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Összefoglaló. A Morel-Lavallée-laesio egy többségében kiterjedt, décollement-nek megfelelő, zárt lágyrész-károsodás, mely a leggyakrabban a hát, a medence, illetve a combok környékén fordul elő; eredete elsősorban közlekedési balesetekhez, sportsérülésekhez kötött. A sérülés gyakran társulhat a medencekörnyéki csontok érintettségével, esetleg többszörös traumával, azonban önálló megjelenése is előfordul. Megfelelő kezelésében nagy jelentőségű a károsodás időben történő felismerése és célzott terápiája, melynek során elsősorban a sebészeti kezelés preferált. A nem megfelelően kezelt eseteknél a panaszok lassan progrediálhatnak, az elváltozás krónikussá is válhat. Kiemelendő, hogy az érintettek nem elhanyagolható része nem feltétlenül centrumintézménybe jelentkezik, hanem önállóan előforduló, krónikus vagy panaszos esetekben gyakran kisebb kórházakban vagy éppenséggel szakrendeléseken jelenhetnek meg. A Morel-Lavallée-laesióval kapcsolatos magyar nyelvű irodalom szegényes. A jelen közleménnyel a szerzők célja, hogy ismertessék az általuk nem centrumintézményben kezelt, deréktáji érintettséggel rendelkező két eset példájához társítva a sérüléssel kapcsolatos legfontosabb tudnivalókat. Orv Hetil. 2022; 163(16): 645–650. Summary. Morel-Lavallée lesion is an extensive, decollement-like closed degloving soft-tissue injury. It occurs most commonly in the thigh, pelvis or lumbar region, primarily due to traffic accidents or sports injuries. The injury is often associated with pelvic or femoral fractures and polytrauma but it may occur separately. Early diagnosis and specific treatment are critically important to achieve adequate therapy in which the operative approach is preferred. If not treated properly, complaints may progress and the condition can become chronic. It should be highlighted that a considerable number of patients suffering from this condition may not present in central institutions but in minor hospitals or outpatient units with separately occurring, chronic or painful injury. Morel-Lavallée lesion is rarely mentioned in the Hungarian literature. The authors aim to present the most important knowledge about the injury in accordance with the case presentation of two patients with lumbar complaints they treated in a non-central institution. Orv Hetil. 2022; 163(16): 645–650.

Összefoglaló. A Morel-Lavallée-laesio egy többségében kiterjedt, décollement-nek megfelelő, zárt lágyrész-károsodás, mely a leggyakrabban a hát, a medence, illetve a combok környékén fordul elő; eredete elsősorban közlekedési balesetekhez, sportsérülésekhez kötött. A sérülés gyakran társulhat a medencekörnyéki csontok érintettségével, esetleg többszörös traumával, azonban önálló megjelenése is előfordul. Megfelelő kezelésében nagy jelentőségű a károsodás időben történő felismerése és célzott terápiája, melynek során elsősorban a sebészeti kezelés preferált. A nem megfelelően kezelt eseteknél a panaszok lassan progrediálhatnak, az elváltozás krónikussá is válhat. Kiemelendő, hogy az érintettek nem elhanyagolható része nem feltétlenül centrumintézménybe jelentkezik, hanem önállóan előforduló, krónikus vagy panaszos esetekben gyakran kisebb kórházakban vagy éppenséggel szakrendeléseken jelenhetnek meg. A Morel-Lavallée-laesióval kapcsolatos magyar nyelvű irodalom szegényes. A jelen közleménnyel a szerzők célja, hogy ismertessék az általuk nem centrumintézményben kezelt, deréktáji érintettséggel rendelkező két eset példájához társítva a sérüléssel kapcsolatos legfontosabb tudnivalókat. Orv Hetil. 2022; 163(16): 645-650. Summary. Morel-Lavallée lesion is an extensive, decollement-like closed degloving soft-tissue injury. It occurs most commonly in the thigh, pelvis or lumbar region, primarily due to traffic accidents or sports injuries. The injury is often associated with pelvic or femoral fractures and polytrauma but it may occur separately. Early diagnosis and specific treatment are critically important to achieve adequate therapy in which the operative approach is preferred. If not treated properly, complaints may progress and the condition can become chronic. It should be highlighted that a considerable number of patients suffering from this condition may not present in central institutions but in minor hospitals or outpatient units with separately occurring, chronic or painful injury. Morel-Lavallée lesion is rarely mentioned in the Hungarian literature. The authors aim to present the most important knowledge about the injury in accordance with the case presentation of two patients with lumbar complaints they treated in a non-central institution. Orv Hetil. 2022; 163(16): 645-650.

