Insufficiency risk of esophagojejunal anastomosis after total abdominal gastrectomy for gastric carcinoma

Background The outcome and quality of surgical treatment in gastric cancer are closely associated with specific postoperative morbidity and mortality, in addition to an oncosurgically adequate resection status. In this context, a preventive concept of decreasing the insufficiency rate of esophageal anastomosis may have a great impact.Method Over a time period of 12 months (from 1 January 2002 to 31 December 2002), 1,199 patients (from 80 East German hospitals) with gastric carcinoma, carcinoma of the esophagogastral junction, or gastrointestinal stroma tumor (GIST) were enrolled in this prospective multicenter observational study with the aim of evaluating their early postoperative outcome. By means of a logistic regression analysis, independent variables, which alter significantly the healing of esophagojejunal anastomosis, were determined; in addition, their clinical impact on preventive management to lower the insufficiency rate of esophageal anastomosis was investigated.Results In 1,139 patients, histological investigation revealed gastric carcinoma. Out of these patients, 1,031 subjects underwent surgical intervention (90.5%) and 891 individuals underwent resection (86.4%). In 813 patients, radical resection (subtotal resection and gastrectomy) was executed (78.9%), whereas in 726 cases, R₀ resection was achieved (81.5%). Gastrectomy was the preferred procedure in 649 patients, resulting in a gastrectomy rate of 62.9% relating to all patients who underwent operation (curative and palliative intention, 80.3% and 19.7%, respectively). The insufficiency rate of esophagojejunal anastomosis was 5.7% (37/649). Neither the comparison between the various procedures for the reconstruction of the esophagojejunal passage and anastomosing techniques after gastrectomy nor that between gastrectomies with curative and palliative intention revealed any significant difference. Dysphagia and gastric outlet syndrome due to a stenosis were determined as independent variables by a logistic regression analysis of all preoperative and intraoperative variables. In all patients with gastric carcinoma, both parameters were recorded in 9.9% (113/1,139) and 6.7% (76/1,139), respectively.Conclusion Dysphagia and gastric stenosis, which significantly influence the healing of esophagojejunal anastomosis after gastrectomy, are considered characteristics of an advanced tumor growth and a pretherapeutic lack of an adequate nutrition. This emphasizes the necessity of an early diagnosis of gastric cancer in order to lower perioperative morbidity. In addition, dysphagia is commonly associated with an obstruction of the upper gastrointestinal tract, which can lead to nutritional deficits, and thus deserves specific care during preventive management.     

Axillary-axillary interarterial chest loop conduit as an alternative for chronic hemodialysis access

OBJECTIVE: After exhaustion of all conventional arteriovenous (AV) access options, an alternative approach is an arterioarterial conduit. The purpose of this study was to examine the utility of an axillary-axillary (AA) interarterial (IA) access in this subset of patients. METHODS: A retrospective review was performed of all patients who underwent placement of an AA IA access. Patients were observed for functional aspects and complications. Outcomes were determined according to the Society for Vascular Surgery/American Association for Vascular Surgery standards for reports for dealing with AV accesses. RESULTS: Twenty patients (median age, 59 years; range, 41-82 years) underwent AA IA access placement under general anesthesia between May 2001 and December 2004. Exhausted upper extremity AV access options were found in 14 patients (70%), with central vein occlusion in 5 patients (25%), and 12 patients (60%) had ischemia from steal syndrome. High-output cardiac failure was present in one patient. Median follow-up was 7.4 months (range, 0.5-45.3 months). The 30-day perioperative mortality rate was 5%. There was one (5%) early access thrombosis that resulted in moderate ischemia. Late access thrombosis occurred in three patients (15%), and all cases were asymptomatic. Early postoperative bleeding necessitated surgical intervention in four patients (20%). Late graft infection (n = 1; 5%) occurred after repeated thrombectomy. The primary and secondary patency rate was 90% and 93%, respectively, at 6 months. CONCLUSIONS: This short-term initial study showed that the AA IA loop access could be implanted with acceptable perioperative morbidity and with an excellent secondary patency rate. Further follow-up is necessary to determine the long-term complication rate and to allow more reasonable comparison with other methods of access.     

