Value of sarcopenia in the resection of colorectal liver metastases-a systematic review and meta-analysis.

Introduction: Sarcopenia is defined as a decline in muscle function as well as muscle mass. Sarcopenia itself and sarcopenic obesity, defined as sarcopenia in obese patients, have been used as surrogates for a worse prognosis in colorectal cancer. This review aims to determine if there is evidence for sarcopenia as a prognostic parameter in colorectal liver metastases (CRLM). Methods: PubMed, Embase, Cochrane Central, Web of Science, SCOPUS, and CINAHL databases were searched for articles that were selected in accordance with the PRISMA guidelines. The primary outcomes were overall survival (OS) and disease-free survival (DFS). A random effects meta-analysis was conducted. Results: After eliminating duplicates and screening abstracts (n = 111), 949 studies were screened, and 33 publications met the inclusion criteria. Of them, 15 were selected after close paper review, and 10 were incorporated into the meta-analysis, which comprised 825 patients. No significant influence of sarcopenia for OS (odds ratio (OR), 2.802 (95% confidence interval (CI), 1.094-1.11); p = 0.4) or DFS (OR, 1.203 (95% CI, 1.162-1.208); p = 0.5) was found, although a trend was defined toward sarcopenia. Sarcopenia significantly influenced postoperative complication rates (OR, 7.905 (95% CI, 1.876-3.32); p = 0.001) in two studies where data were available. Conclusion: Existing evidence on the influence of sarcopenia on postoperative OS as well as DFS in patients undergoing resection for CRLM exists. We were not able to confirm that sarcopenic patients have a significantly worse OS and DFS in our analysis, although a trend toward this hypothesis was visible. Sarcopenia seems to influence complication rates but prospective studies are needed.

Full Discretisations for Nonlinear Evolutionary Inequalities Based on Stiffly Accurate Runge-Kutta and hp-Finite Element Methods.

The convergence of full discretisations by implicit Runge-Kutta and nonconforming Galerkin methods applied to nonlinear evolutionary inequalities is studied. The scope of applications includes differential inclusions governed by a nonlinear operator that is monotone and fulfills a certain growth condition. A basic assumption on the considered class of stiffly accurate Runge-Kutta time discretisations is a stability criterion which is in particular satisfied by the Radau IIA and Lobatto IIIC methods. In order to allow nonconforming hp-finite element approximations of unilateral constraints, set convergence of convex subsets in the sense of Glowinski-Mosco-Stummel is utilised. An appropriate formulation of the fully discrete variational inequality is deduced on the basis of a characteristic example of use, a Signorini-type initial-boundary value problem. Under hypotheses close to the existence theory of nonlinear first-order evolutionary equations and inequalities involving a monotone main part, a convergence result for the piecewise constant in time interpolant is established.

Surgical conversion of abdominal aortic stent-grafts--outcome and technical considerations.

OBJECTIVE: The purpose of this study was to evaluate the outcome of patients with stented abdominal aortic aneurysms who had to undergo open aneurysm repair with partial or total stent-graft removal. METHODS: Between October 1996 and December 2003, 117 patients with abdominal aortic aneurysms underwent endovascular repair. When open surgery was necessary during the initial and same anaesthesia as stent-graft implantation, it was defined as immediate conversion. When conversion was performed during a second anaesthesia, we defined it as late (acute or elective) conversion. RESULTS: A total of 33 patients underwent conversion to open surgery. In 7 (6%) patients, immediate conversion was necessary due to stent-graft misplacement and obstruction of the renal arteries (n=4), type Ia endoleaks (n=2) and stent-graft dislocation into the aneurysm sac (n=1). During a mean follow-up period of 39.6 months (min 0.03 months, max 80.4 months), 26 (23.6%) of the remaining 110 patients underwent late conversion to open surgery for endoleak (n=12), rupture (n=6), thrombosis (n=4), graft fatigue (n=2), aorto-duodenal fistula (n=1), and recurring peripheral embolisms (n=1). The mortality of acute conversion was 38% (5 of 13). Elective conversion did not lead to any mortality. CONCLUSION: Acute conversion of stented abdominal aortic aneurysms is associated with a high mortality. Elective stent-graft explantation with open aortic reconstruction is a safe but complex procedure.

