[Snake charmer NOTES-proctocolectomy in a male patient]. / Snake-charmer-NOTES-Proktokolektomie beim Mann.

Restricted ability of triangulation, a highly flexible intestine, as well as limited control and overview over the abdominal organs, complicated extensive abdominal interventions in the past. Thus, additional access sites were needed to allow sufficient interoperative control. The newly developed snake charmer NOTES-technique enables the reduction of accesses to the umbilicus and rectum. We report the first case of total proctocolectomy with ileoanal pouch formation in hybrid NOTES technique in a male patient.

[Signal stability as key requirement for continuous intraoperative neuromonitoring]. / Signalstabilität als Grundvoraussetzung für kontinuierliches intraoperatives Neuromonitoring.

BACKGROUND: Postoperative recurrent laryngeal nerve (RLN) palsy is a well-known and dreaded complication of thyroid surgery. Continuous intraoperative neuromonitoring (CIONM) has been developed in order to provide an effective real-time surveillance of the RLN to its full extent and to detect subtle changes in nerve conductivity. A key requirement for a reliable interpretation of CIONM is signal stability. PATIENTS AND METHODS: In a prospective randomized controlled pilot study 24 patients corresponding to 30 nerves at risk (NaR) were included to compare a newly developed, flexible, saxophone-shaped backstrap electrode for vagal stimulation (16 NaR) to a commercially available CE-marked cylindrical and rigid electrode (14 NaR). Electrode applicability, safety and signal stability were analyzed by assessment of electrode implantation times, stimulation currents, EMG amplitudes and electrode displacement rates. RESULTS: Implantation and extraction was significantly faster and easier with the saxophone-shaped backstrap electrode. Accidental electrode displacement occurred up to eight times per operation when applying the cylindrical electrode, while a total of two displacements resulted using the backstrap electrode in this study. Stimulation currents necessary for supramaximal RLN stimulation were significantly lower using the newly developed electrode. At the same time, significantly greater stable EMG amplitudes resulted using the new saxophone-shaped electrode. No RLN palsy occurred during the study. CONCLUSIONS: According to the data, only the saxophone-shaped backstrap electrode provided the signal stability required for CIONM. The closed electrode geometry with isolated contacts for nerve stimulation and defined current entry provide the prerequisites required for reliable continuous intraoperative neuromonitoring.

[Case studies of iatrogenic tracheal injury during intraoperative ventral positioning. Symptoms, diagnostics, and differential therapy]. / Iatrogene Trachealverletzung bei intraoperativer Bauchlagerung. Fallbeispiele mit Klinik, Diagnostik und Differenzialtherapie.

Two patients 16 and 21 years old developed tracheal rupture during elective surgery following trouble-free orotracheal intubation and intraoperative ventral positioning. The injuries remained undetected in both patients for more than 12 h. Diagnostic investigation after the onset of first symptoms indicated in each a tear in the posterior tracheal wall. Early operation prevented the development of serious complications in both patients. The casuistics indicate that tracheal injuries can emerge in minor elective surgery that may be carried out on an outpatient basis, and ventral positioning for surgery may represent a risk factor for their occurrence. Clinical symptoms, diagnostic procedure, findings, and therapy are discussed.

[Surgical treatment of early adenocarcinoma arising in Barrett's oesophagus]. / Barrettkarzinom--Chirurgische Therapie.

Endoscopy with biopsy, endoscopic ultrasonography and computed tomography (CT) are prerequisites for an exact preoperative staging of patients with oesophageal cancer. Diagnosing an early adenocarcinoma limited to the mucosa (pT1m), the risk of lymph node metastase is nearly zero. Therefore, consideration could be given to ablate endoscopically the metaplastic mucosa including the pT1m-area. On the other hand, an adenocarcinoma that is invading into the submucosa (pTlsm) has an 18 to 50% likelihood of associated lymphnode metastases. In these patients with a highly curable form of oesophageal cancer only oesophageal resection with systematic abdominal and mediastinal lymph node dissection represents the standard of care. This seems to be also true for more advanced tumours without or with neoadjuvant chemoradiation. Because of substantial complications and long-term side effects the need for extensive resection in patients with early tumour stage (pT1) or down staged 'early' carcinoma (yT1) is questionable. Therefore, a limited resection of distal oesophagus and proximal stomach with two-field lymphadenectomy and jejunal interposition is an attractive alternative in early Barrett's carcinoma providing a low morbidity and mortality and resulting in a more than 90% chance of cure, perhaps in successfully down staged yT1-patients as well. Therefore, the extent of oesophageal resection should be tailored to the patient and the known extent of tumour disease. Although, there is no clear evidence at present that RCTx prolongs survival in patients with potentially resectable oesophageal cancer, preoperative treatment appears to increase the chance for a curative resection. Generally, in case of a T4-tumour or distant metastasis a surgical treatment is not indicated.

