Heinz J. Buhr

Mucosal and invading bacteria in patients with inflammatory bowel disease compared with controls.

Background: Endogenous intestinal bacteria and/or specific bacterial pathogens are suspected of being involved in the pathogenesis of inflammatory bowel diseases (IBD). The aim of this study was to investigate IBD tissues for different bacterial population groups harbouring the mucosal surface and/or invading the mucosa. Methods: Tissue sections from surgical resections from the terminal ileum and/or the colon from 24 IBD patients (12 active ulcerative colitis (UC), 12 active Crohn disease (CD)) and 14 non-IBD controls were studied by fluorescent in situ hybridization on a quantifiable basis. Results: More bacteria were detected on the mucosal surface of IBD patients than on those of non-IBD controls ( P < 0.05). Bacterial invasion of the mucosa was evident in 83.3% of colonic specimens from the UC patients, in 55.6% of the ileal and in 25% of the colonic specimens from the CD patients, but no bacteria were detected in the tissues of the controls. Colonic UC specimens were colonized by a variety of organisms, such as bacteria belonging to the gamma subdivision of Proteobacteria , the Enterobacteriaceae , the Bacteroides/Prevotella cluster, the Clostridium histolyticum/Clostridium lituseburense group, the Clostridium coccoides/Eubacterium rectale group, high G + C Gram-positive bacteria, or sulphate-reducing bacteria, while CD samples harboured mainly bacteria belonging to the former three groups. Conclusion: Pathogenic events in CD and UC may be associated with different alterations in the mucosal flora of the ileum and colon.

The German Registry for Natural Orifice Translumenal Endoscopic Surgery: Report of the First 551 Patients

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.

A Prospective Randomized Study to Test the Transfer of Basic Psychomotor Skills From Virtual Reality to Physical Reality in a Comparable Training Setting

Objective:To test whether basic skills acquired on a virtual endoscopic surgery simulator are transferable from virtual reality to physical reality in a comparable training setting. Summary Background Data:For surgical training in laparoscopic surgery, new training methods have to be developed that allow surgeons to first practice in a simulated setting before operating on real patients. A virtual endoscopic surgery trainer (VEST) has been developed within the framework of a joint project. Because of principal limitations of simulation techniques, it is essential to know whether training with this simulator is comparable to conventional training. Methods:Devices used were the VEST system and a conventional video trainer (CVT). Two basic training tasks were constructed identically (a) as virtual tasks and (b) as mechanical models for the CVT. Test persons were divided into 2 groups each consisting of 12 novices and 4 experts. Each group carried out a defined training program over the course of 4 consecutive days on the VEST or the CVT, respectively. To test the transfer of skills, the groups switched devices on the 5th day. The main parameter was task completion time. Results:The novices in both groups showed similar learning curves. The mean task completion times decreased significantly over the 4 training days of the study. The task completion times for the control task on Day 5 were significantly lower than on Days 1 and 2. The experts’ task completion times were much lower than those of the novices. Conclusions:This study showed that training with a computer simulator, just as with the CVT, resulted in a reproducible training effect. The control task showed that skills learned in virtual reality are transferable to the physical reality of a CVT. The fact that the experts showed little improvement demonstrates that the simulation trains surgeons in basic laparoscopic skills learned in years of practice.

Optical Properties of Native and Coagulated Human Liver Tissue and Liver Metastases in the Near Infrared Range

Knowledge about optical parameters and the resultant light distribution in laser‐treated tissue is important for predicting the effects of laser‐induced thermotherapy of liver metastases (LITT).

Extent of surgery and recurrence rate of hidradenitis suppurativa

Abstract Hidradenitis suppurativa (HS) is a chronic fistula- and abscess-forming disease of the cutis and subcutis of unknown etiology. Disease recurrence is frequent and may cause severe complications. We analyzed patients with HS who underwent surgery between 1976 and 1997. The operative procedures were divided into drainage procedures (n=6), limited regional (n=14), and radical wide excisions (n=11). The extent of surgery was examined in terms of the clinical course and late postoperative sequelae of HS. At a mean follow-up of 72 months, we found developed locoregional recurrent HS in 45% of patients. There was 100% recurrence after drainage, 42.8% after limited, and 27% after radical excision (P<0.05). HS recurred after a median interval of 3 months for drainage, 11 months for limited excision, and 20 months for radical excision (P<0.05). The disease-free interval continued up to 35 months. Long-term sequelae included penile amputation and a case of fatal squamous cell carcinoma. Although radical wide excision of the HS-affected cutis is associated with the lowest recurrence rate, it is still considerable and warrants long-term follow-up.

