V. Zumtobel

Early postoperative enteral nutrition with arginine-omega-3 fatty acids and ribonucleic acid-supplemented diet versus placebo in cancer patients: an immunologic evaluation of Impact.

OBJECTIVE To evaluate the effect of early postoperative feeding with a nutritionally complete enteral diet supplemented with the nutrients arginine, ribonucleic acid (RNA), and omega-3 fatty acids on the immune function in patients undergoing surgery for upper gastrointestinal (GI) malignancies. DESIGN Prospective, randomized, placebo-controlled, double-blind study. SETTING Surgical intensive care unit (ICU) in a German university hospital. PATIENTS Forty-two consecutive patients receiving an enteral diet via needle catheter jejunostomy after GI surgery for cancer. INTERVENTIONS Patients were randomized to receive either the arginine, RNA, and omega-3 fatty acids supplemented diet or an isocaloric and isonitrogenous placebo diet. Early enteral nutrition was started on postoperative day 1 in the surgical ICU with 20 mL/hr and progressed to the optimal goal of 80 mL/hr by postoperative day 5. MEASUREMENTS AND MAIN RESULTS Clinical examination and adverse GI symptoms were recorded on a daily basis. Body weight was determined twice weekly. Immunoglobulin concentrations were determined by laser nephelometry. Interferon-gamma concentrations were measured with a modified enzyme-linked immunosorbent assay method. Fluorescence-activated cell scan flow cytometry was performed to analyze B cells, T lymphocytes and their subsets. Clinical patient characteristics and mean caloric intake were similar between the two groups and both formulas were well tolerated. The number of T lymphocytes and their subsets, helper T cells (CD4) and activated T cells (CD3, HLA-DR), were significantly higher in the supplemented diet group on postoperative days 10 and 16 (p < .05). Mean interferon-gamma concentration after phytohemagglutinin stimulation was higher in the supplemented diet group on postoperative day 16. In the supplemented diet group, mean immunoglobulin M concentrations were significantly higher on postoperative day 10 and mean immunoglobulin G concentrations were higher on postoperative day 16 (p < .05) compared with the results in the placebo group. B-lymphocyte indices were significantly higher in the supplemented vs. the placebo diet group on postoperative days 7 and 10 (p < .05). CONCLUSIONS Supplementation of enteral diet with arginine, RNA, and omega-3 fatty acids in the early postoperative time period improves postoperative immunologic responses and helps to overcome more rapidly the immunologic depression after surgical trauma.

Experimental comparison of monofile light and heavy polypropylene meshes : Less weight does not mean less biological response

BackgroundMesh implantation is a standard procedure in hernia repair. It provides low recurrence rate but increases complication rate due to foreign-body reaction induced by alloplastic materials in surrounding tissues. It is believed that biocompatibility of meshes may be improved by reducing their weight per meter squared (m2) and altering the implant structure.AimThe aim of this study was to evaluate the effect of weight and structure as determinants of mesh biocompatibility.MethodThirty-six Wistar rats were studied. In 12 animals, conventional polypropylene (heavy) meshes (HM) were implanted; in other 12, material-reduced (light) microporous polypropylene meshes (LM); and the remaining 12 served as a sham-operated control group. Meshes were explanted after 21 and 90 days (6 animals per group). All samples were examined by light and electron microscopies. Integration of meshes in surrounding tissue, inflammatory response, fibrotic reactions, and structural changes were recorded. Quantification of the inflammatory response was achieved by CD-68 marking of macrophages and counting their number per surface unit.ResultsAfter 21 days, there was no significant difference in thickness of surrounding connective tissue between meshes in all groups studied. After 90 days, thickness of connective tissue decreased in both groups, and fibrotic reaction in the mesh bed was significantly less in the HM group. Total amount of macrophages per millimeter squared (mm2) decreased with time in HM and LM samples but was significantly lower in the HM group on day 21 (43.5%) and day 90 (46.7%).ConclusionThis study found worse biocompatibility of LM compared with HM. Thus, the amount of implanted mesh was not the main determinant of biocompatibility (expressed as successful incorporation and diminished foreign-body reaction) but the size of the pores.

