Measurements of chlorhexidine, p-chloroaniline, and p-chloronitrobenzene in saliva after mouth wash before and after operation with 0.2% chlorhexidine digluconate in maxillofacial surgery: a randomised controlled trial.

Chlorhexidine gluconate is used to prevent the accumulation of dental plaque and gingivitis, infection of the surgical site, and ventilator-associated pneumonia in maxillofacial surgery, but it is not clear whether the metabolites of chlorhexidine are detectable in the patient's saliva at clinically relevant concentrations. Forty-three patients who had orofacial operations were randomised to use a 0.2% chlorhexidine gluconate (n=23), or an octenidine-based, chlorhexidine-free (n=20), mouthwash once preoperatively and three times daily for five postoperative days. After the first, 8.7 (23.3) mg/L chlorhexidine (0.7%-2.5% of the total amount used) was measured in saliva. The concentration increased to 15.2 (6.2) mg/L after the second rinse (first postoperative day), and peaked at 29.4 (11.2) mg/L on the fourth postoperative day. It remained detectable for up to 12hours after the last one, but was not detectable in serum or urine at any time. The potentially carcinogenic metabolite p-chloroaniline was detectable in saliva at higher concentrations in the chlorhexidine group (0.55mg/L) than the octenidine group (0.21mg/L), and p-chloronitrobenzene was detected in both groups in only minimal concentrations (0.001-0.21mg/L). Chlorhexidine gluconate mouthwashes do increase the concentration of p-chloroaniline, but a single use seems to be safe. Whether prolonged exposure over many years may have carcinogenic potential is still not clear. Based on the hitherto unknown kinetics of p-chloroaniline in saliva, the recent recommendation of the Federal Drug Administration (FDA) in the USA to limit the use of a chlorhexidine gluconate mouthwash to a maximum of six months seems to be justified.

Exercise-induced Natural Killer Cell Activation is Driven by Epigenetic Modifications.

Exercise has been proven to reduce the risk and progression of various diseases, such as cancer, diabetes and neurodegenerative disorders. Increasing evidence suggests that exercise affects the cytokine profile and changes distribution and function of tumor-competitive immune cells. Initial studies have shown that different exercise interventions are associated with epigenetic modifications in different tissues and cell types, such as muscle, fat, brain and blood. The present investigation examines the effect of an intense endurance run (half marathon) on global epigenetic modifications in natural killer (NK) cells in 14 cancer patients compared to 14 healthy controls. We were able to show that histone acetylation and NKG2D expression, a functional NK cell marker, were elevated for at least 24 h after the run. Thus, this is the first study to present a potential mechanism of how exercise may impact NK cell activity on the subcellular level. Further studies should focus on epigenetic mechanisms and dose-dependent effects of exercise.

Analysis of right and left ventricular deformation in former world class swimmers: evaluation using speckle tracking.

AIM: There is a longstanding debate over the long-term effect of intensive endurance training on cardiac function. Usually, echocardiography has been used as a global evaluation of left ventricular (LV) or right ventricular (RV) function and dimensions. Recently, speckle tracking strain (ST) has provided an analysis of regional RV and LV function. Thus, the intention of the study was to carefully evaluate cardiac function in a group of former world class swimmers applying longitudinal strain (LS) and circumferential strain (CS) analysis. METHODS: Twelve athletes (45±1.5 years) of a former training group involved in high intensity endurance training were examined 24.9±4.3 years after the end of their active swimming career. An echocardiography was performed and LV function was analyzed based on CS and LS. Also, LS was evaluated for the RV. All measurements were performed for epicardium and endocardium independently. RESULTS: Mean LV endocardial LS was -20.0±6.3 and epicardial LS -20.2±6.2. LV endocardial CS was -21.3±8.0 and epicardial CS -11.9±4.2. RV endocardial LS had a mean value of -26.4±6.1 and epicardial LS of -28.2±5.6. CONCLUSION: Twenty-five years after the cessation of endurance training, there was no evidence of a deterioration of RV or LV function as values for RV and LV strain measurements were within normal ranges.

