[Education in laparoscopic surgery: national survey on current strategies and relevance of simulation training]. / Ausbildung in der laparoskopischen Chirurgie: Umfrage zu vorhandenen Konzepten und der Bedeutung von Simulationseinheiten.

BACKGROUND: Laparoscopic surgery demands from the surgeon specific operative skills. Learning -curves have been described for many procedures in this technique. In order to evaluate the avail-able laparoscopic teaching resources and meth-ods in Germany an opinion survey was per-formed. MATERIALS AND METHODS: Directors of 284 surgical departments were polled using a questionnaire regarding department and operation statistics, -laparoscopic education and availability of simulation facilities ("Skills Labs" SL). RESULTS: The response rate was 54 %. 88 % of the department directors considered laparoscopic -simulation an efficient teaching method and 91 % felt that simulation improves operating room performance. A SL was available in 27 % of these -departments. The training modules most commonly offered were basic laparoscopic skills such as coordination exercises (100 %) and suturing techniques (89 %). The actual median acquisition costs amounted to 20 000 € in our evaluation, with annual running costs of a median of 1000 €. CONCLUSION: Although most of the questioned surgeons acknowledged the value of SL, this method of education is not widely available in Germany. Therefore we feel that simulation training in Germany still requires stronger support.

[Are leukocytes and CRP early indicators for anastomotic leakage after esophageal resection?]. / Sind Leukozyten und C-reaktives Protein geeignete Parameter als Frühindikatoren der Anastomoseninsuffizienz nach Osophagusresektion?1.

BACKGROUND: Anastomotic leaks represent the most common severe postoperative complications after esophagectomy. In this study standard inflammatory laboratory parameters [leukocytes, C-reactive protein (CRP)] were evaluated as indicators for anastomotic leakage after esophagectomy. PATIENTS AND METHODS: Between 1 / 1997 and 12 / 2006 a total of 558 patients with esophageal cancer underwent an Ivor-Lewis esophagectomy. Among these patients, all those (n = 50, 8.9 %) suffering from an anastomotic leak were matched to 50 patients without anastomotic leakage. Leukocytes, CRP level and clinical parameters (body temperature, cardiac / respiratory problems, wound secretion) were retrospectively analysed at short-term intervals in both groups. RESULTS: Patients with anastomotic leaks showed significant continuously increased CRP levels and leukocyte counts from the second or, respectively, 5 (th) postoperative day onwards compared to patients without anastomotic leaks. Using a stepwise regression, an 80 % sensitivity for leakage detection has been calculated by a cut-off value for CRP set at 13.5 mg / dL from day 2 onwards or, respectively, for leukocytes at 10.5 Gpt / L from day 8 onwards. Concomitantly, patients with anastomotic leaks suffered significantly more from respiratory problems and abdominal pain. CONCLUSION: CRP appears to be a reliable and predictable indicator for anastomotic leakage after esophagectomy and should, therefore, be routinely used as a screening marker to provide a reason for extended diagnosis.

[Metabolic consequences in patients with intestinal stoma]. / Stomaphysiologie Wasser- und Elektrolythaushalt -Kurzdarmsyndrom.

In addition to psychological stress, stomas may lead to metabolic consequences. Colostomies normally cause only minor physiological problems; however, patients with ileostomies are at risk for severe metabolic disturbances. The small intestine essentially manages the balance of water and electrolytes and the absorption of nutrition. In special circumstances such as or short-bowel syndrome, dangerous consequences like kidney disorders may arise. Basic therapeutic strategies such as enteral or parenteral substitution are discussed.

[Neuroendocrine tumors of the gastroenteropancreatic system--reevaluation using the Capella classification]. / Neuroendokrine Tumoren des Gastroenteropankreatischen Systems--Reevaluierung nach der Capella Klassifikation.

INTRODUCTION: Neuroendocrine tumors of the gastroenteropancreatic system (GEP) are heterogeneous regarding hormone production, localisation and biological behaviour making the prognostic evaluation of these rare tumors difficult. Capella et al. proposed a new classification that combines for the first time both biological and prognostic characteristics. This study aimed to evaluate the prognostic value of Capella's classification in the patients treated at our hospital. METHODS: 86 from 1975-1999 surgically treated and histologically confirmed neuroendocrine tumors were retrospectively classified as benign (B), uncertain behavior (UB), low grade malignant (LG) or high grade malignant (HG) following the Capella classification. These data were correlated with the long-term outcome of the patients 8.5 (range: 1-24) years after surgery. RESULTS: 43 % of tumors were localised in the pancreas, the others were equally distributed in the remaining GEP. Most tumors were classified as B (42 %) or LG (41 %), few were UB (10 %) or HG (7 %). 61 patients survived free of disease, 25 patients died, 13 of them not tumor related. Tumor related deaths were only observed in 6 patients with inoperable LG- and 6 patients with HG-neuroendocrine tumors within 3 years after surgery. CONCLUSION: The Capella classification reliably reflects the heterogeneity and the biological behaviour of GEP-neuroendocrine tumors and can therefore be recommended for clinical use.