Chemokine Receptor CCR6 Expression Level and Liver Metastases in Colorectal Cancer

PURPOSE The liver is the primary organ of metastasis in colorectal cancer (CRC). Chemokine receptor CCR6 is expressed on a subset of T cells and is associated with their migration into the liver. This study was performed to analyze a possible association between CCR6 expressed by primary CRC and liver metastases. PATIENTS AND METHODS CCR6 expression levels were evaluated by immunohistology in 64 CRC primary tumor specimens. Twenty-four of 64 patients had synchronous liver metastases. Evaluation of immunostaining was performed semiquantitatively by visual assessment and quantitatively by digital image analysis (DIA). Multiple logistic regression analysis was performed to assess relevant parameters for liver metastases. RESULTS CCR6 expression was verified in all 64 primary tumor specimens with considerable variations in intensity; 21 tumors (33%) demonstrated weak CCR6 staining, 32 (50%) demonstrated intermediate staining, and 11 (17%) demonstrated strong staining. Quantitative assessment by DIA showed an up to 5-log difference in CCR6 values. CCR6 staining was significantly stronger in tumor cells compared with adjacent colon epithelial cells (P < .0005). Multiple logistic regression analysis, controlling for age, sex, tumor stage, nodal status, pathologic grade, and preoperative carcinoembryonic antigen levels, revealed that CCR6 staining in the primary tumor was independently associated with the presence of liver metastases (odds ratio = 2.1; P = .002). CONCLUSION The association between expression level of CCR6 in primary CRC and synchronous liver metastases suggests that CCR6 and its ligand may be involved in the metastatic spread to the liver. Therefore, CCR6 may be a potential target for specific therapeutic interventions.

Risk factors for clinical anastomotic leakage and postoperative mortality in elective surgery for rectal cancer

Background and aimsClinical anastomotic leakage remains a major problem after anterior or low anterior resection for rectal cancer. The aim of this study was to assess the association between risk factors and anastomotic leakage and postoperative mortality.Materials and methodsTwo hundred seventy-six elective anterior or low anterior resections with anastomosis were performed and documented on-line from January 1995 to December 2004. Univariate and multivariate analyses with Bonferroni adjustment were carried out to identify relevant risk factors.ResultsThe rate of anastomotic leakage was 14.9% (41 of 276 patients) with a mortality of 12.2% (5 of 41 patients). Overall mortality was 2.5% (7 of 276 patients). Multiple regression analysis showed that smokers had an increased risk of anastomotic leakage [odds ratio (OR), 6.42; 95% confidence interval (CI), 2.68–15.36] as well as patients with coronary heart disease (OR, 7.79; 95% CI, 2.52–24.08). Smokers (OR, 13.20; 95% CI, 2.48–7.24) and patients with coronary heart disease (OR, 23.46; 95% CI, 4.33–27.04) also had an increased risk of postoperative mortality in the univariate analysis as well as patients with anastomotic leakage (OR, 16.25; 95% CI, 3.04–16.92).ConclusionsSmoking and coronary heart disease are important risk factors for anastomotic leakage and postoperative mortality after elective resection for rectal cancer.