[Acne inversa: influence of associated factors in the extent of the disease and the result of surgery]. / Acne inversa : Einfluss assoziierter Faktoren auf den Schweregrad und das operative Ergebnis.

BACKGROUND: Acne inversa is a chronic inflammatory disease with fistulas and abscesses of unknown etiology. A number of trigger factors have been identified, but their influence on pathogenesis and severity of the disease is controversial. METHODS: In a retrospective study we analyzed 84 patients with AI who underwent 113 surgical procedures. Well-known external and internal trigger factors as well as the surgical procedure and its outcome together with parameters of quality of life and patient satisfaction were assessed. RESULTS: The median severity of disease (Sartorius score) was 43.4 without any gender differences. The amount of smokers was extraordinarily high with 93%, but there was no correlation between smoking and disease severity. Obesity (77% in all patients), the age of primary manifestation of AI, family history of AI, atypical locations, and history of severe acne were significantly associated with the Sartorius score and therefore with AI severity. Except for age of primary manifestation and history of severe acne, the mentioned factors were independent predictors for disease severity in multivariate analysis. The postsurgical recurrence rate was 12.4% and significantly higher in heavy smokers. However, there was no relation between recurrence rate and wound closure. The evaluation of patients' self- assessment on life quality showed a postsurgical improvement of 70%. CONCLUSION: The wide surgical excision of all lesions followed by spontaneous healing or split-skin grafting leads to a reasonable recurrence rate and improves the affected patients' quality of life for a prolonged period of time.

Apelin serum levels are not associated with early atherosclerosis or fat distribution in young subjects with increased risk for type 2 diabetes.

Apelin is proposed to possess protective cardiovascular properties and may furthermore promote favorable effects on glucose metabolism. First data in humans seem to support this hypothesis. Therefore we aimed to assess the meaning of apelin as an early risk indicator in young subjects prone to atherosclerosis and type 2 diabetes. Furthermore we examined the association of apelin serum levels with insulin sensitivity/resistance and body fat distribution as probably dependent cardiovascular risk factors. We examined 344 individuals (f/m=216/128, mean age 46±1 years) with an increased risk for type 2 diabetes. Apelin-36 serum levels were measured via ELISA. Endothelial dysfunction and intima media thickness (IMT) were assessed using high resolution ultrasound. Visceral adipose tissue (VAT) was measured with an axial T1-weighted fast spin echo technique with a 1.5 T whole-body imager. According to the study population's age, FMD (6.4±0.2%) and IMT (0.56±0.01 mm) were within the expected ranges. Gender or age had no influence on serum apelin levels. When looked at early stages of atherosclerosis, we could not detect a significant correlation between apelin serum levels and FMD or IMT. Blood pressure as well was unaffected by serum apelin levels. Furthermore, neither parameters of insulin sensitivity like insulin sensitivity index (ISI), nor fat distribution like BMI, grade of adiposity, total adipose tissue or VAT were associated with apelin serum levels. We conclude that apelin serum levels do not add further information on the cardiovascular-, or diabetes risk pattern in a diabetes prone population.

Comparison of skeletal muscle strength between cardiac patients and age-matched healthy controls.

The purpose of the present study was to compare muscular strength of knee extensors and arm flexor muscles of cardiac patients (n = 638) and healthy controls (n = 961) in different age groups. Isometric torques were measured in a sitting position with the elbow, hip, and knee flexed to 90(0). For statistical analysis, age groups were pooled in decades from the age of 30 to 90 years. Additionally, the influence of physical lifestyle prior to disease on muscular strength was obtained in the patients. For statistical analysis three-way ANOVA (factors age, gender, and physical activity level) was used.Both in patients and in controls a significant age-dependent decline in maximal torque could be observed for arm flexors and knee extensors. Maximal leg extensor muscle showed statistically significant differences between healthy controls and cardiac patients as well as between subgroups of patients: Physically inactive patients showed lowest torques (male: 148 +/- 18 Nm; female: 82 +/- 25 Nm) while highest values were measured in control subjects (male: 167 +/- 16 Nm; female: 93 +/- 17 Nm). In contrast, arm flexor muscles did not show any significant influence of health status or sports history.This qualitative difference between weight-bearing leg muscles and the muscle group of the upper extremity suggest that lower skeletal muscle strength in heart patients is mainly a consequence of selective disuse of leg muscles rather than any pathological skeletal muscle metabolism. Since a certain level of skeletal muscle strength is a prerequisite to cope with everyday activities, strength training is recommended as an important part of cardiac rehabilitation.