Changes in bone structure after augmentation cystoplasty in chronic uraemic rats

OBJECTIVE: To investigate the effect of urinary diversion using several types of intestinal segments on cortical and cancellous bone structure of growing rats with renal insufficiency. MATERIAL AND METHODS: In all, 110 female Sprague-Dawley rats (8 weeks old) had either a two-stage subtotal nephrectomy by removing five-sixths of the renal mass, or a sham operation. Except for a uraemic control group, all uraemic rats then had an enterocystoplasty using stomach, ileum or colon (20 animals per group). An additional group with colic augmentation received the bisphosphonate ibandronate. After 12 weeks, the left tibia was assessed using peripheral quantitative computed tomography and bone histomorphometry. RESULTS: After subtotal nephrectomy all groups had approximately 30% less endogenous creatinine clearance. Renal failure alone or in association with gastric or colic augmentation induced only negligible changes in the mass and structure of cortical and cancellous tibial bone. In contrast, rats after ileal augmentation and renal failure had a significant reduction in cancellous bone mineral density (P < 0.05) whereas the reduction in trabecular bone area and volume was not statistically significant. Furthermore, ileocystoplasty caused a decrease in trabecular number and perimeter, increased trabecular separation and enlarged bone marrow space, whereas ileocystoplasty had no effect on cortical bone. The changes were not associated with alterations in serum pH. Ibandronate treatment in the colonic cystoplasty group increased trabecular bone mass and structural variables over the untreated colonic cystoplasty group. CONCLUSIONS: These results suggest that cystoplasty using an ileal segment causes a decrease in bone mass and architecture in growing rats with mild uraemia. It remains open to question whether the results obtained from experimental animals can be directly extrapolated to the clinical situation.     

Margarine consumption, asthma, and allergy in young adults: results of the German National Health Survey 1998

PURPOSE: To examine whether frequent intake of margarine is associated with allergy prevalence in adults using data of a representative national health survey. METHODS: Data on 7124 subjects aged 18 to 79 years were obtained from the German National Health Survey 1998. Confounder-adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated by multiple logistic regression, using the frequency of intake of low-fat butter, regular and low-fat margarine as explanatory variable in relation to frequent intake of regular butter as reference group. RESULTS: Frequent intake of margarine of any kind was positively associated with current asthma during the past 12 months in young adults aged 18 to 29 years (aOR, 2.33; 95% CI, 1.03-5.26). In subgroup analysis, the positive association was confined to frequent intake of low-fat margarine (4.51; 1.78-11.43) or the combination of low-fat margarine and low-fat butter (4.79; 1.84-12.44). Consumption of margarine of any kind was not related to hay fever, atopic dermatitis, and atopic sensitization to inhalant allergens. CONCLUSIONS: Frequent intake of margarine rich in n-6 PUFA is not consistently associated with allergic diseases in adults. Other constituents of low-fat margarine or certain dietary habits and lifestyle factors, characterized by use of low-fat margarine, may be related to current asthma.     

Nicotine and cotinine in adults' urine: The German Environmental Survey 1998

In 1998, the German Environmental Survey (GerES III) recruited approximately 5000 adults between the ages of 18 and 69 years. The study population for these analyses consisted of 1580 smokers (34% of the total population) and 3126 nonsmokers. Nicotine and cotinine concentrations in urine were determined by HPLC methods with UV-detection and corrected for creatinine. Nicotine and cotinine concentrations differed between smokers and nonsmokers by factors of 10-100. The multiple linear regression models used for the analyses of nicotine detection in the urine of smokers explained 43.2% and 42.3% of the total volume-specific and creatinine-specific variances, respectively. Cigarette smoking was the major factor responsible for 41% of the total variance. The explained variances of the cotinine results were larger, 51.0% and 49.3% of the total variance were volume-specific and creatinine-specific, respectively. More than 20% of nonsmokers in GerES III were exposed to environmental tobacco smoke at home, at work or in other places. The logistic regression analysis approach used for the group of nonsmokers showed the greatest effects for those exposed to tobacco smoke at home (adjusted OR varied between 4 and 6). These results were seen for nicotine as well as for cotinine excretion. Exposure to tobacco smoke in the workplace doubled the risk for the detection of nicotine and cotinine in urine. When other risk factors such as age, sex, social status, community size, season of urine collection, and the consumption of food containing nicotine such as potatoes, cabbage, tea were included, the effect estimates for tobacco smoke exposure remained unchanged. A new federal bill to diminish environmental tobacco smoke (ETS) exposure in the workplace was recently passed in Germany, but protection of nonsmokers from smoking family members at home needs more attention.     

Psychosocial rehabilitation and satisfaction with life in adults with childhood-onset of end-stage renal disease

Little information is available on vocational rehabilitation and satisfaction with the quality of life in adult patients with early onset of end-stage renal disease (ESRD). A sample of 39 patients (mean age =26.7±6, range, 18 to 43 years, n =13 on dialysis, n =26 transplanted successfully) were required to report data on their vocational qualification and employment, and their degree of general and health-related satisfaction with life was surveyed. Data on psychosocial rehabilitation were collected by a structured questionnaire, whereas satisfaction with the quality of life was assessed with the standardized Questionnaire on Satisfaction in Life (FLZ). Fifty-eight percent of the patients had left school with certificates equivalent to high school graduation, 87% had completed vocational training and 67% were in paid employment. Forty-nine percent lived on their own or with a partner and 72% fully or partly earned their own living. The mean general and health-related satisfaction with life is significantly reduced compared to the general population. The patients were least satisfied in the areas partnership/sexuality and family life/offspring in general, as well as physical condition and ability to relax within health-orientated satisfaction. Final mean body height was 167.6±11.9 (SDS –1.54±1.59) for male and 153.77±8.29 for female patients (SDS –1.58±1.54). Thirty-six percent reported to be dissatisfied with their present body height compared to 4% of age-matched healthy controls. Positive perception of quality of life was significantly correlated to satisfaction with adult height ( r =0.41, P =0.008). Vocational rehabilitation of adult patients with early onset of ESRD achieves lower values than among the general population, however, more favorable percentages than among young adult patients or patients with adult onset of ESRD. The patients self-evaluation of both their general and health-related quality of life proves to be clearly muted, which is a clear indication of the physical and psychological strain of living with a chronic disease.     

