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Metastatic calcinosis is a common feature of chronic renal failure. Its first manifestations are bone demineralization and non-visceral and/or visceral calcification with mostly mural deposits in arteries and arterioles. It is initially characterized by hyperphosphataemia followed by secondary or tertiary hyperparathyroidism. Cutaneous involvement is a rare complication. Histologically, the lesions show vascular calcification with ischaemic skin necrosis. Extreme cases may produce calcinosis cutis (calciphylaxis), i.e. disseminated calcification of the subcutaneous tissue and dermis in the form of hard painful cutaneous nodules and plaques with subsequent ulceration. Metastatic calcinosis is a disease affecting adults, while the dystrophic or idiopathic type can develop in children. We present the case of a 6-year-old boy with end-stage renal disease, attributed to congenital renal hypoplasia, and accompanied by secondary hyperparathyroidism. He developed fulminant tertiary hyperparathyroidism and metastatic calcinosis of the lungs, as well as cutaneous necrosis of the buttocks and legs, subsequent to calcification of arteries and arterioles. A maternal renal transplant failed to function. The serum parathormone, calcium and phosphate levels could not be controlled by maintenance dialysis, phosphate binders and calcitriol. Total parathyroidectomy without autotransplantation of parathyroid tissue rapidly returned the serum parathormone, calcium and phosphate levels to normal. In addition, topical treatment using merbromine solution and hydrocolloid dressings, healed the ulcers with significant scar formation, within 2.5 months after parathyroidectomy. A renewed increase of the calcium × phosphate product, 2 months after Parathyroidectomy, was attributed to mobilization of calcium compounds from the viscera, as confirmed by a chest X-ray. [ABSTRACT FROM AUTHOR]

Newly hired nurses often complete orientation to the acute care setting with multiple preceptors, and communication about orientation progress has the potential to be disjointed. Traditionally, orientation has been tracked using various formats relying on pen and paper. The Daily Orientation Tracker or DOT, created by preceptors and nurse educators, has pushed communication into an accessible, user-friendly format found to be successful for the orientation of new nurses. Information about how the DOT was developed and implemented as well as data describing the empirical success of the DOT are shared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This NEUROmonitoring System (NEUROS) trial assessed whether pelvic intraoperative neuromonitoring (pIONM) could improve urogenital and ano-(neo-)rectal functional outcomes in patients who underwent total mesorectal excisions (TMEs) for rectal cancer., Background: High-level evidence from clinical trials is required to clarify the benefits of pIONM., Methods: NEUROS was a 2-arm, randomized, controlled, multicenter clinical trial that included 189 patients with rectal cancer who underwent TMEs at 8 centers, from February 2013 to January 2017. TMEs were performed with pIONM (n=90) or without it (control, n=99). The groups were stratified according to neoadjuvant chemoradiotherapy and sex, with blocks of variable length. Data were analyzed according to a modified intention-to-treat protocol. The primary endpoint was a urinary function at 12 months after surgery, assessed with the International Prostate Symptom Score, a patient-reported outcome measure. Deterioration was defined as an increase of at least 5 points from the preoperative score. Secondary endpoints were sexual and anorectal functional outcomes, safety, and TME quality., Results: The intention-to-treat analysis included 171 patients. Marked urinary deterioration occurred in 22/171 (13%) patients, with significantly different incidence between groups (pIONM: n=6/82, 8%; control: n=16/89, 19%; 95% confidence interval, 12.4-94.4; P =0.0382). pIONM was associated with better sexual and ano-(neo)rectal function. At least 1 serious adverse event occurred in 36/88 (41%) in the pIONM group and 53/99 (54%) in the control group, none associated with the study treatment. The groups had similar TME quality, surgery times, intraoperative complication incidence, and postoperative mortality., Conclusion: pIONM is safe and has the potential to improve functional outcomes in rectal cancer patients undergoing TME., Competing Interests: W.K., D.W.K., and H.L. are involved in patents, as part of the university service inventions for pIONM (DE 10 2010 019 796 B4; EP 2589410 B1). The remaining authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Postoperative hypoparathyroidism remains the most often complication in thyroid surgery. Near-infrared autofluorescence (NIR-AF) is a modality to identify parathyroid glands (PG) in vivo with high accuracy, but its use in daily routine surgery is unclear so far. In this randomized controlled trial, we evaluate the ability of NIR-AF to prevent postoperative hypoparathyroidism following total thyroidectomy., Methods: Patients undergoing total thyroidectomy were allocated in two groups with the use of NIR-AF in the intervention group or according to standard practice in the control group. The aim was to identify the PGs in an early most stage of the operation to prevent their devascularization or removal. Parathyroid hormone was measured pre- and postoperatively and on postoperative day (POD) 1. Serum calcium was measured on POD 1 and 2. Possible symptoms and calcium/calcitriol supplement were recorded., Results: A total of 60 patients were randomized, of whom 30 underwent NIR-AF-based PG identification. Hypoparathyroidism at skin closure occurred in 7 out of 30 patients using NIR-AF, respectively, in 14 out of 30 patients in the control group (p=0.058). There was no significant difference in serum calcium and parathyroid hormone levels between both groups. Likewise, NIR-AF could not detect PGs at a higher rate., Conclusion: The use of NIR-AF may help surgeons identify and preserve PGs but did not significantly reduce the incidence of postoperative hypoparathyroidism in this trial. Larger case series have to clarify whether there is a benefit in routine thyroidectomy., Trial Registration Number: DRKS00009242 (German Clinical Trial Register). Registration date: 03.09.2015., (© 2022. The Author(s).)

Purpose: The augmentation of hiatoplasty (HP) with the ligamentum teres hepatis (LTA) is a new concept for intrathoracic migration of a gastric sleeve or pouch (ITGM). We retrospectively analyzed all cases of hiatal hernia repair in a single center between 2015 and 2019., Methods: A total of 171 patients underwent 307 hiatal hernia repairs after sleeve gastrectomy (SG) (n = 79), Roux-en-Y gastric bypass (RYGB) (n = 129), and one anastomosis gastric bypass (OAGB) (n = 99). Each hiatal hernia repair was defined as a "case" and assigned to the LTA group or the non-LTA group. The primary outcome was the recurrence of ITGM as detected by endoscopy or CT., Results: The basic characteristics in the LTA group (78 cases) and the non-LTA group (229 cases) were comparable with the exception of the rate of revisional HP (72% vs. 21%), the rate of prior conversion to RYGB (33% vs. 17%), the initial BMI (45.9 ± 8.2 kg/m 2 vs. 49.0 ± 8.8 kg/m 2 ), and the follow-up (7 months (1-16) vs. 8 months (1-54)). The ITGM recurrence rate was 15% in the LTA group and 72% in non-LTA group (p < 0.001). Multivariate analysis showed that the length of ITGM and the type of surgical repair were independent risk factors. The addition of LTA to HP lowered the probability of ITGM recurrence by a factor of 0.35 (p = 0.015), but the conversion from SG or OAGB to RYGB did not reduce the risk., Conclusions: LTA reduces the risk of early ITGM recurrence. The long-term durability, however, needs to be further investigated.

