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Objectives: The study compares three minimally invasive approaches for the retention of implant supported mandibular complete dentures, particularly focusing on patient satisfaction., Background: The McGill Consensus Statement recommends restoration of the edentulous mandible with an overdenture retained on two implants. Alternatively, less invasive treatment concepts with shorter treatment times have been developed for critical cases., Material and Methods: Thirty-nine patients (with a total of 78 implants) with advanced mandibular bone atrophy were randomly assigned to three groups: "single standard implant-retained overdentures" (SSO) and "mini-implant-retained overdentures" (MO), which was further subdivided into "two mini-implant-retained overdentures" (TMO) and "four mini-implant-retained overdentures" (FMO). The technical and biological parameters and oral health-related quality of life were evaluated over a 10-year period. Data were analysed for group comparisons and longitudinal trend analysis., Results: Sixteen patients (42%) dropped out during the study period. At the time of follow-up, 98.4% of the implants were in situ. The first need for technical intervention occurred after 3.8 ± 1.1, 4.2 ± 0.9, and 4.6 ± 1.3 years in the TMO, SSO, and FMO groups, respectively. Attachment exchange (39%) was the most frequently performed intervention in all groups. Healthy peri-implant and mucosal conditions were observed in 74% and 40% of patients after 1 and 10 years, respectively. The OHIP-G14 score was 22.6 before implantation, 7.6 at 1 year (effect size [ES]: 1.1), and 5.4 at 10 years (ES: 2.3)., Conclusion: Irrespective of the minimal concept selected, complete mandibular dentures retained on implants improved the subjective perception of the quality of life. Application of these alternative minimal concepts may be practical in clinical practice., (© 2024 The Author(s). Gerodontology published by Gerodontology Association and John Wiley & Sons Ltd.)

Studying the genetic basis of leaf wax composition and its correlation with leaf cuticular conductance (gc) is crucial for improving crop productivity. The leaf cuticle, which comprises a cutin matrix and various waxes, functions as an extracellular hydrophobic layer, protecting against water loss upon stomatal closure. To address the limited understanding of genes associated with the natural variation of adult leaf cuticular waxes and their connection to gc, we conducted statistical genetic analyses using leaf transcriptomic, metabolomic, and physiological data sets collected from a maize (Zea mays L.) panel of ∼300 inbred lines. Through a random forest analysis with 60 cuticular wax traits, it was shown that high molecular weight wax esters play an important role in predicting gc. Integrating results from genome-wide and transcriptome-wide studies (GWAS and TWAS) via a Fisher's combined test revealed 231 candidate genes detected by all three association tests. Among these, 11 genes exhibit known or predicted roles in cuticle-related processes. Throughout the genome, multiple hotspots consisting of GWAS signals for several traits from one or more wax classes were discovered, identifying four additional plausible candidate genes and providing insights into the genetic basis of correlated wax traits. Establishing a partially shared genetic architecture, we identified 35 genes for both gc and at least one wax trait, with four considered plausible candidates. Our study enhances the understanding of how adult leaf cuticle wax composition relates to gc and implicates both known and novel candidate genes as potential targets for optimizing productivity in maize., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Genetics Society of America.)

Water scarcity is the primary environmental constraint affecting wheat growth and production and is increasingly exacerbated due to climatic fluctuation, which jeopardizes future food security. Most breeding efforts to improve wheat yields under drought have focused on above-ground traits. Root traits are closely associated with various drought adaptability mechanisms, but the genetic variation underlying these traits remains untapped, even though it holds tremendous potential for improving crop resilience. Here, we examined this potential by re-introducing ancestral alleles from wild emmer wheat (Triticum turgidum ssp. dicoccoides) and studied their impact on root architecture diversity under terminal drought stress. We applied an active sensing electrical resistivity tomography approach to compare a wild emmer introgression line (IL20) and its drought-sensitive recurrent parent (Svevo) under field conditions. IL20 exhibited greater root elongation under drought, which resulted in higher root water uptake from deeper soil layers. This advantage initiated at the pseudo-stem stage and increased during the transition to the reproductive stage. The increased water uptake promoted higher gas exchange rates and enhanced grain yield under drought. Overall, we show that this presumably 'lost' drought-induced mechanism of deeper rooting profile can serve as a breeding target to improve wheat productiveness under changing climate., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society for Experimental Biology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Our understanding of the physiological responses of rice inflorescence (panicle) to environmental stresses is limited by the challenge of accurately determining panicle photosynthetic parameters and their impact on grain yield. This is primarily due to the lack of a suitable gas exchange methodology for panicles and non-destructive methods to accurately determine panicle surface area., Results: To address these challenges, we have developed a custom panicle gas exchange cylinder compatible with the LiCor 6800 Infra-red Gas Analyzer. Accurate surface area measurements were determined using 3D panicle imaging to normalize the panicle-level photosynthetic measurements. We observed differential responses in both panicle and flag leaf for two temperate Japonica rice genotypes (accessions TEJ-1 and TEJ-2) exposed to heat stress during early grain filling. There was a notable divergence in the relative photosynthetic contribution of flag leaf and panicles for the heat-tolerant genotype (TEJ-2) compared to the sensitive genotype (TEJ-1)., Conclusion: The novelty of this method is the non-destructive and accurate determination of panicle area and photosynthetic parameters, enabling researchers to monitor temporal changes in panicle physiology during the reproductive development. The method is useful for panicle-level measurements under diverse environmental stresses and is sensitive enough to evaluate genotypic variation for panicle physiology and architecture in cereals with compact inflorescences., (© 2022. The Author(s).)

Drought intensity as experienced by plants depends upon soil moisture status and atmospheric variables such as temperature, radiation, and air vapour pressure deficit. Although the role of shoot architecture with these edaphic and atmospheric factors is well characterized, the extent to which shoot and root dynamic interactions as a continuum are controlled by genotypic variation is less well known. Here, we targeted these interactions using a wild emmer wheat introgression line (IL20) with a distinct drought-induced shift in the shoot-to-root ratio and its drought-sensitive recurrent parent Svevo. Using a gravimetric platform, we show that IL20 maintained higher root water influx and gas exchange under drought stress, which supported a greater growth. Interestingly, the advantage of IL20 in root water influx and transpiration was expressed earlier during the daily diurnal cycle under lower vapour pressure deficit and therefore supported higher transpiration efficiency. Application of a structural equation model indicates that under drought, vapour pressure deficit and radiation are antagonistic to transpiration rate, whereas the root water influx operates as a feedback for the higher atmospheric responsiveness of leaves. Collectively, our results suggest that a drought-induced shift in root-to-shoot ratio can improve plant water uptake potential in a short preferable time window during early morning when vapour pressure deficit is low and the light intensity is not a limiting factor for assimilation., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Experimental Biology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Water deficit during the early vegetative growth stages of wheat (Triticum) can limit shoot growth and ultimately impact grain productivity. Introducing diversity in wheat cultivars to enhance the range of phenotypic responses to water limitations during vegetative growth can provide potential avenues for mitigating subsequent yield losses. We tested this hypothesis in an elite durum wheat background by introducing a series of introgressions from a wild emmer (Triticum turgidum ssp. dicoccoides) wheat. Wild emmer populations harbor rich phenotypic diversity for drought-adaptive traits. To determine the effect of these introgressions on vegetative growth under water-limited conditions, we used image-based phenotyping to catalog divergent growth responses to water stress ranging from high plasticity to high stability. One of the introgression lines exhibited a significant shift in root-to-shoot ratio in response to water stress. We characterized this shift by combining genetic analysis and root transcriptome profiling to identify candidate genes (including a root-specific kinase) that may be linked to the root-to-shoot carbon reallocation under water stress. Our results highlight the potential of introducing functional diversity into elite durum wheat for enhancing the range of water stress adaptation., (© American Society of Plant Biologists 2021. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The rejection of composite veneerings in fixed partial dentures is primarily caused by the inadequacy of the bonds between the metal framework and the composite veneering. The development of improved veneering composites necessitates an investigation of their clinical suitability compared with ceramic materials. Nineteen patients with at least two suitable, adjacent natural teeth for crowning were treated with 64 high noble alloy crowns. The adjacent crowns were veneered with ceramic (IPS inline) and composite materials (SR Adoro). Seven follow-up examinations were carried out over a period of 10 years. The crowns were investigated for mechanical defects, periodontal parameters, and discolorations. The survival rates of the ceramic veneered metal crowns (CeMCs) and composite veneered metal crowns (CoMCs) at the 10-year follow-up were 87.1 and 87.9%, respectively. The success rates of the crowns after 10 years were 83.9% for CeMCs and 51.5% for CoMCs (log-rank test, p = 0.009). No significant differences between the groups were found in the periodontal parameters (Kruskal-Wallis one-way analysis of variance, ANOVA p ⟩ 0.05). After 10 years, discoloration patterns of the two materials differed significantly (Mann-Whitney-U-test, p = 0.017). Thus, despite the improvements associated with CoMCs, CeMCs remain the gold standard for veneered metal crowns., (Copyright© 2021 Dennis Barber Ltd.)

Root axial conductance, which describes the ability of water to move through the xylem, contributes to the rate of water uptake from the soil throughout the whole plant lifecycle. Under the rainfed wheat agro-system, grain-filling is typically occurring during declining water availability (i.e., terminal drought). Therefore, preserving soil water moisture during grain filling could serve as a key adaptive trait. We hypothesized that lower wheat root axial conductance can promote higher yields under terminal drought. A segregating population derived from a cross between durum wheat and its direct progenitor wild emmer wheat was used to underpin the genetic basis of seminal root architectural and functional traits. We detected 75 QTL associated with seminal roots morphological, anatomical and physiological traits, with several hotspots harbouring co-localized QTL. We further validated the axial conductance and central metaxylem QTL using wild introgression lines. Field-based characterization of genotypes with contrasting axial conductance suggested the contribution of low axial conductance as a mechanism for water conservation during grain filling and consequent increase in grain size and yield. Our findings underscore the potential of harnessing wild alleles to reshape the wheat root system architecture and associated hydraulic properties for greater adaptability under changing climate., (© 2021 John Wiley & Sons Ltd.)

Introduction: Sarcoidosis is a systemic granulomatous disease with a variable clinical presentation and disease course. There is still no reliable biomarker available, which assists in the diagnosis or prediction of the clinical course. According to a murine model, the expression level of the metabolic checkpoint kinase mechanistic target of Rapamycin complex 1 (mTORC1) in granulomas of sarcoidosis patients may be used as a clinical biomarker., Material and Methods: This is a retrospective analysis of 58 patients with histologically confirmed sarcoidosis. Immunohistochemical staining of granulomas from tissue samples was evaluated for the expression of activated mTORC1 signaling, including phosphorylated mTOR, its downstream effectors S6K1, 4EBP1 and the proliferation marker Ki-67. Patients were categorized according to different clinical phenotypes, serum biomarkers, and immunomodulatory therapy., Results: All patients showed activated mTORC1 signaling in granulomas, which correlated with its downstream effectors S6K1 and 4EBP1 but was not related to Ki-67 expression. The mTORC1 activity revealed an association neither to disease severity nor the necessity of treatment; however, p-mTOR inversely correlated with cumulative corticosteroid dosage., Conclusion: Our data confirm activation of the mTORC1 pathway in sarcoidosis, supporting the hypothesis that mTOR is a significant driver in granuloma formation. However, we could not find a relationship between the degree of mTOR activation and disease severity or the need for therapy., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: The aim of the study was to develop an optimally designed and comprehensibly formulated patient information leaflet (PIL) to improve patients' memory of information provided by physicians during a radiotherapy (head and neck area) consultation. This PIL was tested on unaffected probands for its usefulness in clinical practice., Patients and Methods: A panel of experts compiled the main topics using Lawshe's content validity ratio. Flesch's Reading Ease Score (FRE) and the Baker Able Leaflet Design (BALD) index were adapted to appropriate values to determine text comprehensibility and graphic design. The evaluation involving unaffected participants (231 men, 380 women, 21 not specified; mean age = 32 ± 13.63 years, range = 18-79 years) was conducted based on three questionnaires for four groups of respondents with varying prior knowledge of the subject. When answering the questionnaires, only half the participants had access to the PIL., Results: The expert panel included 59 out of 75 proposed topics. After reformulations, the FRE was adjusted from 38.5 to 51.4. The BALD index ranged from 24 to 26, depending on the printout edition. The evaluation of 632 unaffected participants indicated a difference in the correctly answered items that ranged from 2.86% to 30.76% between participants with and without access to the PIL., Conclusion: The general guidelines for the design of written patient information material were met. The evaluation of unaffected volunteers resulted in an advantage by answering the questionnaires after receiving the PIL. This study supports health practitioners in the development, design, and evaluation of written information material using scientific methods. An evaluation should be performed on affected patients., Competing Interests: The authors declare that they have no conflicts of interest for this work., (© 2020 Bacher et al.)

Purpose: A patient information leaflet (PIL) on oral and dental care during radiotherapy was tested whether and at which time during therapy it would be helpful to increase the knowledge about the therapy and the resulting side effects and the management of these. Additionally, the participants' subjective perception of being well informed about the topic was examined., Participants and Methods: Surveys were conducted in August 2018-April 2019, at the University Hospitals Halle and Leipzig (Germany). The study population consisted of patients who were treated with radiotherapy in the head and neck region. Half of them received access to the PIL. The survey was conducted with three different versions of a printout questionnaire, which covered the relevant topics at three different times of therapy. The time the participants were surveyed depended on the time of their first therapy appointment. The items of the questionnaires tested their concrete knowledge and assessed the subjective perception of the level of information received., Results: Of the 81 participants who received the PIL, 93.8% read it and 92.1% of them considered it helpful. The sample comprised 181 participants aged 32 to 85 years (M = 62.9), of which 135 were males, 42 were females, and 4 were unspecified. Evaluation showed a difference of 4.7%; 18.5%; and 13.6% in correct answers between subjects with and without access to the PIL before, during, and after the therapy, respectively. The assessment of the participants' personal information level was independent of their access to the PIL (chi-squared test, p = 0.89)., Conclusion: Having access to the PIL increased participants' ability to answer the questionnaires correctly. Access to the PIL had no influence on the subjective feeling of being well informed., Competing Interests: The authors report no conflicts of interest in this work., (© 2020 Bacher et al.)

Background/aim: The liver is a frequent site for metastases of colorectal cancer. Approximately 15% of patients have hepatic metastases at the time of diagnosis and another 50% develop them over the course of their disease. Only 10-25% of patients are candidates for liver resection. The aim of this study was to assess the benefit of preoperative computed tomography (CT)-guided wire marking of disappearing colorectal liver metastases (CRLMs) (radiological disappearance of metastases) before surgical resection., Patients and Methods: Between January 2011 and January 2014, 20 patients with potentially disappearing CRLMs were selected for CT-guided wire marking. Following treatment with neoadjuvant chemotherapy, disappearing CRLMs were marked via CT guidance. Afterwards, the marked sites were resected., Results: Complete histological response to neoadjuvant chemotherapy was only in 10 resected sites (18%), and 46 (82%) resected liver metastases showed metastatic tissue present. Both overall survival and the disease-free rates in patients after using our method were 55%., Conclusion: This study demonstrated the usefulness of CT-guided wire marking to mark disappearing CRLMs in order to improve long-term effectiveness of surgical treatment., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Introduction: Low skeletal muscle mass is a known predictor of morbidity and mortality in patients undergoing major pancreatic surgeries. We sought to combine low skeletal muscle mass with established risk predictors to improve their prognostic capacity for postoperative outcome and morbidity., Methods: As established parameters to predict preoperative mortality risk for patients, the ASA classification and the Charlson Comorbidity Index (CCI) were used. The Hounsfield Units Average Calculation (HUAC) was measured to define low skeletal muscle mass in 424 patients undergoing pancreatic resections for malignancies. Patients in the lowest sex-adjusted quartile for HUAC were defined as having low skeletal muscle mass (muscle wasting). Multivariable Cox regression analysis was utilized to identify preoperative risk factors associated with postoperative morbidity., Results: Median patient age was 63 years (19-87), 47.9% patients were male, and half the cohort had multiple comorbidities (Charlson Comorbidity Index [CCI]>6, 63.2%), 30-day mortality was 5.8% (n = 25). Median HUAC was 19.78 HU (IQR: 15.94-23.54) with 145 patients (34.2%) having low skeletal muscle mass. Preoperative frailty defined by low skeletal muscle mass was associated with an increased risk for postoperative complications (OR 1.55, CI 95% 0.98-2.45, p = 0.014), and a higher 30-day mortality (HR 5.17, CI 95% 1.57-16.69, p = 0.004). With an AUC of 0.85 HUAC showed the highest predictability for 30-day mortality (CI 95% 0.78-0.91, p = 0.0001). Patients with CCI ≥6 and low skeletal muscle mass defined by the HUAC had a 9.78 higher risk of dying in the immediate postoperative phase (HR 9.78, CI 95% 2.98-12.2, p = 0.0001)., Conclusion: Low skeletal muscle mass predicts postoperative mortality and complications best and it should be incorporated to conventional risk scores to identify high risk patients., (Copyright © 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background/aim: Liver resection is the best treatment for metastatic colorectal cancer (CRC). Hepatic lymph node metastases are considered as extrahepatic disease and represent an unfavorable prognostic factor. However, extrahepatic disease, when resectable, provides no contraindication for surgical therapy. The aim of this study was to evaluate the prevalence of hepatic lymph node involvement in our patients' cohort., Patients and Methods: Twenty patients submitted to resection for colorectal liver metastases were studied prospectively. Three areas for lymph node dissection were defined and analyzed separately. Lymph nodes were examined by hematoxylin and eosin staining and immunohistochemistry for Pan-Keratin., Results: In average, 5 lymph nodes were harvested per patient. Macroscopic enlargement was not a definite sign for metastatic involvement. No morbidity or mortality was associated with lymphadenectomy. In our patients' collective, no cases of lymph node metastases occurred., Conclusion: There is no evidence of a survival benefit after lymph node dissection in patients with CRC liver metastases in the literature. Systematic lymphadenectomy can, however, provide a prognostic tool to better plan further treatment., (Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Introduction: Laparoscopic appendectomy is widely used for the treatment of complicated appendicitis. Its use in patients with high operative risk is still on debate. The aim of the presented study was to investigate the benefits of laparoscopic appendectomy in patients with high peri- and postoperative risk factors., Methods: We performed a retrospective analysis of all patients who underwent appendectomy in our center between 2006 and 2013. Patients were classified according to their preoperative risk (classification of the American Society of Anesthesia--ASA score). Only patients with ASA 3 and 4 were included and were divided into two groups--open appendectomy (OA group) and laparoscopic appendectomy (LA group)., Results: The operation time was slightly longer in the LA group (p = 0.05), but hospital stay was shorter (p = 0.05). Complications graded according to the Clavien Dindo classification were slightly more frequent in patients after LA, whereas severe complications occurred more frequently in patients after OA (p = 0.01). The postoperative WBC decreased steadily and significantly in patients after OA, whereas the decrease in patients after LA was delayed (p = 0.03). CRP slightly increased after OA and decreased thereafter, whereas it steadily decreased after LA (p = 0.05)., Conclusion: Laparoscopic appendectomy can be recommended for patients with complicated appendicitis even with higher risk categories.

Incisional hernias (IHs) occur universally after orthotopic liver transplantation (OLT). This study aimed to investigate the effectiveness of porcine dermal collagen (PDC) as a closing aid in giant hernias after OLT in a prospective trial. If direct closure (DC) was not feasible due to the hernia size and abdominal wall constitution, a PDC mesh was implanted. All patients from the PDC and DC groups were followed prospectively for 24 months. IH recurrence rates served as the primary endpoint, and the development of infections and wound healing disorders served as the secondary endpoints. Recurrence rate was 21% (4/19) in DC patients and 12% (2/16) in PDC patients (P = 0.045). Implant site infections occurred in five of PDC and one of DC patients (P < 0.05). All of them were managed with antibiotics; two of the PDC patients required surgical drainage. Histological analysis of PDC mesh biopsies indicated good angiogenesis and integration of the PDC into the abdominal wall. PDC was effective in our study for incisional hernia repair, and our results compared favourably with those of patients in whom direct hernia closure was feasible., (© 2014 Steunstichting ESOT.)

Background and Aims: Post-operative hyperbilirubinaemia in patients undergoing liver resections is associated with high morbidity and mortality. Apart from different known factors responsible for the development of post-operative jaundice, little is known about the role of hepatobiliary transport systems in the pathogenesis of post-operative jaundice in humans after liver resection., Methods: Two liver tissue samples were taken from 14 patients undergoing liver resection before and after Pringle manoeuvre. Patients were retrospectively divided into two groups according to post-operative bilirubin serum levels. The two groups were analysed comparing the results of hepatobiliary transporter [Na-taurocholate cotransporter (NTCP); multidrug resistance gene/phospholipid export pump(MDR3); bile salt export pump (BSEP); canalicular bile salt export pump (MRP2)], heat shock protein 70 (HSP70) expression as well as the results of routinely taken post-operative liver chemistry tests., Results: Patients with low post-operative bilirubin had lower levels of NTCP, MDR3 and BSEP mRNA compared to those with high bilirubin after Pringle manoeuvre. HSP70 levels were significantly higher after ischaemia-reperfusion (IR) injury in both groups resulting in 4.5-fold median increase. Baseline median mRNA expression of all four transporters prior to Pringle manoeuvre tended to be lower in the low bilirubin group whereas expression of HSP70 was higher in the low bilirubin group compared to the high bilirubin group., Discussion: Higher mRNA levels of HSP70 in the low bilirubin group could indicate a possible protective effect of high HSP70 levels against IR injury. Although the exact role of hepatobiliary transport systems in the development of post-operative hyper bilirubinemia is not yet completely understood, this study provides new insights into the molecular aspects of post-operative jaundice after liver surgery., (© 2011 John Wiley & Sons A/S.)

Introduction: Liver metastases originating from various types of sarcoma are a rare reason for hepatic resection. So far, even multicentre studies do hardly provide statistically relevant sample sizes. Thus, review of available data can provide surgeons with useful information in similar cases. Therefore, this study can be regarded more as a contribution to this pool of data than as a stand-alone paper., Patients and Methods: The study includes 10 women and five men who underwent subtotal hepatic resection for solitary (n = 4) and multiple (n = 11) liver metastases originating from sarcoma. The median tumour diameter was 60 mm (range 20-200 mm)., Results: Morbidity was 33%. One patient died within 30 days after surgery. Resection was complete (R0) in 67%. Median overall survival was 33.6 months, 5-year survival 27%. The use of Pringle manoeuvre was significantly associated with poorer outcome (p = 0.014) and shorter period of recurrence-free survival (p = 0.012). Diameter of liver lesion over 50 mm showed significantly shorter recurrence-free survival (p = 0.042)., Conclusion: Hepatic resection may be beneficial in patients with isolated sarcoma metastasis in the liver.

Background: Increasing concern has been expressed worldwide on the problem of finding young doctors to enter a training programme in an operative speciality., Materials and Methods: A survey comprising 22 questions on working conditions and job satisfaction was placed on the homepage of the Austrian Society of Surgery; 667 questionnaires were completed., Results: The question whether surgery is threatened by a trainee shortage was answered with "yes" by 68%. Only 37% were satisfied with their working conditions. The majority (61%) specified documentation as making up between 20% and 40% of their workload, 22.5% estimated an even higher percentage. Only 17.7% were satisfied with payment. A clear majority works 60 to 80 h per week or more. Only 32.5% stated that they can leave the hospital in the morning after weekend duty; for night duty during the week, this percentage decreased to just 4.2%. As for surgical training, 33.3% were satisfied. Regular assessments between the trainees and their department heads were confirmed by only 34%. A clear majority (96%) is in favour of rotations in other hospitals during residency for the sake of broader experience., Conclusion: Working hour restrictions are essential, but not enough: Substantial improvements in the professional profile and in training are required.

Background/aims: Diagnosis of pancreatic trauma and its complications may be difficult due to non-specific signs and symptoms and treatment recommendations are not unequivocal., Methodology: Clinical data of a series of 47 patients with pancreatic trauma were analyzed; most of them were polytraumatized and treated by an interdisciplinary team., Results: The most common causes were traffic accidents and sport injuries with 66% and 15%, respectively. Concomitant injuries were seen in 96% (nonpancreatic intra-abdominal injuries 85% including spleen 38% and liver 34%, extra-abdominal injuries 70%). Concomitant liver injuries were treated conservatively in 31% and operatively in 69% (including hepatic packing in 38%). Concomitant splenic injuries were usually very severe and could be managed conservatively in only 11%. All patients with pancreatic injuries grade III, IV or V (17%) according to the American Association of Surgical Trauma Classification required surgery, endoscopic treatment or interventional radiology. The most common posttraumatic complications were necrotizing pancreatitis (15%), pseudocyst formation (9%), abscesses (6%) and fistulas (4%)., Conclusions: The status of the pancreatic duct is the crucial point for management of pancreatic trauma and should be assessed as early as possible. Treatment has to be tailored to the individual situation, especially in patients with severe concomitant injuries or prolonged course.

Background and Aims: Laparoscopic surgery has become the treatment of choice for cholecystectomy. Many studies showed that while this approach benefits the patient, the surgeon faces such distinct disadvantages as a poor ergonomic situation and limited degrees of freedom with limited motion as a consequence. Robots have the potential to overcome these problems. To evaluate the efficiency and feasibility of robotically assisted surgery (RAC), we designed a prospective study to compare it with standard laparoscopic cholecystectomy (SLC)., Materials and Methods: Between 2001 and 2003, 26 patients underwent SLC and 20 patients underwent RAC using the ZEUS system. The feasibility, safety, and possible advantages were evaluated. To assess the efficacy, the total time in the operating room was divided into preoperative, operative, and postoperative time frames., Results: For RAC in comparison with SLC, the preoperative phase including equipment setup was significantly longer. In the intraoperative phase, the cut-closure time and camera and trocar insertion times were significantly longer. It is interesting to note that the net dissection time for the cystic artery, duct, and the gall bladder was not different from SLC., Conclusions: The study demonstrates the feasibility of robotically assisted cholecystectomy without system-specific morbidity. There is time loss in several phases of robotic surgery due to equipment setup and deinstallation and therefore, presents no benefit in using the robot in laparoscopic cholecystectomy.

Background: The outcome of liver resections depends on complete removal of all detectable foci. Our aim was to determine the value of preoperative routine magnetic resonance imaging (MRI) for complete detection of hepatic lesions., Methods: We compared 271 lesions seen on MRI in 182 patients to intraoperative findings (including intraoperative ultrasonography) and histology., Results: The overall rate of lesions was 7% each for segments 2 and 3, as compared to 14-17% each for segments 5, 6, 7, and 8. Twenty-three additional lesions were found intraoperatively, two thirds of them in the left lobe (mean size: 1.4 cm; mean total number of lesions in those patients: 2.2). In segments 2 and 3, the relative frequency for intraoperative diagnosis of additional lesions was 17% and 20%, respectively. On the other hand, most of the 15 MRI lesions not verified intra- or postoperatively had been described in the right hepatic lobe (maximum: segment 6)., Conclusion: MRI provided reliable preoperative lesion detection. Special attention should be paid to segments 2 and 3, which showed a lower total number of lesions but an elevated relative frequency of intraoperatively detected additional foci.

Background: Pyogenic liver abscess (PLA) remains a serious disease with a mortality of 6-14%., Methods: Clinical data of 76 patients with PLA were analyzed. Treatment options comprised antibiotics, percutaneous puncture/drainage, endoscopic papillotomy/stenting and/or surgery as indicated., Results: Fifty-eight patients (76%) had single and 18 patients multiple PLA (right lobe: 65%; both lobes: 22%). The most frequent etiologies were: biliary (38%), hematogenous and posttraumatic (11%). Factors associated with the need for surgery included gallbladder empyema, biliary fistulas, malignancy, perforation, multicentricity, vascular complications and foreign bodies (e.g. infected ventriculo-peritoneal shunt, toothpick)., Conclusions: Microbiological testing provides important information for treatment monitoring and modification. Complementary assessment of risk factors for a complicated course is crucial for timely identification of patients requiring additional treatment., (Copyright 2005 S. Karger AG, Basel.)

Introduction: Polycystic liver disease (PLD) is a rare affliction frequently observed in association with polycystic kidney disease. Only symptomatic patients require treatment, which can be conservative or surgical, i.e. laparoscopic or conventional. We report the results of our experience in the surgical management of polycystic liver disease., Methods: Between 1994 and 2003, 19 patients (16 female, 3 male) were referred to our center for the management of PLD. Their median age was 50 years (range 33-72). All were symptomatic and their cysts had a median diameter of 11 cm (range 5-22)., Results: Laparoscopic management was undertaken in eight patients, with one conversion to open technique because of bleeding from a superficial hepatic vein. An open procedure was performed in 11 patients: one left hemihepatectomy, deroofing in two patients, segment resection 2/3 plus deroofing in six patients, and segment resection 5/6 plus deroofing in two patients. Four patients had complications: one case of biliary leakage was managed conservatively; two patients had pneumothorax caused by the cava catheter inserted for anesthesia, and one patient's abdominal drain tore off and had to be removed by relaparotomy on the fourth postoperative day. Median follow-up of all patients was 49 months (range 7-98). In one patient there was symptomatic recurrence with hepatomegaly and compression of the inferior vena cava 84 months after the first operation., Conclusions: Careful selection of patients and meticulous surgical technique are recommended in the management of PLD. The treatment of choice for symptomatic Gigot or Morino type 1 PLD is laparoscopic surgery, and for advanced stage PLD combined hepatic resection and cyst fenestration.

Background: Liver cysts occur with a prevalence of 4%-7% in the general population. Laparoscopic surgery is effective for solitary cysts and in selected patients with polycystic liver disease (PLD). We present our experience in the laparoscopic management of dysontogenetic cysts., Patients and Methods: Between 1994 and 2002, 36 patients were referred to our centre for the management of dysontogenetic cystic liver disease. Management was laparoscopic in 16 cases. Indications were solitary giant cysts (n=9) and PLD (n=7)., Results: Laparoscopic procedures were completed in 15 patients. Mean operating time was 90 min. There were no deaths. In one case there was an intraoperative complication: bleeding from a superficial hepatic vein necessitated conversion to an open procedure. There were two postoperative complications: one patient with biliary leakage, which was managed conservatively, and one patient with a pneumothorax caused by the cava catheter installed for anaesthesia. Median follow-up was 36 months. There was no symptomatic recurrence., Conclusion: Laparoscopy can be recommended as the procedure of choice for symptomatic solitary giant cysts and PLD Gigot type I.

Introduction: Malignant gastric outlet stenosis is caused by tumour obstruction and restricts the oral intake of food, resulting in a seriously reduced quality of life. Endoscopic implantation of self expanding metal stents (SEMS) can clear stenosis in the GI-tract and reestablish and preserve the passage in the GI-tract., Patients and Methods: Between October 2001 and April 2003 seven patients with malignant gastric outlet stenosis have been treated by the implantation of SEMS. Four patients had malignant stenosis in the upper duodenum or gastric antrum, two patients had stenosis because of tumour recurrence in the efferent loop of the jejunum after gastric resection because of gastric carcinoma and one patient had an obstruction 20 cm distal of the oesophagus after gastrectomy because of gastric cancer., Results: In all patients obstruction was cleared by the implantation of SEMS, and oral intake of food was possible in all patients after two days. No serious complications occurred during or after stent implantation., Conclusion: Stent implantation for the treatment of malignant gastric outlet stenosis is a cost effective procedure, associated with low risk and low stress for the patient, and provides excellent palliation of symptoms in patients with malignant gastric outlet stenosis.

Background/aims: The aim of our study was to determine if intraoperative ultrasonography is still necessary in the time of magnetic resonance imaging., Methodology: Our prospective study comprised 122 patients (82% with malignant tumors) undergoing partial hepatectomy with preoperative magnetic resonance imaging, done at the same institution using a standardized liver protocol as well as intraoperative ultrasonography performed in a systematic fashion., Results: Seventeen additional malignant lesions in 16/122 patients (13.1%) were found intraoperatively [7 visible, 2 palpable, 8 (6.6%) diagnosed by intraoperative ultrasonography only; mean size: 1.5 cm; left:right lobe = 11:6]. This caused a change in surgical strategy in 14 patients (11.5%), including 6 patients (4.9%) with lesions seen on intraoperative ultrasonography only. The average total number of lesions in those patients was 3.4. Ten lesions (7 benign, 3 malignant) described on magnetic resonance imaging were not found on intraoperative ultrasonography, but no unnecessary operations resulted from this. In one patient additional micrometastases seen neither on magnetic resonance imaging nor on intraoperative ultrasonography were found histologically., Conclusions: Intraoperative ultrasonography is still worthwhile as it remains unsurpassed in the ultimate determination of the number of lesions, tumor extension and anatomical resolution. However, in the course of time its benefits may decrease further due to ongoing improvement of preoperative imaging.

Hyperplastic gastric polyps account for the majority of benign gastric polyps and are generally diagnosed by routine gastroscopy as they rarely become symptomatic. We report a 79-year-old woman who presented with intermittent attacks of bloating, belching, nausea and vomiting. Endoscopy showed a pedunculated polyp in the gastric antrum prolapsing through the pylorus, thus obstructing the gastric outlet. The polyp was repositioned with an endoscopic forceps and then removed at its pedicle by endoscopic snare excision. Histologic examination showed a hyperplastic polyp without dysplasia or malignancy. The significance of gastric polyps is discussed from the clinical point of view.

Background: Pancreatitis-associated protein (PAP) is known as a marker for pancreatitis and cystic fibrosis. The aim of our study was to evaluate PAP in patients with pancreatic cancer, to assess its correlation to the extent of the disease and to compare it to CA19-9., Patients and Methods: This prospective study comprised 75 individuals. Thirty had pancreatic cancer, 30 were healthy controls and 15 had benign lesions of the pancreas. PAP was determined by enzyme-linked immunosorbent assay. Statistical analysis was by Wilcoxon test and Spearman correlation coefficients., Results: As compared to healthy individuals and using a cut-off of 18 micrograms/l corresponding to a sensitivity of 90%, the specificity of PAP for pancreatic cancer was 82.8%. PAP elevation in cancer patients could not be explained by concomitant pancreatitis (p = 0.649). PAP did not show correlation to tumour size (p = 0.14), T-stages (p = 0.706) or tumour grading (p = 0.105), but was significantly correlated to the overall extent of the disease according to the UICC stages (p = 0.002). No correlation between PAP and CA19-9 was seen. Jaundice was not found to influence PAP values (p = 0.4)., Conclusion: Elevation of PAP in patients with pancreatic cancer is not merely explainable by concomitant pancreatitis, but seems to be due to increased PAP production by the cancer cells and is also correlated to tumour load as expressed by the UICC stages.

The aim of our study was to assess the influence of intraoperative hypoxic stress -unavoidably brought about by so called Pringle maneuver - on free and conjugated catecholamines during major hepatic resection. Judging from earlier results of fatigue-experiments in rats we also wanted to check the relationship between of poor general preoperative condition and conspicuously low triglyceride serum concentrations. The study included 26 patients with primary and secondary liver tumors. The mean age was 54 years (range 27-79). Twenty-one patients had segmental liver resections, 3 had hemihepatectomies and 2 hydatid cysts were treated by cystectomy. Blood samples were taken 2 days before and throughout surgery. Catecholamine plasma values were determined by high performance liquid chromatography. Statistical comparisons were made by t-test, ANOVA and chi square test. Free plasma catecholamines increased significantly during prolonged intraoperative ischemia (Pringle time 50-125 minutes). Patients with elevated intraoperative catecholamines had a significant correlation to postoperative episodes of tachycardia, and prolonged hospital stay. On the other hand, we could also see postoperative tachycardias in patients with short Pringle times (18-49 minutes) but with decreased preoperative serum triglycerides as an indicator of chronic stress and reduced general condition. Intraoperative hypoxic stress is associated with increased catecholamine values. Elevated catecholamines may well cause postoperative sinus-tachycardias (mean 20 hours) and are strongly related to postoperative liver failure and prolonged hospital stay.

Because bronchogenic cysts may be found in or near any organ derived from the embryonic foregut, they sometimes pose considerable diagnostic difficulties. We describe the plain chest X-ray, computed tomographic, and angiographic findings in a patient with elevated CA 19-9 and upper quadrant abdominal pain due to a cystic tumor appearing as a hepatic mass. Surgery and histology showed a bronchogenic cyst located in the lower lobe of the right lung.

The purpose of our study was to evaluate the clinical impact of reperfusion injury after normothermic ischemia during major liver resections and the effect of an intraoperative antioxidant infusion. This prospective randomized study comprised 50 patients; half of them (treatment group) were given an antioxidant infusion containing tocopherol and ascorbate immediately prior to reperfusion onset. Venous blood samples for the determination of MDA-TBARS (malondialdehyde-thiobarbituric acid reactive substances) by a HPLC-based test as a marker of lipid peroxidation were taken prior to ischemia, 30 min after reperfusion onset and at the end of the operation. In the control group there was a significant increase of MDA-TBARS (p = 0.001) at 30 min after reperfusion onset. At the end of the operation the values had returned to the initial level. The treatment group showed only a marginal increase (p-value for the difference between the two groups: 0.007). After exclusion of the patients with histologically proven advanced cirrhosis the increase in the control group (p < 0.001) and the difference between the increase in the two groups (p = 0.001) became more significant. Prothrombin time was also significantly better in the treatment group (p = 0.003). Postoperative complications such as prolonged liver failure, bleeding disorders and infections were seen more often in the control group. In our study MDA-TBARS was increased after liver ischemia, but in patients with advanced cirrhosis the effect was smaller or even absent. This increase and possible clinical consequences of reperfusion injury could be reduced by intraoperative administration of an antioxidant infusion.

Purpose: Perianal endometriosis is an infrequent form of extragenital endometriosis and is usually situated in episiotomy scars., Methods: We report a rare case involving the external anal sphincter in a 24 year-old female. The precise anatomical location of the endometriotic lesion was confirmed using preoperative and intraoperative anal endosonography., Conclusion: We believe this procedure to be essential when history, digital examination, and proctoscopy are not conclusive in the differential diagnosis of perianal pain or mass. Although hormonal suppression often is the therapy of choice in extrapelvic endometriosis, we think surgical excision, respecting the anatomical fiber architecture of the anal sphincter, is the best treatment for perianal endometriosis. Surgical excision is required for histological diagnosis, which is imperative in view of the albeit rare development of malignancy in extragenital endometriosis.

We report the case of a 76-year-old woman with biliary cystadenocarcinoma perforating the left biliary tree and exhibiting intra-tumoral gas bubbles resulting from invasion of the duodenum. The clinical history included subfebrile temperatures of 3 months duration, and pains associated with an abdominal mass in the right upper quadrant. Blood tests showed leucocytosis, and radiological studies revealed the features of a partially calcified septated tumor with nodular components combined with multiple gas-fluid levels, mimicking an infected hydatid cyst. Intraoperative ultrasonography, cholangiography and frozen section histology were necessary to prove the malignant nature of this cystic tumor. Provided that complete resection with strict adherence to oncological precepts is possible, the prognosis of cystadenocarcinoma is better than in hepatocellular or cholangiocellular carcinoma.

The diagnostic value of the tumor marker pyruvate kinase type tumor M2 was evaluated in patients with benign, malignant and metastasizing pancreatic lesions and compared to the reference markers CA19-9 and CEA. This prospective study comprised 166 individuals; 66 patients had various pancreatic pathologies (38 histologically proven pancreatic cancer, 28 benign pancreatic lesions such as pseudotumorous pancreatitis, pseudocysts or pancreatic (cyst)adenoma) and 100 healthy blood donors served as controls. With a cut-off value of 28 U/ml (corresponding to a specificity of 90%) the sensitivity of TUM2-PK for pancreatic cancer (as related to the control group) was 79% (CA19-9: 65%, CEA: 22%). There was a good correlation between the TUM2-PK levels and tumor metastasis (p < 0.001 for no versus distant metastasis, p = n.s. for CA19-9 and CEA). However, TUM2-PK was also elevated in 64.3% of the patients with benign pancreatic pathologies. In our study TUM2-PK had good diagnostic qualities for pancreatic cancer and also showed better correlation to metastasis than CA 19-9 and CEA.

Biliary cystadenocarcinoma is a rare, usually intrahepatic neoplasm. A case is described in which an intrahepatic cystadenocarcinoma invaded the duodenum. This resulted in intratumoral gas.

Background/aims: Many experimental studies on ischemia-reperfusion injury in animals suggest a preventive effect of antioxidants, but the clinical significance of these findings is still unclear. The aim of our study was to evaluate the effect of antioxidant treatment with vitamins on liver function parameters during liver resection., Methodology: Our prospective randomized study comprised 58 patients undergoing major liver surgery, including the Pringle maneuver. In the treatment group 32 patients received a multivitamin infusion (Omnibionta) which included 10 mg of alpha-tocopherol acetate, 2 mg of DL-alpha-tocopherol and 1 g of ascorbate. The control group consisted of 26 patients. Various parameters associated with liver function, such as transaminases, lactate, ammonia, bilirubin, cholinesterase and clotting parameters were measured preoperatively, at the beginning of liver ischemia, 15, 30 and 60 minutes after reperfusion onset and every 12 hours after the operation., Results: The Mann-Whitney-Wilcoxon-Test showed statistically significant differences in the postischemic changes between the treatment group and the control group for the Quick test (prothrombin time): p = 0.01. The transaminases were also markedly better in the treatment group (splitting-up slightly more delayed than with the Quick test). A smaller effect was seen with cholinesterase. Lactate, however, increased intraoperatively with a strong correlation to the duration of ischemia and returned quickly to baseline values without any remarkable influence of the antioxidant treatment., Conclusion: In our study, antioxidant treatment with a multivitamin infusion showed a positive effect on postischemic liver function parameters.

Background/aims: Pancreatic secretory trypsin inhibitor (PSTI). Procarboxypeptidase B (PCPB or Human pancreas-specific protein HPASP), CA19-9 and CEA were evaluated for their performance in preoperative differential diagnosis of benign and malignant pancreatic lesions., Methodology: Our prospective study included 92 patients with pancreatic lesions diagnosed by imaging techniques. In 45 of them (group I), the lesions turned out to be malignant tumors (35 pancreatic cancer, 10 other carcinoma of the pancreatic region); 47 patients (group II) had benign lesions (38 inflammatory disease of the pancreas, 9 other benign lesions)., Results: Statistical analysis showed significant differences between these two groups for PSTI, PCPB and CA19-9, but not for CEA. When only pancreatitis versus pancreatic cancer was analyzed, differences were more significant for PSTI and PCPB, but less significant for CA19-9. Because of a strong trend toward false positive values in patients with pancreatic inflammation, the specificity of CA19-9 in our selected patient group was only 67%, but in combination with normal PSTI (< 13.5 ng/ml), it reached 96%., Conclusion: In our study, PSTI and PCPB were useful markers for pancreatitis. PSTI also showed good correlation with the severity of the inflammation and provided additional preoperative information, in combination with CA19-9.

Purpose: Nitric oxide is an important neurotransmitter mediating internal anal sphincter relaxation. Patients suffering from fissure-in-ano were treated with topical nitroglycerine. The clinical evidence for therapeutic adequacy was examined in a prospective, randomized study., Methods: The study included 35 patients with acute and chronic anal fissures. In Group A, including 20 patients with the clinical diagnosis of acute (12 patients) and chronic (8 patients) anal fissures, treatment consisted of topical nitroglycerine. Group B, consisting of 15 patients (10 acute and 5 chronic fissures), received topical anesthetic gel during therapy. Manometry was performed before and on days 14 and 28 in the course of topical application of either 0.2 percent glyceryl trinitrate ointment or anesthetic gel (lignocaine). Anal pressures were documented by recording the maximum resting and squeeze pressures., Results: In 60 percent of cases treated with topical nitroglycerine (Group A, 11 acute (91.6 percent) and 1 chronic (12.5 percent)), anal fissure healed within 14 days, in contrast to Group B in which no healing was observed. The healing rate after one month was 80 percent (11 acute (91.6 percent); 5 chronic (62.5 percent)) in Group A and was significantly superior to Group B (healing rate, 40 percent: 5 acute (50 percent); 1 chronic (20 percent))., Discussion: Previously increased maximum resting pressures decreased from a mean value of 110 to 87 cm H2O. This represents a mean reduction of 20 percent (P = 0.0022). We also noted a significant decrease in squeeze pressures (from 177.8 to 157.9 cm H2O (11 percent)). However, anal pressures did not decrease significantly in the four chronic fissure patients from Group A, whose fissures only healed after 28 days. Similarly to these Group A chronic fissure patients, no significant anal pressure reduction was observed in any Group B patients. Except for mild headache (20 percent), no side effects of treatment were reported., Conclusions: Topical application of nitroglycerine represents a new, easily handled, and effective alternative in the treatment of anal fissures. All of our patients reported a dramatic reduction in acute anal pain. However, it should be noted that a lack of sphincter tone reduction is a likely reason for the great tendency of chronic anal fissures to recur.

Usually liver hematoma after blunt trauma is treated conservatively as long as clinically possible, in order to avoid infection via drainage. We report a patient who developed a huge liver abscess after a minor blunt trauma caused by a piece of wood that hit his hepatic region during work with a circular saw. Neither conservative treatment nor percutaneous drainage was successful and intraoperatively a biliary fistula was identified as the route of infection by salmonella. Cholecystectomy (here meaning removal of the salmonella reservoir) and consequent drainage of the gall flow via T-drain were the crucial therapeutic steps and the fistula finally closed after three months. Therapeutic possibilities in the management of blunt liver trauma, and biliary and septic complications are discussed.

The aim of this study was to present whether the heparin has on influence on course of experimental acute pancreatitis (AP) and some organ complications. The research referred to histological changes in liver, lungs and kidneys. The study was conducted on 69 rats divided into 5 groups: I--operated, without induction AP, II--control, induction of AP without treatment, III--induction of AP and immediate administration of heparin, IV--induction of AP and administration of heparin 3 hours after, V--induction of AP and administration of heparin 6 hours after. AP was induced by administration 5% sodium taurocholate. In all groups the animals were anesthetised after the period of 3, 6 and 12 hours from the induction of AP respectively. The specimens of mentioned organs were formalinized and stained with hematoxylin/eosin, and in addition specimens of the liver with p.a.S, Sudan IV and Brachets methods. In group I we observed pulmonary oedema after 6 and 12 hours but kidneys and liver were unchanged. In group II pathological changes were most evident in lungs, while we observed on acute passive hyperaemia, pulmonary emphysema and single coagulative thrombosis in vessels. In the liver number of lining cells was increased and minor or major droplets of lipids in hepatocytes were present. Using Brachets method we revealed regular staining of hepatocytes, and p.a.S. method regular staining of their cytoplasm. In group III examined organs do not show any significant differences as compared with group II, except for lungs where the coagulative thrombosis was not present. In groups IV and V changes were similar to those described in group II. This study showed decreased inflammatory and thrombotic process in lungs in experimental AP in rats after heparin treatment.

A 45-year-old woman underwent a resection for a hepatic metastasis of the liver caused by a carcinoma of the colon. Shortly after the Pringle maneuver severe hemorrhage from the upper left quadrant of the abdomen was observed. Exploration revealed a spontaneous parenchymal laceration of the spleen.

In 44 patients with biliary obstructions, percutaneous transhepatic cholangioscopy (PTCS) was performed during percutaneous transhepatic biliary drainage procedures (PTCD). In all patients the obstruction could be decompressed via the PTCD sufficiently. 30 of these cases who had PTCS showed suspect hepatic and pancreatic malignancies. In contrast to the brush cytology (14% false negative) the biopsies revealed insufficient histology in 33%. However, in 3 cases a more extended tumor site was seen that at the initial exploration, shown by ERCP.