Operative results and outcome of twenty-four totally laparoscopic vascular procedures for aortoiliac occlusive disease

PURPOSE The study objective was to apply laparoscopic techniques to conventional bypass procedures for aortoiliac occlusive disease. METHODS From October 1995 to August 1997, we performed seven iliofemoral (IFB), five unilateral aortofemoral (UAFB), and 11 aortobifemoral (AFB) bypass procedures and one aortic endarterectomy (TEA) totally laparoscopic. A transabdominal approach with pneumoperitoneum was preferred, and only laparoscopic vascular instruments were used. Endoscopic intervention followed principles of vascular surgery. As in open surgery, we used Dacron grafts and polypropylene sutures. RESULTS Twenty procedures were carried out totally laparoscopic; four conversions to open surgery were necessary. Severe complications included one postoperative respiratory failure requiring ventilatory support for four days, and one iliac vein lesion with subsequent open surgery. Mean operating time was 258 +/- 49 minutes for IFB, 218 +/- 54 minutes for UAFB, 279 +/- 69 minutes for AFB, and 290 minutes for aortic TEA. Mean blood loss was 92 +/- 49 ml for IFB, 390 +/- 316 ml for UAFB, 563 +/- 516 ml for AFB, and 100 ml for aortic TEA. Mean postoperative stay was 7.4 days for IFB, 7.8 days for UAFB, and 10.1 days for AFB. After the aortic TEA, the patient was discharged on day 6. At control examination all grafts were patent; two patients had mild claudication because of one progressive disease and one distal suture stenosis. CONCLUSION Laparoscopic vascular surgery for aortoiliac occlusive disease is feasible, safe, and effective. At the beginning, a cooperation between experienced laparoscopists and vascular surgeons is needed to overcome procedural challenge, because operating time and conversion rate decrease with growing experience. The advantages observed in the majority of our patients were minimal tissue trauma, decreased blood loss, and faster postoperative recovery when compared with patients who had open aortic surgery at our institution. Further evidence has to be gained by clinical trials to define the role of laparoscopic vascular surgery for aortoiliac occlusive disease.

Thyroid nodules in recurrent multinodular goiters are predominantly polyclonal

Not only thyroid adenomas and carcinomas, but also the majority of single and well delimited goiter nodules, even if morphologically heterogeneous, are of clonal origin. However, it is still unknown whether the nodules of rapidly growing, recurrent goiters are clonal or polyclonal. We investigated by PCR-based analysis of exon 1 of the human androgen receptor gene clonality of nodules grown in recurrent multinodular goiters (MNG) of 14 female patients. The total goiter volume varied widely between 15 ml and 170 ml. The mean age of patients undergoing surgery for recurrent goiter at the time of their first operation was significantly lower with 34.6±10.9 yr in comparison to 50 consecutive patients who were operated for MNG for the first time (53.7±13.5 yr). The interval between first and recurrent operation was 18±8.5 yr. The mean volume of well circumscribed nodules selected for the present investigation was 3.8±1.4 ml. Assessment of clonality in at least 2 samples of each lesion revealed a polyclonal pattern in 10 out of 14 nodules, whereas only 3 nodules were clonal and in one case the result remained unclear. The unexpected finding that most nodules within MNG, that had re-grown after a first subtotal thyroidectomy, were of polyclonal rather than clonal composition, suggests that these lesions are generated by de novo — proliferation of cohorts of differing thyrocytes sharing the common trait of an exceedingly high intrinsic growth rate or alternatively, by unknown growth stimulating molecular events acting focally on clusters of cells derived from different ancestors. In addition, the relatively young age of patients with recurrent MNG at the time of their first surgery and the comparatively short interval between first and second operation point to a genetic element in the occurrence of growth-prone thyrocytes.

Laparoscopic needle catheter jejunostomy: modification of the technique and outcome results

Background: We describe a modification of the technique for laparoscopic jejunostomy in patients with stenosis of the upper gastrointestinal tract and assess the patients outcomes with this enteral access. Methods: In a retrospective study of 80 patients, we evaluated the outcome of a modified technique for the laparoscopic placement of a jejunostomy catheter into the proximal jejunum. Standard laparoscopy equipment and ready-to-use jejunostomy catheters were used. After the creation of a pneumoperitoneum, the proximal jejunal loop was fixed to the parietal peritoneum. The jejunum was then punctured with a split needle, and the catheter (9F) was pushed into the jejunum. Finally, the catheter was secured with an additional purse-string suture. The external fixation was performed with nonabsorbable sutures. Enteral nutritional support with a polymeric enteral diet was initiated after fluoroscopic control on the first postoperative day at a rate of 20 ml/h. The flow rate was increased progressively until the nutritional goal of 60–80 ml/h was reached on the 3rd or 4th postoperative day. Results: In all patients (n = 80), the placement site of the catheter was correct, and all patients were able to receive enteral nutrition on the 1st postoperative day. There were no intraoperative complications. The mean operating time was 51 min. Two patients developed a localized infection at the catheter site; one patient developed an abscess; and three patients had catheter obstructions. Conclusions: Patients in need of intermediate or long-term enteral nutrition may benefit from laparoscopic catheter jejunostomy. The technique described is safe, effective, and less invasive than alternative techniques of laparoscopic jejunostomy.