[Barrett esophagus--esophageal carcinoma: surgical therapy]. / Barrett-Osophagus--Osophagus-Karzinom: Chirurgische Therapie.

Barrett's oesophagus is an acquired condition that occurs as a consequence of gastrooesophageal reflux. Continuous exposure of the Barrett's epithelium to gastric juice may lead from a low-grade to a high-grade dysplasia and subsequently to an invasive adenocarcinoma. Therefore, the first goal of treatment for patients with Barrett's oesophagus is the prevention of reflux to eliminate the risk of a progression to dyplasia and cancer. In contrast to medical treatment antireflux surgery restores the low oesophageal sphincter, abolishes reflux of gastric contents into the oesophagus and ends the repetitive injury to both the metaplastic and normal oesophageal mucosa. In case of Barrett's carcinoma of the distal oesophagus a radical transhiatal oesophagectomy with systematic abdominal and mediastinal lymph node dissection is the procedure of choice. After forming a gastric tube the reconstruction is done by a transposition of stomach through the posterior mediastinum and a cervical anastomosis. Because of substantial complications and long-term side effects the need for extensive resection in patients with early tumour stage (pT1) is questionable. Therefore, a limited resection of distal oesophagus and proximal stomach with two-field lymphadenectomy and jejunal interposition is an attractive alternative in early Barrett's carcinoma providing a low morbidity and mortality and resulting in a 90% chance of cure in patients without lymph node metastasis.

In vitro interaction of codeine and diclofenac.

There is very limited knowledge about possible pharmacokinetic interactions between opioid analgesics and nonsteroidal antiinflammatory drugs (NSAIDs), which are commonly used in combination for the treatment of chronic pain. The major metabolic pathway of the weak opioid codeine is glucuronidation to codeine-6-glucuronide. Therefore we investigated the influence of the NSAID diclofenac on the formation of codeine-6-glucuronide in vitro, using human liver tissue homogenate. The formation of codeine-6-glucuronide exhibited single enzyme Michaelis-Menten kinetics with an average V(max) of 93.6 +/- 35.3 pmol/mg/min. A noncompetitive inhibition of codeine-6-glucuronidation by diclofenac was observed with an average K(i) of 7.9 microM. These in vitro findings suggest that a pharmacokinetic interaction occurs in vivo, which has to be confirmed by an interaction study in human subjects. It can be speculated that in case of inhibition of glucuronidation, the amount of codeine available for other pathways especially O-demethylation to morphine is increased, resulting in higher morphine serum levels and therefore higher analgesic efficacy.

Psychotropic drug use, falls and hip fracture in the elderly.

The use of benzodiazepines (BZD) or other psychotropic agents is an established risk factor for falls and hip fractures. The evidence supporting this association has been based solely on history and/or prescription data. In a case-control study we monitored the intake of BZD, tricyclic antidepressants (TCA) and barbiturates in patients with hip fracture by serum analysis, and compared this measurement with drug history and prescription records. The serum was BZD positive in 41% of 82 community-dwelling patients; an equivalent by history and/or prescription records, however, was detected in only 18% (p < 0.0001). In contrast, in 82 age- and gender-matched community-dwelling control patients, there was only a minor discrepancy (3%) in BZD use between anamnestic (N = 19) and analytical (N = 21) data. In 23 patients admitted from nursing homes, a similar trend was visible (39% serum positive for BZD vs 26% by drug history). Barbiturate use (N = 2) could be neglected, and TCA intake was minor (N = 7); in each case both assessments were in accordance. In conclusion, in patients with hip fracture, BZD use is substantially more frequent than reported and previously assumed, pointing to an underestimated risk factor for this injury.

[Luxatio antebrachii ulnaris: a very rare form of elbow dislocation]. / Luxatio antebrachii ulnaris. Eine sehr seltene Form der Ellenbogenluxation.