[Rectal carcinoma in a patient with familial adenomatous polyposis coli after colectomy with ileorectal anastomosis and consecutive chemoprevention with sulindac suppositories]. / Entwicklung eines Rektumkarzinoms bei familiärer adenomatöser Polyposis coli nach ileorektaler Anastomose und lokoregionaler Chemoprävention mit Sulindac.

Surgery is the definitive treatment in familial adenomatous polyposis coli (FAP). Proctocolectomy with ileal pouch anal anastomosis is recommended for the majority of FAP patients. Only in patients with attenuated FAP, is a colectomy with ileorectal anastomosis (IRA) accepted, although the risk for rectum carcinoma remains increased. Sulindac, a chemoprophylactic agent, regresses colorectal adenomas in patients with FAP. Under systemic Sulindac-therapy, three carcinomas in the rectum after colectomy with IRA have been described. We report the first known case of rectum carcinoma in a patient with FAP, 51 months after IRA and local Sulindac therapy.

Role of appendix and spleen in experimental colitis.

There is growing clinical evidence suggesting that certain secondary lymphoid tissues (e.g., appendix and spleen) contribute to the initiation and/or perpetuation of ulcerative colitis. In this study, the importance of secondary lymphoid tissues in inducing colitis was assessed experimentally by removing the spleen and/or appendix (or sham operation) prior to inducing colitis in mice. Feeding 2.5% dextran sulphate sodium (DSS) in drinking water over 7 days induced colitis. Clinical disease activity was assessed based on weight loss, stool consistency, and presence of blood in stools. Additional measurements included white blood cell count and hematocrit, and myeloperoxidase activity (MPO) in colon samples. Colonic injury was assessed by histology and computerized image analysis. DSS treatment in sham-operated mice produced colitis associated with weight loss, bloody diarrhea, and mucosal ulceration. Clinical assessment of DSS-treated mice subjected to appendectomy or combined appendectomy/splenectomy exhibited a delayed onset and course of disease activity. Histomorphologic examination revealed significantly lower damage scores and a reduction in ulcerated mucosal surface area. Colonic MPO activity, which correlated with tissue injury and disease activity, was lowest in appendectomized mice. No beneficial effects of splenectomy were observed after 7 days of colitis. These findings support the hypothesis that appendicular lymphoid tissue, but not the spleen, contributes to the development of colitis.

Increased expression of metallothionein in inflammatory bowel disease.

OBJECTIVE: Metallothioneins (MT) are cytoprotective against the damaging effects of oxygen-derived free radicals. Therefore MT may be involved in defence mechanisms to counter Crohn's disease (CD) and ulcerative colitis (UC). MATERIALS: 107 routinely processed tissue samples from 22 patients with CD and 48 patients with UC were tested with the monoclonal anti-MT antibody E9. METHODS: Immunohistochemistry was used to assess MT staining in a semiquantitative manner. Chi-square test was used for statistical analysis. RESULTS: MT overexpression was found in the fibroblasts of all ulcerative and/or fissural lesions in UC and CD. MT overexpression in intestinal epithelial cells of 40% of UC and CD lesions correlated significantly with the grade of inflammation. CONCLUSIONS: MT-immunoreactivity in fibroblasts supports a protective role for MT in inflammatory bowel disease. It remains unclear whether MT overexpression in epithelial cells is also important in this protection.

[Colorectal carcinoma. Minimally invasive surgery under quality aspects--limitations]. / Kolorektales Karzinom. Minimal-invasive Chirurgie unter Qualitätsgesichtspunkten--Grenzen.

Owing to a lack of long-term survival in prospective randomized studies controversy continues to surround the use of laparoscopic resection in cases of colorectal carcinoma. However short-term survival and recurrence rate seem to be similar to conventional procedures. Mortality and morbidity rates following laparoscopic surgery seem to be equal to conventional surgery. Oncological problems associated with laparoscopic colorectal surgery with curative intent include inadequate radicality, incorrect surgical technique, and failure to observe the technical and/or oncological limitations applicable to certain tumor sites. Carcinomas of the right and left hemicolon, colon sigmoideum and of the lower rectum without a possibility of continence preservation can be safely treated by laparoscopy. All other locations, tumors with a size greater than 8 cm and tumors involving the surrounding tissue are technically demanding and difficult to be treated laparoscopically following oncological criteria. The incidence and pathogenesis of trocar site metastases are unknown. Surgical concepts to avoid these sequelae are not established.