Purpose Esophageal perforation constitutes a potentially life-threatening condition, and this study aimed to evaluate the indications and outcome for the different treatment modalities. Patients and methods In total, 43 patients with esophageal perforation were considered for this retrospective analysis. Age, sex, length of hospital stay and intensive care treatment, in-hospital mortality, localization of perforation and etiology, treatment modality, and 90-day morbidity were analyzed. Results Most patients suffered from Boerhaave syndrome and from iatrogenic esophageal perforation. In total, 63% of patients (26/41) received successful nonoperative treatment, whereas 36% required additional surgery. Two patients (5%) underwent primary surgery. In all cases no esophagectomy was necessary. In-hospital mortality was 7%. During the 90-day follow-up 1 patient with stenosis required repetitive dilatations. Conclusions Initial endoscopic treatment, either by stent or by endosponge, alone or combined with an additional operative treatment, seems feasible in patients suffering from esophageal perforation. In all patients, there was no need for esophagectomy.

Laparoscopic appendectomy is now the treatment of choice in uncomplicated appendicitis. To date its importance in the treatment of complicated appendicitis is not clearly defined. From January 2005 to June 2013 a total of 1762 patients underwent appendectomy for the suspected diagnosis of appendicitis at our institution. Of these patients 1516 suffered from complicated appendicitis and were enrolled. In total 926 (61 %) underwent open appendectomy (OA) and 590 (39 %) underwent laparoscopic appendectomy (LA). The following parameters were retrospectively analyzed: age, sex, operative times, histology, length of hospital stay, 30-day morbidity focusing on occurrence of surgical site infections, intraabdominal abscess formation, postoperative ileus and appendiceal stump insufficiency, conversion rate, use of endoloops and endostapler. A statistically significant difference in operative time was observed between the laparoscopic and the open group (64.5 vs. 60 min; p = 0.002). Median length of hospitalization was significantly shorter in the laparoscopic group (p

Die Divertikelkrankheit des Kolons gehort zu den haufigsten Erkrankungen des Gastrointestinaltrakts. Eine kurzlich erschienene konsensbasierte Leitlinie setzt neue Akzente bei der Behandlung der Erkrankung. So hat der Stellenwert interventioneller Verfahren zugenommen, auch das Paradigma einer generellen Indikation zur Resektion nach dem zweiten Entzundungsschub wurde verlassen. Der folgende Artikel fasst Diagnostik und Therapie unter Berucksichtigung der aktuellen Leitlinie zusammen.

Die laparoskopische Sigmaresektion bei Sigmadivertikulitis hat sich als sicheres Verfahren etabliert: Aufgrund des minimalinvasiven Zugangs ist die Morbiditat geringer und der Krankenhausaufenthalt kurzer 1 2 . Dieser Beitrag zeigt die operative Vorgehensweise mit Fokus auf Sondersituationen wie die perforierte Sigmadivertikulitis und die Sigma-Blasen-Fistel.

Objective Serum concentrations of the hepatokine fibroblast growth factor (FGF) 21 are elevated in obesity, type-2 diabetes, and the metabolic syndrome. We asked whether FGF21 levels differ between subjects with metabolically healthy vs. unhealthy obesity (MHO vs. MUHO), opening the possibility that FGF21 is a cross-talker between liver and adipose tissue in MUHO. Furthermore, we studied the effects of chronic FGF21 treatment on adipocyte differentiation, lipid storage, and adipokine secretion. Methods In 20 morbidly obese donors of abdominal subcutaneous fat biopsies discordant for their whole-body insulin sensitivity (hereby classified as MHO or MUHO subjects), serum FGF21 was quantified. The impact of chronic FGF21 treatment on differentiation, lipid accumulation, and adipokine release was assessed in isolated preadipocytes differentiated in vitro. Results Serum FGF21 concentrations were more than two-fold higher in MUHO as compared to MHO subjects (457 ± 378 vs. 211 ± 123 pg/mL; p, Highlights • Metabolically healthy and unhealthy obese subjects differ in FGF21 blood levels. • FGF21 alters the secretome of human preadipocytes differentiated in vitro. • FGF21 exerts potent adiponectin-suppressive effects. • FGF21 and adiponectin may constitute a humoral vicious cycle between liver and fat.

Surgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis. A retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results. Ninety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified. Laparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.