Complications after transanal endoscopic microsurgical resection correlate with location of rectal neoplasms.

PURPOSE: Transanal endoscopic microsurgery (TEM) is a technique that has found its place in routine practice due to its minimal invasive character and associated low morbidity. The purpose of this study was to assess the influence of anatomical variables of rectal neoplasms as well as surgeon experience on postoperative complications in patients undergoing TEM at a tertiary care center. METHODS: Data from 288 patients undergoing TEM over a 16 year period were entered in a prospective data base. Anatomical data of rectal neoplasms, operative data, and early postoperative outcome were analyzed retrospectively. RESULTS: Overall surgical complications [OR 7.0 (1.5-45,5); p < 0.01] and bleeding [OR 222 (82 - 14316); p < 0.01] correlated with the localization of the neoplasm on the lateral wall of the rectum. Furthermore there was a trend for more surgical overall complications as well as bleeding in neoplasms with a diameter of >2 cm and neoplasms located >8 cm from the anal verge. Complications did not correlate with the number of TEM procedures performed. CONCLUSION: TEM resection of neoplasms located on the lateral rectal wall have a higher risk of bleeding. The learning curve for transanal endoscopic microsurgery appears to be negligible in surgeons with experience in minimal invasive surgery.

Element distribution in mycorrhizal and nonmycorrhizal roots of the halophyte Aster tripolium determined by proton induced X-ray emission.

The salt aster (Aster tripolium L.) colonized by the arbuscular mycorrhizal fungus Glomus intraradices Sy167 and noncolonized control plants were grown in a greenhouse for nine months with regular fertilization by Hoagland nutrient solution supplemented with 2% NaCl. Mycorrhizal roots showed a high degree of mycorrhizal colonization of 60-70% and formed approximately 25% more dry weight and much less aerenchyma than the nonmycorrhizal controls. Cryosectioning essentially preserved the root cell structures and apparently did not cause significant ion movements within the roots during cuttings. The experimental conditions, however, did not allow to discriminate between fungal and plant structures within the roots. Quantification of proton-induced X-ray emission (PIXE) data revealed that in control roots, Na(+) was mainly concentrated in the outer epidermal and exodermal cells, whereas the Cl(-) concentration was about the same in all cells of the roots. Cross sections of roots colonized by the mycorrhizal fungus did not show this Na(+) gradient in the concentration from outside to inside but contained a much higher percentage of NaCl among the elements determined than the controls. PIXE images are also presented for the four other elements K, P, S, and Ca. Both in colonized and control roots, the concentration of potassium was high, probably for maintaining homoeostasis under salt stress. This is seemingly the first attempt to localize both Na(+) and Cl(-) in a plant tissue by a biophysical method and also demonstrates the usefulness of PIXE analysis for such kind of investigation.

Single-surgeon surgery in laparoscopic colonic resection.