[Fulminant necrotizing fasciitis secondary to Crohn's disease]. / Fulminante Fasciitis necroticans bei Morbus Crohn-assoziiertem Verlauf.

Necrotizing fasciitis is a life-threatening infection, commonly caused by group A streptococci, which has to be treated by surgical exploration and debridement during the first 24 h. Clinical clues are severe pain, in some cases followed by the appearance of bullous formations, and the detection of gas in the soft tissues by computed tomography or MRI. In addition to that, the infection is characterized by rapid inflammatory progression, producing a highly life-threatening situation. Diagnosis is finally based on surgical exploration obtaining specimens for culture and histopathologic examination. Debridement and exploration, in some cases amputation of the extremity, are indicated as soon as possible. Antibiotic therapy increases efficacy too, but there is no substitute for surgical treatment. Inflammatory bowel disease (Crohn's disease in this case) followed by necrotizing fasciitis is rarely mentioned in the literature. Therapeutic management in a situation of immunosuppression is discussed by illustration of an actual case.

[Intraoperative radiotherapy as multimodal therapy approach in epithelial tumors of the gastrointestinal system]. / Die intraoperative Radiotherapie als Bestandteil multimodaler Therapiekonzepte bei epithelialen Tumoren des Gastrointestinaltrakts.

Surgery alone often fails to achieve local control in advanced gastrointestinal tumors. With multimodal therapy approaches, both local tumor control and long-term survival appear to be improved. Intraoperative radiation therapy (IORT) is an attempt to achieve higher doses of irradiation while dose-limiting structures are surgically displaced. It has been shown previously that both local tumor control and long-term survival are improved in patients undergoing surgery combined with IORT for both primary and recurrent rectal carcinoma. In advanced gastric carcinoma, IORT has achieved optimistic survival results in a few studies. In locally advanced pancreatic cancer, an apparent improvement in local control has been noted with IORT, but survival has not been prolonged because of a high incidence of both liver and peritoneal metastases. The data concerning IORT for esophageal carcinoma are not yet sufficient to allow judgement.

[Stoma physiology]. / Stomaphysiologie.

In addition to psychological stress, stomas may lead to metabolic consequences. Colostomies normally cause only minor physiological problems; however, patients with ileostomies are at risk for severe metabolic disturbances. The small intestine essentially manages the balance of water and electrolytes and the absorption of nutrition. In special circumstances such as "high output" or short-bowel syndrome, dangerous consequences like kidney disorders may arise. Basic therapeutic strategies such as enteral or parenteral substitution are discussed.

Transepithelial transport processes at the intestinal mucosa in inflammatory bowel disease.

Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) of unknown etiology. Oral absorption studies have shown an increased intestinal permeability for various sugar molecules in patients with IBD and their healthy relatives as a possible pathogenetic factor. However, the various transport pathways through the mucosal barrier have not yet been examined. This study therefore investigated whether antigens pass the epithelial barrier by a transcellular or a paracellular pathway. Mucosa of freshly resected specimens from CD (n = 10) or UC (n = 10) patients was investigated by immunoelectron microscopy and compared with healthy mucosa. Epithelial transport was studied with the antigens ovalbumin and horseradish peroxidase after defined incubation. Labeling density of subunit c of ATP synthetase was determined in mitochondria of enterocytes of all specimens. In all specimens epithelial transport of OVA and HRP was principally transcellular through enterocytes with normal ultrastructure, although some tight junctions in CD and UC were dilated. Antigens were transported within vesicles to the basolateral membrane 2.5 min after incubation. The level of enterocytes with electron-lucent cytoplasm containing a high amount of antigens was higher in CD and UC than in healthy mucosa, depending on the grade of inflammation. ATP synthetase was significantly decreased in electron-lucent cytoplasm of CD and UC to normal ultrastructure of healthy mucosa. Our study shows that ovalbumin and horseradish peroxidase taken up by the apical membrane reach the paracellular space by vesicular transport in healthy and IBD enterocytes within a few minutes. Transcellular pathway is affected in both CD and UC, which is indicated by a high level of antigens within the cytosol. We speculate that increased intestinal permeability in IBD results substantially from enhanced transcellular transport.

[Effect of proctocolectomy on fluid balance--comparison of conventional ileostomy, ileorectal anastomosis and ileoanal pouch operation]. / Einfluss der Proktokolektomie auf die Flüssigkeitsbilanz--konventionelle Ileostomie, ileorektale Anastomose und ileoanale Pouch-Operation im Vergleich.