The clonality of nodules in recurrent goiters at second surgery

Introduction: Some studies showed that in multinodular goiters clonal and polyclonal nodules coexist. The clonality of nodules in recurrent goiters is, however, still unknown and may contribute to help explain the pathogenesis of this thyroid disease. Methods and results: The clonality of 14 nodules derived from recurrent goiters was assessed by means of an X-chromosome-inactivation method. Of 14 nodules, 10 showed a polyclonal pattern, 3 were clonal and, in 1 case, the result remained unclear. The mean age of the patients with recurrent goiter at the time of their first operation was significantly lower than the mean age of 50 patients who underwent thyroid surgery for the first time over the same period of time (34.6±10.9 years vs 53.7±13.5 years; P<0.05). The mean interval between first and second operation was 18 years. Conclusion: The finding that nodules in recurrent goiters are predominantly polyclonal suggests that these lesions have their origin in a de novo proliferation of different cohorts of thyrocytes due to unknown growth stimulating molecular events.

Lokale Auswirkungen und Veränderungen von Wunddrainagen in der freien Bauchhöhle

In a prospective randomised study 30 mongrel rabbits recieved two standard colon-resections. Three types of drains were testet: (latex-rubber-) Penrose-drains, rubbertube- and silikontube-drains, which were placed in the lower abdomen. As a closed drainage-system the extraperitoneal tip of the drain was placed in a closed subcutis-pocket. One of the two colon-anastomoses also was drained. The findings were recorded on the 7th postoperative day. A single mechanic alteration was found, an ulcer caused by a silicon-drain, that pushed against the abdominal wall. The other signs of mechanic irritation were microscopically unspecified inflammatory reactions to the foreign body drain. There was no ascending infection caused by the drain. All infections came from complications of the colon resections. In contrast to common opinions the drains in the lower abdomen showed no adhäsions to the abdominal wall or organs. Only the entrance of the drain into the peritoneum and the cotton-gaze of Penrosedrains showed in nearly all cases adhesions. The large amount of adhesions to the anastomosis-drains came from complications of the colon-anastomoses. As a cause of material, rubber- and latex-rubber-drains showed large fibrinclotts on their surfaces. 7 days after the operation only about 20% of the drains had sufficient function. The rest was occluded by fibrin-clotts in the lumen of the drain or the cotton-gaze. Over all there is no difference in changes and effects of the three different types of drains, but silicon as material showed advantages.ZusammenfassungIn einer prospektiven randomisierten Studie an 30 Mischrassekaninchen wurden nach 2 standardisierten Dickdarmresektionen bei je 10 Tieren Penrose-, Gummirohr- und Silikonkautschukrohrdrainagen in den Unterbauch eingesetzt und als geschlossenes Drainagesystem subkutan abgeleitet. Eine der Darmanastomosen wurde ebenfalls drainiert. Auswertung und Befunderhebung erfolgten am 7. postoperativen Tag. An mechanischen Auswirkungen wurde nur 1mal ein Druckulkus durch Anstemmen einer Silikonrohrdrainage im Unterbauch beobachtet. „Wetz“-Spuren waren sonst nur lokale unspezifische Entzündungsreaktionen gegen den Fremdkörper Drain, die in gleichem Maß bei allen Draintypen auftraten. Eine vom Drain ausgehende, aufsteigende Infektion wurde nicht beobachtet. Infektionen hatten ihren Ursprung immer von Komplikationen im Operationsgebiet. Entgegen bisheriger Vorstellungen waren die Drainagen im Unterbauch frei von Verwachsungen und Verklebungen zu den Organen der Bauchhöhle. Lediglich die Durchtrittsstelle an der Bauchdecke und der Baumwolldocht der Penrose-Drainage zeigten regelmäßig Verwachsungen. Die ausgedehnten Verwachsungen der Anastomosendrainagen waren auf Auswirkungen der Darmanastomosen und deren Komplikationen zurückzuführen. Gummirohr und Latexgummi zeigten materialbedingt großflächige Fibrinauflagerungen. Durch Verstopfung des Drainrohrs und des Baumwolldochts mit Fibrinkoageln waren nach 7 Tagen nur noch ca. 20% der Drainagen durchgängig. Prinzipiell bestand kein Unterschied im Verhalten der 3 verschiedenen Drainagetypen bei Materialvorteilen des Silikonkautschuks.