Acute appendicitis frequently needs acute surgical intervention. Laparoscopic appendectomy (LA) and conventional open appendectomy (OA) are well established procedures, but appendectomy for intraoperative inconspicuous or vascular injected appendixes remains under debate because of potential postoperative morbidity. The aim of this study was to correlate intraoperative nonacute appendixes with histological and clinical outcome.Between 2005 and 2009, a total of 1,017 patients underwent OA or LA. A total of 1,005 patients were enrolled with inclusion criteria of suspicious acute appendicitis preoperatively. One hundred twenty-nine of 1,005 patients had intraoperative normal, vascular injected or chronic appendixes that were defined as nonacute appendicitis. Intraoperative findings were correlated with histological results and clinical outcome of patients.Of 129 (12.8 %) of 1,005 patients with macroscopically nonacute appendicitis intraoperatively, 16.3 % had normal findings, 81.4 % vascular injection, and 2.3 % chronic alterations; and 94.6 % of nonacute appendixes had histopathological alterations: 38.9 % chronic, 14.0 % neurogenic, 26.4 % acute, 13.2 % phlegmonous, and 2.3 % malignant. Coproliths were found in 21.7 % of patients, most in vascular injected appendixes. Four of seven patients with histopathological normal appendixes had coproliths. Morbidity rate was 2.3 %, with no mortality.Appendiceal resection for intraoperative nonacute appendixes should be recommended because of high incidence of histopathological findings with low morbidity. In particular, chronic and neurogenous alterations cannot be predicted clinically or verified by radiological examination, but may cause recurrent symptoms.

A novel 5 mm steerable instrument system (r2-DRIVE) was developed with active tip deflection and tip and shaft rotation. The feasibility and training effect of the r2 instruments were determined in a phantom model.Experienced laparoscopic surgeons and untrained novices performed laparoscopic gastro-jejunal anastomoses using porcine tissue and r2 DRIVE-instruments. Mean anastomosis time, anastomosis width and burst pressure were measured. Number of stitches, skipped stitches and dropped needles were counted. Results of trained and untrained subjects were compared.Mean time for suturing decreased rapidly for all participants, but was more evident for untrained persons. After five anastomoses no relevant improvement in anastomotic time was seen for the skilled group. The ease of use, efficacy of manipulation and swift training effect with the novel r2 instruments for both experienced laparoscopic surgeons and untrained non-surgeons could be demonstrated and after few cases stable anastomosis times and a fast learning curve were obtained.This study demonstrates the ease of use, efficacy of manipulation and swift training effect with the novel r2 instruments for both experienced laparoscopic surgeons and untrained non-surgeons. After few cases stable anastomosis times and a fast learning curve were obtained.

Obesity is characterized by excess body fat measured in body mass index (BMI), which is the weight in kilograms (kg) divided by the height in square meters [m2]. In the Northern Hemisphere, the prevalence of overweight has increased by up to 34%. This situation is associated with high incidence of comorbidities such as gastroesophageal reflux disease. Bariatric surgery is the only effective treatment for severe obesity, resulting in amelioration of obesity comorbidities. Data on LES competence following sleeve gastrectomy (SG), one of the several bariatric procedures, are conflicting. In a prospective study, we enrolled 37 patients and divided them into two subgroups in order to evaluate lower esophageal sphincter pressure (LESP) and esophageal motility before and after laparoscopic sleeve gastrectomy (LSG) by means of stationary esophageal manometry. A study collective also underwent a gastroscopy. Participants (20) were healthy controls who volunteered. Preoperative median BMI in group I (control) differed statistically significantly (p

Diverticulosis of the vermiform appendix is rare and usually asymptomatic or associated with mild, chronic or intermittent abdominal pain. A 52-year-old patient was admitted to our department due to lower abdominal pain. Assuming the second episode of diverticulitis of the sigmoid, a computed tomography (CT) was performed, and complicated sigmoid diverticulitis and an accentuated appendix without inflammatory signs were diagnosed. Laparoscopic sigmoid resection was performed with an intraoperative macroscopic inconspicuous appendix. Two months later, right-sided abdominal pain returned. CT scan showed increasing signs of thickened appendix. Because of a gallbladder polyp, a combined laparoscopic appendectomy and cholecystectomy with one additional laparoscopic access was performed. Pathology detected a small diverticulum of the appendix and a small tubular adenoma with low-grade intraepithelial neoplasia in the gallbladder. Although diverticulitis of the appendix is very rare, it should be considered in patients with right lower abdominal pain, and appendectomy should be performed even in macroscopic unsuspicious cases.