PURPOSE: Short-term benefits have been demonstrated for laparoscopic-assisted colectomy. However, minimally invasive surgery is still in an evolutionary phase. In demonstrating that robotic devices also are useful in laparoscopic colonic surgery, it is fundamental to prove that a single surgeon can perform almost the entire operation on his own. METHODS: A single surgeon performed forty-one, laparoscopic-assisted, colorectal resections with the assistance of a robotic device (Automated Endoscopic System for Optimal Positioning, Computer Motion) maneuvering the laparoscope. A surgical assistant was included only for the open part of the operation. Main outcome measures were conversion rate, total operating time, and percentage of assistance by a second surgeon. RESULTS: There were no intraoperative complications, one case of conversion to open surgery, and three postoperative complications. The total operating time ranged from 126 to 252 minutes. A single surgeon with the assistance of a robotic device was able to perform approximately 70 percent of an ileocecal resection, 70 percent of a right hemicolectomy, 80 percent of a sigmoid resection, and 85 percent of a anterior rectal resection without further help of a surgeon. CONCLUSIONS: A single surgeon with the assistance of a computerized robotic system can complete at least two-thirds of a laparoscopic-assisted, colorectal resection on his own. The use of a robotic device in laparoscopic-assisted, colonic surgery is safe, efficient, and feasible, and will prove even more so in future. This also will result in a patient-driven demand for high-standard, minimally invasive surgery.

Comparison of surgical stress between laparoscopic and open colonic resections.

BACKGROUND: The magnitude of surgical trauma after laparoscopic and open colonic resection was evaluated by examining postoperative serum values of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and granulocyte elastase (GE) for further evidence of the benefit realized with minimally invasive approaches in colonic surgery. METHODS: Altogether, 42 patients with Crohn's disease (n = 20) or colon carcinomas/adenomas (n = 22) were matched by age, gender, body mass index (BMI), and Crohn's Disease Activity Index for either a laparoscopic (n = 21) or an open colonic resection (n = 21). In both groups the postoperative serum levels of IL-6, IL-10, C-RP, and granulocyte elastase were determined, as indicators of surgical stress. RESULTS: Laparoscopic and open colonic resection caused a significant increase in serum IL-6, IL-10, CRP, and granulocyte elastase levels. The comparison between laparoscopic and open colonic resections, however, showed significantly lower serum IL-6, IL-10, CRP, and granulocyte elastase levels after laparoscopic colonic resection, which was most evident for IL-6 and granulocyte elastase. CONCLUSIONS: Our study demonstrated that IL-6 and granulocyte elastase may be appropriated particularly to monitor surgical stress. By using these parameters, we found a significant reduction in surgical trauma after laparoscopic surgery, was compared with the open procedure. This supports the clinical findings of a clear benefit for patients undergoing laparoscopic colonic surgery.

Laparoscopic surgery for inflammatory bowel disease.

BACKGROUND: Common laparoscopic colorectal procedures in patients with Crohn's disease include ileocolic resection and subtotal colectomy. The aim of this study was to compare and contrast the results of these two procedures. METHODS: Patients who underwent one of these procedures between June 1992 and January 1999 were identified and included in the study. Statistical analysis was performed using the Mann-Whitney test, Student's t-test, or Fisher's exact test. RESULTS: In all 109 patients (63 women and 46 men) with an average age of 36.7 years (range, 15-74) underwent ileocolic resection (ICR), while 21 patients (16 women and five men) with an average age of 36.5 years (range, 18-77) underwent subtotal colectomy (STC) (p = NS). There were 14 intraoperative complications, eight (7%) in the ICR group and six (29%) in the STC group (p = 0.01). Total operative time was 167 min (range, 90-285) in the ICR group and 231 min (range, 140-340) in the STC group (p < 0.01). Despite this difference in operating time, the hospital stays were very similar at 8.8 days (range, 3-27) and 8.8 days (range, 3-14) (p = NS). In 19 (17%) of the ICR patients and five (24%) of the STC patients, their procedure was converted to a laparotomy (p = NS). In the ICR group, 20 of the patients (18%) had surgery-related postoperative complications, including five anastomotic leaks. In the STC group, six of the patients (29%) had surgery-related complications, including two anastomotic leaks (p = NS). CONCLUSION: Although STC is a far more extensive procedure than ICR, the overall postoperative complication rate is not significantly different between the two groups; however, we found that there were more intraoperative complications associated with STC.

Loss of physiologic hepatic blood flow control ("hepatic arterial buffer response") during CO2-pneumoperitoneum in the rat.