Central perineal hernia mimicking rectocele: a case report

BackgroundA perineal hernia is a very rare clinical finding. Three forms are distinguished: anterior, posterior, and central. Diagnosis of the last one is difficult, and sometimes, it is falsely named a posterior rectocele.AimThis work presents a successfully treated case of central perineal hernia and makes a brief summary of existent literature on the problem.Presentation of the caseWe report of a 67-year-old female patient with a symptomatic central pelvic floor hernia. After radiological confirmation of the diagnosis, a transperitoneal approach was chosen to reposition the protruded segment of the small bowel. The hernial orifice was closed by extraperitoneal implantation of a polypropylene mesh.DiscussionIn the present case, the use of a laparoscopic technique seemed unsuitable due to the extension of the findings. For the repair of perineal hernia, we followed the principles of the “tension-free” concept. If there are no signs of a pelvic floor infection and if the mesh can be implanted totally extraperitoneally, we recommend the use of nonabsorbable alloplastic material (polypropylene) for reinforcement of the pelvic floor as a suitable technique for the repair of large perineal hernias.

Mikrozirkulationsstörungen bei Colonanastomosen und ihre Bedeutung für die Pathogenese der Nahtinsuffizienz

SummaryIn this morphologic experimental study in the rabbit disturbances in the microcirculation at the site of colonic anastomoses were found in all suture techniques employed. They are caused by resection, intraoperative traumatization, the suture technique, and, secondarily, by abscess formation on the anastomosis. The suture-induced disturbances of the microcirculation lead to necroses of the mucosa, partial and complete necroses of the inverted cuff, and transmural necroses with destruction of the sero-serous contact zone. For the pathogenesis of anastomotic dehiscence only transmural and extensive complete necroses of the anastomotic bulge, including the serosal contact, are important. They result in transmural abscess formations which correspond to microscopic small secondary anastomotic leakages.ZusammenfassungMikrozirkulationsstörungen der Colonanastomose finden sich nach einer morphologischen experimentellen Untersuchung am Kaninchen bei stoßgerechten wie invertierenden Nahttechniken. Ursache sind die Resektion, die intraoperative Traumatisierung, vor allem die Nahttechnik selbst, sekundär auch Abscedierungen an der Anastomose. Folgen der nahtbedingten Mikrozirkulationsstörungen sind je nach Ausdehnung und Nahttechnik Mucosanekrosen, partielle und vollständige Wulstnekrosen sowie transmurale Nekrosen unter Zerstörung der sero-serösen Kontaktzone. Mucosanekrosen und die partiellen Wulstnekrosen bei den invertierenden Techniken haben für die Pathogenese der Nahtinsuffzienz keine Bedeulung. Aus transmuralen Nekrosen bei stoßgerechter Naht and aus ausgedehnten vollständigen Wulstnekrosen mit Destruktion des Serosakontaktes bei der invertierenden Naht resultieren jedoch transmurale Abscedierungen. Sie entsprechen histologisch kleinen sekunddren Insuffizienzen und zeigen so den pathogenetischen Weg von der Nekrose über eine Abscedierung zu einem Leck an der Anastomose.In this morphologic experimental study in the rabbit disturbances in the microcirculation at the site of colonic anastomoses were found in all suture techniques employed. They are caused by resection, intraoperative traumatization, the suture technique, and, secondarily, by abscess formation on the anastomosis. The suture-induced disturbances of the microcirculation lead to necroses of the mucosa, partial and complete necroses of the inverted cuff, and transmural necroses with destruction of the sero-serous contact zone. For the pathogenesis of anastomotic dehiscence only transmural and extensive complete necroses of the anastomotic bulge, including the serosal contact, are important. They result in transmural abscess formations which correspond to microscopic small secondary anastomotic leakages.

Effects of Proximal Gastric Vagotomy on the Gastrointestinal Transit Time of a Mixed Solid-Liquid Test Meal through the Stomach, Small Intestine and Colon

In order to detect the effects of proximal gastric vagotomy on the gastrointestinal transit time during the early and late postoperative periods, a mixed solid-liquid test meal containing 0.5 mCi