Purpose: The standard of surgical correction of post-bariatric intrathoracic gastric migration (ITGM) is hiatal hernia repair, but little is known about its efficacy in patients with one anastomosis gastric bypass (OAGB). We present our experience., Methods: This retrospective cohort study includes all patients with OAGB who had undergone hiatal hernia repair from 2014 to 2019. The primary outcome was recurrence of ITGM as diagnosed by computed tomography and gastroscopy., Results: A total of 63 patients underwent hiatal hernia repair 2-54 months (median 13) after primary OAGB (40 patients) or concurrent with revisional OAGB after prior sleeve gastrectomy (23 patients). ITGM recurred in 48% of patients with hiatal repair after primary OAGB and in 91% of patients with concomitant hiatal repair. Recurrences were diagnosed after a median interval of 9 and 8.5 months, respectively. Thirty-six patients (57% of total number) required a revision, and a re-recurrence of ITGM was detected in 15 patients. The Cox regression analysis of all hiatal repairs showed that two variables significantly influenced the likelihood of ITGM recurrence: the length of the migrated pouch (hazard ratio 1.32; p = 0.016) and the type of repair. Combining hiatoplasty with ligamentum teres augmentation (LTA) and conversion to Roux-en-Y gastric bypass (RYGB) lowered the probability of ITGM recurrence (compared with stand-alone hiatoplasty; hazard ratio 0.21, p = 0.029)., Conclusion: The outcome of hiatal repair in patients with OAGB is unsatisfactory. Stand-alone hiatoplasty is particularly ineffective. The combination of hiatoplasty with LTA and conversion to RYGB improves the early results, but the long-term durability needs to be tested.

The search for an operation that effectively prevents and treats intrathoracic gastric migration (ITGM) after bariatric surgery has revived a long-forgotten technique: ligamentum teres cardiopexy (LTC) by which a vascularized flap of the teres ligament is wrapped around the distal esophagus. The systematic search of publications in the English language revealed 4 studies (total number of patients 53) in the non-bariatric literature with an unsatisfactory resolution of GERD. There were 5 reports from the bariatric literature with small patient numbers (total 64) and a short follow-up (6-36 months). There were no objective signs of gastric remigration in 93% of investigated patients. Acknowledging the limitations of these preliminary reports, bariatric surgeons are encouraged to further investigate the potentials of LTC in their patients.

Background: Candy cane syndrome (CCS), which is also called Roux syndrome, is a rarely reported and neglected complication of proximal Roux-en-Y gastric bypass (RYGB) surgery., Methods: Forty-seven cases of CCS that underwent candy cane (CC) resection were analyzed retrospectively for pain remission to determine whether intussusception is a possible underlying mechanism., Results: Forty-three patients (89.6%) benefited from laparoscopic CC resection (p < 0.001). The highly sensitive diagnostic tests were upper gastrointestinal series (91%) and gastroscopy (96%). Intussusception of the CC into the gastric pouch was demonstrated in most cases and was postulated as the trigger for CCS. In some cases, retroperistaltic intussusception led to nonspecific upper gastrointestinal bleeding., Conclusion: A vast majority of CCS cases benefited significantly from CC resection. The long-described retroperistaltic intussusception of the CC was suggested as an important underlying mechanism of the symptoms. Although CC resection remains a stopgap, evidence on its clinical significance has been shown for a century. Building on this wealth of experience and the already vast storage of practical knowledge, awareness of this underestimated complication after RYGB should be raised.

Background: C-reactive protein (CRP) rise might be different in patients with obesity due to chronic inflammation., Objectives: The aim was to analyze postoperative CRP rise and its role as an early prognostic marker of infectious complications., Setting: Center of maximum care in Germany., Methods: Patients who underwent laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, or laparoscopic one-anastomosis gastric bypass as primary treatment for severe obesity were included. Serum CRP and leukocyte count were measured preoperatively, on postoperative days (POD) 1 and 4 and were analyzed regarding sex, body mass index, waist circumference, obesity-associated diseases, laboratory measurements (glycosylated hemoglobin, triglycerides, cholesterol), surgical procedure, infectious complications, and infectious with anastomotic leakage., Results: Four hundred seventy-one patients underwent surgery. Postoperative CRP rise was similar across sexes but lower in the super-super obese group (P < .05) and higher in the gastric bypass groups (P < .05). Linear regression model showed, that the higher preoperative value of waist circumference, the higher the preoperative CRP (beta value: .159, P = .006) and the lower the postoperative CRP rise on POD1 (beta value: -.171, P = .004) and 4 (beta value: -.170, P = .003). Only in the laparoscopic one-anastomosis gastric bypass group did a higher glycosylated hemoglobin predict a higher postoperative CRP rise (POD1: beta value: .434, P = .012; POD4: beta value: .513, P = .006). Fourteen patients (3%) developed infections, 7 of whom (1.5%) had anastomotic leakage. Leukocyte count was no predictor of infectious complications. The cut-off for CRP was 80.5 mg/L (POD1) and 164 mg/L (POD4), with 57.1% and 85.7% sensitivity and 97.9% and 99.6% specificity for anastomotic leakage., Conclusion: Standard postoperative CRP rises less in patients with higher waist circumference and super-super obesity, but more after gastric bypass procedures. CRP but not leukocyte count predicts early anastomotic healing after obesity surgery. These findings should be considered when interpreting CRP values in the routine clinical setting., Competing Interests: Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

One Anastomosis Gastric Bypass (OAGB) is a bariatric technique that combines a long tube-like gastric conduit with a wide end-to-side gastro-jejunostomy. It is a non-complex operation with a low frequency of intestinal obstructions and an excellent long-term weight loss, however, there is a fear of esophagogastric cancer. This narrative review explores the risk of cancer development after OAGB. Five gastric cancers were published after loop gastric bypass (an early version of OAGB, n=4) and after modern OAGB (n=1), four of which occurred in the remnant stomach and one in the gastric stump. Jejuno-gastric reflux is normal after OAGB, but there is little or no evidence to suggest bile-induced malignant degeneration in the stomach. On the contrary, gastro-esophageal reflux is a clear cause of metaplasia and AEG, although gastro-esophageal reflux is rare after OAGB with only two cases of AEG in the literature. Postoperative gastroscopic surveillance should be considered in patients with gastro-esophageal reflux and/or hiatal hernia. When reflux becomes symptomatic, diversion of the OAGB into a Roux-en-Y construction should be recommended., (Celsius.)

Intraoperative verification of parathyroid glands relies on visual identification by the surgeon and, with some time delay, on serum parathormon measurements and frozen section. Fluorescence imaging, however, is an instant on-table method for direct visualization of parathyroid tissue which is known to exhibit increased autofluorescence intensity when exposed to near-infrared light. In this retrospective observational study, we evaluate the clinical use of this method in a series of patients with primary and secondary hyperparathyroidism. A total of 66 adenomatous and hyperplastic parathyroid glands were examined with intraoperative autofluorescence in 39 patients with primary and secondary hyperparathyroidism using a near-infrared system (KARL STORZ GmbH & Co. KG). The specimens were verified by conventional histology. Fifty-seven of 66 histologically proven adenomatous/hyperplastic glands exhibited autofluorescence. The sensitivity of near-infrared autofluorescence was 0.9 in pHPT and 0.83 in sHPT, respectively. The positive predictive value was 0.93 in pHPT and 1.0 in sHPT, respectively. Near-infrared autofluorescence guidance presents an innovative instant surgical imaging tool with sensitivity in detecting adenomatous and hyperplastic parathyroid glands comparable to current intraoperative methods. Due to its elegant and tracer-free design combined with low follow-up costs, this method can be useful for routine use.