UNLABELLED: We analyzed whether a compensatory increase of hepatic arterial (HA) flow, known as the "hepatic arterial buffer response" (HABR), may serve for maintenance of liver blood supply during laparoscopy-associated portal venous (PV) flow reduction. We assessed HA and PV flow, as well as hepatic tissue oxygenation (PO2) during CO2-pneumoperitoneum in anesthetized and mechanically ventilated Sprague-Dawley rats (n = 7). Control animals (n = 7) without pneumoperitoneum, but tourniquet-induced PV flow reduction served to demonstrate physiologic HABR. Although stepwise tourniquet-induced reduction of PV flow to 20% of baseline values led to a significant (P < 0.05) increase of HA flow from 4.3 +/- 0.7 mL/min to 9.9 +/- 1.7 mL/min, stepwise intraabdominal pressure-induced decrease of PV flow was paralleled by a linear reduction of HA flow from 2.4 +/- 0.3 mL/min to 1.2 +/- 0.5 mL/min at 18 mm Hg intraabdominal pressure. This loss of HABR was sustained during a subsequent 2 h-period of CO2-pneumoperitoneum contrasting the 2 h of maintenance of HABR in controls. Hepatic tissue PO2 decreased during the 2 h-period of pressure- and tourniquet-induced PV flow reduction by 35% to 51%, respectively. On tourniquet release, all variables regained baseline values, whereas evacuation of the pneumoperitoneum allowed all variables except hepatic PO2 to return to baseline, indicating prolonged tissue hypoxia despite restored total liver blood flow in the Laparoscopic group. Concomitantly, increased liver enzyme activities reflected moderate tissue damage after 2 h of pneumoperitoneum. In conclusion, intraabdominal CO2-insufflation-induced hemodynamic alterations may impair tissue oxygenation and enzyme release, indicating the potential risk for hepatic tissue damage after prolonged periods of laparoscopic interventions. IMPLICATIONS: We investigated the effect of CO2-pneumoperitoneum on liver blood flow, hepatic tissue oxygenation (PO2) and liver enzyme release. CO2-insufflation reduces portal venous flow without a compensatory increase of hepatic arterial flow ("hepatic arterial buffer response"), resulting in reduced hepatic PO2 and increased ratios of serum alanine aminotransferase to serum aspartate aminotransferase.

[Laparoscopy-assisted colorectal resections: morbidity, conversions, outcomes of a decade]. / Laparoskopisch assistierte kolorektale Resektionen. Morbidität, Konversionen, Komplikationen--Ergebnisse eines Jahrzehnts.

BACKGROUND: After one decade of laparoscopic resections of the colon and rectum the parameters morbidity, conversion and complications were analyzed. The analysis of the literature comprises the results of operations performed for benign and malignant indications. METHODS: The analysis is based on the medline research of the past ten years. Publications in German language not listed were added. Results of multicenter studies were included if differentiation by indication and dignity could be achieved. Surveys of different operations of the colon and rectum not differentiated by the parameters to be analyzed were excluded. Publications of the early beginning of laparoscopic surgery were included even if not more than 10 cases were presented but the parameters described in detail. RESULTS: ADENOMAS OF THE COLON: The morbidity ranges from 0-17.4%, the conversion rate is 17.4 and 18.4% in 23 respectively 38 patients. SIGMOID DIVERTICULITIS: Mortality 0-1.8%. The morbidity was 16% in the early series and was later below 10% (8.7 and 7.3%). In the beginning the conversion rate was over 10% (12.0-38.9%) with one exception (0%). It dropped below 10% (4.6-9.2%) and was 0% in a recent study of 64 patients. The reasons for conversion are: inflammatory mass, fistula; perforation and obesity. Intraoperative complications are rare. The rate of postoperative complications did not change within 10 years (9.7 to 25.0% against 7.3 to 17.0%). CROHN'S DISEASE: The morbidity is around 10% (10.6-14.0%) and is lower in series with exclusively ileocoecal resections. The conversion rate is low or zero in ileocoecal resections and raises with the degree of inflammation and the spectrum of procedures. COLON CANCER: Mortality: 0-1.9%. The morbidity ranges from 6.8 to 30% and is especially high after conversions (up to 50%). The conversion rate reflects with the range of 4.2 to 21.0% in the beginning and 1.6 to 23.5% later the experience of the individual surgeon. RECTAL CANCER: Even in large series (n = 157) the mortality of laparoscopic rectal resections is zero. The conversion rate is 0-7.6%; the morbidity 11.5 to 26.4%. REVERSAL OF HARTMANN PROCEDURE: The number of cases is low, the conversion rate is around 20%. The morbidity ranges from 14.3-41.1% with one exception (0%). RECTOPEXY: Four different techniques are applied laparoscopically. The morbidity ranges from 0 to 16%. The conversion rate is 0-2.6%, except one (16.0%). CONCLUSION: After one decade of laparoscopic colorectal surgery there are advantages for benign indications (adenomas, Crohn's disease, rectopexy) when compared with open surgery. Disadvantages arise from conversions. Experience of the surgeon is a strong parameter for a successful outcome. Results of ongoing studies are awaited for malignant indications.