Observer assessment of femoral neck radiographs after reduction and dynamic hip screw fixation

Introduction It is not known how the described methods of reduction and dynamic hip screw (DHS) fixation of displaced intracapsular femoral neck fractures translate into proper assessment of the postoperative radiographs. At teaching or evaluation sessions in daily practice, frequent discussion arises about postoperative technical assessment. The assessment of correct reduction and DHS fixation using the described methods in the literature may be subject to differences between observers. The aim of this study was to assess the extent of inter- and intraobserver agreement on technique, based on the methods in the literature, in a simulated daily practice setting. Materials and methods The postoperative anteroposterior (AP) and lateral radiographs of 35 randomly selected patients aged 60–90 years were rated twice, 2 months apart, by six surgical observers from three institutions with similar views on reduction and DHS fixation for this fracture type. The radiographs were of sufficient quality for proper assessment. Criteria for reduction and fixation could be rated as either adequate or inadequate. An adequate rating was assigned if in the observers opinion, regardless of likely outcome, technical perfection according to the described methods had been achieved. The kappa statistic was calculated as a measure of agreement.Results Fracture reduction on the AP view approached a good kappa value (0.54). Poor to moderate interobserver agreement was found for fracture reduction on the lateral view and aspects of DHS fixation (kappa 0.10–0.36). Intraobserver agreement was good for five out of six observers for reduction and DHS fixation aspects (kappa 0.51–0.81).Conclusion During routine practice six surgical observers can nearly agree on adequate fracture reduction on the AP view, but do not agree on adequate reduction on the lateral view and adequate DHS fixation on the postoperative radiographs of displaced intracapsular femoral neck fractures.     

Distribution of substance-P nerves inside the infrapatellar fat pad and the adjacent synovial tissue: a neurohistological approach to anterior knee pain syndrome

Introduction The purpose of the study was to determine the distribution and number of nerves inside the infrapatellar fat pad and the adjacent synovium, in particular with regards to nociceptive substance-P nerves.Materials and methods The infrapatellar fat pad of the knee was resected from 21 patients (4 male, 17 female, mean age 69 years) during the course of standard total knee arthroplasty operations performed in our clinic. The fat pad was dissected into five standardized segments, fixed in formalin and embedded in paraffin. Immunohistochemical techniques using antibodies against S-100 protein and substance-P (SP) were employed to determine and specify the nerves.Results Studying all the detectable nerves present in 50 observation fields (200-fold magnification), we found an average of 106 S-100 versus 25 SP nerves (24%) in the synovium and 27 S-100- versus 7 SP nerves (26%) in the interior of the fat pad. The total nerve count was significantly ( P <0.001) higher in the synovium than in the fat pad for both marker types. The number of S-100 nerves was significantly ( P <0.05) higher in the central and lateral segments of the fat pad, while SP nerves were equally distributed throughout all segments of the fat-pad. SP nerves were significantly more frequently associated with blood vessels inside the fat pad (43%, P <0.05) than in the synovial tissue (28%).Conclusion The occurrence and distribution of SP nerves inside the infrapatellar fat pad suggest a nociceptive function and a neurohistological role in anterior knee pain syndrome. The data support the hypothesis that a neurogenous infection of the infrapatellar fat pad could contribute to anterior knee pain syndrome.     

Transverse Versus Midline Incision for Upper Abdominal Surgery

Purpose Transverse and midline abdominal incisions are both commonly used for laparotomy to perform surgery on the pancreas and stomach, but comparative data are limited, especially from prospective randomized trials.Methods During a predefined 2-year recruitment period, 94 patients undergoing an elective major laparotomy for disorders of the pancreas or stomach were enrolled in this study. The outcome measures were pulmonary function, incisional pain, and wound characteristics.Results The operation groups were equally divided according to the type of incision used. The patients who underwent transverse incision laparotomy had significantly better postoperative pulmonary function and significantly less postoperative incisional pain than those who underwent midline incision laparotomy (P < 0.05), but there were no differences in morbidity and the incidence of wound complications.Conclusion Performing a transverse incision for surgery on the pancreas or stomach results in better postoperative pulmonary function and less incisional pain than a midline incision, without affecting postoperative morbidity.