also prevented by glycine. Since proteolytic activity is increased in both fatty and manipulated livers, amino acids were measured in rinse effluents collected at harvest. A combination of four amino acids correlated with graft function. It is concluded that glycine could be beneficial in clinical liver transplantation to prevent reperfusion injury, and that amino acids measured at harvest may predict graft function.

Release of amino acids from fatty livers during organ harvest for transplantation.

Shortage of organ donors presents a perplexing problem in liver transplantation, and improved methods for evaluating the viability of organs prior to implantation are urgently needed. In the present study, the hypothesis was evaluated that grafts from fatty livers release more amino acids than non-fatty controls during organ harvest. Amino acids in graft rinse effluents at the time of harvest and after cold storage were measured by reverse-phase high performance liquid chromatography and compared with plasma aspartate aminotransferase (AST) levels and recipient survival. Twenty-four hours after transplantation of fatty livers, AST levels in recipient rats were increased more than two-fold compared to non-fatty controls (p < 0.01). Survival in the control group was 83 percent, whereas animals receiving fatty livers from ethanol-treated rats survived no longer than 7 days after transplantation (p < 0.05). The rate of release of amino acids from the liver explant was two-fold higher during the harvest procedure (0.5 h) than during the subsequent 23.5 hour cold storage period (435 +/- 70 vs. 186 +/- 14 nmol/ml/hr/g liver, p < 0.001). Further, in the early rinse effluent, amino acids were released about two-fold faster from fatty livers than from controls (p < 0.05). This study demonstrates that the release of amino acids from liver explants increases during the harvesting procedure and is about two-fold higher in fatty livers which fail after transplantation than in surviving controls. It is proposed that amino acid release from explants after organ harvest might serve as a useful marker to evaluate graft function prior to transplantation.

Prevention of cyclosporine-induced nephrotoxicity with dietary glycine.

BACKGROUND: The nonessential amino acid glycine has been used previously to prevent hypoxic and ischemic injury to kidney tissue in vitro. Furthermore, it was recently shown that glycine prevents activation of macrophages and neutrophils in vitro. Because there is some evidence that the immunosuppressant cyclosporine causes nephrotoxicity through a hypoxia-reoxygenation mechanism that could involve infiltration and activation of macrophages and neutrophils, we hypothesized that dietary glycine could prevent this injury. METHODS: Rats were fed a diet containing glycine (5%) or a control diet for 3 days before cyclosporine treatment. To produce nephrotoxicity, cyclosporine (25 mg/kg daily by gavage) was administered for 28 days while animals were maintained on glycine or control diets. Serum creatinine, urea, glomerular filtration rates, and kidney histology were evaluated in different treatment groups. RESULTS: All rats gained weight; however, overall weight gain in the cyclosporine, glycine, and cyclosporine+glycine groups was significantly less by about 40% compared with the control group. Diet consumption was not statistically different between the groups. As expected, cyclosporine caused kidney damage in the rats fed control diet, reflected in significantly elevated serum urea and creatinine. In addition, cyclosporine treatment decreased glomerular filtration rate by nearly 70%, caused proximal tubular dilation and necrosis as well as increased macrophage and neutrophil infiltration into the kidney. Dietary glycine prevented or minimized kidney damage due to cyclosporine in all parameters studied nearly completely. Furthermore, feeding glycine for up to 1 month had no detrimental effect on kidney function. CONCLUSIONS: Dietary glycine is a safe and effective treatment to reduce the nephrotoxicity of cyclosporine.

[Effect of anastomosis reconstruction on vascular complications after liver transplantation]. / Einfluss der Anastomosenrekonstruktion auf vaskuläre Komplikationen nach Lebertransplantation.

AIM: Besides primary non function (PNF), vascular complications are responsible for the majority of early surgical and interventional therapy following liver transplantation. The purpose of this study was to evaluate the influence of the variety of arterial anastomosis on postoperative morbidity and mortality. METHOD USED: In 179 liver transplantations, vascular (arterial and portal) complications within the first 3 months were analyzed with respect to the type of reconstruction. The arterial anastomoses were divided into 3 groups according to the recipient artery used [Group (I): common hepatic artery (CHA), (II): hepatic artery (HA), (III): aorta]. For statistical analysis comparison of two proportions and the logrank test were used. RESULTS: The reconstruction was done primarily to the recipient CHA (69%, n = 124), less often to the HA (15%, n = 26) or directly to the aorta (16%, n = 29). The portal anastomosis-with the exception of two cases (dacron graft and internal iliac vein interposition)-was always end to end and resulted in four reinterventions (2.2%, kinking: n = 1, thrombosis: n = 3). Arterial complications (11.7%) like thrombosis, stenosis and dissection (n = 17), bleeding (n = 2) and steal phenomenon (n = 2) occurred more frequently. The difference in one year survival between patients with (n = 12/25, 47%) and without (n = 42/53, 79%) vascular complications was significant (chi 2 = 4.72, FG 1, logrank test p < 0.05). CONCLUSION: The rate of complications causing surgical or interventional therapy is independent of the choice of arterial reconstruction. The one year survival rate in patients with vascular complications is significantly decreased.

Effect of bilateral decortication on nerve growth factor content in basal nucleus and neostriatum of adult rat brain.

The content of nerve growth factor (NGF) was measured by a sensitive two-site enzyme-linked immunosorbent assay in the basal nucleus and neostriatum at various times following bilateral suction lesions of the cerebral neocortex in adult rats. At 14 and 29 postlesion days, NGF levels in basal nucleus were significantly elevated by 270 and 126%, respectively. In addition, 29 days after cortical lesions, NGF content in the neostriatum was increased 145% above controls. Thus, enhanced NGF production occurs in both basal nucleus and neostriatum of adult rats in response to antero- and/or retrograde neuronal degeneration.