Impact of microcirculatory flow pattern changes on the development of acute edematous and necrotizing pancreatitis in rabbit pancreas

Impairment of pancreatic microcirculation has often been advocated as one pathogenic mechanism in necrotizing pancreatitis. In contrast, data on pancreatic capillary perfusion in edematous pancreatitis are scarce. It was the aim of this experimental study to compare changes in pancreatic microcirculation in edematous and necrotizing pancreatitis. Twelve rabbits were allocated to two groups. Two different models of acute pancreatitis were used. Edematous pancreatitis was elicited by intravenous administration of cerulein (25 µg/kg/hr) (N=6). Necrotizing pancreatitis of the biliary type was induced by pressure-controlled intraductal infusion of a mixture of taurocholate, trypsin, and blood (N=6). Pancreatic microcirculation was quantified by means of intravital microscopy assessing functional capillary density, blood cell velocity, and distribution of the plasma marker FITC-dextran 70. Systemic hemodynamics were maintained at baseline values by fluid administration. Regardless of edema or necrosis, pronounced extravasation of FITC-dextran was recorded in the early stage of pancreatitis. In cerulein-induced pancreatitis, hyperemia developed as indicated by an increase in blood cell velocity in the presence of homogeneous capillary perfusion. In contrast, a progressive reduction of the number of perfused capillaries was detected in necrotizing pancreatitis. In conclusion, pancreatic microvascular perfusion may be regarded as an important pathogenetic factor for the determination of acute pancreatitis.

Outcome of patients with acute sigmoid diverticulitis: Multivariate analysis of risk factors for free perforation

BACKGROUND Sigmoid diverticulitis (SD) is common in the West; its incidence is increasing as the average age of the population increases. The aim of this study was to assess the clinical outcomes of patients with acute SD and to determine whether emergency operation was associated more often with previous episodes of acute diverticulitis. METHODS All consecutive patients admitted for acute SD were recruited prospectively over an 11-year period from January 1998 to December 2008. Multiple logistic regression was used to identify risk factors for free perforation. RESULTS We included 934 patients (490 men and 444 women; median age, 59.2 years): 450 (48.2%) presented for their first SD episode and 484 (51.8%) had a prior history of SD. Free perforation occurred in 152 patients: during the first episode of SD in 114 patients (25.3%), during the second in 29 (12.7%), during the third in 8 (5.9%), and during the fifth in 1 patient (0.9%; P < .001). No patient with >5 previous episodes of SD had free perforation. All 152 patients with free perforation required emergent operative intervention. After initial conservative therapy in 782 patients, 82 required early elective operative intervention owing to exacerbation of infection under antibiotic treatment. Late elective colectomy was performed in 299 patients during the inflammation-free interval, and operative intervention was recommended in 345 patients owing to complicated diverticulitis. Uncomplicated SD in 56 patients was managed conservatively. Comorbidity (>1 disorder) and the first episode of SD were identified as risk factors for free perforation on multiple logistic regression. CONCLUSION The risk of free perforation in acute SD decreases with the number of previous episodes of SD. The first episode thus is the most dangerous for a free perforation. The indication for colectomy should not be made based on the potential risk of free perforation.

Intravenous contrast medium aggravates the impairment of pancreatic microcirculation in necrotizing pancreatitis in the rat.

BackgroundPrevious reports demonstrated that radiographic contrast medium, as used in contrast-enhanced computed tomography, increases acinar necrosis and mortality in experimental pancreatitis. The authors studed the possibility that these changes may be related to an additional impairment of pancreatic microcirulation. MethodsFifty Wistar rats had acute pancreatitis induced by intraductal glycodeoxycholic acid (10 mmol/L for 10 min) and intravenous cerulein (5 μg/kg/hr for 6 hrs). After rehydration (16 mL/kg), pancreatic capillary perfusion was quantified by means of intravital microscopy at baseline before intravenous infusion of contrast medium (n = 25) or saline (n = 25), and 30 and 60 minutes thereafter. In addition to total capillary flow, capillaries were categorized as high-or low-flow (> or <1.6nL/min). ResultsPancreatic capillary flow did not change in either high- or low-flow capillaries after saline infusion. However, contrast medium infusion induced a significant decrease of total capillary flow (p < 0.001). Analysis according to the relative flow rate revealed that this was primarity because of a significant additional reduction of perfusion in low-flow capillaries (p < 0.0001). Furthermore, complete capillary stasis was observed in 15.9 ± 3.4% after contrast medium as compared with 3.2 ± 1.2% after saline infusion (p < 0.006). ConclusionRadiographic contrast medium aggravates the impairment of pancreatic microcirculation in experimental necrotizing pancreatitis.