Reliable noninvasive parameters for early detection of cardiopulmonary compromise induced by carbon dioxide thoracoretroperitoneum in minimally invasive thoracolumboendoscopic spine surgery.

BACKGROUND: Using a novel endoscopic retroperitoneal approach for thoracolumbar anterior spine fusion, we examined the cardiopulmonary effects of the inevitably associated carbon dioxide (CO2) thoracoretroperitoneum and evaluated noninvasive parameters, which may provide early and adequate recognition of cardiopulmonary dysfunction. METHODS: Under balanced anesthesia and paralysis, six pigs subjected to endoscopic CO2 thoracoretroperitoneal spine fusion underwent extensive pulmonary and hemodynamic online monitoring throughout the operative procedure. Open thoracophrenolumbotomy in six pigs served as a control procedure. RESULTS: In contrast to unchanged cardiopulmonary parameters during open thoracolumbar spine surgery, CO2 thoracoretroperitoneum caused significant hypercapnia, hypoxia, and acidemia with concomitant tachycardia, pulmonary hypertension, and systemic hypotension. Ventilatory adjustment, CO2 evacuation, or both promptly reversed the cardiopulmonary effects. Noninvasively assessed end-tidal CO2, peak respiratory pressure, and heart rate were early clues for detecting the tension pneumothorax-like cardiopulmonary dysfunction, as indicated by a significant correlation with the invasively assessed pulmonary hemodynamic parameters and arterial blood gases. CONCLUSIONS: During endoscopic thoracolumbar spine fusion, CO2 thoracoretroperitoneum induces cardiopulmonary dysfunction, which, however, can be detected reliably by changes in end-tidal CO2, peak respiratory pressure, and heart rate, and which can be corrected immediately by appropriate ventilatory adjustments. Therefore, endoscopic CO2 thoracoretroperitoneal spine fusion might not necessarily require extraordinarily extensive and invasive monitoring of systemic and pulmonary hemodynamics, but ventilatory adjustment and intrathoracic pressure evacuation should be readily available to reexpand the lung, and to facilitate rapid normalization of hemodynamic conditions.

Experimental development and validation of a technique for lumboendoscopic anterior fusion of lumbar spine fractures: comparison of endoscopic and open surgery in a live porcine model.