Background In most pelvic malignancies radiation therapy is a main part of the treatment concept. The main dose limiting organ is the small intestine. Different mechanical methods to prevent radiation damage to the small intestine have been described. We herein report a retrospective study of laparoscopic placement of an absorbable vicryl mesh in patients requiring pelvic radiotherapy displacing the bowel out of the radiation field. Patients/Methods The study included 6 consecutive patients requiring definitive radiotherapy due to locally advanced prostate cancer. All patients had small intestine within the radiation fields despite the use of non-invasive displacement methods. Results All patients underwent laparoscopic small bowel displacement from the pelvis and closure of the pelvic floor entrance using vicryl mesh placement. Peri- or postoperative complications were not seen. Postoperative radiotherapy planning CT scans confirmed displacement of the small intestine allowing all patients to receive the planned radiotherapy volume. Conclusion Laparoscopic mesh placement represents a safe and efficient procedure in patients requiring high-dose pelvic radiation, presenting with unacceptable small intestine volume in the radiation field. As an alternate to native tissue, the vicryl mesh is a safe, effective substitute for small bowel exclusion from external-beam radiation therapy.

Transpedicular instrumentation in the thoracic spine is technically difficult because of small pedicle diameters. There are not many studies assessing in vivo accuracy, complications, and the revision rate of transpedicular screws in the thoracic spine. In this retrospective study 278 thoracic pedicle screws of 43 patients were assessed using a scoring system and postoperative computed tomography (CT) scans. 43 consecutive patients with traumatic thoracic spine fractures underwent posterior transpedicular reduction and fixation. The universal spine system was used for placement of 278 pedicle screws under fluoroscopic control. Fractures were classified according to the Magerl classification by plain radiographs and CT scans. Evaluation of pedicle screw placement was assessed by a scoring system from grade I to grade III. Revision rate of pedicle screws as well as pre- and postoperative neurologic status were analyzed. In the thoracic spine, vertebral body T7 was mainly fractured followed by T6 and T5. In 37 (86.0%) of 43 patients type C fractures and in three patients each type A and B fractures were determined, respectively. Of all 278 pedicle screws, 78.1% were inserted in pedicles T4–T9. The rate of optimally placed grade I screws was 84.5%. Grade II screws were scored in 6.8% and grade III screws in 8.6%. The revision rate of all pedicle screws was 5.0%, whereas 64.3% of these were grade III. None of the patients suffered neurologic or vascular structure compromise postoperatively. Although most pedicle screws were placed in pedicles of the middle thoracic spine where the pedicle width is smallest, most screws were optimally placed with grade I. The revision rate of pedicle screws was acceptable and associated with the grade of pedicle screw placement.

Esophageal perforation in ankylosing spondylitis (AS) is a rare complication in anterior cervical spine surgery and has not been reported before. A 50-year-old patient with AS developed incomplete tetraplegia after minimal trauma. C5 pedicle fracture was diagnosed and treated predominantly by physical therapy until neurological symptoms progressed. Cervical spine MRI showed C6/7 fracture and spinal cord compression. The patient underwent dorsal laminectomy, C5-7 anterior cervical fusion using allograft iliac crest and CASPAR-plate fixation. Delayed esophageal perforation appeared 10 months postoperatively when he came first to our hospital. He complained of dysphagia and developed acute dyspnea. Posterior stabilization with two plates was performed followed by removal of the ventral plate and screws. The esophageal laceration was sutured. The patient was treated with antibiotics and percutaneous endoscopic gastrostomy. Position of fracture and implants were accurate at 18 months postoperatively. The patient had persistent minor neurological deficits (Frankel D) at last follow-up. We conclude that esophageal perforation after anterior spinal fusion is a rare complication. Minor traumas in patients with AS are unstable and can result in significant spinal injury. Dorsoventral stabilization should be performed to avoid further complications.

Laparoscopic procedures for children and adults already provide many advantages in two-dimensional (2D) vision. Only limited experiences exist for laparoscopic three-dimensional (3D) procedures in vivo. The aim of this prospective trial was to identify indications and limitations of the 3D-system in laparoscopic minimally invasive procedures in children and adults.In a prospective quality assurance for laparoscopic 3D evaluation in children and adults, a total of 53 consecutive patients (22 children, 31 adults) were included. Laparoscopic transabdominal, retroperitoneal and thoracoscopic procedures were performed. For laparoscopic 3D imaging a Camera Control Unit (CCU), 3D monitor and 3D-TIPCAM® were used. Patient data, operative procedures and image quality of the 3D system were assessed.Of 53 patients, 22/53 were children and 31/53 adults with a mean age of 7.6 years (range, 10 months to 15 years) and 51.5 years (range, 18 to 79 years), respectively. 8/22 children were two years old or younger. No relevant difficulties occurred with nausea, fatigue, vertigo, eye blurring or double vision, burning eyes, visual fatigue, inconvenience of visual adaptation of 3D to 2D, or medical discomforts for the surgeons in both children and adults. Difficulties were mainly addressed to the small distance of the video endoscope and the organ tissue in small children and affected mainly image definition, resolution and eye focusing.Advantages of 3D over 2D were mainly considered to be of relevant benefit in adults. Subjective advantages were seen in children and adults for stereoscopic depth perception, better visualization of anatomical structures and understanding of the anatomy, as well as for complex maneuvers such as suturing.