Total colectomy for ulcerative colitis (UC) and familiar adenomatous polyposis coli (FAP) is mainly performed as an ileoanal Pouch procedure (IAP). Alternatives are ileorectal anastomosis (IRA) and conventional proctocolectomy with Brooke ileostomy (CPS). The different surgical techniques may influence the excretion of water and electrolytes in stool and urine and may lead to a higher risk for urolithiasis. We investigated patients (12 IAP, 12 IRA and 8 CPS) several years after surgery and compared them to twelve normal controls. Total fecal and urinary output was collected at two consecutive days. Volume and electrolytes were determined in stool and urine. The risk for urinary stone formation was calculated by nomograms. Fecal volume and sodium (Na+) excretion was increased in all therapy groups compared to controls. IAP and IRA had significant less stool volume and Na+ excretion compared to CPS. Augmented fecal Na+ excretion was compensated by reduction of renal output after colectomy compared to controls. There were no significant differences in the daily urine volume between any groups. There was no urolithiasis in any groups. The nomograms showed a risk for all groups and controls to develop urinary stones.

[Classification of neuroendocrine tumors and the effect on surgical technique]. / Die Klassifizierung der neuroendokrinen Tumoren und der Einfluss auf das chirurgisch-taktische Vorgehen.

Neuroendocrine tumors of the gastrointestinal tract are heterogenous regarding hormone production and tumor biology and have a varying disease course and survival time. In 1995 Capella et al. proposed a new classification of neuroendocrine tumors combining characteristics of the primary (i.e. histological differentiation, size, extension into surrounding tissues, hormonal activity and angioinvasion) and its suspected biological behavior (benign, uncertain, low-grade malignant, high-grade malignant). The extent of surgical therapy depends on the malignant potential of the primary tumor. To evaluate the usefulness of this classification in practical work neuroendocrine tumors have to be categorized by this classification and these data have to be correlated with the individual long-term course of patients.

[Indications for restorative proctocolectomy in systemic colorectal diseases (ulcerative colitis and familial adenomatous polyposis coli)]. / Indikationen zur restorativen Proktokolektomie bei Dickdarmsystemerkrankungen (Colitis ulcerosa und familiäre adenomatöse Polyposis coli).

Restorative proctocolectomy is now the procedure of choice for patients suffering from ulcerative colitis (UC) and familial adenomatous polyposis coli (FAP). The majority of patients with UC require surgery for failure or development of side effects of medical therapy. Other indications include dysplasia, carcinoma and complications from either medical therapy or the disease, such as massive bleeding or perforation. In the adolescent patient, resection may be necessary owing to growth retardation. In patients with FAP the 100% risk of developing colorectal carcinoma can be avoided only by proctocolectomy. Crohn's colitis and carcinoma of the lower rectum represent absolute contraindications. A relative contraindication exists in indeterminate colitis, patients with poor sphincter function, mesenteric desmoids, obesity and an age above 65 years.

Control of human arm movements in two dimensions: influence of pointer length on obstacle avoidance.

Human subjects (N = 13) made arm movements in a horizontal plane by using the shoulder, elbow, and wrist to move a pointer to a target while avoiding simple obstacles. Movements with no pointer and with pointers of three different lengths were tested so that the lever arm of the wrist could be changed and its effective redundancy altered. With increasing pointer length, movement durations decreased, wrist movement used in avoiding obstacles increased, and variability in proximal joint angles increased. Most characteristics of paths and joint movements previously described for movements with the long pointer were found to generalize to movements with shorter pointers or with no pointer-the condition used in several previous comparisons of 2- and 3-joint movements. Both joint angles and path parameters changed in accommodating to the constraints added by obstacles and by increasing pointer length, implying that criteria defined in workspace and in joint space together influence paths in workspace and joint movement, as postulated by bidirectional models. Increased wrist extension and flexion during movement, compared with static pointing, indicate that dynamic factors are also important.

[Changes in fecal bile acid excretion after proctocolectomy]. / Veränderungen der Fäkalen Gallensäurenexkretion nach Proktokolektomie.

To study the effect of total colectomy for fecal bile acid excretion we examined groups of patients with ulcerative colitis and familial adenomatous polyposis coli 4,8 +/- 2.9 years after surgery. Patients after total colectomy showed a significant higher fecal bile acid excretion compared to healthy persons (mean +/- SD: 190.8 +/- 195.2 mumol/d). The highest fecal output occurred in patients with permanent ileostomies (mean +/- SD: 7595.0 +/- 5651.4 mumol/d), it was significantly higher compared to patients with ileoanal pouch anastomosis (mean +/- SD: 2212.8 +/- 2132.8 mumol/d). The daily fecal output of patients with ileorectal anastomosis (mean +/- SD: 4331.8 +/- 6314.7 mumol/d) is between the results of both other groups without any significance. After total colectomy only primary bile acids were found in each group whereas healthy people had almost identically rates of primary and secondary bile acids in their stools.