Objectives: The aim of this study was to determine the efficacy of coaching on outcome in low volume centers of excellence and to evaluate the influence of mentorship programs on the center development., Background: The number of bariatric procedures has increased steadily in the last years. Providing nationwide bariatric care on a high professional level needs structures to train and guide upcoming centers and ensure high quality in patient care., Methods: A prospective multicentered, observational study including laparoscopic sleeve gastrectomies (SG) and Roux-en-Y gastric bypass (RYGB) procedures was performed. Twelve emerging bariatric centers were coached by five experienced bariatric centers. Surgeons of the mentor centers gave guidance on pre- and postsurgical management of their patients including complications and proctored the first interventions. The results were compared regarding operative outcomes, percentage of excess weight loss, complications, and resolution of comorbidities., Results: A total of 214 of 293 patients (73.0%) completed the study. The most frequently reported complications were wound infection (4.4%), disorder of emptying stomach/new reflux (2.4%), anastomotic leaks, intra-abdominal secondary hemorrhage, and dumping syndrome (2.0% each). The mortality rate was zero. We found no difference in overall complication rates or resolution of obesity-related comorbidities when comparing experienced surgeons with less experienced surgeons., Conclusions: Our results suggest that under the conditions of the practices of this study, coaching and mentoring were associated with comparable outcomes both in experienced and emerging centers. In addition, mentorship programs ensure equal outcome quality in terms of improvement of obesity-associated comorbidities., Trial Registration: NCT Number: NCT01754194 .

Background: Complete mesocolic excision is gradually becoming an established oncologic surgical principle for right hemicolectomy. However, the procedure is technically demanding and carries the risk of serious complications, especially when performed laparoscopically. A standardized procedure that minimizes technical hazards and facilitates teaching is, therefore, highly desirable., Methods: An expert group of surgeons and one anatomist met three times. The initial aim was to achieve consensus about the surgical anatomy before agreeing on a sequence for dissection in laparoscopic CME. This proposal was evaluated and discussed in an anatomy workshop using post-mortem body donors along with videos of process-informed procedures, leading to a definite consensus., Results: In order to provide a clear picture of the surgical anatomy, the "open book" model was developed, consisting of symbolic pages representing the corresponding dissection planes (retroperitoneal, ileocolic, transverse mesocolic, and mesogastric), vascular relations, and radicality criteria. The description of the procedure is based on eight preparative milestones, which all serve as critical views of safety. The chosen sequence of the milestones was designed to maximize control during central vascular dissection. Failure to reach any of the critical views should alert the surgeon to a possible incorrect dissection and to consider converting to an open procedure., Conclusion: Combining the open-book anatomical model with a clearly structured dissection sequence, using critical views as safety checkpoints, may provide a safe and efficient platform for teaching laparoscopic right hemicolectomy with CME.

Background: Bariatric surgery is gastrointestinal surgery for weight control, and metabolic surgery refers to the use of surgery to primarily and purposely treat type 2 diabetes mellitus (T2DM)/metabolic syndrome mellitus., Methods: The most recent literature was reviewed for surgery and T2DM in a non-systematic fashion., Results: Roux-Y gastric bypass, biliopancreatic diversion with duodenal switch, and sleeve gastrectomy (SG) are the dominant procedures today. SG is emerging as the most popular operation worldwide. Laparoscopy has made metabolic surgery as safe as other common abdominal procedures. A BMI > 60 kg/m 2 , however, exposes a significantly higher perioperative risk. Most patients experience a sustained improvement of glycemic control with subsequent reduction of cardiovascular events. The remission rates depend on the severity and duration of diabetes. Prevention of long-term nutritional deficits and monitoring of metabolism require lifelong medical surveillance of the patients., Conclusions: The profound impact of weight reduction surgery on glucose metabolism explains the growing interest in treating T2DM by surgical means. Metabolic surgery is a safe option for carefully selected patients with metabolic syndrome.

Background: After low anterior resection for rectal cancer, creation of a diverting stoma is recommended. Data on the impact of a diverting stoma on quality of life are conflicting. Optimal timing of stoma closure in the setting of adjuvant chemotherapy is unclear., Objective: The purpose of this study was to investigate the impact of a diverting stoma on quality of life in patients undergoing rectal cancer resection before and after stoma closure. Furthermore, the study was conducted to look at the timing of stoma reversal and the potential influence of factors such as adjuvant chemotherapy., Design: This was a longitudinal, observational, multicenter study., Settings: The study was conducted at 17 German colorectal centers., Patients: Patients with rectal cancer who planned for elective curative surgery with creation of temporary diverting stoma were included., Main Outcome Measures: This longitudinal observational study assessed quality of life at 3 occasions using European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core Questionnaire/Colorectal Cancer Module before cancer resection, before stoma closure, and 6 months after stoma closure. Furthermore, the timing of stoma closure and continence were evaluated., Results: A total of 120 patients (64% men; mean age, 63.2 ± 11.5 years) were analyzed. Longitudinal global quality of life was not influenced by the presence of a stoma. Several functional and GI symptom scales were markedly impaired after stoma creation. Physical, role functioning, and sexual interest recovered after stoma closure. Social functioning stayed impaired (p < 0.0001). Median time to stoma closure was 5 months (range, 17 days to 18 months). A total of 3.4% of patients had very early stoma closure (within 30 days). Adjuvant chemotherapy delayed stoma closure (median, 5.6 vs 3.4 months without chemotherapy; p = 0.0001)., Limitations: The study was limited by its missing quality-of-life data for sexual function., Conclusions: The presence of a stoma had a negative impact on social functioning and GI symptoms. However, this had no clinically relevant influence on global quality of life. Time to stoma closure was nearly doubled when patients underwent adjuvant chemotherapy.

Background: Peristomal skin lesions are frequent complications of ostomy; however, there is no generally accepted nomenclature and classification system., Objective: An interdisciplinary German expert panel (GESS) composed of ten members, developed an innovative semiquantitative classification system for peristomal skin lesions for further stratification of ostomy therapy. This score is based on criteria which can be assessed by stomal therapists and treating physicians., Results: The new peristomal skin lesion score grades three categories: lesion (L), status of ostomy (S) and disease (D). The L category describes the integrity of the skin as normal (L0), lesion with sustained integrity of skin (L1), integrity destroyed (L2) and local infection (L3). The S category rates the complexity of ostomy therapy as normal (S0), increased (S1) and high but not sufficiently effective (S2). The additional letters for categorization O. R. P. H. E. US describe anatomical pathologies of the stoma itself: ostomy stenosis (O), retraction (R), prolapse (P), hernia (H), edema (E) and unfavorable site (US). A systemic disorder is either absent (D0), irrelevant (D1) or relevant (D2). The LSD score is the basis for a management algorithm., Conclusion: The LSD score is comprehensive, standardized and holistic. Its straightforward use by health professionals can improve the consistency of the description of skin lesions and enhance the quality of ostomy therapy.

Minimally invasive surgery (MIS) is fundamentally different from open surgery regarding positioning of the patient, access routes and instrumentation. Each of these aspects is associated with its own specific morbidity, such as positioning-related complications, trocar-induced lesions, hypercapnia-associated phenomena and thermal damage. The growing experience of surgeons and technological progress have increased patient safety to a maximum and have resulted in an impressive spread of MIS in the various fields of surgery including the most common, such as cholecystectomy and hernia repair and special fields, such as bariatric, thoracic and oncological surgery. This narrative review summarizes the current knowledge on the inherent complications of MIS.

Introduction: The increasing number of morbidly obese patients leads to a rising number of bariatric procedures in Germany. The operative techniques are highly standardized but such a standardization is lacking for the management of postoperative complications such as stenosis and ulceration after Roux-en-Y gastric bypass (RYGB) surgery and sleeve gastrectomy (SG)., Methods: The current literature is reviewed and a complication management is developed and presented in this article., Results and Conclusion: Postoperative stenoses occure with a frequency of 0.1-3.9% after SG and 3-27% after RYGB. Stenosis is secondary to inadequate surgical technique or microinsufficiency. Ulcers can be due to reaction to foreign body, local ischemia, peptic lesion, fistula and microinsufficiency., Conclusion: Endoscopic interventions are successful in most cases for stenosis after RYGB and for short stenoses after SG. After SG long stenoses require redo surgery and conversion to RYGB. Ulcers can be managed by medication with the exception of perforation and hemorrhage, which require emergency laparoscopy.

Background: Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) rank among the most frequently applied bariatric procedures worldwide due to their positive risk/benefit correlation. A systematic review revealed a similar excess weight loss (EWL) 2 years postoperatively between SG and RYGB. However, there is a lack of randomized controlled multi-centre trials comparing SG and RYGB, not only concerning EWL, but also in terms of remission of obesity-related co-morbidities, gastroesophageal reflux disease (GERD) and quality of life (QoL) in the mid- and long-term., Methods: The BariSurg trial was designed as a multi-centre, randomized controlled patient and observer blind trial. The trial protocol was approved by the corresponding ethics committees of the centres. To demonstrate EWL non-inferiority of SG compared to RYGB, power calculation was performed according to a non-inferiority study design. Morbidity, mortality, remission of obesity-related co-morbidities, GERD course and QoL are major secondary endpoints. 248 patients between 18 and 70 years, with a body mass index (BMI) between 35-60 kg/m(2) and indication for bariatric surgery according to the most recent German S3-guidelines will be randomized. The primary and secondary endpoints will be assessed prior to surgery and afterwards at discharge and at the time points 3-6, 12, 24, 36, 48 and 60 months postoperatively., Discussion: With its five year follow-up, the BariSurg-trial will provide further evidence based data concerning the impact of SG and RYGB on EWL, remission of obesity-related co-morbidities, the course of GERD and QoL., Trial Registration: The trial protocol has been registered in the German Clinical Trials Register DRKS00004766 .

Background: To evaluate the effectiveness and safety of the DS Titanium Ligation Clip for appendicular stump closure in laparoscopic appendectomy., Methods: Overall, 502 patients undergoing laparoscopic appendectomy were recruited for this observational multicentre study in nine study centres between October 2011 and July 2013. The clip was finally applied in 390 patients. Primary outcome variables were feasibility of the clip, intra-abdominal surgical site (abscesses, stump leakages) and superficial wound infections. Patients were followed 30 days after surgery., Results: The clip was applicable in nearly 80 % of patients. Reasons for not applying the clip were mainly an inflamed caecum or a too large diameter of the appendix base. Superficial wound infections were found in nine (2.31 %), intra-abdominal abscesses in five (1.28 %), appendicular stump leak in one (0.26 %), and other adverse events in 22 (5.64 %) patients. In total, 12 (3.08 %) patients were re-admitted to hospital for treatment. Seven re-admissions were surgery-related; ten (2.56 %) patients had to be re-operated. One patient died during the course of the study due to persisting peritonitis (mortality 0.26 %)., Conclusions: The results suggest that the DS Titanium Ligation Clip is a safe and effective option in securing the appendicular stump in laparoscopic appendectomy. The complication rates found with the use of the DS-Clip are comparable to the rates in the literature when other methods are used., Trial Registration: NCT01734837 .

Background: The German NOTES registry (GNR) was initiated by the German Society for General and Visceral Surgery (DGAV) as a treatment and outcome database for natural orifice transluminal endoscopic surgery (NOTES)., Aim: The aim of this study was the descriptive analysis of all GNR data collected over a 5-year period since its start in 2008 with more than 3000 interventions., Material and Methods: The GNR is an online database with voluntary participation available to all German-speaking clinics. Demographic data, therapy details, complications and data on the postoperative course of patients are recorded. All cases in the GNR between March 2008 and November 2013 were included in the analysis., Results: From a total of 3150 data sets 2992 (95 %) were valid and suited for the analysis. Hybrid transvaginal cholecystectomy was the most frequently used procedure (88.7 %), followed by hybrid transvaginal/transgastric appendectomy (6.1 %) and hybrid transvaginal/transrectal colon procedures (5.1 %). Intraoperative complications occurred in 1.6 %, postoperative complications in 3.7 % and conversions were reported in 1.5 %. Intraoperative bladder injuries and postoperative urinary tract infections were identified as method-specific complications of transvaginal procedures. Bowel injuries occurred as a rare (0.2 %) but potentially serious complication of transvaginal operations., Conclusion: The German surgical community ensures a safe and responsible introduction of the new NOTES operation techniques with its active participation in the GNR. Despite an overall low complication rate, the high number of procedures in the GNR permitted the identification of method-specific complications. This knowledge can be used to further increase the safety of NOTES in practice.

Background: The clinical and scientific interest in minimally invasive techniques for esophagectomy (MIE) are increasing; however, the intrathoracic esophagogastric anastomosis remains a surgical challenge and lacks standardization. Surgeons either transpose the anastomosis to the cervical region or perform hybrid thoracotomy for stapler access., Aim: This article reports technical details and early experiences with a completely laparoscopic-thoracoscopic approach for Ivor Lewis esophagectomy without additional thoracotomy., Material and Methods: The extent of radical dissection follows clinical guidelines. Laparoscopy is performed with the patient in a beach chair position and thoracoscopy in a left lateral decubitus position using single lung ventilation. The anvil of the circular stapler is placed transorally into the esophageal stump. The specimen and gastric conduit are exteriorized through a subcostal rectus muscle split incision. The stapler body is placed into the gastric conduit and both are advanced through the abdominal mini-incision transhiatally into the right thoracic cavity, where the anastomosis is constructed. Data were collected prospectively and analyzed retrospectively., Results: A total of 23 non-selected consecutive patients (mean age 69 years, range 46-80 years) with adenocarcinoma (n = 19) or squamous cell carcinoma (n = 4) were surgically treated between June 2010 and July 2013. Neoadjuvant therapy was performed in 15 patients resulting in 10 partial and 4 complete remissions. There were no technical complications and no conversions. Mean operative time was 305 min (range 220-441 min). The median lymph node count was 16 (range 4-42). An R0 resection was achieved in 91 % of patients and 3 anastomotic leaks occurred which were successfully managed endoscopically. There were no postoperative deaths., Conclusion: The intrathoracic esophagogastric anastomosis during minimally invasive Ivor Lewis esophagectomy can be constructed in a standardized fashion without an additional thoracotomy. Reduction of surgical morbidity remains the highest priority.

Background: There is overwhelming evidence for the antidiabetic effect of obesity surgery, but few reports involve objective longitudinal measurements of severity of type-2 diabetes mellitus (T2DM). This study applies a grading scheme and analyses the prognostic impact of routine clinical factors., Material and Methods: This retrospective study includes 77 obese diabetic patients with a preoperative BMI of 48.9 ± 7.8 kg/m(2) who underwent gastric banding (n = 4), Roux-en-Y gastric bypass (n = 57), or sleeve gastrectomy (n = 16) between 2007 and 2013. A 6-point scoring system graded the level of antidiabetic therapy. Downgrading was calculated from the difference between pre- and postoperative grades., Results: Downgrading reached its maximum at 3 months well before maximal weight loss: one grade in 6 (8 %) patients, two grades in 36 (47 %) patients, and three or more grades in 20 (26 %) patients. Age, gender, and preoperative weight had no impact on downgrading. There were no significant differences between gastric banding (median 1; 0-2), gastric bypass (median 2; 0-5), and sleeve gastrectomy (median 2; 0-4). Preoperative duration of T2DM and its severity grade were independent prognostic factors in multivariate analysis. The rate of patients who could discontinue insulin was more than 80 % when the duration of preexisting T2DM was less than 5 years as compared to 62 % when the duration was more than 5 years., Conclusion: The severity of T2DM downgrades in most patients within the initial period of postoperative weight loss. Downgrading increases with shorter duration and lower severity grade of pre-existing T2DM.

Introduction: Negative Pressure Wound Therapy (NPWT) is widely used in the management of the open abdomen despite uncertainty regarding several aspects of usage. An expert panel was convened to develop evidence-based recommendations describing the use of NPWT in the open abdomen., Methods: A systematic review was carried out to investigate the efficacy of a range of Temporary Abdominal Closure methods including variants of NPWT. Evidence-based recommendations were developed by an International Expert Panel and graded according to the quality of supporting evidence., Results: Pooled results, in non-septic patients showed a 72% fascial closure rate following use of commercial NPWT kits in the open abdomen. This increased to 82% by the addition of a 'dynamic' closure method. Slightly lower rates were showed with use of Wittmann Patch (68%) and home-made NPWT (vac-pack) (58%). Patients with septic complications achieved a lower rate of fascial closure than non-septic patients but NPWT with dynamic closure remained the best option to achieve fascial closure. Mortality rates were consistent and seemed to be related to the underlying medical condition rather than being influenced by the choice of dressing, Treatment goals for open abdomen were defined prior to developing eleven specific evidence-based recommendations suitable for different stages and grades of open abdomen., Discussion and Conclusion: The most efficient temporary abdominal closure techniques are NPWT kits with or without a dynamic closure procedure. Evidence-based recommendations will help to tailor its use in a complex treatment pathway for the individual patient., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The German NOTES registry (GNR) is the largest published database for natural orifice transluminal endoscopic surgery (NOTES) worldwide. Although transvaginal cholecystectomy is the most frequent procedure in the GNR, the number of colorectal resections is increasing. The objective of this study was to analyze the first 139 colonic procedures of the GNR., Methods: All colonic procedures from the GNR were analyzed regarding patient- and therapy-related parameters. A multivariate analysis was conducted for transvaginal sigmoid resections regarding procedural time, hospital stay, conversion rate, and rate of complications., Results: From October 2008 to January 2013, 139 colon NOTES procedures (12 male, 127 female) were registered. Main diagnoses were sigmoid diverticulitis (85.6 %), colon carcinoma (9.4 %), and ulcerative colitis (3.6 %). Sigmoid resections (87.1 %), proctocolectomies (3.6 %), right-sided resections (2.9 %), left-sided resections (3.6 %), segmental resections (2.2 %), and 1 ileocecal resection (0.7 %) were performed. All procedures were conducted in transvaginal (87.8 %) or transrectal (12.2 %) hybrid technique, with a median of 3 percutaneous trocars. Conversions to laparoscopic technique were necessary in 3.6 % (none to conventional technique). Intraoperative complications were recorded in 2.9 % and postoperative complications in 12.2 %. The institutional case number in transvaginal sigmoid resections correlated negatively with procedural time (p = 0.041) and the number of percutaneous trocars (p = 0.002)., Conclusion: The analysis of the first 139 colon NOTES operations of the GNR shows the feasibility of co on operations in hybrid technique, especially for transvaginal sigmoid resection as the most frequent procedure.

Mesh repair has evolved as the gold standard for umbilical hernias. Surgical reconstruction of umbilical hernias in association with diastasis recti has not been discussed in the recent literature. We describe a novel surgical technique of midline mesh repair for this combined lesion. This is a retrospective review of 44 consecutive patients. Forty-four patients underwent surgery for umbilical hernia with diastasis recti between January 2010 and August 2012. All excess skin, subcutaneous tissue, and distracted midline (linea alba) were excised supraumbilically and paraumbilically according to preoperative marking. Surgical repair began with a midline running suture of the posterior rectal sheath. A light prolene mesh was placed retromuscularly into this sheath and anchored in all directions with a distance of about 5 cm from the midline using U-shaped stitches. The anterior rectal fascia was closed with a continuous suture. All information was obtained from the hospital records. The median operative time was 93.3 minutes (28 to 219 minutes). The median length of postoperative hospital stay was 5.9 days (3 to 12 days). There was no major complication. One minimal umbilical skin necrosis was observed. Analgesic medication was required in all patients. Opiods were added in 84.0% of patients on day 1, in 75.0% on day 3, and in 2.3% on day 7. Our novel technique of sublay mesh repair for combined umbilical hernia and diastasis recti is safe and effectively restores the abdominal midline.

Purpose: We have developed nerve-oriented mesorectal excision (NOME) as a novel concept in rectal cancer surgery by which autonomic pelvic nerves serve as landmarks for a standardized navigation along fascial planes. This article describes the technique step by step and presents our results from 2008 to 2012., Material and Methods: The key steps are: preparation of the splanchnic nerves at the mid-posterior sidewall, the hypogastric nerves at the upper sidewall, and the urogenital nerve branches (Walsh) at the caudal-anterior sidewall. The dissection of the lateral ligament is strictly performed as the last step. NOME was applied in 274 consecutive mesorectal excisions (partial 20.4%, total 79.6%); a subgroup of 42 male patients underwent a questionnaire-based interview on sexual activity., Results: The conversion rate was 0.7%. High (complete) specimen quality and circumferential margin negativity were achieved in 90.1% and 95.3%, respectively. Anastomotic leaks occurred in 13 (4.7%) patients. Mortality was 1.8%. The frequency of prolonged urinary catheter was 1.8%. Of 22 sexually active males interviewed, 18 (81.8%) maintained activity postoperatively., Conclusions: NOME achieves high-quality mesorectal specimens and a high rate of preservation of autonomic nerve function. The concept of using nerves as laparoscopic landmarks may help to standardize and master laparoscopic rectal cancer surgery.

The incidence of parastomal hernia in ileal conduit urinary diversion ranges from 4% to 16%. Surgical correction is necessary in about one third of cases and different techniques of surgical reconstruction have been described. Primary fascial repair has a high recurrence rate of 46-100% whereas stoma translocation is associated with complication rates of up to 88%. The use of alloplastic material (usually polypropylene meshes) has reduced the recurrence rate by up to 100% for primary fascial repair and 71% for stoma translocation down to 33%.Composite meshes consist of two layers, a polypropylene layer and an expanded polytetrafluoroethylene (ePTFE) layer. The former is placed against the abdominal wall for permanent reinforcement by ingrowing connective tissue and the ePTFE layer is placed against the abdominal organs preventing adhesions with the bowel. The intraperitoneal placement of such composite meshes is a standardized, simplified, gentle and controllable surgical procedure. This article reports experiences with the surgical correction of parastomal hernias in ileal conduits using composite meshes.

Purpose: Different techniques, including clips, have been used to close the stump in laparoscopic appendectomy. The aim was to investigate the results after application of a newly developed titanium clip for this operation., Methods: From June 2008 to February 2010, 104 patients from two different hospitals undergoing laparoscopic appendectomy were included in this prospective study. Closure of the appendix base was generally intended with a titanium double-shanked clip (DS-Clip). The variables of interest were intra-and postoperative complications, operation time and hospital stay. Furthermore, an evaluation of the clip's practicability by the surgeon was performed using a standardised questionnaire., Results: In 104 patients screened intraoperatively, four patients had to be excluded as the operating surgeon felt that the clip was not adequate for closing the stump, generally because of severe inflammation of the base of the appendix with involvement of the caecum. One patient developed an intra-abdominal abscess which had to be drained interventionally; no reoperations were necessary. The overall complication rate, the operation time and the hospital stay were well comparable with other devices for appendix stump closure such as staplers, loops or polymeric clips. The practicability of the clip was mainly rated as excellent or good by the operating surgeons., Conclusion: This study suggests that the presented titanium DS-Clip is a safe and cost-effective technique for securing the appendix base in laparoscopic appendectomy. The application is easy and can be learned quickly, making it a good option also for teaching hospitals.

Aim: Negative Pressure Wound Therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer-reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this communication the results of the study of evidence in chronic wounds including pressure ulcers, diabetic foot ulcers (DFU), venous leg ulcers (VLU), and ischaemic lower limb wounds are reported., Methods: Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% agreement. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system., Results: The primary treatment goal of NPWT in most chronic wounds is to achieve wound closure (either by secondary intention or preparing the wound for surgical closure). Secondary goals commonly include: to reduce wound dimensions, and to improve the quality of the wound bed. Thirteen evidence based recommendations were developed in total to address these treatment goals; 4 for pressure ulcers, 4 for DFU, 3 for ischaemic lower limb wounds and 2 for VLU., Conclusion: The present evidence base is strongest for the use of NPWT in non-ischaemic DFU and weakest in VLU. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone., (Copyright © 2011. Published by Elsevier Ltd.)

Originally, sleeve gastrectomy (SG) was part of biliopancreatic diversion (BPD), which is the most effective bariatric procedure for super obese patients. As BPD is a complex procedure with substantial morbidity and mortality, attempts were undertaken to split the procedure into two steps. SG became the first step in a staged BPD procedure assuming that this less-invasive operation would reduce the surgical risk in super obese patients. The second step - the duodenal switch - was thus postponed until after a major weight loss. Several studies have since been published showing data that, besides the successful weight loss, the procedure itself had a positive effect on obesity-associated comorbidities. Sleeve gastrectomy has gained widespread acceptance as a primary and definite bariatric procedure. SG has become an innovative tool in the battle against obesity. Although several variations of SG have been described, standardization is paramount for optimal results. Of particular interest are: the minimally invasive access, the dissection, preservation of the antrum, position of staple-line and buttress material, as well as the size of the bougie and the extent of fundal resection. This article describes the different procedural and technical aspects of the operation. In addition, it will line out how we transferred our skills and experience in single incision laparoscopic surgery (SILS) from cholecystectomy and sigmoid resection to sleeve gastrectomy.

Negative pressure wound therapy (NPWT) is becoming a commonplace treatment in many clinical settings. New devices and dressings are being introduced. Despite widespread adoption, there remains uncertainty regarding several aspects of NPWT use. To respond to these gaps, a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In a previous communication, we have reviewed the evidence base for the use of NPWT within trauma and reconstructive surgery. In this communication, we present results of the assessment of evidence relating to the different NPWT treatment variables: different wound fillers (principally foam and gauze); when to use a wound contact layer; different pressure settings; and the impact of NPWT on bacterial bioburden. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence and drafting of the recommendations by a global expert panel. Evidence and recommendations were graded according to the Scottish Intercollegiate Guidelines Network (SIGN) classification system. In general, there is relatively weak evidence on which to base recommendations for any one NPWT treatment variable over another. Overall, 14 recommendations were developed: five for the choice of wound filler and wound contact layer, four for choice of pressure setting and five for use of NPWT in infected wounds. With respect to bioburden, evidence suggests that reduction of bacteria in wounds is not a major mode of action of NPWT., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Bariatric surgery has increased in numbers, but the treatment of morbid obesity in Germany still needs improvement. The new interdisciplinary S3-guideline provides information on the appropriate indications, procedures, techniques, and follow-up care., Methods: Systematic review of the literature, classification of the evidence, graded recommendations, and interdisciplinary consensus-building., Results: Bariatric surgery is a component of the multimodal treatment of obesity, which consists of multidisciplinary evaluation and diagnosis, conservative and surgical treatments, and lifelong follow-up care. The current guideline extends the BMI-based spectrum of indications that was previously proposed (BMI greater than 40 kg/m(2), or greater than 35 kg/m(2)with secondary diseases) by eliminating age limits, as well as most of the contraindications. A prerequisite for surgery is that a structured, conservative weight-loss program has failed or is considered to be futile. Type 2 diabetes is now considered an independent indication under clinical study conditions for patients whose BMI is less than 35 kg/m(2) (metabolic surgery). The standard laparoscopic techniques are gastric banding, gastric bypass, sleeve gastrectomy, and biliopancreatic diversion. The choice of procedure is based on knowledge of the results, long-term effects, complications, and individual circumstances. Structured lifelong follow-up should be provided and should, in particular, prevent metabolic deficiencies., Conclusion: The guideline contains recommendations based on the scientific evidence and on a consensus of experts from multiple disciplines about the indications for bariatric surgery, the choice of procedure, techniques, and follow-up care. It should be broadly implemented to improve patient care in this field.

Background: The young field of obesity surgery (bariatric surgery) in Germany expands as a consequence of the rapid increase of overweight and obesity. New surgical methods, minimal access techniques, and the enormous increase of scientific studies and evidence, all contribute to the success of bariatric surgery, which is the only realistic chance of permanent weight loss and regression of secondary diseases in many cases., Methods: A systematic literature review, classification of evidence, graded recommendations, and interdisciplinary consensus., Results: Obesity surgery is an integral component of the multimodal treatment of obesity, which consists of multidisciplinary evaluation and preparation, conservative and surgical treatment elements, and a life-long follow-up. The guideline confirms the body mass index (BMI)-based spectrum of indications (BMI > 40 kg/m(2) or >35 kg/m(2) with secondary diseases) and extends it through elimination of all age restrictions (>18 years and <60 years) and most of the contraindications. Precondition for surgery is the failure of a structured conservative program of 6-12 months or the expected futility of it. Type II diabetes mellitus becomes an independent indication criterion for BMI < 35 kg/m(2) (metabolic surgery). The standard techniques are gastric balloon, gastric banding, gastric bypass, gastric sleeve, and biliopancreatic diversion. The choice of procedure is based on profound knowledge of results, long-term effects, complications, and patient-specific circumstances. The after-care should be structured and organized long term., Conclusion: The S3-guidelines contain evidence-based recommendations for the indication, selection of procedure, technique, and follow-up. Patient care should improve after implementation of these guidelines in clinical practice. Compliance by decision makers and health insurers is warranted.

