Nedim Yücel

Functional treatment and early weightbearing after an ankle fracture : A prospective study

Objective: Postoperative care for ankle fractures is generally 1 of 2 regimens: 1) functional treatment combined with early weightbearing (EWB), or 2) immobilization in a cast/orthosis for 6 weeks without weightbearing (6WC). The objective of this study was 2-fold: 1) to follow a prospective group treated with EWB as to long-term subjective and objective outcomes, and 2) to compare a subset of this group with a matched group of historic controls treated with 6WC. Design: Prospective, clinical, cohort observation, and retrospective matched pair analysis. Setting: University hospital, level 1 trauma center. Patients: Forty-three patients (20 males; mean age, 49 ± 14 years) with operated Weber B/C fractures underwent EWB. For comparison, 23 patients of this group were matched to a same number of historic controls with respect to age, gender, body mass index, and fracture type. Intervention: Open reduction and internal fixation (ORIF) using a 1/3-tubular-fibula-plate for the fibula, and malleolar screws for the medial malleolus fracture (in cases with a bimalleolar ankle fracture) followed by EWB or 6WC. Main Outcome Measurements: Olerud and Tegner scores at follow-up (at least 12 months after surgery), time to full weightbearing, return to work, pain intensity (numerical rating scale (NRS)), and hospital stay. Statistical comparisons were performed by using the Mann-Whitney U test or Fisher exact test (P < 0.05). Results: Patients with EWB were full weightbearing at 7 ± 3 weeks and returned to work at 8 ± 5 weeks after surgery. At follow-up (mean, 20 ± 11 months after surgery), all EWB patients showed good results in the Olerud score (90 ± 13 points). Matched-pair analysis in 23 patients in each group revealed differences between EWB and 6WC groups for hospital stay (mean, 10.8 ± 4.7 vs. 13.6 ± 6 days; P = 0.12), time to full weightbearing (mean, 7.7 ± 3.1 vs. 13.5 ± 9.4 weeks; P = 0.01), and time until return to work (mean 9.2 ± 5.5 vs. 10.8 ± 7 weeks; P = 0.63). No differences concerning pain intensities were observed (EWB vs. 6WC: NRS = 1.9 vs. 1.7; P = 0.12). At follow-up, Olerud scores were generally considered good for both groups; however, mean values in EWB patients were slightly higher (87 ± 14 vs. 79 ± 19 points; P = 0.25). In both groups, the majority of patients reached their preinjury level of activity as demonstrated by Tegner scores. Conclusions: EWB patients tolerated earlier full weightbearing compared with 6WC patients, and there were no disadvantages with EWB compared with 6WC concerning hospital stay, pain intensities, time until return to work, and Olerud/Tegner Scores. Potential candidates for EWB are patients with a stable osteosynthesis of their fractured ankles as judged by the responsible surgeon, compliance, and high motivation.

Antiinfective and encrustation-inhibiting materials—myth and facts

Catheters, urethral and ureteral stents and other urological implants are frequently affected by encrustration and infection due to their permanent contact with urine. Indwelling urinary catheters provide a haven for microorganisms and thus require extensive monitoring. Several surface modification techniques have been proposed to improve the performance of devices including the immobilization of biomolecules, the incorporation of hydrophilic grafts to reduce protein adsorption, the creation of hydrophobic surfaces, the creation of microdomains to regulate cellular and protein adhesion, new polymers and antimicrobial coatings. Physico-chemical explanation to elucidate the mechanism of such encrustation or infection inhibiting materials is still not available. Our series of experiments showed a marked decrease of silver-activity in biological fluids which corresponds with the controversial clinical results obtained with silver coated urinary catheters. Rifampicin/minocycline coated catheters had very low activity against Gram-negative rods, enterococci and Candida spp., the main causing organisms of urinary catheter infection. Surface engineered materials and antimicrobial drug delivery systems will be the next generation of sophisticated urinary catheters and stents, if both efficacy as well as efficiency has been proved clinically.

Port function after laparoscopic adjustable gastric banding for morbid obesity

Background: Laparoscopic adjustable gastric banding (LGB) has gained wide popularity, but information on port function is limited. Methods: In a prospective nonrandomized study, we analyzed port function and related symptoms in 50 consecutive patients with severe obesity. All patients underwent LGP in a five trocar technique. In 11 patients, the port was placed subcutaneously in the subxiphoid region. In 39 patients, the port was implanted in the left upper abdomen. Mean duration of follow-up was 2.8 years. Results: Patients (12 males and 38 females) had an initial body mass index (BMI) of 47.1 kg/m2. Puncturing the subxiphoidal port was without problems in all 11 patients. However, seven women reported pain and inconvenience when wearing a brassiere. Two underwent port reimplantation in the left upper abdomen (one due to infection; one due to pain). Among the 39 patients with abdominal port implantation, nine patients required port correction (two of them twice). The causes were port dislocation (four cases), difficult puncturing (three), tube leakage (three), and infection (one).Conclusion: The high number of complications suggests that the port is the Achilles’ heel of LGB. Ports at the subxiphoid site were easier to puncture, but frequently caused pain in female patients.