The aim of the study was the development and validation of a new subjective rating scale for assessment of outcome in patients with thoracolumbar fractures and fracture dislocations. The VAS spine score consists of 19 score items, using 100-mm visual analogue scales. The items are answered by the patients independently of rater assessment. To measure the analogue scales and calculate the score, a computer-aided system was evolved consisting of self-developed software and digitizer board. The overall score is the mean of all items answered with values between 0 and 100. The individual score loss is calculated as the difference between the preinjury score and at follow-up with values between 0 and 100. The VAS spine score was tested for reliability with a group of 136 healthy volunteers. We performed a test-retest study with an interval of 24 h. For statistical analysis of the validity, we prospectively followed a group of 53 patients with the new outcome score. We chose patients with injuries of the thoracolumbar spine, all having been operatively treated by combined posterior-anterior stabilization and fusion between 1994 and 1996. In the reference group, the average test score was 91.95 (58-100) and 92.10 (58-100) at retest. The mean individual difference between test and retest scored 1.037 (0-8). A high reliability was proved by a strong correlation with a coefficient of 0.976 (p 0.95, indicating a high internal consistency. With the VAS spine score the authors have inaugurated a new tool for outcome measurement in the treatment of patients with thoracolumbar injuries. The study has proved the score to be both reliable and valid. The application of the score is helpful in analyzing the subjective outcome, and the results can be correlated with objective measures. The score is a useful tool for comparative clinical studies, addressing the outcome after different methods of treatment.

Laparoscopic gastric banding is an easy to perform procedure with low morbidity and mortality. The benefits of the operation on the metabolic outcome have been demonstrated in long-term studies and are directly proportional to the amount of weight loss. Beside a closely monitored interdisciplinary follow-up, patient compliance is an essential prerequisite for success.

Background. High-dose tacrolimus (FK506) monotherapy has significantly prolonged rat hindlimb allograft survival. With an eye toward direct clinical application, we used a large-animal extremity composite tissue allograft model to assess the antirejection efficacy and systemic toxicity of combination FK506-mycophenolate mofetil (MMF) treatment. Methods. Radial forelimb osteomyocutaneous flap transplants were performed between size-matched out-bred pigs assigned to one of two groups: 5 control pigs received no immunosuppression and 9 animals received a once-daily oral FK506-MMF-prednisone regimen. Rejection was assessed by visual inspection of flap skin and was correlated with serial histopathologic examination of skin biopsy specimens. Results. In all control pigs the flap was completely rejected on day 7. Of the 9 pigs receiving treatment, 3 died from pneumonia on days 29, 30, and 83 without signs of rejection and another died from gastric rupture on day 42 with persistent mild rejection. The remaining 5 animals were free of rejection at the end of the 90-day follow-up period (P < 0.005 vs controls). Overall, 5 pigs had pneumonia, 4 septic arthritis, 3 toe abscesses, and 5 diarrhea and decreased weight gain. Conclusions. Combination oral FK506-MMF treatment provided a superior antirejection effect but more produced more toxicity than that previously demonstrated with cyclosporin A-MMF therapy in our model. Our results suggest that reduction ofFK506 or MMF doses might decrease both infectious and drug-specific side effects while still providing adequate prophylaxis against rejection.

Background. For the first time, we define and correlate visual and histologic grading systems of composite tissue allograft (CTA) skin rejection in a large-animal model and determine the utility of these grading systems for early diagnosis and monitoring of rejection. Materials and methods. Sixteen pairs of outbred swine underwent transplant of a forelimb osteomyocutaneous free flap. Group I ( n = 6) did not receive immunosuppressive therapy. Group II ( n = 10) received oral cyclosporin A, mycophenolate mofetil, and prednisone. The flap was visually inspected and protocol skin biopsies were taken at frequent intervals over a 90-day period. Visual Grades 0 (no rejection) to 4 (severe rejection) were assigned based on skin color, bleeding from biopsy site, and blister formation. Histologic Grades 0 to 4 were assigned based on the degree of vasculitis, folliculitis, dermal inflammation, and epidermal degeneration present. Results. All Group I animals progressively rejected their graft by Day 7. Group II grafts survived from 19 and 90 days; 93% of 115 biopsy specimens were read to be within ±1 histologic score of their assigned flap visual grade. Visual assessment carried an 8% false positive and 39% false negative rate with regard to biopsy-proven rejection. However, 81% of missed rejection specimens were histologic Grade 1. Biopsy, when visually indicated, would detect all rejection episodes when histologically Grade 1 or 2 and still potentially reversible. Conclusions . Visual scoring of CTA skin serves as a useful tool for initially detecting rejection, but repeated histologic evaluation is necessary for monitoring the subsequent course of the graft.

Background. Low-dose cyclosporine (CsA)'mycophenolate mofetil (MMF) therapy has significantly reduced the frequency of rejection and drug-induced side effects in rat hindlimb allograft recipients. With an eye toward direct clinical application, we developed a large-animal extremity composite tissue allograft model to assess the antirejection efficacy and systemic toxicity of combination CsA/MMF treatment. Methods. Radial forelimb osteomyocutaneous flap transplants were performed between size-matched, outbred pigs assigned to one of two groups: 5 control pigs received no immunosuppression, and 10 pigs received a once-daily oral CsA/MMF/prednisone regimen. Rejection was assessed by visual inspection of flap skin and correlated with serial histopathologic examination of skin biopsies. Results. In all control pigs, the flap was completely rejected on day 7. Of the 10 pigs receiving treatment, one died from pneumonia and an another from an anesthetic complication on days 19 and 30, respectively, without signs of rejection. Two flaps were lost on days 25 and 29 from severe rejection. Three pigs were free of rejection at the end of the 90-day follow-up period, and three had stable mild-to-moderate rejection at 90 days (P= 0.0007 vs. controls). White blood cell and platelet counts, serum creatinine values, and liver function tests remained normal in all animals receiving immunosuppressive therapy. Conclusions. Our results, to our knowledge, demonstrate for the first time that rejection can be significantly delayed in a large-animal composite tissue allograft model including skin using only orally administered agents dosed according to clinically relevant strategies without significant drug-specific systemic side effects.

The participation of the humoral immune system in rheumatoid arthritis (RA) is characterized by the production of rheumatoid factors (RF). RF are autoantibodies against the Fc part of IgG which are encoded by diverse germ-line genes. Most of the RF-encoding genes are unmutated, but in RA, a substantial quantity is encoded by somatically mutated genes. In addition, the synovial membranes (SM) of the diseased joints of RA patients are infiltrated by B lymphocytes which form germinal center-like aggregates. To analyze the local immune response, B cell foci from two RA SM were isolated by micromanipulation. From DNA of these foci, the rearranged kappa light chain variable region (V kappa) genes were amplified by polymerase chain reaction (PCR), cloned and sequenced. The amplification of different V kappa-J kappa combinations of different foci suggested oligoclonal expansion of B lymphocytes, which was confirmed by sequence analysis: each PCR product contained members of a single B cell clone. The sequence analysis of 29 different clones revealed rearrangements of diverse V kappa genes. Both frequent representatives of the V kappa 3 and the V kappa 1 family, as well as rarely used genes such as the L10 and B2 genes of the V kappa 2 and V kappa 5 families were found. Of the eleven potentially functional gene rearrangements, eight were significantly mutated, indicating their derivation from antigen-selected B cells. Intraclonal diversity in one of these clones may suggest ongoing mutation in the diseased synovial membrane of patients with RA.

Laparoscopic cholecystectomy (LC) remains one of the most frequent surgical therapies for symptomatic gallstone disorders. Prolonged operative time is frequently associated with increased complication rates. The aim of this study was to identify the risk factors for prolonged operative times to minimize perioperative morbidity and optimize clinical management.A total of 677 consecutive patients underwent LC. The exclusion criteria were conversion to an open procedure, intraoperative cholangiography, and liver cirrhosis (n=81). Data were analyzed retrospectively with respect to age, sex, BMI, ASA score, previous abdominal surgery, preoperative endoscopic retrograde cholangiopancreatography, acute cholecystitis, and surgeon's experience. Univariate and multivariate analyses were performed.A total of 596 patients, mean (± SD) age of 52.2 ± 16.7 years, were analyzed. In all, 29% of the patients were obese (BMI ≥ 30 kg/m); 11% had ASA III. Five percent of patients had undergone previous upper abdominal surgery. Overall, 105/596 patients had an acute cholecystitis. Residents of general surgery performed 58% of all operations. The median operative time was 80 min (range, 15-281 min). No statistical significance was found between intraoperative and postoperative complications by surgeon's experience. Statistically, independent preoperative predictors for prolonged operative time as identified through multivariate analysis were acute cholecystitis, obesity, previous upper abdominal surgery, male sex, and low degree of surgical expertise.The risk for prolonged operative times in LC can be assessed on the basis of patients' characteristics. Assessment of these factors not only helps to optimize the individual outcome for each patient but also improves the decision process toward operative training for junior surgeons.

Introduction Lymphangiomatous cysts are submucosal masses that are rarely found in the gastrointestinal tract and more often in the neck, oral cavity, and skin. These cysts are benign tumors and mostly clinically silent. Symptoms include abdominal pain, diarrhea, and rectal bleeding. Their pathogenesis remains unclear. Case presentation During a routine ultrasound examination of a Caucasian 25-year-old woman, a structure that raised our suspicions of an ovarian cyst was found. MRI showed a 4.5 cm cystic lesion in the cecal region. Laparoscopic exploration revealed unexpected contact with the ascending colon. The cyst, including its base and of portion of the colon, was resected laparoscopically. The histological examination revealed cystic lymphangioma. Conclusion Lymphangiomatous cysts of the colon are very rare lesions. Although their pathology is benign, the recommended treatment is resection, which can be performed with minimal invasiveness.

Purpose: Circadian rhythms are daily oscillations of multiple biological processes driven by endogenous clocks. Imbalance of these rhythms has been associated with cancerogenesis in humans. To further elucidate the role circadian clocks have in cellular growth control, tumor suppression and cancer treatment, it is revealing to know how clock genes and clock-controlled genes are regulated in healthy humans. Materials and Methods: Therefore comparative microarray analyses were conducted investigating the relative mRNA expression of clock genes throughout a 24-hour period in cell samples obtained from oral mucosa of eight healthy diurnally active male study participants. Differentially expressed selected genes of interest were additionally evaluated using qRT-PCR. Results: Microarray analysis revealed 33 significant differentially regulated clock genes and clock- controlled genes, throughout a one day period (6.00h, 12.00h, 18.00h, 24.00h). Hereof were 16 clock genes and 17 clock- controlled genes including tumor suppressor- and oncogenes. qRT-PCR of selected genes of interest, such as hPER2, hCRY1, hBMAL1, hCCRN4L and hSMAD5 revealed significant circadian regulations. Conclusion: Our study revealed a proper circadian regulation profile of several clock- and tumor suppressor genes at defined points in time in the participants studied. These findings could provide important information regarding genes displaying the same expression profile in the gastrointestinal tract amounting to a physiological expression profile of healthy humans. In the future asynchronous regulations of those genes might be an additional assistant method to detect derivations distinguishing normal from malignant tissue or assessing risk factors for cancer.

A temporary non-surgical approach for treatment of obesity is the gastric balloon that serves as an alternative procedure for many patients with frustrated diet attempts. Deflation and displacement of the balloon resulting in acute intestinal obstruction and subsequent surgical intervention is a rare complication. A BioEnterics Intragastric Balloon was endoscopically implanted in a 35-year-old female with a body mass index (BMI) of 28 kg/m 2 . The procedure succeeded without complications, and weight loss was effective during the first 6 months. One year after balloon implantation, the patient presented with abdominal cramps and vomiting due to ileal obstruction. Since endoscopic efforts to remove the deflated and displaced balloon failed, emergency laparotomy and enterotomy were necessary. Vascularization of the dilated small bowel was compromised, but recovered after decompression. Patients' postoperative course was uneventful. The gastric balloon model can be associated with major complications and should be used critically. Removal of the balloon should be assured not later than 6 months when weight loss decreases.

Obesity is becoming an epidemic health problem and is associated with concomitant diseases, such as sleep apnea syndrome and gastroesophageal reflux disease (GERD). There is no standardized diagnostic workup for the upper gastrointestinal tract in obese patients; many patients have no upper gastrointestinal symptoms, and few data are available on safety of endoscopy in morbidly obese patients. Sixty-nine consecutive diagnostic upper gastrointestinal endoscopies in morbidly obese patients (26 men, 43 women; mean age 43.4 ± 10.9 years) were prospectively evaluated from January to December 2008 in an outpatient setting before bariatric procedures. Sedation was administered with propofol. Data on sedation, critical events, and examination times were recorded, as well as pathological findings. The patients’ mean body mass index was 47.6 ± 7.9 (range, 35.1–73.3) kg/m2; 17.4% reported GERD symptoms. The mean duration of the endoscopy procedure (including sedation) was 20.3 ± 9.3 (range, 5–50) min, and the whole procedure (including preparation and postprocessing) took 58.2 ± 19 (range, 20–120) min. The mean propofol dosage was 380 ± 150 (range, 80–900) mg. Two patients had critical events that required bronchoscopic intratracheal O2 insufflation due to severe hypoxemia (

Morbid obesity is a recognized risk factor for gastrointestinal cancer. Little is known about pancreatic cancer developing after gastric bypass surgery or about surgery for this type of tumor following bariatric surgery. This report describes a case of pancreatic head cancer identified 3 months after laparoscopic sleeve gastrectomy for morbid obesity. During routine follow-up, mild abdominal pain and elevated pancreatic enzymes prompted computed tomography, which revealed mild edematous pancreatitis. Hyperbilirubinemia developed, and magnetic resonance imaging showed a pancreatic head tumor. CA19-9 was elevated. After a pylorus-preserving pancreatic head resection, the postoperative course was uneventful. The patient received adjuvant chemotherapy. Unfortunately, at the time of writing (9 months postoperatively), a local recurrence and hepatic metastases were diagnosed. Patients treated with bariatric surgery who develop new symptoms or report constant mild symptoms should be evaluated using endoscopy and radiomorphological imaging. Interdisciplinary obesity treatment can then offer significant benefits for the patient, particularly in the case of pancreatic cancer, which is still difficult to diagnose. In addition, there is a need for epidemiological studies of patients who undergo bariatric surgery and subsequently develop cancer.

Pheochromocytoma (PCC) is a usually benign tumor originated in the majority of patients from the adrenal medulla. Regarding sporadic forms of PCC, mechanisms of pathogenesis are largely unknown. Recently, microsatellite-instability (MSI) was discussed as genetic factor contributing to PCC development. Since microsatellite markers used for MSI detection have only been recommended for colorectal carcinoma (CRC), we established an extended marker set for MSI detection in PCC.Twenty-two PCC patients were analyzed applying 11 microsatellite markers. Our marker set comprised the reference panel for CRC and six additional markers, which have already been described to detect MSI in tumors other than CRC. Moreover, 23 endocrine tumors with gastrointestinal origin were examined in order to test the applicability of this marker panel.Microsatellite-instability was detected in 41% of PCCs. Twenty-seven percent showed loss of heterozygosity (LOH) events affecting different chromosomal regions. Among the 23 patients with endocrine tumors, only three (one pancreatic endocrine tumor, one duodenal neuro-endocrine tumor, one hepatic metastasis of a primary tumor with unknown origin) demonstrated MSI.The extended microsatellite panel is qualified to detect MSI in PCC. Nine percent of MSI-positive cases would have not been noticed by the use of the reference panel alone. PCCs are characterized by low frequency MSI pointing to failures in factors involved in DNA replication.

Background. Tacrolimus (FK506)/mycophenolate mofetil (MMF)/prednisone combination immunosuppression therapy has been found to effectively prevent composite tissue allograft (CTA) rejection with minimal toxicity in a preclinical porcine model. These findings have been reproduced in 24 human hands transplanted in 18 patients. In CTAs containing bone, adequate bone quality and healing are essential for long-term functional success. The purpose of this study was to determine the effect FK506/MMF/prednisone immunotherapy has on bone quality and healing. Methods. Forelimb CTA-flaps were transplanted in nine pigs. Recipient animals received FK506/MMF/prednisone therapy for 3 months. Bone quality was studied pre- and posttransplant by measuring acoustic velocity and density and by calculating elastic coefficients. Additional bone quality analyses were performed on unoperated limbs, and in bone grafts from two pigs that had autograft procedures performed. Bone healing was assessed using radiographic analysis. Results. Three animals were lost to immunosuppression-related complications before the endpoint of the study. The bone component of all six CTA-flaps showed normal healing. Although results of the bone density measurements were not significantly different when comparing pre- to posttransplant values, acoustic velocity and elastic coefficient measurements showed a significant decrease posttransplant indicating a decrease in bone quality. Conclusions. FK506/MMF/prednisone combination therapy prevented rejection, did not adversely affect bone quality, and showed normal bone healing. The transplant procedure itself decreased bone quality more than the immunosuppression regimen did over the observation period in this study. Based on these findings, we conclude to prevent CTA failure it is important to monitor bone quality posttransplant.

Laparoscopic sigmoid colectomy has been widely accepted as elective approach but is, however, still discussed controversially for acute cases. Patients receiving a laparoscopic early single-stage procedure benefit from an early postoperative convalescence with a minimum of disability. As more surgeons gain expertise in minimally invasive surgery of the rectosigmoid, this video highlights the main steps of a rectosigmoid resection for acute complicated diverticulitis.