[Postalimentary hypoglycaemia in post-gastrectomy late dumping syndrome]. / Postalimentäre Hypoglykämien bei Spätdumping-Syndrom.

HISTORY AND CLINICAL FINDINGS: A 48-year-old patient had been suffering from postalimentary hypoglycemias for several months, occurring regularly 2 hours after a meal. 5 years before, repeated fundaplications as well as a selective proximal vagotomy due to reflux oesophagitis had been performed. INVESTIGATIONS: Physical examination revealed no pathological findings. The diurnal blood sugar profile with hourly capillary glucose measurement showed a physiological fasting glucose homeostasis and two-hour postprandial decrease of blood glucose down to 20 mg/dl. The oral glucose tolerance test revealed a noticeable insulin secretion with a pathologically increased insulin/glucose index. Scintigraphy demonstrated an initially delayed, then accelerated gastric emptying as a consequence of the selective proximal vagotomy. DIAGNOSIS, TREATMENT AND COURSE: A postalimentary hypoglycemia by hypersecretion of insulin in the context of a post-gastrectomy late dumping syndrome was diagnosed. A surgical pyloroplasty was not effective. In addition to the modification of eating habits, treatment with subcutaneous applied octreotide (Sandostatin), a somatostatin-analogue, was initiated. CONCLUSIONS: Postalimentary hypoglycemia can be assigned to late dumping syndrome in most cases already by ascribed history taking. The correct diagnosis can be achieved by an oral glucose tolerance test with measurement of insulin secretion and gastric emptying scintigraphy. Beside other therapeutical options the treatment with octreotide is a promising alternative with manageable side effects.

[Economic aspects of intensive care medicine--cost and reimbursement according to diagnosis related grouping]. / Okonomische Aspekte in der Intensivmedizin: Kosten und Reimbursement unter DRG-Bedingungen 2004.

We analyse relevant modifications of the new German diagnosis related reimbursement system for 2004. It is difficult to judge the consequences of financing intensive care systems by such flat rates. In our surgical ICU total treatment costs were 1 050.-euro /day and 11 530.-euro /patient. Comparison of our total costs and German federal calculation 2003 for long-term ventilation revealed that our costs resulting from a tertiary unit topped the average by 36-60 %. Already the present reimbursement was not cost rewarding. Evaluation according to the 2003 criteria resulted in profound further deterioration to a cost covering of only 49 %. The 2004 system, however, allows for better differentiation of patients and should result in improved reimbursement of long-term ventilation. Further professional analysis of the DRG system is essential for its "learning" development.

Single vessel revascularization with beating heart techniques -- minithoracotomy or sternotomy?

OBJECTIVE: The purpose of the study was to evaluate the best surgical approach in off-pump single vessel revascularization of the left anterior descending coronary artery (LAD). METHODS: In 256 patients a single left internal mammary artery (LIMA) to LAD bypass was performed with beating heart techniques through a left anterior minithoracotomy (minimally invasive direct coronary artery bypass (MIDCAB), n=129) or a full sternotomy (off-pump coronary artery bypass (OPCAB), n=127). RESULTS: In the OPCAB group, significantly more severe comorbidities (P=0.001) and redo-operations were noted (P<0.001). Conversion to sternotomy or CPB was necessary in five MIDCAB patients and one OPCAB patient. No cerebrovascular accident was seen in both groups. There was no hospital death in MIDCAB- and two deaths in OPCAB procedures (P=ns). There was a significant reduction in time of surgery (P=0.028) and coronary occlusion (P=0.009) in the OPCAB group. No differences in postoperative ventilation time, ICU stay and length of hospital stay were recorded between groups. Wound infections occurred in six MIDCAB patients (4.7%) and one OPCAB patient (0.8%). Early postoperative reoperation due to graft failure was necessary in three patients after MIDCAB and two patients after OPCAB (P=ns). Confirmed by angiography, the early graft patency rate was 96 and 98%, respectively (P=ns). CONCLUSIONS: Both beating heart techniques showed good results with low hospital mortality, low early complications and comparable angiographic results. Nevertheless, MIDCAB is a challenging technique as demonstrated by the longer times of surgery and coronary occlusion with a tendency towards a higher risk of conversion and wound infection. Thus, this technique should only be performed in selected patients with favourable coronary anatomy. Through a sternotomy approach, single vessel revascularization can be performed safely off-pump even in high-risk patients.

[Traumatic aortic rupture in ankylosing spondylitis--a fatal complication]. / Traumatische Aortenruptur bei ankylosierender Spondylitis--eine letale Komplikation.

Fractures of the spine represent a severe complication particularly in patients with ankylosing spondylitis because of high morbidity and mortality. We report on a patient with a hyperextension fracture of the lumbar spine, leading to disruption of the aorta and caval vein.

Endovascular stentgraft infection--a life-threatening complication.

The implantation of covered stents or stentgrafts has increased greatly in the last few years for the endovascular reconstruction of arterial aneurysms. We report of three patients experiencing severe septic complications after stentgraft implantation. Endovascular stentgraft infection is a serious complication with high morbidity and mortality. General antibiotic prophylaxis seems to be indicated when implanting stentgrafts.

[Primary bacterial aortitis]. / Die primär bakterielle Aortitis.

Primary bacterial aortitis represents a rare disease with a high lethality. From June 1997 to April 1999 5 patients with an abdominal aortic infection were treated by resection of the infected aorta and in-situ reconstruction or by extra-anatomic bypass. There was no treatment in one case because of the infaust prognosis. 3 patients survived, one with a paraparesis as a result of spinal ischemia. On the basis of our patients the pathogenesis, clinical symptoms with diagnosis and the therapeutic options are discussed.

Aplasia of the vena cava inferior as a cause for recurring thrombosis of the lower extremities and pelvic veins.

Congenital anomalies of the caval vein are often associated with other abnormalities such as heart defects, situs inversus or a polysplenia-asplenia-syndrome. An isolated, congenital malformation like aplasia of the inferior vena cava is a rare finding. A review of the embryology and abnormalities, diagnostics, clinical signs and treatment is given together with the histories of two patients having thrombosis of the lower extremities and pelvic veins, caused by aplasia of the inferior vena cava. After thrombotic complications caused by vena cava aplasia there is high risk of recurrence. Those patients should be anticoagulated for lifetime.

[Primary bacterial infection of an artery]. / Die primär bakteriell infizierte Arterie.

INTRODUCTION: Primary bacterial infection of an artery is difficult to diagnose, especially at the beginning of the illness. Most of the patients come for emergency treatment in the phase of rupture. METHODS: The course of illness in four patients serves as background for discussion of the problems of diagnosis and therapy. RESULTS: Bacterial infection of arteries shows a high rate of complications and, for the aorta, high mortality. CONCLUSION: If fever of uncertain origin is combined with pain of the stomach or of the back, or with a painful reddish swelling on a limb, this rare disease should be considered in the differential diagnosis.

[Posttraumatic aneurysm of the brachiocephalic trunk: a rare injury]. / Aneurysma des Truncus brachiocephalicus nach stumpfem Thoraxtrauma. Eine seltene Verletzung.

We report on a posttraumatic aneurysm of the brachiocephalic trunk, something which is rather rare. The injury was caused by blunt chest trauma following a car accident. Computed tomography could not find the brachiocephalic lesion. In patients with fractures of the upper ribs after blunt chest trauma, angiography should be done to exclude severe injuries of the aorta and brachiocephalic vessels.

Experience with a high speed biopsy gun in breast cancer diagnosis.

Pre-operative determination of histology and receptor status is important in optimizing the management of breast cancer. The purpose of our study was to evaluate the high speed biopsy gun in 109 patients with palpable breast tumours. High speed biopsies were performed using the system BIP High Speed Multi 22 with 16-gauge-needles at a speed of 30 m/s. All biopsies could be used for frozen sections and for determination of receptor status. In 81 patients (74.3%) malignant breast tumours were diagnosed, and three patients (2.8%) had highly suspicious lesions. The oestrogen receptor status was negative in 32%, progesterone receptor status negative in 41%. In one patient (0.9%) a high grade non-Hodgkin's lymphoma of B-cell-type was diagnosed. In 21.1% benign tumours were found. In one patient a malignant tumour was missed at biopsy (0.9% false-negative). It was concluded that high speed biopsy is a reliable and simple method for preoperative sampling of breast lesions.

[Epithelioid leiomyosarcoma of the stomach. Clinical experiences with a rare stomach tumor]. / Das epithelioide Leiomyosarkom des Magens. Klinische Erfahrungen mit einem seltenen Magentumor.

Gastric epithelioid leiomyosarcoma (epLMS), which generally occurs in mid- or late adult life, is a rare smooth muscle tumor of the stomach. Out of 25 soft tissue tumors of the stomach operated at the Department of Surgery, University of Graz, two epLMS were diagnosed. This paper presents the case of a 67-year-old male with an epLMS in the corpus and of a 80-year-old female with an epLMS in the fundus of the stomach. The tumors were not diagnosed by gastroscopy; they were localized by sonography and CT-scan. In both cases the tumor was completely removed surgically, using a TA 90 4.8 mm respectively a TA 55 4.8 mm stapler. Diagnosis was reached by histological and immunohistochemical examination of the tumor tissue. Surgical excision with wide tumor-free resection margins is the therapy of choice in this tumor group.

[Basic formulation of the tasks of special education in rehabilitating the physically handicapped]. / Grundlegende Aufgabenstellung der Sonderpädagogik in der Rehabilitation Körperbehinderter.

Special educational reflexion is directed at, and analyses, the ever specific situation of the child with a physical disability, in order to attain the conditions enabling subjective and intersubjective reality to be formed and stabilized. 'Dealing with the external world' means complex and differentiated perception and internalization, particularly, subjectively relevant and meaningful activity: all this describes the individual learning and achievement behaviour of the child with a physical disablement. 'Achievement' becomes a category of high subjective significance, which requires constant intersubjective recognition. Motor behaviour as an objectifyable phenomenon must be distinguished from personal motor activity, at however limited a level of constitutional and functional motor competency it may occur. Expectation of success, and the avoidance of failure, are intrinsic constituents of educational reality in dealing with a physically disabled child. As Krappmann puts it, the achievement the individual must accomplish as a condition for enabling his participation in communication processes to occur, is designated as the category of identity.

[Comparison of brain scintigraphy with 99mTc-pertechnate and 99mTc-citrate]. / Vergleichende Hirnszintigraphie mit 99mTc-Pertechnetat und 99mTc-Zitrat.

20 patients with ultimately proven cerebral lesion were studied consecutively with 99mTc-pertechnetate and 99mTc-citrate. A comparison of the brain scans showed neoplastic lesions to be visualized more clearly with 99mTc-citrate, and vascular lesions to be demonstrated better with 99mTc-pertechnetate. Comparative brain scanning utilizing 99mTc-citrate and 99mTc-pertechnetate facilitates the differentiation between acute brain infarcts and neoplastic lesions which is difficult or may be impossible by cerebral computer tomography. The reduced radiation exposure from 99mTc-citrate and its superior usefulness in the visualization of neoplastic lesions suggest its use as the primary brain scanning agent.