BACKGROUND: Using a porcine model, this study describes the feasibility of a lumboendoscopically guided approach to the lumbar spine for anterior interbody fusion, and compares the results with that of the open procedure. The objectives of this study were to develop a minimally invasive approach to the lumbar spine for anterior fusion in pigs, and to test the validity and safety of the procedure in this porcine model. Besides posterior stabilization, considerable number of thoracolumbar spine (Th12-L5) fractures require intervention for anterior fusion to prevent loss of height of the injured segment and kyphotic deformation. Because anterior fusion needs major surgery (thoracophrenolumbotomy for Th12-L1), which is associated with high morbidity, this study aimed to develop a less traumatic minimally invasive approach. METHODS: Six pigs under balanced anesthesia were used to study the feasibility of the lumboendoscopic approach for bisegmental fusion (iliac crest bone block and dynamic compression plate) from Th15 to L6. In an additional six animals, lumboendoscopic fusion was performed at the level of diaphragm insertion (Th14-Th16), representing Th12-L1 in patients. For comparative analysis, six animals undergoing open thoracophrenolumbotomy and anterior Th14-Th16 fusion served as control subjects. RESULTS: Endoscopic anterior fusion could be successfully performed at all levels of the thoracolumbar spine without major complications. In three cases, unintended opening of the peritoneal cavity was observed, however, without the operative procedure being affected. Comparative analysis revealed a significantly longer p < 0.01 operation time (126 +/- 6.5 min) and increased femoral vein pressure (11.3 +/- 0.7 mmHg) in animals undergoing endoscopic surgery (open procedure, 76.0 +/- 11.6 min and 5.2 +/- 0.5 mmHg). However, the microvascular blood supply (perfusion) to the distal extremities, as assessed by laser Doppler flowmetry, was not affected. CONCLUSIONS: Our study demonstrates that lumboendoscopic anterior spine fusion in pigs is feasible at all levels from Th14 to L6, and can be performed in an acceptable operation time without major complications.

Diagnosis of nonpalpable testes in childhood: comparison of magnetic resonance imaging and laparoscopy in a prospective study.

In a prospective study, the accuracy of magnetic resonance imaging (MRI) and laparoscopy in the diagnosis of nonpalpable testes was evaluated. Advantages and disadvantages of the two procedures were compared. 29 boys with unilateral nonpalpable testis underwent MRI. When MRI failed to demonstrate a testis, laparoscopy with a 1.9 mm mini-laparoscope was performed. All cases were verified by operative exploration of the inguinal region. MRI demonstrated 10 inguinal and 7 abdominal testes. MRI revealed no testis in 12 boys. The false positive rate was 32%, correct negative findings were confirmed in four patients. When laparoscopy was performed, preservable testis could be demonstrated in 8 of 12 patients (1 abdominal, 7 inguinal) which otherwise were not visible on MRI. The correct positive rate was 100%. We encountered no complications with laparoscopy. In summary, laparoscopic evaluation is recommended as the preferable method in pediatric cases of nonpalpable testes.

First clinical experience with an endoscopic retroperitoneal approach for anterior fusion of lumbar spine fractures from levels T12 to L5.

BACKGROUND: Recent experience indicates that unstable spine fractures should be stabilized dorsoventrally. To avoid the high morbidity associated with the common anterior approach-i.e., thoraco-phreno-lumbotomy-we developed a technique that allows the anterior fusion of lumbar spine fractures using an endoscopic retroperitoneal (lumboscopic) approach. METHODS: Lumboscopic anterior fusion was performed a few days after the initial dorsal stabilization. The retroperitoneal space was accessed endoscopically via a suprailic incision and enlarged using a balloon spacer and CO(2) insufflation. The peritoneum and the kidney were gently pushed ventrally. Mobilization of the psoas muscle dorsally then allowed exposure of the fractured spine bodies. Via two additional trocars placed opposite the fractured level, the damaged disc and bone were removed, and anterior spondylodesis was performed with an iliac crest bone block and a titanium plate. RESULTS: The technique was applied successfully in 12 patients with fractures of L1 (n = 6), L2 (n = 4), L3 (n = 1), and L4 (n = 1) as a mono- or bisegmental fusion, requiring instrumentation from T12 to L5. No major complications (including neurological problems) were encountered. Blood loss was minimal. None of the patients required conversion to open surgery. Patients were mobilized early, starting regularly at the second postoperative day. CONCLUSIONS: Lumboscopic instrumentation of the lumbar spine is a safe, minimally invasive method for the treatment of spine fractures. The patients benefit from reduced pain, low morbidity, and excellent cosmetic results.