Laparoscopic Gastric Bypass for Morbid Obesity with Linear Gastroenterostomy

Background: Laparoscopic gastric bypass (LGBP) is a well-established procedure for the surgical management of morbid obesity. Most surgeons create the gastroenteral anastomosis by using the circular EEA stapler. We describe an alternative laparoscopic anastomotic technique using the EndoGIA linear stapling device. Methods: The stomach was proximally transected with a linear stapler (45 mm, Endo-GIA) to create a 15 to 20 ml pouch. Next, an antecolic Roux-en-Y gastroenterostomy was performed, using the 45 mm Endo-GIA. The proximal loop of the intestine was then separated from the anastomotic site by the Endo-GIA. Finally, the Endo-GIA was used for the intraabdominal creation of a side-to-side enteroenterostomy. Results: Between June and August 2001, 5 patients with mean BMI 56.7 kg/m2±7.3 underwent LGBP. All patients were seen 6 months post-surgery. Operating time was 7.5 and 6.5 hours for the first 2 operations, but was under 4.5 h for the next 3 cases. 1 patient suffered from perioperative hypoxia leading to long-term artificial respiration. 6 weeks after surgery, 1 patient developed obstruction due to torsion of the enteroenterostomy and required open revision. The 3 remaining patients made an uneventful recovery. All patients lost considerable weight (mean 36.5 kg; [range 32 to 45] after 6 months). No stenosis or anastomotic leakage was noted. Conclusions: A linear stapled anastomosis is an alternative to the use of the circular stapler.

Stellenwert der stationären ösophagusdurchzugsmanometrie zur präoperativen Abklärung von Patienten mit gastro-ösophagealer Refluxkrankheit

Einleitung: Die stationare Osophagusdurchzugsmanometrie hat sich inzwischen als Standard in der Diagnostik von Osophagusfunktionsstorungen etabliert. Jedoch ist die Bedeutung der einzelnen Komponenten des Manometrieprotokolls fur die Wahl der OP-Methode bei gastroosophagealer Refluxkrankheit (GERD) nicht adaquat untersucht. Ziel dieser Studie war die Evaluierung des Einflusses der verschiedenen Parameter der Osophagusmanometrie auf die chirurgischen Strategie bei GERD. Patienten und Methoden: Von Januar 1995 bis Januar 2000 wurden 123 konsekutiv zugewiesene GERD-Patienten untersucht. 97 dieser Patienten (52 Frauen und 45 Manner, mittleres Alter 48 Jahre) wurden mit einer Fundoplikatio nach Nissen in konventioneller oder laparoskopischer Technik versorgt. Praoperativ wurden bei jedem Patienten eine stationare Osophagusdurchzugsmanometrie mit Wasserperfusionskatheter, sowie Gastroduodenoskopie und 24 h-osophagus-pH-Metrie standardmasig durchgefuhrt. Unabhangig von den Ergebnissen der Osophagusmanometrie erhielt jeder Patient eine 360°-Fundoplikatio mit 2 cm langer Manschette („floppy-Nissen“). Ergebnisse: Praoperativ wiesen 85 der 97 Patienten (88%) eine Inkompetenz des unteren osophagussphinkters auf. Bei 17 (18%) Patienten wurde eine Osophagushypomotilitat diagnostiziert. Bei 2 bzw. 1 nicht operierten Patienten wurde eine amotile Achalasie bzw. ein diffuser Osophagusspasmus festgestellt. Postoperativ wurden 92% der Patienten nachuntersucht (mittlere Nachuntersuchungszeit 1,8 Jahren). 5 bzw. 8 Patienten (1 bzw. 2 davon hypomotil) entwickelten postoperativ eine persistierende Dysphagie bzw. ein Rezidiv (Relatives Risiko 1,2 bzw. 1,6). Zwei Patienten (einer hypomotil) wurden reoperiert. Schlussfolgerungen: Die praoperative Osophagusmanometrie bei GERD kann auf die Bestimmung der oberen Grenze des unteren Osophagussphinkters, sowie den Ausschluss spezieller Osophagusmotilitatsstorungen eingeschrankt werden. Die „floppy-Nissen“ Fundoplikatio kann ohne zusatzliches Dysphagierisiko bei Patienten mit hypomotilem Osophagus angewandt werden.