We report about a 61 years old patient, who suffered a rare ulnar dislocation of the elbow after being arrested by the police.

[Angiodysplasia of the colon as the etiology of severe, chronic recurrent intestinal hemorrhage. Idiopathic thrombocytopenia hinders early diagnosis and therapy]. / Angiodysplasie des Kolons als Ursache einer schweren, chronisch rezidivierenden Intestinalblutung. Idiopathische Thrombozytopenie verhindert rechtzeitige Diagnose und Therapie.

MEDICAL HISTORY: In 1992 a 54-year-old female patient was admitted to hospital for a severe episode of intestinal bleeding. Her medical history dated back till 1958, when an increased hemorrhagic tendency due to a thrombocytopenia was first diagnosed at the age of 20. Despite several hospital admissions and intense diagnostics, an etiological cause of the thrombocytopenia could not be found. Finally, a combination of thrombocytopenia and pathological thrombocytes had to be assumed. Because of recurrent intestinal bleedings requiring more than 250 blood transfusions and almost 100 platelet transfusions a wide spectrum of diagnostics was performed. After the cause seemed to have been found in the large bowel system during another bleeding episode, the patient was transferred to our hospital for operation. DIAGNOSTICS: In clinical examination, except of pathological blood in her stool, nothing abnormal could be detected. The patient's hemoglobin on admission was 8.3 mg/dl. The thrombocytes ranged from 9,000 to 25,000/microliter. An ultrasound examination revealed multiple gallbladder stones. The cause of the bleeding in the right colon could finally be assured by blood scintiscanning. THERAPY: As the bleeding was localized in the right colon, a right hemicolectomy as well as a cholecystectomy were performed. After a normal postoperative course the patient could be discharged from hospital after 12 days. Without another occurrence of an intestinal bleeding the thrombocytes ranged between 50,000 and 100,000/microliter during the following 6 years. In 1998 2 further intestinal hemorrhagic episodes with severe thrombocytopenia occurred without successful localization of the bleeding due to its spontaneous cessation. CONCLUSION: The combination of thrombocytopenia and recurrent angioblastic bleeding of the colon has not yet been described. A more sophisticated search for the cause of the bleeding was thus hindered, as the thrombocytopenia was misinterpreted to be more the reason for than the result of the recurrent bleeding episodes.

[The abdominal emergency after heart surgery interventions]. / Der abdominelle Notfall nach kardiochirurgischen Eingriffen.

In 4726 patients undergoing cardiopulmonary bypass surgery in a 5-year period 15 major acute abdominal complications (0.3%) occurred, with an overall mortality rate of 47%--compared with a mortality rate of 3.2% for all patients undergoing heart surgery (p < 0.0001). Patients with combined cardiac operation (ACB and valve replacement) or those requiring an intraaortic balloon pump were more likely to develop abdominal complications; however, complications can not be predicted. The focus should be on early diagnosis and therapy, especially in acute mesenteric ischemia, in close cooperation between heart and general surgeons to improve prognosis.

Which peptic ulcers bleed? Results of a case-control study. DUSUK Study Group.

BACKGROUND: The incidence of ulcer bleeding has not decrease despite effective medical treatment of peptic ulcer disease. Numerous studies have been performed on risk factors for ulcer bleeding, but only a few studies have related the risk of developing ulcer bleeding to the risk of developing uncomplicated ulcer disease. METHODS: This study was performed as a multicenter interdisciplinary case-control study and was based on diagnosis by endoscopy, prospective data collection, and multivariate analysis. To every study patient with ulcer bleeding (case) one patient with uncomplicated peptic ulcer proven at endoscopy (control) was assigned with regard to sex, ulcer localization, and age (+/-5 years). The controls were randomly taken from three sources: inpatients, outpatients, and patients treated by a private physician. RESULTS: Owing to strict inclusion and exclusion criteria, 209 matched pairs were available for evaluation out of 401 patients with peptic ulcer bleeding. In univariate analysis the duration of ulcer pain and the number of previous ulcer treatments proved to be protective factors for ulcer bleeding. The intake of non-steroidal anti-inflammatory drugs (NSAID) as a whole, acetylsalicylic acid (aspirin), and paracetamol gave an increased risk for ulcer bleeding. Multivariate analysis identified four risk factors for peptic ulcer bleeding: lung disease, NSAID intake, no pretreatment with H2 blockers, and acetylsalicylic acid intake. CONCLUSIONS: The following patient groups represent a risk for peptic ulcer bleeding: multimorbid patients, receiving NSAID and/or aspirin, and patients with no previous ulcer history.