Granulocyte elastase and systemic cytokine response after laparoscopic-assisted and open resections in Crohn's disease.

PURPOSE: The aim of this study was to assess whether systemic proinflammatory cytokines (IL-6), anti-inflammatory cytokines (IL-4, IL-10), acute phase proteins (C-reactive protein), or granulocyte elastase are valuable indicators for determining the degree of surgical trauma after open vs. laparoscopic-assisted resections in Crohn's disease. METHOD: Eleven patients in each group (open and laparoscopic-assisted surgery) were matched for indication, surgical procedure, and Crohn's disease activity index. Serum IL-4, IL-6, and IL-10 were measured using enzyme-linked immunosorbent assay. Serum C-reactive protein was determined by immunoturbidimetric assay. Plasma granulocyte elastase was determined by immunoactivation immunoassay. Blood was sampled preoperatively, six hours after the operation, and at postoperative Days 1 to 5. RESULTS: IL-4 was not detectable in any sample analyzed. Serum IL-6 and IL-10 levels peaked postoperatively in both groups without significant differences between laparoscopic-assisted (185.6 +/-54.1 pg/ml and 112.1 +/- 19.4 pg/ml, respectively; mean +/-standard error of the mean) and open surgery (431.1 +/-240.4 pg/ml and 196.7 +/- 56.5 pg/ml, respectively). Serum C-reactive protein levels also rose postoperatively, with a peak on the second day, but showed similar values after laparoscopic-assisted (107.1 +/- 12.1 mg/l) and open (128.3 +/- 17.5 mg/l) surgery. Plasma granulocyte elastase levels peaked on the first and second postoperative day and were found elevated almost throughout the five-day observation period. Comparison between the groups revealed significantly (P < 0.02) lower values after laparoscopic-assisted (Day 1, 46.5 +/- 8.9 microg/l; Day 2, 41.9 +/- 5.9 microg/l) when compared with open surgery (Day 1, 89.7 +/- 13.8 microg/l; Day 2, 91.4 +/- 14). CONCLUSIONS: Serum IL-6 and IL-10 may not be ideal measures for evaluation of the degree of tissue trauma in laparoscopic-assisted and open resections in Crohn's disease, probably because of interference with disease-specific cytokine interactions. In contrast, granulocyte elastase has to be considered a strong marker discriminating the different severity of surgical trauma induced by laparoscopic-assisted vs. open resection in Crohn's disease.

[Rectal carcinoma. Optimizing the procedures in an emergency]. / Rektumkarzinom. Optimierung des Vorgehens in der Notfallsituation.

Emergency conditions in rectal cancer can happen pre-, intra-, and postoperatively. Preoperative emergencies are perforation and obstipation. Spontaneous intraperitoneal perforations have a mortality of 17 to 33% and a five year survival of only 7 to 10%. The site of the perforation is not identical with the the site of the tumor. Due to fecal peritonitis a defunctioning stoma and planned repeat laparotomies are indicated. Initial fecal diversion is followed by tumor resection with anastomosis when the peritonitis has subsided. Iatrogenic perforations from endoscopy or barium enema examination are rare (0.09 to 0.004%). Tumor obstruction occurs in 15% of colorectal cancers. Immediate resection with primary anastomosis is deemed to be feasible if preceded by on-table colonic lavage. Immediate resection has a lower mortality (13.6%) than two staged fecal diversion and resection (35.5%). Intraoperative emergency conditions are bleeding and tumor cell spillage. Bleeding from the presacral veins will be controlled with the hemorrhage occluder pin. Inadvertent perforation of the tumor leads to dissemination of tumor cells. In case of spillage local recurrence was seen in 39% of resections within five years. Multivisceral resection and precise preparation with respect to anatomical planes may prevent damage of the rectum. The leading postoperative emergency condition is anastomotic leak. The incidence of clinical leaks is 6%. In diffuse peritonitis the anastomosis should be taken down and planned repeat laparotomy should be performed. This concept reduces the mortality down to 18.7%.