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Background Pheochromocytomatosis is a rare but dramatic complication of pheochromocytoma surgery. In this study, we collected and analysed our experience with the surgical treatment of cases of this rare condition. Methods In total 9 patients were operated on between December 2001 and August 2022 at the Kliniken Essen-Mitte due to pheochromocytomatosis. There were 5 female and 4 male patients, mean age of 58 ± 18 (range: 22 to 86). The data was prospectively collected and retrospectively analysed. Results All patients were initially operated on due to pheochromocytoma (2 with SDHB-Syndrome and 1 with MEN-IIa-Syndrome). In 4 cases an intraoperative tumour capsule injury during the initial surgery was described. The operation due to pheochromocytomatosis was performed minimally invasive in 8 cases, 1 patient was operated on by open approach. The mean time between the primary surgery and the pheochromocytomatosis operation was 107 ± 60 months. Operation time was 246 + 119 minutes. Follow-up data were available for 8 patients (mean follow-up time 12 years). 2 patients were cured at the time of the last follow-up. 7 patients developed recurrent disease: loco-regional recurrence in 6 cases and distant metastasis in 3 cases. 4 patients with loco-regional recurrence were reoperated within 54 ± 50 months (range 10–137 months). By the follow-up, 3 patients died. Conclusion Pheochromocytomatosis is a potentially lethal complication of pheochromocytoma surgery. Even if the initial pheochomocytomatosis could be managed minimally invasive, the recurrence rate is extremely high.

Purpose Esophageal perforation is associated with high morbidity and mortality. In addition to surgical treatment, endoscopic endoluminal stent placement and endoscopic vacuum therapy (EVT) are established methods in the management of this emergency condition. Although health-related quality of life (HRQoL) is becoming a major issue in the evaluation of any therapeutic intervention, not much is known about HRQoL, particularly in the long-term follow-up of patients treated for non-neoplastic esophageal perforation with different treatment strategies. The aim of this study was to evaluate patients’ outcome after non-neoplastic esophageal perforation with focus on HRQoL in the long-term follow-up. Methods Patients treated for non-neoplastic esophageal perforation at the University Hospital Cologne from January 2003 to December 2014 were included. Primary outcome and management of esophageal perforation were documented. Long-term quality of life was assessed using the Gastrointestinal Quality of Life Index (GIQLI), the Health-Related Quality of Life Index (HRQL) for patients with gastroesophageal reflux disease (GERD), and the European Organization for Research and Treatment of Cancer (EORTC) questionnaires for general and esophageal specific QoL (QLQ-C30 and QLQ-OES18). Results Fifty-eight patients were included in the study. Based on primary treatment, patients were divided into an endoscopic (n = 27; 46.6%), surgical (n = 20; 34.5%), and a conservative group (n = 11; 19%). Short- and long-term outcome and quality of life were compared. HRQoL was measured after a median follow-up of 49 months. HRQoL was generally reduced in patients with non-neoplastic esophageal perforation. Endoscopically treated patients showed the highest GIQLI overall score and highest EORTC general health status, followed by the conservative and the surgical group. Conclusion HRQoL in patients with non-neoplastic esophageal perforation is reduced even in the long-term follow-up. Temporary stent or EVT is effective and provides a good alternative to surgery, not only in the short-term but also in the long-term follow-up.

Background Ivor-Lewis esophagectomy (ILE) is the standard surgical care for esophageal cancer patients but postoperative morbidity impairs quality of life and reduces long-term oncological outcome. Two-stage ILE separating the abdominal and thoracic phase into two distinct surgical procedures has proven to enhance microcirculation of the gastric conduit and therefore most likely reduces complications. However, two-stage ILE has not been evaluated systematically in selected groups of patients scheduled for this procedure. This investigation aims to demonstrate the feasibility of two-stage ILE in high-risk patients. Patients and methods In this retrospective analysis of data obtained from a prospective database, a consecutive series of 275 hybrid ILE (hILE) were included. Patients were divided into two groups based on one- or two-stage hILE. Postoperative complications were assessed according to ECCG (Esophageal Complication Consensus Group) criteria and compared using the Clavien–Dindo score. Indication for two-stage esophagectomy was classified as pre- or intraoperative decision. Results 34 out of 275 patients (12.7%) underwent two-stage hILE. Patients of the two-stage group were significantly older. In 21 of 34 patients (61.8%) the decision for a two-stage procedure was made prior to esophagectomy, in 13 (38.2%) patients intraoperatively after completion of the laparoscopic gastric mobilization. The most frequent preoperative reason to select the two-stage procedure was a stenosis of the coeliac trunc and superior mesenteric artery (n = 10). The predominant cause for an intraoperative change of strategy was a laparoscopically diagnosed hepatic fibrosis/cirrhosis (n = 5).Overall morbidity and major’ complications (CD > IIIa) were comparable for both groups (11.7% in both groups). The overall anastomotic leak rate was 12.4% and was non-significant lower for the two-stage procedure. Conclusion Two-stage hILE is a feasible concept to individualize the surgical treatment of patients with well-defined clinical risk factors for postoperative morbidity. It can also be applied after completion of the abdominal phase of IL esophagectomy without compromising the patient safety.

