Search

Purpose: Adequate training and close supervision by an experienced surgeon are crucial to assure the patient safety during laparoscopic training. This study evaluated the impact of tutorial assistance on the duration of surgery and postoperative complications after laparoscopic sigmoidectomy. Methods: The data from 235 patients undergoing laparoscopic sigmoidectomy were collected. Operating surgeons were classified as either residents/registrars (group A, tutorial assistance) or consultants operating autonomously (group B). Groups were compared concerning the duration of surgery and in-hospital complications using a multivariable regression model accounting for the most relevant confounders. Results: The median duration of the operation in group A (n=75) was 221min, and that in group B (n=160) 189min (p

We performed a prospective analysis of two consecutive biopsy cohorts investigated by the same team to compare the Mammotome system with the ABBI procedure. From April 1997 to August 2003 a series of 413 nonpalpable mammographic lesions in 387 women (median age 56 years, range 30-84 years) were stereotactically biopsied in the University Hospital of Basel, Switzerland. Until October 1999 the ABBI system was applied exclusively, it was subsequently superseded by the Mammotome device in our clinic. Main outcome measures were accuracy, technical demand, and morbidity. Sensitivity (97.3%/96.8%), negative predictive value (99.2%/98.7%), and diagnostic accuracy (99.4%/99.1%) regarding the detection of malignancy were excellent for both techniques (ABBI/ Mammotome). The Mammotome procedure was faster and less invasive, thus causing significantly less morbidity. The larger specimen obtained by the ABBI procedure resulted in more detailed histology. In conclusion, recommend the Mammotome system as the method of choice for detecting nonpalpable early breast cancer.

Grundlagen: Die Axilladissektion liefert zuverlassige prognostische Information, bestimmt mehrheitlich die adjuvante Therapie und reduziert die axillaren Tumorrezidive. Die Morbiditat nach Axilladissektion kann jedoch nicht vernachlassigt werden (sensible Storungen, Schmerzen, motorische Schwache, Lymphodem). Patientinnen mit kleinen Tumoren (pT1a, b, c) konnten von neueren weniger invasiven Verfahren (endoskopische Axilladissektion) oder von selektiveren Methoden (Sentinel-lymph-node-Procedere) profitieren. In dieser prospektiven Studie wurde die axilloskopische Lymphadenektomie evaluiert. Methodik: 55 klinisch nodal negative Patientinnen (Durchschnittsalter: 60 Jahre [30 bis 86 Jahre]) wurden von einem Chirurgen endoskopisch operiert (Januar 1996 bis Juni 1998). Nach Liposuktion des axillaren Fettkorpers wurden die Lymphknoten von Level I+II identifiziert und unter direkter endoskopischer Sicht reseziert (erfolgreiches Verfahren in 95 %: n=52). Die Patientinnen wurden entsprechend dem Nachsorgeschema alle 4 Monate kontrolliert. Nach einer mittleren Beobachtungszeit von 22 Monaten (7 bis 37 Monate; n=51 [eine Patientin verweigerte die Nachsorge]) wurden die Patientinnen mit einem Evaluationsfragebogen, einem Interview und einer klinischen Untersuchung (inklusiv Schultergelenksfunktion, Zirkumferenzmessungen der oberen Extremitat) nachkontrolliert. Ergebnisse: Durchschnittlich wurden 13,3 (5 bis 25) Lymphknoten endoskopisch entfernt. Nodal positive Lymphknoten wurden in 31 % (n=16) beobachtet. Der Durchschnittswert der positiven Lymphknoten/Patientin betrug 3,1 (1 bis 10). Acht Serome (15 %) musten in der fruhpostoperativen Phase punktiert werden. Es traten keine Hamatome, jedoch ein Infekt in der Axilla nach Chemotherapie auf (2 %). Nach einer mittleren Beobachtungszeit von 22 Monaten (7 bis 37 Monate) konnten keine axillaren Rezidive nachgewiesen werden. Eine subkutane Implantationsmetastase in der Narbe eines Trokarkanals (1/55, 2 %) wurde diagnostiziert und reseziert. Klinisch traten keine Lymphodeme auf. Die fruhe Mobilisation des Schultergelenkes war subjektiv und objektiv gut. Schlusfolgerungen: Die durchschnittlich 13 axilloskopisch entfernten Lymphknoten entsprechen der Anzahl resezierter Lymphknoten bei offener Axilladissektion. Die Morbiditat dieses in Evaluation begriffenen Verfahrens ist niedrig. Nach einer mittleren Beobachtungszeit von 22 Monaten wurde ein Implantationsrezidiv im subkutanen Kanal des anterioren Arbeitstrokar nachgewiesen. Eine langere Beobachtungszeit ist notig, um die Technik empfehlen zu konnen. Es zeichnet sich ab, das die endoskopische, axillare Lymphknotendissektion durch das selektivere Sentinel-lymph-node-Verfahren abgelost wird.

Background. Complications at the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) are challenging in terms of diagnosis, therapy, and prevention. This study aims at identifying these complications and discussing their management.Methods. Data of 228 patients who underwent a LRYGB between October 2008 and December 2011 were reviewed retrospectively to evaluate the frequency and treatment of complications such as stenoses, marginal ulcers, perforated marginal ulcers, or anastomotic leaks related to the operation.Results. Follow-up information was available for 209 patients (91.7%) with a median follow-up of 38 months (range 24–62 months). Of these patients 16 patients (7.7%) experienced complications at the gastrojejunostomy. Four patients (1.9%) had stenoses and 12 patients (5.7%) marginal ulcers, one of them with perforation (0.5%). No anastomotic leaks were reported. One case with perforated ulcer and one with recurrent ulcers required surgical revision.Conclusion. Gastrojejunal anastomotic complications are frequent and occur within the first few days or up to several years after surgery. Stenoses or marginal ulcers are usually successfully treated nonoperatively. Laparoscopic repair, meanwhile, is an appropriate therapeutic option for perforated ulcers.

Background: The study evaluates the scope of non-uniform classification practices concerning breast carcinomas with non-inflammatory skin involvement. Patients and methods: We compared the clinical course of patients with histologically proven non-inflammatory skin involvement: 119 (65.4%) with clinically obvious ‘classical’ skin changes (Group A) and 63 (34.6%) with no or only discreet changes (Group B). A questionnaire was circulated to pathology departments in 24 countries to assess the practice concerning the placement of skin- involved breast carcinomas in the TNM classification. Results: Patients in Group B showed a significantly better disease specific survival (P = 0.0002). Eighty-six respondents (70.5%) of the survey preferred the ‘histological view’ and classified tumors with only histological proven skin involvement as T4b/stage IIIB. The opposing classification principle (‘clinical view’), which dictates that T4b breast cancer is a clinical diagnosis and the classical signs must be present, was supported by 31 respondents (25.4%). Conclusions: A large number of breast cancer patients with non-inflammatory skin involvement are only histologically proven and show, compared with cases exhibiting the classical clinical signs, significant differences in clinical course and prognosis. In general, both subsets were aggregated in one T category/stage (T4b/IIIB). This results in a considerable distortion of the reported statistical data.

The prognostic significance of bone marrow micro‐metastases (BMM) in colon cancer patients remains unclear. We conducted a prospective cohort study with long‐term follow‐up to evaluate the relevance of BMM as a prognostic factor for disease free (DFS) and overall survival (OS) in stage I‐III colon cancer patients. In this prospective multicenter cohort study 144 stage I‐III colon cancer patients underwent bone marrow aspiration from both iliac crests prior to open oncologic resection. The bone marrow aspirates were stained with the pancytokeratin antibody A45‐B/B3 and analyzed for the presence of epithelial tumor cells. DFS and OS were analyzed using a Cox proportional hazard model and robust standard errors to account for clustering in the multicenter setting. Median overall follow‐up was 6.2 years with no losses to follow‐up, and 7.3 years in patients who survived. BMM were found in 55 (38%) patients. In total, 30 (21%) patients had disease recurrence and 56 (39%) patients died. After adjusting for known prognostic factors, BMM positive patients had a significantly worse DFS (hazard ratio [HR] 1.33; 95% confidence interval [95% CI]: 1.02‐1.73; P = 0.037) and OS (HR 1.30; 95% CI: 1.09‐1.55; P = 0.003) compared to BMM negative patients. Bone marrow micro‐metastases occur in over one third of stage I‐III colon cancer patients and are a significant, independent negative prognostic factor for DFS and OS. Future trials should evaluate whether node‐negative colon cancer patients with BMM benefit from adjuvant chemotherapy.

Tutorial assistance is related to extra time and cost, and the hospitals’ financial compensation for this activity is under debate. We therefore aimed at quantifying the extra time and resulting cost required to train one surgical resident in the operating theatre for board certification in Switzerland as an example of a training curriculum involving several surgical subspecialties. Additionally, we intended to quantify the percentage of tutorial assistance. We analysed 200,700 operations carried out between 2008 and 2012. Median duration of procedure categories was calculated according to four different seniority levels. The extra time if the procedure was performed by residents, and resulting cost were analysed. The percentage of procedures carried out by residents as compared to more experienced surgeons was assessed over time. On average, residents performed about a third of all operations including typical teaching procedures like appendectomies. An increase in duration and cost of well-defined procedures categories, e.g. cholecystectomies was demonstrated if a resident performed the procedure. In less well-defined categories, residents seemed to perform less difficult procedures than senior consultants resulting in shorter durations of surgery. The financial impact of tutorial assistance is important, and solutions need to be found to compensate for this activity. The low percentage of procedures performed by trainees may make it difficult to fulfil requirements for board certification within a reasonable period of time. This should be addressed within the training curriculum.

Background The study evaluates characteristics and prognostic significance of breast cancer with histologically proven non-inflammatory skin involvement but without the clinical and histological features that are mandatory for inclusion in the T4 category. Methods We compared retrospectively the clinical course of 55 patients with this clinico-pathologic entity to the outcome of a control group of 309 consecutive patients with tumors of the same size but without skin involvement. The median follow-up time was 6.6 years in the study and 8.4 years in the control group. Two subsets were analyzed: (A) 1.1–2.0 cm (T1c); (B) 2.1–5.0 cm (T2). Results The distribution of TNM stages within Study Group A was: Stage I: 28.6%, Stage II: 61.9%, Stage III: 9.5%. The distribution within Study Group B was: Stage II: 67.7%, Stage III: 23.5%, and Stage IV: 8.8%. Differences in disease-specific survival (DSS) between study and control groups were not significant. In multivariate analysis, skin involvement was not a significant variable, while lymph node involvement was found to be significant for worse outcome (Group A: HR = 3.99 [1.33–12.05], P = 0.014; Group B: HR = 2.37 [1.37–4.08], P = 0.002). Conclusion Breast carcinomas with histologically proven skin involvement without the clinical and histological correlate are a heterogeneous group of cases, but the majority of the patients have Stage I/II disease. While lymph node involvement had a most significant effect on DSS, skin involvement was not a significant prognostic factor. Physicians must be aware of this clinico-pathologic entity in order not to misclassify these cases as T4 and consider them falsely as being locally advanced breast cancer. J. Surg. Oncol. 2007;95:291–297. © 2007 Wiley-Liss, Inc.

Das Konsensusmeeting wurde am 5. Juni 2004 im BrustCentrum Zurich-Bethanien als Veranstaltung der Arbeitsgemeinschaft Gynakologische Onkologie (AGO) durchgefuhrt. Das Expertenpanel war interdisziplinar und national ausgewogen zusammengesetzt und diskutierte an der Veranstaltung mit den anwesenden Teilnehmern die offenen Punkte anhand von vorbereiteten Konsensusstatements. Das vorliegende Konsensuspapier wurde von den vier Studienleitern zusammengestellt und den Panelmitgliedern in schriftlicher Form zur definitiven Genehmigung prasentiert und stellt in der jetzigen Form einen Konsens dieses Panels dar und nicht nur einen solchen der AGO, obwohl an dem von der AGO organisierten Meeting viele AGO-Mitglieder und -Vorstandsmitglieder beteiligt waren. Warum ist ein solches Papier notig? Die Nachfrage fur klare Statements kam von den Kolleginnen und Kollegen, die Patientinnen mit Mammakarzinom operieren bzw. therapieren. Nach Abschluss der schweizerischen Multizenterstudie (AGO-Studien I und II) Ende 2003 stieg das Bedurfnis nach Klarheit, was aktuell nach nationalen und internationalen Erfahrungen fur die Sentinelchirurgie beim Mammakarzinom gilt. Das vorliegende Papier gliedert sich in 9 Teile: 1. Grundlagen, Definitionen, Begriffe, Erklarungen; 2. Strukturvoraussetzungen (Anforderungen an Operateure und die Behandlungsteams); 3. Indikationen und Kontraindikationen; 4. Operationstechnik und Identifikation des Sentinellymphknotens; 5. Histopathologische Aufarbeitung; 6. Nachsorge; 7. Dokumentation; 8. Patientinnenaufklarung; 9. Offene Fragen. I. Grundlagen, Definitionen und Begriffe

The widely accepted image of breast cancer with non-inflammatory skin involvement (T4b) is determined by the tenet that all these tumors are locally advanced (Stage IIIB). The study addresses the question whether this view is justified. Data from 453 non-metastatic breast cancer patients were collected retrospectively. Eighty-one patients had T4b disease. To assess the malignant potential of tumors independent of the feature skin involvement, a reclassification only considering tumor size was undertaken. We compared the clinical course of three study groups (A: Stage II; B: Stage IIIA; C: Stage IIIC) with control groups of 372 patients without skin involvement. In the study groups, we found a broad distribution among the stages (A:36.2%; B:33.7%; and C:27.7%) with significant differences in disease-specific survival (DSS) (A/B: p = 0.032; B/C: p = 0.048). There were no significant differences in DSS between the study and the corresponding control group. In multivariate analysis, skin involvement was not a significant predictor of DSS. Heterogeneity of the T4b category and a lack of prognostic significance expand the widely accepted image of breast cancer with non-inflammatory skin involvement. The highest T category, or Stage III, is not the appropriate classification for a considerable number of patients having this clinicopathologic entity.

Background. Reports on long-term outcomes after endoscopic axillary lymph node dissection (ALND) of breast cancer patients are still lacking in the medical literature. The objective of this prospective study was to assess the oncological and functional outcomes in breast cancer patients after endoscopic ALND. Methods. Fifty-five breast cancer patients were prospectively enrolled, of whom 52 were available for follow-up with a median of 71.9 months (range 11–96). The following oncological and functional endpoints were evaluated during follow-up at several time points: occurrence of local, axillary and distant metastases, seroma or infection, shoulder mobility (range of motion), numbness, pain, presence of lymphoedema as well as restriction in activities of daily living. Results. In 52 patients endoscopic ALND of level I and II was successfully performed. Two port-site metastases (2/52, 4%) occurred, one of which in a patient with negative axillary lymph nodes. The same patient suffered from the only axillary recurrence (1/52, 2%). Three patients (3/52, 6%) developed lymphoedema. No other functional adverse events (shoulder mobility, pain, numbness, hypertrophic scar) were noticed at the end of the observation period. Conclusion. The present investigation with long-term follow-up after endoscopic ALND – the first one in the literature – reveals minor morbidity, good functional and cosmetic results. In contrary to conventional surgery, the endoscopic procedure is associated with the occurrence of port-site metastases, not seen in the open approach. Axillary recurrences do not appear more frequently when compared with results after conventional ALND. In the meantime the less invasive sentinel lymph node (SLN) biopsy is the established standard technique in evaluating the axillary lymph node status.

The discovery that the human Jagged1 gene (JAG1) is the Alagille syndrome disease gene indicated that Notch signaling has an important role in bile duct homeostasis. The functional study of this signaling pathway has been difficult because mice with targeted mutations in Jagged1, Notch1, or Notch2 have an embryonic lethal phenotype. We have previously generated mice with inducible Notch1 disruption using an interferon-inducible Cre-recombinase transgene in combination with the loxP flanked Notch1 gene. We used this conditional Notch1 knockout mouse model to investigate the role of Notch1 signaling in liver cell proliferation and differentiation. Deletion of Notch1 did not result in bile duct paucity, but, surprisingly, resulted in a continuous proliferation of hepatocytes. In conclusion, within weeks after Notch1 inactivation, the mice developed nodular regenerative hyperplasia without vascular changes in the liver.

A purely retroperitoneoscopic approach in living kidney donation is used by only a few centers worldwide. Data from 28 consecutive purely retroperitoneoscopic living donor nephrectomies (RLDN) were compared to the most recent 30 open living donor nephrectomies (OLDN). Right-sided donation was performed in 12 cases (43%) of the RLDN and 11 cases (37%) of the OLDN. Comparison of the results between the two groups showed a shorter operation time and hospital stay for the RLDN group (P < 0.001). Warm ischemia time was significantly shorter in the OLDN group (P < 0.02). The rate of complications did not differ significantly between the groups. No significant difference in terms of renal graft function was detected within 30 days after surgery. As a result of the direct access, RLDN is superior in terms of operation time, even to the open access on our series, while maintaining the advantage of minimal invasiveness.

Circulating levels of calcitonin precursors (CTpr), including procalcitonin (ProCT), increase up to several thousand-fold in human sepsis, and immunoneutralization improves survival in two animal models of this disease. Herein, we analyzed inflammation-mediated calcitonin I gene (CALC I) expression in human adipocyte primary cultures and in adipose tissue samples from infected and noninfected patients with different levels of serum ProCT. In ex vivo differentiated adipocytes, the expression of CT mRNA increased 24-fold (P < 0.05) after the administration of Escherichia coli endotoxin (lipopolysaccharide) and 37-fold (P < 0.05) after IL-1 administration by 6 h. ProCT protein secretion into culture supernatant increased 13.5-fold (P < 0.01) with lipopolysaccharide treatment and 15.2-fold (P < 0.01) with IL-1 after 48 h. In coculture experiments, adipocyte CT mRNA expression was evoked by E. coliactivated macrophages in which CT mRNA was undetectable. The marked IL-1-mediated ProCT release was inhibited by 89% during coadministration with interferon- (IFN). In patients with infection and markedly increased serum ProCT, CT mRNA was detected in adipose tissue biopsies. Hence, we demonstrate that ProCT, which is suspected to mediate deleterious effects in sepsis and inflammation, is a novel product of adipose tissue secretion. The inhibiting effect of IFN on IL-1-induced CT mRNA expression and on ProCT secretion might explain previous observations that serum ProCT concentrations increase less in systemic viral compared with bacterial infections. (Endocrinology 144: 5578 –5584, 2003)

The response to partial hepatectomy (PH) is impaired in interleukin 6 (IL-6)-deficient mice. IL-6 is well known for its role in the induction of the acute phase (AP) response, and the impairment of this response after surgery and hepatectomy could explain the defective hepatocyte regeneration. In addition, it was proposed that IL-6 has an important role in stimulating the reentry of quiescent cells into the cell cycle within the first 2 to 4 hours after PH. To further analyze the role for IL-6, we performed two third hepatectomies in wild-type mice, in IL-6 knockout (KO) mice, and in IL-6 KO mice that were treated 30 minutes before surgery with intravenous (IV) (short acting) or subcutaneous (SC) (long acting) injections of recombinant IL-6. The high postoperative mortality of IL-6-deficient mice could be completely prevented by SC, but not by IV IL-6 treatment, showing the requirement of a sustained action of IL-6. However, there is a subset of IL-6 KO mice that survives a PH in good health even without IL-6 treatment. When we analyzed these mice, we found an intact liver regeneration and no indication of a block in cell cycle reentry. We conclude that the major role of IL-6 is the induction of an adaptive response to PH that ensures body homeostasis and survival.

Hintergrund. Der perianale, durch humane Papillomaviren verursachte Buschke-Lowenstein-Tumor (Riesenkondylom) ist sehr selten. Obwohl es sich histologisch um eine benigne Neoplasie handelt, ist sein klinisches Wachstumsmuster maligne mit Infiltration und Destruktion der Umgebung. Charakteristisch sind die hohe Rezidivrate und die haufige Transformation in ein malignes Plattenepithelkarzinom. Therapie der Wahl ist die radikale chirurgische Resektion.

The prognostic value of sentinel lymph node (SLN) micro-metastases and the question whether patients with SLN micro-metastases should undergo axillary lymph node dissection remain a matter of great debate. Based on the current literature and on our own data, we provide suggestive evidence that SLN micro-metastases in early stage breast cancer patients appear to have prognostic value and should impact the decision-making regarding adjuvant therapy, however, do not necessarily require further surgical treatment.

In den aktuellen Aktivitaten zur Medizinischen Qualitatssicherung werde der Aspekt der Selbststeuerung vernachlassigt und gefahrdet, finden die Autoren. Sie listen funf Fragen auf, die an jede Qualitatssicherungmassnahme gestellt werden mussten..

Einleitung: Die Axilladissektion (ALND) ist integraler Bestandteil der Therapie des Mammakarzinoms. Nodalstatus und Tumorgrösse sind die wichtigsten prognostischen Parameter. Die Beschränkung der Axilladissektion auf die Level I und II nach Berg senkte die hohe Morbidität. Die Zunahme der Diagnose im Frühstadium ohne axillären Befall führte zu selektiveren Verfahren, um eine ALND in diesen Fällen zu vermeiden. Der Sentinel Lymphknoten (SLN) - der erste drainierende Lymphknoten eines Tumors - repräsentiert den Status der Axilla. Bei fehlendem Befall kann auf eine komplette ALND verzichtet werden. Patientinnen und Methode: Von 9/97 bis 1/99 wurden 44 Patientinnen (Pat.) mit Mammakarzinom in die prospektive Studie aufgenommen und erhielten eine Darstellung des SLN mit Isosulfanblau und/oder eine Lymphoszintigraphie mit 99m Technetium markiertem Humankolloid. Eine handgeführter Gammadetektor wurde intraoperativ eingesetzt. Der SLN wurde selektiv entfernt und histologisch (H&E) sowie immunhistochemisch untersucht. Eine ALND von Level I und II wurde bei allen Pat. zur Korrelation des Befundes durchgeführt. Resultate: Der SLN wurde in 93% der Fälle identifiziert (41 von 44). 2,4 SLN pro Pat. wurden entfernt, insgesamt 17,6 Lymphknoten. 21 Pat. hatten befallene, 20 Pat. negative SLN. In der Gruppe mit negativen SLN zeigte nur eine Pat. (5%) metastatischen Befall von axillären Lymphknoten bei der ALND (negativer prädiktiver Wert 95%). Von 17 Pat. mit positiven axillären Lymphknoten hatten 16 Pat. auch Metastasen in den SLN, nur ein SLN war negativ (falsch negative Rate von 5,9%). Bei 2 von 41 Pat. wurden in der Immunhistochemie Mikrometastasen entdeckt. