Bernhard Kraemer

A direct comparison of seprafilm, adept, intercoat, and spraygel for adhesion prophylaxis.

BACKGROUND Commercially available agents for adhesion prophylaxis are legion but there is a lack of direct comparisons between them. Here we compare four of the most commonly used adhesion barriers against a control group in a clinically relevant rat model. MATERIAL AND METHODS Standardized lesions were created in Wistar rats using electrocautery and suturing. Subsequently, the experimental lesions were treated with Seprafilm (n = 30), Adept (n = 30), Intercoat (n = 30), Spraygel (n = 30), or no barrier (n = 30). The resulting adhesions were examined 14 d postoperatively. RESULTS The mean area covered by adhesion was 77% in the control group, 46% in animals treated with Seprafilm, 54% in animals treated with Adept, 55% in animals treated with Intercoat, and 68% in animals treated with Spraygel. The adhesion-free incidence was 20% (n = 6) of lesions treated with Seprafilm, 20% (n = 6) of lesions treated with Intercoat, 3% of lesions treated with Spraygel (n = 1), and 0% of lesions treated with Adept or the control group. CONCLUSIONS There were statistically significant differences between the barriers with regards to the area covered by adhesions and the adhesion-free incidence. In spite of this, a significant adhesion burden remains with all of the tested barriers.

The extent of adhesion induction through electrocoagulation and suturing in an experimental rat study

OBJECTIVE To investigate the effect of three types of peritoneal trauma occurring during surgery (high-frequency bipolar current, suturing, and mechanical damage) on postoperative adhesion formation in a rodent animal model. DESIGN Randomized, controlled experimental trial in an in vitro animal model. SETTING Laboratory facilities of a university department of obstetrics and gynecology. ANIMAL(S) Thirty-five female Wistar rats. INTERVENTION(S) Bilateral experimental lesions were created on the abdominal wall in every animal. The effect of minimal electrocoagulation was examined by creating lesions (n = 14) through sweeps of a bipolar forceps with a duration of 1 second and standardized pressure. For extensive electrocoagulation standardized lesions (n = 14) were created using sweeps of a duration of 3 seconds and three times more pressure. For mechanical trauma, standardized lesions (n = 14) were created by denuding the peritoneum mechanically. To study the additive effect of suturing, experimental lesions were created by suturing plus minimal electrocoagulation (n = 14) or mechanical denuding (n = 14). MAIN OUTCOME MEASURE(S) Adhesion incidence, quantity, and quality of the resulting adhesions were scored 14 days postoperatively. Adhesions were studied histopathologically. RESULT(S) Mechanical denuding of the peritoneum did not result in adhesion formation. After minimal electrocoagulation, mean adhesion quantity of the traumatized area averaged 0%. This contrasted with extensive electrocoagulation, where there was 50% adhesion. Additional suturing increased mean adhesion quantity to 73% and 64% for superficial electrocoagulation and mechanical denuding, respectively. CONCLUSION(S) We conclude that superficial trauma limited mostly to the parietal peritoneum may be a negligible factor in adhesion formation in this model. This appears to be irrespective of the mode of trauma. However, additional trauma to the underlying tissues, either by deeper electrocoagulation or suturing, leads to significantly increased adhesion formation. These data also show that there is a spectrum of electrocoagulation trauma at the lower end of which there is little adhesion formation.

Influence of zoledronic acid on disseminated tumor cells in bone marrow and survival: results of a prospective clinical trial

BackgroundThe presence of disseminated tumor cells (DTC) in bone marrow (BM) of breast cancer patients is associated with reduced clinical outcome. Bisphosphonate treatment was shown to eradicate DTC from BM in several studies. This controlled randomized open-label multi-center study aimed to investigate the influence of zoledronic acid (ZOL) on DTC and survival of breast cancer patients (Clinical Trial Registration Number: NCT00172068).MethodsPatients with primary breast cancer and DTC-positive bone marrow were randomized to treatment with ZOL plus adjuvant systemic therapy (n = 40) or adjuvant systemic therapy alone (n = 46) between 03/2002 and 12/2004. DTC were identified by immunocytochemistry using the pancytokeratin antibody A45B/B3 and by cytomorphology. The change in DTC numbers at 12 months and 24 months versus baseline, as well as patient outcomes were evaluated.Results86 patients could be included into survival analysis (median follow-up: 88 months, range: 8–108 mths). Patients in the control group were more likely to die during follow-up than those in the ZOL-group (11% vs. 2%, p = 0.106). 15% of patients in the control group presented with relapse whereas only 8% of ZOL group patients developed metastatic or recurrent disease during follow-up (p = 0.205). At 24 months, 16% of patients from the control group were still DTC positive, whereas all patients treated with ZOL became DTC negative (p = 0.032). Patients presenting with persistent DTC 12 months after diagnosis had significantly shorter overall survival (p = 0.011).ConclusionsBisphosphonate therapy contributes to eradication of disseminated tumor cells. The positive influence of bisphosphonates on survival in the adjuvant setting may be due to their effects on DTC.Trial registrationClinicalTrials.gov Identifier: NCT00172068 [Zoledronic Acid in the Treatment of Breast Cancer With Minimal Residual Disease in the Bone Marrow (MRD-1)].

Adhesion prophylaxis using a copolymer with rationally designed material properties

BACKGROUND Physical barriers are the only licensed adjuncts for adhesion prophylaxis in the United States and Europe. Here, we investigate D,L-polylactide-epsilon-caprolactonetrimethylenecarbonate (PCT copolymer), which is a rationally designed biomaterial, as an adhesion barrier. METHODS PCT copolymer membranes were produced by polymerization of the monomers, dissolution in organic solvents, and subsequently processing them by means of modified phase inversion and freeze drying. In vitro cytotoxicity was assayed by fibroblast culture. In vivo adhesion prophylaxis was studied in a rat model that involved standardized traumatization by electrocautery and suturing. The quantity and quality of the resulting adhesions were scored 14 days postoperatively. Complete autopsy was performed in each animal, and the implantation sites were examined histologically. The suitability for human laparoscopic application was investigated in a patient admitted for routine myomectomy. RESULTS The PCT copolymer had no effect on the proliferation of cultured cells in vitro. The in vivo model showed that the quantity of adhesions that cover the traumatized areas was significantly less in animals treated with PCT copolymer membrane (32%) than in untreated animals (78%) (P < .01). Adhesions of both dense and filmy quality were affected. In the animals, autopsy and histologic examination of the relevant tissues revealed no indication of adverse reactions to the PCT copolymer. Human laparoscopic application was successful. CONCLUSION The PCT copolymer membrane is biocompatible with the abdominal cavity and decreased adhesions in the animal model. It is also suitable for human laparoscopic application. Therefore, the PCT copolymer represents a candidate for additional clinical evaluation.

Dynamic magnetic resonance imaging for assessment of minimally invasive pelvic floor reconstruction with polypropylene implant

INTRODUCTION The purpose of the study was to assess the usefulness of dynamic MRI in patients with pelvic organ prolapse after pelvic floor repair with polypropylene mesh. MATERIALS AND METHODS Fifteen consecutive patients (mean age 66.5 years) who were scheduled for either anterior (n=9) or posterior (n=6) pelvic floor repair were prospectively evaluated by clinical assessment and dynamic MRI 1 day before and 3 months after surgery. MRI diagnoses and MRI measurements of relevant anatomical points at rest and on straining were analysed before and after surgery. RESULTS At follow-up assessment 93.3% of all patients were clinically cured. Dynamic MRI showed newly developed (n=6) or increased (n=6) pelvic organ prolapse in 80% (n=12) of all patients 3 months after pelvic floor repair. Most of them (n=11; 91.7%) affected the untreated pelvic floor compartment. On straining anatomical points of reference in the anterior pelvic floor compartment were significantly (p<0.05) elevated after anterior repair and rectal bulging was significantly (p=0.036) reduced after posterior pelvic floor repair. CONCLUSIONS In this study dynamic MRI could verify the effective support of anterior and posterior pelvic floor structures by anterior and posterior polypropylene implant respectively. But dynamic MRI demonstrates if one compartment of the pelvic floor is repaired another compartment frequently (73.3%) develops dysfunction. These results did not correspond to clinical symptoms on short-term follow-up (3 months). Studies with long-term follow-up are necessary to prove if dynamic MRI can reliably identify clinically significant pelvic organ prolapse after pelvic floor repair before the onset of symptoms.

Ovarian ectopic pregnancy: diagnosis, treatment, correlation to Carnegie stage 16 and review based on a clinical case

OBJECTIVE To present a case of a vital ectopic pregnancy after 8 weeks that was located in the right ovary. DESIGN Case study and literature review. SETTING Hospital outpatient clinic. PATIENT(S) A 29-year-old primigravida presented with lower abdominal pain and mild vaginal bleeding at 8 weeks after her last menstrual period. INTERVENTION(S) Wedge resection of the ovary which did not affect subsequent fertility. MAIN OUTCOME MEASURE(S) Conservative treatment options and preservation of patients reproductive capacity. RESULT(S) The embryo was laparoscopically removed in toto and visualized. Therefore, macroscopic correlation to Carnegie stage 16 of development was possible. CONCLUSION(S) Approximately 3% of all ectopic pregnancies are located in the ovaries. Preoperative diagnosis of this extremely rare condition is challenging, because the ectopic tumor often resembles cysts of the corpus luteum. At surgery, the trophoblast tissue or the embryo can rarely be visualized completely.

Vacuum-assisted breast biopsy: A comparison of 11-gauge and 8-gauge needles in benign breast disease

BackgroundMinimal invasive breast biopsy is standard care for the diagnosis of suspicious breast lesions. There are different vacuum biopsy (VB) systems in use. The aim of the study was to determine the differences between the 8-gauge and the 11-gauge needle with respect to a) diagnostic reliability, b) complication rate and c) subjective perception of pain when used for vacuum-assisted breast biopsy.MethodsBetween 01/2000 and 09/2004, 923 patients at St. Josefs-Hospital Wiesbaden underwent VB using the Mammotome® (Ethicon Endosurgery, Hamburg). Depending on preoperative detection, the procedure was performed under sonographic or mammographic guidance under local anaesthesia. All patients included in the study were followed up both clinically and using imaging techniques one week after the VB and a second time after a median of 41 months. Excisional biopsy on the ipsilateral breast was an exclusion criteria. Subjective pain scores were recorded on a scale of 0 – 10 (0 = no pain, 10 = unbearable pain). The mean age of the patients was 53 years (30 – 88).Results123 patients were included in the study in total. 48 patients were biopsied with the 8-gauge needle and 75 with the 11-gauge needle. The use of the 8-gauge needle did not show any significant differences to the 11-gauge needle with regard to diagnostic reliability, complication rate and subjective perception of pain.ConclusionOur data show that there are no relevant differences between the 8-gauge and 11-gauge needle when used for VB. Under sonographic guidance, the use of the 8-gauge needle is recommended for firm breast tissue due to its sharp scalpel point and especially for complete removal of benign lesions. We did not find any advantages in the use of the larger 8-gauge needle compared to the 11-gauge needle in the mammography setting. The utilisation costs of the 8-gauge needle are somewhat higher.

Cystosarcoma phyllodes of the breast: a rare diagnosis: case studies and review of literature

Cystosarcoma phyllodes (CP), otherwise known as phyllodes tumour (PT) of the breast, is a very rare but locally aggressive fibroepithelial tumour in its malignant form, and accounts for 0.3–1% of all breast neoplasias. Using 4 cases reports with different histological classifications as examples (benign—borderline—malignant), we describe the (differential) diagnosis and treatment options of this tumour entity and give an additional review of the available literature.

An Improved Model for the Induction of Experimental Adhesions

ABSTRACT Background: The creation of ischemic buttons from parietal peritoneal tissue using a ligature is among the most established models for adhesion induction. However this model is plagued by slipping of ligatures and subsequent obliteration of the buttons when the animals mobilize postoperatively. Here we describe an improved model that involves creating the buttons with a backstitch ligature and compare it to the traditional model. Methods: A total of 160 ischemic buttons were created in 20 adult Wistar rats. Ischemic buttons in the control group (n == 80) were created using the traditional technique whereas ischemic buttons in the investigative group (n == 80) were created using the novel technique with a backstitch ligature. The resulting adhesions and the frequency of slipped ligatures were analyzed on postoperative day 10. Results: Slipping of the ligature with obliteration of the button occurred in 18.8%% (n == 15/80) of buttons in the control group and in 3.8%% (n == 3/80) of buttons in the investigative group (p < .01). Adhesions formed to 69.2%% (n == 45/65) of the remaining buttons in the control group and to 62.3%% (n == 48/77) of the remaining buttons in the investigative group (p == .38). Conclusion: There was no statistically significant difference in adhesion quantity between the models. However, the novel technique significantly reduced postoperative slipping of the ligatures with obliteration of buttons. As a result, a greater number of intact buttons are available for data collection. Furthermore slipped sutures, which act as foreign bodies in uncontrollable locations, no longer confound adhesion formation to the remaining buttons.

Cervical ectopic pregnancy on the portio: conservative case management and clinical review

OBJECTIVE To present a case and management of an early ectopic pregnancy on the portio. DESIGN Case study and literature review. SETTING Hospital outpatient clinic. PATIENT(S) A 38-year-old woman who presented in the outpatient clinic with a 2-week history of painless acyclic vaginal bleeding. INTERVENTION(S) Excision of the ectopic pregnancy under local anesthesia after clinical examination, urine pregnancy test, and serum ss-hCG measurement. MAIN OUTCOME MEASURE(S) Conservative treatment options and preservation of patients reproductive capacity. RESULT(S) Serum ss-hCG was raised. Complete excision of the ectopic lesion was performed without the need for administration of chemotherapeutic agents and curettage. Histology revealed fragments of the cervical wall with a layer of chorionic giant cells and one intact chorionic villi. CONCLUSION(S) Cervical pregnancy is a rare form of ectopic pregnancy. It can be associated with high morbidity and adverse consequences for future fertility, but spontaneous abortion is also possible. We present a case and successful management of an early ectopic pregnancy on the surface of the portio.