Background This study was conducted to validate a pretreatment (i.e. prior to neoadjuvant chemoradiotherapy) pathological staging system in the resection specimen after neoadjuvant chemoradiotherapy for esophageal cancer. The study investigated the prognostic value of pretreatment pathological T and N categories (prepT and prepN categories) in both an independent and a combined patient cohort. Methods Patients with esophageal cancer treated with neoadjuvant chemotherapy and esophagectomy between 2012 and 2015 were included. PrepT and prepN categories were estimated based on the extent of tumor regression and regressional changes of lymph nodes in the resection specimen. The difference in Akaike’s information criterion (ΔAIC) was used to assess prognostic performance. PrepN and ypN categories were combined to determine the effect of nodal sterilization on prognosis. A multivariable Cox regression model was used to identify combined prepN and ypN categories as independent prognostic factors. Results The prognostic strength of the prepT category was better than the cT and ypT categories (ΔAIC 7.7 vs. 3.0 and 2.9, respectively), and the prognostic strength of the prepN category was better than the cN category and similar to the ypN category (ΔAIC 29.2 vs. − 1.0 and 27.9, respectively). PrepN + patients who became ypN0 had significantly worse survival than prepN0 patients (2-year overall survival 69% vs. 86% in 137 patients; p = 0.044). Similar results were found in a combined cohort of 317 patients (2-year overall survival 62% vs. 85%; p = 0.002). Combined prepN/ypN stage was independently associated with overall survival. Conclusions These results independently confirm the prognostic value of prepTNM staging. PrepTNM staging is of additional prognostic value to cTNM and ypTNM. PrepN0/ypN0 patients have a better survival than prepN +/ypN0 patients.

With progress in genome sequencing and data sharing, 1000s of bacterial genomes are publicly available. Genome mining – using bioinformatics tools in terms of biosynthetic gene cluster (BGC) identification, analysis and rating – has become a key technology to explore the capabilities for natural product (NP) biosynthesis. Comprehensively, analyzing the genetic potential of the phylum Bacteroidetes revealed Chitinophaga as the most talented genus in terms of BGC abundance and diversity. Guided by the computational predictions, we conducted a metabolomics and bioactivity driven NP discovery program on 25 Chitinophaga strains. High numbers of peerless strain-specific metabolite buckets confirmed the upfront predicted biosynthetic potential and revealed a tremendous uncharted chemical space. Sourcing this dataset, we isolated the new iron chelating nonribosomally-synthesized cyclic tetradeca- and pentadecalipodepsipeptide antibiotics chitinopeptins with activity against Candida, produced by C. eiseniae DSM 22224 and C. flava KCTC 62435, respectively.TeaserCombination of omics-technologies revealed taxonomical hotspots for specialized metabolites within Bacteroidetes.

Background The coronavirus disease 2019 (COVID-19) pandemic led to far-reaching restrictions of social and professional life, affecting societies all over the world. To contain the virus, medical schools had to restructure their curriculum by switching to online learning. However, only few medical schools had implemented such novel learning concepts. We aimed to evaluate students’ attitudes to online learning to provide a broad scientific basis to guide future development of medical education. Methods Overall, 3286 medical students from 12 different countries participated in this cross-sectional, web-based study investigating various aspects of online learning in medical education. On a 7-point Likert scale, participants rated the online learning situation during the pandemic at their medical schools, technical and social aspects, and the current and future role of online learning in medical education. Results The majority of medical schools managed the rapid switch to online learning (78%) and most students were satisfied with the quantity (67%) and quality (62%) of the courses. Online learning provided greater flexibility (84%) and led to unchanged or even higher attendance of courses (70%). Possible downsides included motivational problems (42%), insufficient possibilities for interaction with fellow students (67%) and thus the risk of social isolation (64%). The vast majority felt comfortable using the software solutions (80%). Most were convinced that medical education lags behind current capabilities regarding online learning (78%) and estimated the proportion of online learning before the pandemic at only 14%. In order to improve the current curriculum, they wish for a more balanced ratio with at least 40% of online teaching compared to on-site teaching. Conclusion This study demonstrates the positive attitude of medical students towards online learning. Furthermore, it reveals a considerable discrepancy between what students demand and what the curriculum offers. Thus, the COVID-19 pandemic might be the long-awaited catalyst for a new “online era” in medical education.

Cholangiocarcinoma (CCA) is an aggressive malignancy with a 5-year-survival rate of

Background Esophageal perforation is associated with high morbidity and mortality. In addition to surgical treatment, endoscopic endoluminal stent placement and endoscopic vacuum therapy (EVT) are established methods in the management of this emergency condition. As health-related quality of life (HRQoL) is becoming a major issue in the evaluation of any therapeutic intervention not much is known about HRQoL, particular in the long-term follow-up of patients treated for benign esophageal perforation with different treatment strategies. Methods Patients treated for benign esophageal perforation at the University Hospital Cologne from January 2003 to December 2014 were included. Primary outcome and management of esophageal perforation were documented and long-term quality of life was assessed using the Gastrointestinal Quality of Life Index (GIQLI), the Health-Related Quality of Life Index (HRQL) for patients with gastroesophageal reflux disease (GERD) and the European Organization for Research and Treatment of Cancer (EORTC) questionnaires for general and esophageal cancer specific QoL (QLQ-C30 and QLQ-OES18). . Results 58 patients were included in the study. Based on primary treatment patients were divided into an endoscopic (n = 27; 46.6%), surgical (n = 20; 34.5%) and conservative group (n = 11; 19%). Short- and long-term outcome, as well as quality of life were compared. HRQoL was measured after a median follow-up of 49 months HRQoL was generally reduced in patients with benign esophageal perforation. Endoscopically treated patients showed the highest GIQLI overall score and highest EORTC general health status, followed by the conservative and the surgical group. Conclusion HRQoL in patients with benign esophageal perforation is reduced even in the long-term follow-up. Temporary stent or EVT is effective and provides a good alternative to surgery not only in the short-term but also in the long-term follow-up.

Perforation of the esophagus is the most severe complication of transesophageal echocardiography (TEE) and can lead to mediastinitis, pleural empyema, or peritonitis. Currently, the majority of patients receive operative treatment with only 6% treated endoscopically. We report our experience with endoscopic and conservative approaches.We retrospectively reviewed all patients treated for esophageal perforation and included all patients with perforation caused by TEE. All patients with perforation of the esophagus by TEE probe underwent conservative or endoscopic treatment, drainage of pleural and mediastinal retentions, and adjusted to antibiotic therapy.From January 2004 to December 2014 a total of 109 patients were treated for esophageal perforation in our department. In 6 patients (5.5%) the perforation was caused by TEE. Location was cervical and midthoracic in 2 and 4 cases, respectively. All patients underwent successful endoscopic treatment and no further surgical procedure, such as esophageal suture or resection was necessary. The mean time between TEE and therapy of the perforation was 7.3 days. In all patients closure of the leakage could be achieved within 30 days. Mortality rate was 0%.Esophageal perforations caused by TEE are typically small, in the cervical and mid esophagus, and minimally contaminated. These are good prognostic factors for successful endoscopic treatment with preservation of the esophagus. Operative treatment should only be considered in cases of failed endoscopic treatment.

Introduction: Tuberculous meningitis (TBM) is often diagnostically challenging. Only limited data exist on the performance of interferon-ã release assays (IGRA) and molecular assays in children with TBM in routine clinical practice, particularly in the European setting. Methods: Multicentre, retrospective study involving 27 healthcare institutions providing care for children with tuberculosis (TB) in nine European countries. Results: Of 118 children included, 54 (45.8%) had definite, 38 (32.2%) probable and 26 (22.0%) possible TBM; 39 (33.1%) had TBM grade 1, 68 (57.6%) grade 2 and 11 (9.3%) grade 3. Of 108 patients who underwent cranial imaging 90 (83.3%) had at least one abnormal finding consistent with TBM. At the 5-mm cut-off the tuberculin skin test had a sensitivity of 61.9% (95% CI 51.2-71.6%) and at the 10-mm cut-off 50.0% (95% CI 40.0-60.0%). The test sensitivities of QuantiFERON-TB and T-SPOT.TB assays were 71.7% (95% CI 58.4-82.1%) and 82.5% (95% CI 58.2-94.6%), respectively (p=0.53). Indeterminate results were common, occurring in 17.0% of QuantiFERON-TB assays performed. Cerebrospinal fluid (CSF) cultures were positive in 50.0% (95% CI 40.1-59.9%) of cases, and CSF PCR in 34.8% (95% CI 22.9-43.7%). In the subgroup of children who underwent tuberculin skin test, IGRA, CSF culture and CSF PCR simultaneously, 84.4% had at least one positive test result (95% CI 67.8%-93.6%). Conclusions: Existing immunological and microbiological TB tests have suboptimal sensitivity in children with TBM, with each test producing false-negative results in a substantial proportion of patients. Combining immune-based tests with CSF culture and CSF PCR results in considerably higher positive diagnostic yields, and should therefore be standard clinical practice in high-resource settings. Copyright © 2020 ERS.

Aim The aim of the study is to analyze the structure and the patient population of a consultation hour for benign diseases of the upper gastrointestinal tract at a centre of excellence for esophageal and gastric surgery. Background and Methods The increasing specialization in visceral surgery leads to a higher number of special consultation hours, e.g. for benign diseases of the esophagus and stomach. In this study we examine both the reasons for an introduction at a specialized clinic and the therapy suggestions. The clinical and demographic data of all patients who visited an appointment for functional diseases of the upper gastrointestinal tract of the University Hospital Cologne during the entire year 2018 were collected prospectively for this study and evaluated at the end of the year. Results In 2018, a total of 412 patients attended the benign OGI consultation hour (54% male). 107 patients (26%) attended more than once. 293 patients attended the consultation hour for the first time. The following diagnoses most frequently led to the presentation in the special consultation hour: GERD (n=262, 63%), achalasia (n=52, 13%), upside-down-stomach (n=24, 6%), dysphagia of unknown genesis (n=15, 4%), and other motility disorders of the esophagus (n=14, 3%). 190 patients received an EGD because they had not received an endoscopic examination in the last year. Functional diagnostics were performed in almost all new presentations: High- resolution-manometry (n=243), 24h-pH-metry (n=199). Even though the surgical department led the consultation hour, a conservative approach was recommended to 231 patients (56%). Surgery was recommended to 156 patients (38%) and an endoscopic approach was recommended in 25 cases (6%). Overall, 101 patients (43%) received an operation during the observation period. Most common indication for surgery was GERD (n=63, 62%). Of those 63 patients, 42 received a laparoscopic Nissen fundoplication. Conclusion The demand for a specialized clinic for reflux treatment is significant and includes a high degree of diagnostics. A differentiation of the symptoms is decisive in order to select the right patients for surgical therapy. Only about every third patient is recommended for surgery.

In this work, we propose a new care concept for dementia patients in their own apartments: interconnected living in a quarter. We describe a technical setup that is comprised of a safety system and an activity detection system. The latter detects, processes and illustrates activities of daily living to help the quarter managers to provide appropriate interventions for persons with dementia in the quarter.The nine-month field study reported in this work was conducted in two quarters with eight participants.We evaluated different possibilities to determine activity indicators with the aim of providing information that enables the quarter managers to offer exactly the level of support needed by each individual patient. To evaluate the usefulness and the perception of the technical infrastructure, qualitative interviews with the dementia patients and the quarter managers were conducted.The results indicate that the interconnected living concept helps to increase the safety of the dementia patients. Additionally, several activity indicators that help the quarter managers to offer the appropriate level of support to the dementia patients have been identified.The presented concept, which has been evaluated in a real-world-setting, constitutes a new holistic and cross-disciplinary dementia care approach.

Background: Percutaneous endoscopic gastrostomy (PEG) placed in the pull through (PT) technique is a common procedure to restore enteral feeding in patients with swallowing disorders. Limitations of this technique are patients with obstruction of the pharynx or esophagus or with an esophageal stent. We report our experience with the direct puncture (DP) PEG device. Methods: We included 154 patients (55 women). One hundred forty patients had cancer. After passing the endoscope into the stomach, 4 gastropexies were performed with a gastropexy device and the PEG was placed with the introducer method. After 1 month, the sutures were removed and a constant gastrocutaneous fistula had been created and the new catheter could be placed safely. Results: The DP PEG was successfully placed in all patients. Overall complication rate was 11% (minor: 6%, major: 5%). The most common event was tube dislocation (40 cases). In 5 cases of dislocation, this resulted in a major complication with injuring the gastric wall and the necessity for surgical treatment. Conclusions: The DP PEG system is safe, and can be used in cases in which a standard PT PEG is not feasible. To avoid dislocation, strict adherence to a post-interventional protocol is highly recommended.

De-Hua Chang,1,* Sebastian Brinkmann,2,* Lucy Smith,3 Ingrid Becker,4 Wolfgang Schroeder,2 Arnulf H Hoelscher,5 Stefan Haneder,1 David Maintz,1 Judith Eva Spiro6 1Department of Radiology, University Hospital of Cologne, Cologne, Germany; 2Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany; 3Faculty of Medicine, Memorial University of Newfoundland, St John’s, Canada; 4Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany; 5Agaplesion Markus Hospital, Frankfurt am Main, Germany; 6Department of Radiology, University Hospital, LMU Munich, Munich, Germany *These authors contributed equally to this work Purpose: Anastomotic leakage is a major surgical complication following esophagectomy and gastric pull-up. Specific risk factors such as celiac trunk (TC) stenosis and high calcification score of the aorta have been identified, but no data are available on their relative prognostic values. This retrospective study aimed to compare and evaluate calcification score versus stenosis quantification with regards to prognostic impact on anastomotic leakage.Patients and methods: Preoperative contrast-enhanced computed tomography scans of 164 consecutive patients with primary esophageal cancer were evaluated by two radiologists to apply a calcification score (0–3 scale) assessing the aorta, the celiac axis and the right and left postceliac arteries. Concurrently, the presence and degree of stenosis of TC and superior mesenteric artery were recorded for stenosis quantification.Results: Anastomotic leakage was noted in 14/164 patients and 12/14 showed stenosis of TC (n=11). The presence of TC stenosis was found to have a significant impact on anastomotic healing (p=0.004). The odds ratio for the prediction of anastomotic leakage by the degree of stenosis was 1.04 (95% CI, 1.02–1.07). Ten of 14 patients had aortic calcification scores of 1 or 2, but calcification scores of the aorta, the celiac axis and the right and left postceliac arteries did not correlate with the corresponding TC stenosis values and showed no influence on patient outcome as defined by the occurrence of anastomotic insufficiency (p=0.565, 0.855, 0.518 and 1.000, respectively). Inter-reader reliability of computed tomography analysis and absolute agreement on calcium scoring was mostly over 90%. No significant differences in preoperative comorbidities and patient characteristics were found between those with and without anastomotic leakage.Conclusion: Measurement of TC stenosis in preoperative contrast-enhanced computed tomography scans proved to be more reliable than calcification scores in predicting anastomotic leakage and should, therefore, be used in the risk assessment of patients undergoing esophagectomy and gastric pull-up. Keywords: TC stenosis, calcification score, anastomotic leakage, stenosis quantification, Ivor Lewis esophagectomy, graft perfusion

This study aims to assess the feasibility of 4D flow MRI measurements in complex vascular territories; namely, the celiac artery (CA) and superior mesenteric artery (SMA).In this prospective study, 22 healthy volunteers and 10 patients were scanned at 3 T. Blood flow parameters were compared between healthy volunteers and patients with stenosis of the CA and/or SMA as a function of stenosis grade characterized by prior contrast-enhanced computed tomography (CE-CT). The 4D flow MRI acquisition covered the CA, SMA and adjusting parts of the abdominal aorta (AO). Measurements of velocity- (peak velocity [PV], average velocity [AV]) and volume-related parameters (peak flow [PF], stroke volume [SV]) were conducted. Further, stenosis grade and wall shear stress in the CA, SMA and AO were evaluated.In patients, prior evaluation by CE-CT revealed 11 low- and 5 mid-grade stenoses of the CA and/or SMA. PV and AV were significantly higher in patients than in healthy volunteers [PV: p 0.0001; AV: p = 0.03, p 0.001]. PF and SV did not differ significantly between healthy volunteers and patients; however, a trend towards lower PF and SV could be detected in patients with mid-grade stenoses. Comparison of 4D flow MRI with CE-CT revealed a strong positive correlation in estimated degree of stenosis (CA: r = 0.86, SMA: r = 0.98). Patients with mid-grade stenoses had a significantly higher average WSS magnitude (AWM) than healthy volunteers (p = 0.02).This feasibility study suggests that 4D flow MRI is a viable technique for the evaluation of complex flow characteristics in small vessels such as the CA and SMA. 4D flow MRI approves comparable to the morphologic assessment of complex vascular territories using CE-CT but, in addition, offers the functional evaluation of flow parameters that goes beyond the morphology.

Respiratory complications are responsible to a high degree for postoperative morbidity and mortality after Ivor-Lewis esophagectomy. The etiology of respiratory failure is known to be multifactorial with preoperative impaired lung function being the most important one. The aim of this study was to investigate the correlation between preoperative airway colonization (PAC) and postoperative respiratory complications.In this observational study, 64 patients with esophageal cancer were included. All patients underwent Ivor-Lewis esophagectomy with laparoscopic or open gastric mobilization. After induction of anesthesia and intubation with a double-lumen tube, bronchial exudate was collected by random endoluminal suction for further microbiological work-up. Length of postoperative mechanical ventilation (24 h, 24-72 h,72 h), re-intubation, and tracheostomy were recorded as primary and secondary study endpoints.In 13 of 64 study patients (20.3 %), pathological colonization of the bronchial airways could be proved prior to esophagectomy. Haemophilus species was the most frequently identified pathogen. PAC was associated with a longer history of smoking (p = 0.025), a lower preoperative forced expiratory volume (FEV1, p = 0.009) or vital capacity (VC, p = 0.038), a prolonged postoperative mechanical ventilation (p 0.001), and a higher frequency of re-intubation (p 0.001) and tracheostomy (p = 0.017). In the multivariate analysis, PAC was identified as an independent predictor of respiratory failure (hazard ratio 11.4, 95 % confidence interval 2.6-54, p = 0.002). Mortality in the PAC group was 30.8 % compared to 0 % in patients without PAC (p 0.0001).PAC is a significant risk factor for postoperative respiratory failure. A routine bronchoscopy and bronchoalveolar lavage as part of preoperative management prior to esophagectomy need to be discussed.

Gastroesophageal reflux is a common problem following esophagectomy and reconstruction with gastric interposition. Despite a routine prescription of proton pump inhibitors, reflux-associated mucosal damage in the remnant esophagus is frequently observed. Purpose of this study is to evaluate mucosal damage in the esophageal remnant during long-term follow-up and to compare the prevalence of this damage between the subgroups of esophageal squamous cell and adenocarcinoma. All patients undergoing transthoracic Ivor-Lewis esophagectomy were prospectively entered in our IRB approved database. All patients underwent a routine check-up program with yearly surveillance endoscopies following esophagectomy. Only patients with a complete follow-up were included into this study. Endoscopic and histopathologic mucosal changes of the remnant esophagus were analyzed in close intervals. A total of 50 patients met the inclusion criteria, consisting of 31 adenocarcinomas (AC) and 19 squamous cell carcinomas (SCC). Mucosal damage was already seen 1 year after surgery in 20 patients macroscopically (43%) and in 21 patients microscopically (45%). At 5-year follow-up the prevalence for macroscopic and microscopic damage was 55% and 60%, respectively. The prevalence of mucosal damage was higher in AC patients than in SCC patients (1y-FU: 51% [AC] vs. 28% [SCC]; 5y-FU: 68% [AC] vs. 35% [SCC], P < 0.05). Newly acquired Barrett's esophagus was seen in 10 patients (20%) with two of those patients (20%) showing histopathologic proof of neoplasia. This study shows a high prevalence of reflux-associated mucosal damage in the remnant esophagus one year out of surgery and only a moderate increase in prevalence in the following years. Mucosal damage was more frequently seen in AC patients and the occurrence of de-novo Barrett's esophagus and de-novo neoplasia was high. Endoscopic surveillance with targeted biopsies seems to be an indispensable tool to follow patients after esophagectomy appropriately.

Objective Chylothorax is a major complication after esophagectomy. As recent studies refer to heterogeneous patient cohorts and surgical procedures, this study was conducted to report the incidence and evaluate the optimal management of chylous fistula in patients treated with transthoracic esophagectomy and 2-field lymphadenectomy for esophageal cancer. Methods From January 2005 to December 2013, a total of 906 patients underwent transthoracic esophageal resection for esophageal carcinoma at our institution. En bloc esophagectomy was performed with routine supradiaphragmatic ligation of the thoracic duct. The incidence of chylothorax, and associated morbidity and mortality, were analyzed, and subsequent therapeutic management was reviewed. Results Chylothorax after Ivor Lewis esophagectomy was observed in 17 (1.9%) patients. Fifteen patients required surgical intervention with rethoracotomy and repeat duct ligation. Thoracic duct ligation was successful in all patients. Two patients died within 90 days after primary esophageal resection. The median time between initial tumor resection and rethoracotomy was 13 days. Average daily chest-tube output at time of reoperation was 1900 mL. In 2 patients, pleural effusion did not exceed 1000 mL per day. In these cases, conservative management with additional thoracic drainage and total parenteral nutrition led to complete resolution of chylous fistula. Conclusions Occurrence of chylothorax after prophylactic thoracic duct ligation during transthoracic esophagectomy for esophageal cancer is rare. In patients with high-output chylous fistula, an early rethoracotomy with repeat ligation of the thoracic duct is safe and helps to shorten recovery time. In cases of low-volume drainage, a conservative approach is feasible.

Background: Esophagectomy with gastric tube reconstruction and extended transhiatal gastrectomy with Roux-en-Y reconstruction are alternative procedures in current therapeutic concepts for adenocarcinoma of the esophagogastric junction (AEG). The impact of these operations on long-term health-related quality of life (HRQL) is incompletely understood.Methods: Patients with cancer-free survival of at least 24 months after esophagectomy (ESO) or extended gastrectomy (GAST) for AEG were identified from a prospectively maintained database. EORTC questionnaires were sent out to assess health-related general (QLQ-C30) and cancer-specific (OG-25) quality of life. Numeric scores were calculated for each conceptual area and compared with those of healthy reference populations.Results: 123 patients (ESO n = 71; GAST n = 52) completed the self-rated questionnaires. HRQL was consistently lower in surgical patients (GAST and ESO) compared with healthy reference populations. Also, there was a general trend for a better HRQL in GAST compared with ESO patients. This trend was statistically significant for physical function (p = 0.04), dyspnea (p = 0.02), and reflux (p = 0.03). Subgroup analysis revealed no significant differences between patients with or without prior neoadjuvant therapy.Conclusions: After mid- and long-term follow-up, HRQL after extended gastrectomy with Roux-en-Y reconstruction is superior to that after esophagectomy and gastric tube reconstruction. Improved HRQL after gastrectomy is mainly due to less pulmonary and reflux-related symptoms. Our findings may influence the choice of the surgical strategy for patients with AEG.

Internal combustion engines are still of major importance as propulsion systems. To fulfil future market and legislative demands it is necessary to improve engine performance, reduce fuel consumption, and limit exhaust emissions. Mechanical and thermodynamic losses, wear, and the emissions caused by lubricating oil combustion are principally influenced by the tribological behaviour of the piston assembly. The trend towards compact engines with high power densities and increased thermomechanical loads increases the importance of this tribological system and requires new approaches. One promising possibility is the utilisation of liner surfaces with specially machined microstructures. This paper describes a comparison between a conventional liner surface and a laser-structured liner as regards their tribological behaviour. Measurements of wear as well as of oil film thickness and friction force in operation have been carried out. The results show better tribological behaviour for the laser-structured liner surface than for the conventional plateau-honed surface. This leads to lower fuel consumption and less wear.

Surface topography plays a significant role in functional performance situations like friction, lubrication and wear. A European Community funded research programme on areal characterization of steel sheet has recently assisted research in this area. This article is dedicated to the software that supported most of the programme. Born as a rudimentary collection of procedures, it grew steadily to become an integrated package, later equipped with a graphical interface and circulated to the research community employing the Open-Source philosophy.

Background/Aims: The effect of laparoscopic antireflux surgery on esophageal motility is incompletely understood, and any indication for this procedure in patients with motility disorder is disputed in literature. We evaluated the influence of laparoscopic Nissen fundoplication on impaired esophageal motility. Methods: In this pathological manometric study, we divided the patients into two groups preoperatively: the hypomotility group (mean amplitude of esophageal contraction wave 40 mm Hg; NORM group, n = 43). The amplitudes of esophageal contraction waves 3 and 8 cm above the lower esophageal sphincter and the percentage of peristaltic contraction waves of the tubular esophagus were analyzed pre- and postoperatively. Results: In total, 54 patients with GERD underwent esophageal manometry before and 6 months after Nissen fundoplication. The length and pressure of the lower esophageal sphincter were increased in both groups postoperatively (p < 0.01). Patients in the HYPO group (n = 11) showed a statistically significant increase of mean amplitude of esophageal contraction (32.8 vs. 57.3 mm Hg; p < 0.01), while no change was found in the NORM group (n = 43). A total of 72% of patients with preoperative motility disorder showed normal postoperative manometry. Conclusion: Nissen fundoplication normalizes esophageal motility, especially in patients with preoperative hypomotility. Patients with impaired esophageal motility should not per se be excluded from antireflux surgery.

Fragestellung: Hypoglykamien sind die haufigsten Nebenwirkungen der Pharmakotherapie des Diabetes mellitus. Aktuelle Arbeitsmedizinrichtlinien stutzen sich auf Daten mit hohen Inzidenzraten von Hypoglykamien, mit 10% der insulinbehandelten Patienten mit mindestens einer schweren Hypoglykamie/J und 2 – 3 nicht schweren Hypoglykamien/Woche. Wir untersuchten die Inzidenz schwerer und nicht schwerer Hypoglykamien bei insulinbehandelten Patienten mit Typ 2 Diabetes (DM 2) in der Primarversorgung. Methodik: Patienten mit DM 2 und Insulintherapie (n = 82, Alter 67,5J, HbA1c 7,99%, 47,6% Frauen, Diabetesdauer 16,55J, BMI 30,58 kg/m2) wurden in 3 Thuringer Hausarztpraxen uber 6 Wochen in einem strukturierten Interview zum Auftreten von Hypoglykamien befragt. Nicht schwere Hypoglykamien wurden definiert als Zustand mit typischen Symptomen und rascher Besserung nach Kohlenhydratzufuhr oder einem Blutglukosemesswert < 2,2 mmol/l auch ohne Symptome, schwere Hypoglykamie durch Notwendigkeit von i.v. Glukosgabe oder Glukagoninjektion. Ergebnisse: 65,9% (n = 54) der Patienten hatten eine intensive Insulintherapie (ICT), 31,7% (n = 26) eine konventionelle Insulintherapie (CT) und 40,7% (n = 22) der ICT- bzw. 42,3% (n = 11) der CT-Gruppe eine Kombinationstherapie mit oralen Antidiabetika. Eine basal unterstutzte orale Insulintherapie (BOT) hatten 2,4% (n = 2) der Patienten. 81,7% der Pat. hatten Humaninsulin. Alter, Diabetesdauer, BMI und HbA1c waren nicht sign. unterschiedlich zwischen CT bzw. ICT: Alter 70,5/65,8J, HbA1c 7,95/8,0%, Diabetesdauer 17,5/16,2J, BMI 30,5/30,7 kg/m2. In der tagl. Insulindosis gab es sign. Unterschiede: 42,4/67,2 IE/d (p = 0,003). 59,8% (n = 49) der Patienten gaben in den letzten 12 Monaten mind. eine nicht schwere Hypoglykamie an: CT 46,2% (n = 12), ICT 68,5% (n = 37). Bei der BOT gab es keine nicht schweren Hypoglykamien. Die mittlere Haufigkeit an nicht schweren Unterzuckerungen war 1,33 pro Patient/Quartal fur die Gesamtgruppe, sowie 0,34 bei CT und 1,86 bei ICT (p = 0,018). Bei einer mittleren Diabetesdauer von 16 Jahren hatten nur 2 Patienten mit ICT eine schwere Hypoglykamie (CT: n = 0; p = 0,588). 92,7% (n = 76) aller Patienten nahmen mind. ein Mal an einer strukturierten Patientenschulung teil. In der CT- waren es 84,6% (n = 22), in der ICT-98,1% (n = 53) und in der BOT-Gruppe 100% (n = 2). Blutzuckerselbstkontrollen fuhren 98,8% (n = 81) der Patienten durch: alle Patienten der ICT- (n = 54) und BOT- (n = 2) und 96,2% (n = 25) der CT-Gruppe. Die Patienten messen im Durchschnitt ihren Blutzucker 13,09 Mal pro Woche. Patienten der ICT- messen 16,18 Mal, der CT-Gruppe 6,71 Mal pro Woche (p = 0,006). Schlussfolgerung: Nicht schwere Unterzuckerungen bei insulinbehandelten Patienten mit DM 2 in Hausarztpraxen sind sehr selten und liegen weit unter der in Standardwerken der Arbeitsmedizin angegebenen Haufigkeit. Wie in der der britischen 4T-Studie treten Unterzuckerungen bei der intensiven Insulintherapie haufiger auf als bei der konventionellen Therapie.

The phase diagram of the quasiternary system (Snt Pb1-k)(S,Te1-l) for 900 K is determined by X-ray diffraction and by electron microprobe analysis. Moreover, the free enthalpy faces g(k, I) for the phases with cubic rocksalt structure (cub) or with the orthorhombic SnS structure (orh) are calculated from the interaction parameters and from the orh → cub transition data of the 4 quasibinary subsystems. The interaction parameters are also used to calculate the termodynamic factor for interdiffusion along quasibinary sections through the phase square and to calculate the energies of four-particle clusters. By application of the cluster model one obtains information on the local environment of the mixing particles and on the cluster processes that have effect upon interdiffusion