Negative pressure wound therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this paper the results of the study of evidence in traumatic wounds (including soft tissue defects, open fractures and burns) and reconstructive procedures (including flaps and grafts) are reported. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel, followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% approval. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. Twelve recommendations were developed in total; 4 for soft tissue trauma and open fracture injuries, 1 for burn injuries, 3 for flaps and 4 for skin grafts. The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns. In the consultative process, 11/12 of the proposed recommendations reached the 80% agreement threshold. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: To analyze patient outcome in the first 14 months of the German natural orifice translumenal endoscopic surgery (NOTES) registry (GNR)., Summary Background Data: NOTES is a new surgical concept, which permits scarless intra-abdominal operations through natural orifices, such as the mouth, vagina, rectum, or urethra. The GNR was established as a nationwide outcome database to allow the monitoring and safe introduction of this technique in Germany., Methods: The GNR was designed as a voluntary database with online access. All surgeons in Germany who performed NOTES procedures were requested to participate in the registry. The GNR recorded demographical and therapy data as well as data on the postoperative course., Results: A total of 572 target organs were operated in 551 patients. Cholecystectomies accounted for 85.3% of all NOTES procedures. All procedures were performed in female patients using transvaginal hybrid technique. Complications occurred in 3.1% of all patients, conversions to laparoscopy or open surgery in 4.9%. In cholecystectomies, institutional case volume, obesity, and age had substantial effect on conversion rate, operation length, and length of hospital stay, but no effect on complications., Conclusions: Despite the fact that NOTES has just recently been introduced, the technique has already gained considerable clinical application. Transvaginal hybrid NOTES cholecystectomy is a practicable and safe alternative to laparoscopic resection even in obese or older patients.

Integrins are cell surface molecules that mediate cell adhesion, but are also important regulators of tumor cell interactions with their microenvironment, tumor cell survival and growth. In addition, the alpha(v)beta3-integrins appear to be critical for microvessel formation in tumor-induced neoangiogenesis. The present study is the first to investigate the effects of therapeutic alpha(v)beta3-integrin inhibition in a chemically induced tumor model that largely resembles human colon carcinomas. Tumor induction was performed in 47 male Sprague-Dawley rats using 1,2 dimethylhydrazin (21 mg/kg) twice a week. After 20 weeks of tumor induction, 100% of the animals developed adenocarcinomas with a median of 13.5 macroscopic tumor nodules (range 12-17), but no distant metastases. During further tumor induction for an additional 10 weeks, rats were treated three times/week with (a) 15 mg/kg RGDfV-peptide that can block vitronectin and fibronectin receptors; (b) an equimolar amount of an ineffective cyclic control peptide; or (c) with equimolar amounts of a linear RGDS-peptide. At the end of this treatment period, rats were sacrificed, and tumor load was quantified macroscopically and confirmed by histological examination. For investigation of the involvement of tumor-induced neoangiogenesis microvessel, density was determined using CD31-immunostaining. After 30 weeks, control animals (group B) had 5-18 tumors (median 14.5). If rats were treated with RGDfV-peptide (group A), the number of tumor nodules was significantly reduced (P < 0.005) to a median of seven macroscopic tumors (range 2-10 tumors), which also represented a significant reduction (P < 0.005) compared with prior to treatment. Application of noncylic RGDS-peptides (group C) did not affect the number of tumor nodules (median 18; range 10-30 tumors). The diameters of tumor nodules were comparable (3.2-6.1 mm) in animals of all groups. In addition, microvessel density was significantly (P < 0.05) reduced in tumors in group A compared to control rats. The major side effect in the treatment group was increased susceptibility to respiratory infections. Our results demonstrate that alpha(v)beta3-integrin-receptor inhibition appears to be a therapeutic strategy for colorectal cancer. In our therapeutic model, late onset of treatment with integrin-blocking peptides resulted in an inhibition of tumor growth and a reduced tumor load which appeared to be mediated, at least in part, by inhibition of neoangiogenesis.

The majority of mutations in hereditary nonpolyposis colon carcinoma (HNPCC) patients affect the mismatch-repair genes (MMRG) MLHI and MSH2. In addition, mutations of these genes were found in about 15% of sporadic colorectal carcinomas which appear to be related to microsatellite instability (MSI). However, mutations in MMRG were not found in all MSI-positive carcinomas, but MMRG mutations may be relevant for the assessment of tumor characteristics and patients' prognosis. Therefore, we investigated the relationship between expression of MMRG, tumor biology and patients' survival. In 127 patients with sporadic colorectal carcinomas and a minimum of 5 years follow-up after curative surgery immunohistochemical detection of MLHI and MSH2 was analyzed semiquantitatively. Lost expression of MLHI has been found in tumor specimens from 10 patients, whereas MSH2 expression was missing in 5 patients. This reduced expression did not correlate with tumor stage, lymph node involvement, grading or tumor invasion into blood vessels. However, a significant correlation was found for lymphovascular invasion (P = 0.02) and localization within the colorectum (P = 0.003) in MLH1-negative carcinomas. In addition, although there was a clear tendency for longer overall survival (72 vs. 63 months) for patients with MLH1-negative carcinomas, significant differences for overall and recurrence-free survival were not seen. In conclusion of our results and a critical review of literature, the prognostic importance of the MMR genes in sporadic colorectal carcinomas remains controversial.

Ca(2+)-activated K(+) (K(Ca)) channels have been suggested to play a role in the control of endothelial functions such as regulation of vascular tone and cell proliferation. We established a method for single-cell reverse transcriptase-polymerase chain reaction analysis in combination with the patch-clamp technique to characterize K(Ca) channel expression and function in single endothelial cells (ECs) within the endothelial monolayer of intact human mesenteric arteries (MAs) and in disease states. We tested whether endothelial K(Ca) channel expression and function are altered in MAs obtained from patients with colonic adenocarcinoma (CA) compared with those in MAs from non-cancer patients with inactive diverticulitis. Expression of the intermediate-conductance K(Ca) channel (hIK1) was detected in non-cancer and CA patients. In whole-cell patch-clamp measurements, only ECs expressing hIK1 exhibited corresponding K(Ca) currents, whereas respective K(Ca) currents were missing in hIK1-negative ECs. This heterogeneity of hIK1 expression patterns is indicative of a specialized subset of ECs within the endothelial monolayer. In CA patients, compared with non-cancer patients, a 2.5-fold increase in hIK1-expressing ECs per MA was observed (P:<0.05). However, K(Ca) current densities in hIK1-expressing ECs of both groups were similar. In addition to hIK1, expression of the large-conductance K(Ca) channel (hSlo) was detected in single ECs from CA patients. The increased K(Ca) channel expression in CA patients resulted in a 2. 7-fold increase of bradykinin-induced endothelial hyperpolarization compared with controls (P:<0.05). This increased expression and function of K(Ca) channels might indicate an altered functional state of the endothelium in cancer patients and could play a role in tumor angiogenesis.

Background: The prognosis of patients with adenocarcinoma of the pancreas remains poor. Only patients with small tumors and complete resection have a curative chance. The value of combined radio-chemotherapy adjuvant or even palliative in case of unresectable tumors is controversial due to the short median survival times of all patients ranging from 8 to 15 months. Within the last years, significant new treatment modalities were introduced into the multimodality approach. Even the intraoperative boost therapy (IORT) with fast electrons remains still controversial., Material and Methods: Since the publication of the results of the historic GITSG study, in the US postoperative adjuvant radio-chemotherapy with 5-FU remains the treatment of choice. Successor studies of the ESPAC and the EORTC have been closed or are recruiting patients, the results are still pending. Neoadjuvant treatment modalities were investigated within the last 3 years, mostly in case of primary operable but also in unresectable tumors. Using 3-D-treatment planning, the total dose of radiotherapy was increased from 40 up to 45 to 50 Gy. In centers with great experience, an IORT was added to these combined modalities. More modern chemotherapeutic agents like gemcitabine or the taxanes are under investigation, using combined radio-chemotherapy in phase-II protocols in patients with unresectable tumors., Results: In case of both, adjuvant or neoadjuvant radio-chemotherapy following or before pancreaticoduodenectomy, median survival times range from 15 to 25 months. The neoadjuvant radio-chemotherapy seems to reduce the rate of positive surgical margins and the rate of patients with positive lymph nodes. For the moment, there is no proven survival advantage or increase of local control (about 80% in both cases) for patients treated with neoadjuvant radio-chemotherapy compared with adjuvant radio-chemotherapy. However, about 25% of the patients don't receive adjuvant therapy due to the perioperative morbidity. Because prolongation of survival with adjuvant therapy is only 5 to 10 months, in Europe adjuvant radio-chemotherapy is not accepted as the treatment standard. Combined radio-chemotherapy in patients with unresectable tumors results in significant improvement of survival. 5-FU continuous infusion with 250 mg/m2 seems to be the treatment of choice. IORT is effective in achieving long-term local control and an effective pain palliation. More modern chemotherapeutic agents seem to be effective in vitro as radio-sensitizers. In first reported results, the MTD was not found. Toxicity seems not to be increased with single radiotherapy doses of 1.8 to 2 Gy. However, higher single doses should not be used., Conclusions: Due to the worse prognosis of patients with adenocarcinoma of the pancreas, new combined treatment modalities as adjuvant and neoadjuvant radio-chemotherapy, particularly with more modern chemotherapeutic agents, for patients with resectable and unresectable tumors are under investigation. For some reasons, the neoadjuvant setting seems to be better. However, these results are not proven by prospective randomized clinical trials. Therefore, these trials are necessary to define the treatment of choice in these patients. IORT is a helpful tool to improve local control. However, these aggressive multimodality approaches are only indicated in a minority of patients. In patients with unresectable tumors and good condition, combined radio-chemotherapy remains the treatment of choice.

The problem of T classification of proximal gastric carcinomas is becoming increasingly important due to a rise in the incidence of these tumors. The aim of this study was to examine the gastric insertion of the lesser and greater omenta and its role in the T classification of gastric carcinomas. The stomach and greater and lesser omenta were removed from 76 fixed cadavers and 12 measurements each were done in defined localizations. The lesser omentum extended to the gastric wall in 98% of the cases. This junction as well as the omental thickness and thus the retroperitoneal part are especially pronounced in the cardiac region. According to the current UICC classification, even advanced tumors extending into the gastric wall can be classified T2 as long as they do not penetrate the visceral peritoneum. This results in "understaging" and a seemingly poorer prognosis for cardiac carcinomas. Our study results support the recommendation of Hermanek and Wittekind [5] to subdivide the T2 stage of gastric carcinomas on the basis of infiltration depth.

Angiogenesis is essential for tumor growth and metastasis, and vascular density is known as an independent prognostic factor in several tumor entities. We studied the prognostic relevance of vascular density in colorectal cancer, examining 146 patients treated surgically for cure. Tumor sections were immunostained with JC70, an endothelial cell marker. Microvessel quantification used light microscopy. The slides were scanned at a low magnification, and individual microvessel counts were made on a x200 field in the area of the most dense neovascularization. Vascular density was found to be 75+/-27/visual field and to be independent of age, sex, pT and pN categories, tumor recurrence, and overall survival. Overall survival in the subgroup of patients with tumor recurrence was significantly shorter with tumors of greater vessel density (>75) than in those of less vessel density (<75). Multivariate analysis showed microvessel count to be an independent prognostic factor for the overall survival rate of patients with tumor recurrence; among these patients there was also a significant difference in the relapse-free survival rates between the hypovascular and the hypervascular groups. Our findings suggest that the microvessel density of the primary tumor determines the speed of tumor recurrence after metastatic disease has been triggered by other, unknown mechanisms. Although tumor vascularization can be linked to the aggressiveness of colorectal cancer, it has no value as a new prognostic marker in clinical practice.

A constant reduction in anal sphincter pressure follows an ileoanal pouch procedure for ulcerative colitis and familiar adenomatous polyposis. We analyzed whether this reduction is more likely due to neurogenic damage or to direct sphincter trauma. Three-dimensional vector volume manometry was performed in 75 patients prior to the ileoanal pouch procedure and 3 months thereafter. Resting pressure was significantly reduced from 83.5 +/- 24.4 to 58.1 +/- 18.0 mmHg and squeezing pressure from 204.7 +/- 63.3 to 173.4 +/- 50.6 mmHg. Moreover, significant vector volume reductions were recorded postoperatively, and the asymmetry index increased significantly (resting: 11.5 +/- 4.1% to 18.4 +/- 7.4%; squeezing: 9.6 +/- 3.1 to 13.0 +/- 6.7%). Functional anal sphincter length at the high-pressure zone remained unchanged. Thus, there was no local damage to proximal or distal anal sphincter segments, which suggests that the postoperative impairment of sphincter function is secondary to neurogenic rather than morphological damage.

Objective: The renin-angiotensin system plays a central role in blood pressure regulation, both by affecting renal function and by modulating vascular tone and structure. Recent studies in rodents demonstrated the existence of several components of this system in adipose tissue. The activity of the renin-angiotensin system appears to be regulated by food intake, suggesting that it may be involved in obesity-associated hypertension. Few data are available on the presence of renin-angiotensin system components in human adipose tissue., Materials and Methods: In order to explore the expression of renin-angiotensin system genes in human adipose tissue and adipocytes, total RNA was isolated from whole adipose tissue (subcutaneous and omental) or cultured adipocytes (mammary) and subjected to reverse-transcriptase polymerase chain reaction with primers specific for human angiotensinogen, renin, renin-binding protein, angiotensin converting enzyme, chymase and type 1 and type 2 angiotensin receptors., Results: Angiotensinogen, angiotensin converting enzyme and type 1 angiotensin receptor genes were widely expressed, both in human adipose tissue and in cultured human adipocytes. Furthermore, we found expression of the chymase and renin-binding protein genes in these samples., Conclusions: Our findings suggest the presence of a local renin -angiotensin system in human adipose tissue, with adipocytes being an important part of this system, and prompt speculation that this local renin-angiotensin system may be involved in obesity-related disorders, including hypertension and the metabolic syndrome.

A 19-year-old woman suffered from recurrent peranal hemorrhage. Over a period of five years she was treated under the suspicion of ulcerative colitis. After a sigmoid resection with a colostomy, proctectomy with an end colostomy followed due to recurrent intractable peranal hemorrhage. Histology of the specimen showed surprisingly a hemangioma of the rectum. Thereafter reconstruction was performed by colopouchanal anastomosis. Afterwards the patient was free of disease and had a good stool-continence. Stool-frequency was twice daily. The second case consisted in a 27-year-old woman who underwent emergency sigmoidectomy due to massive peranal hemorrhage. Here as well diagnosis was a hemangioma of the sigmoid. One year after the first operation the patient had a recurrence of peranal bleeding again due to rectal hemangioma. Since endoscopy and endosonography confirmed a rectal hemangioma a rectal exstirpation with a colopouchanal reconstruction was performed successfully. The reviewed literature shows including the two presented cases a total of 81 cases with rectal hemangiomas. Because of the good results concerning function and morbidity the therapy of choice is rectal exstirpation with colopouchanal reconstruction.