[Surgical hemostasis in recurrent peptic ulcer hemorrhage after endoscopic hemostasis--indications and results]. / Operative Blutstillung bei Rezidivblutung nach endoskopischer Blutstillung--Indikation und Ergebnisse.

The identification of prognostic factors in patients with bleeding peptic ulcer is an important step for improving the outcome. Besides of age, concomitant diseases and bleeding activity, recurrent bleeding is the principal determinant of mortality in peptic ulcer bleeding. Obviously, there is still a considerable proportion of patients who cannot be successfully managed by endoscopic treatment alone. Therefore the identification of high-risk patients before rebleeding, an adequate early surgical intervention during a stable period after endoscopic haemostasis can prevent recurrent haemorrhage. Emergency endoscopy and, possibly, Doppler ultrasound provide prognostic relevant information allowing 'prospective' therapeutic decisions. By using this strategy in a clinical trial (291 patients) the overall mortality rate could be reduced markedly from 14% (139 patients) to 5% (152 patients). The results were mainly reproducible under clinical routine circumstances.

[Organic hyperinsulinism in advanced age]. / Organischer Hyperinsulinismus im hohen Alter.

Case report of a 87 years old women with symptomatic organic hyperinsulinism for 30 years. After description of the clinical course following resection of the left pancreas, diagnostic and therapeutic procedures are discussed.

[Acute ulcer hemorrhage: when to operate--when to wait?]. / Die akute Ulkusblutung: wann operieren--wann zuwarten?

The identification of prognostic factors in patients with bleeding peptic ulcer is an essential step for improving the outcome. Since recurrence of bleeding is associated with increased mortality, we therefore developed a new treatment policy based on prognostic information identified at emergency endoscopy. Patients with actively bleeding lesions or visible vessel and high risk of recurrent bleeding were operated upon within 6 h (duodenal ulcer) or 24 h (gastric ulcer) even after successful endoscopic control of bleeding. All other patients with oozing type of bleeding or with signs of recent bleeding during emergency endoscopy were primarily treated in a conservative manner. By using this strategy in a prospective trial the overall mortality rate could be markedly reduced from 14 to 5%.

Acute cholecystitis: a complication in severely injured intensive care patients.

Acute cholecystitis is an often unrecognized and potentially life-threatening complication seen among ICU patients with multiple injury. To investigate the epidemiology of this entity and to evaluate significant etiologic precursors, a prospective clinical and sonographic study was performed in 45 consecutive patients (mean age, 29 years) treated for multiple trauma (mean ISS, 27) in the ICU. Eight of 45 patients developed a cholecystitis during intensive care treatment (18%). Six patients recovered with conservative therapy; in two instances a cholecystectomy was necessary. There was no mortality as a result of cholecystitis. A significant relationship between the severity of the initial trauma (p less than 0.05), the number of blood transfusions (p less than 0.01), and the incidence of acute cholecystitis was found. Other factors such as prolonged shock, respiratory failure, or parenteral alimentation were less prevalent and were not temporally related to the onset of the disease. All patients had large amounts of narcotics administered over a prolonged period, so that narcotic-induced biliary stasis appeared to be another eminent factor involved in the genesis of posttraumatic cholecystitis. Our results lead to the conclusion that acute cholecystitis occurs with an unexpectedly high incidence and that a high remission rate can be expected following conservative treatment provided that appropriate serial ultrasound examinations are performed.

Can the use of an endoscopic Congo red test decrease the incidence of incomplete proximal gastric vagotomy?

The endoscopic Congo red test allows accurate and rapid evaluation of the completeness of vagotomy and may result in a lower incidence of postoperative incomplete vagotomy. This report describes 44 patients tested during proximal gastric vagotomy. Evidence of incomplete vagotomy was found in over 95% at the conclusion of the conventional operation. Importantly, the test was a guide to further operative maneuvers which abolished the evidence of incomplete vagotomy upon subsequent testing. The endoscopic Congo red test satisfies the requirements for an ideal test for complete vagotomy: it is easily performed, does not require special equipment, and can be repeated several times if necessary to verify that desired effects have been achieved. The wider use of this test, therefore, appears justified.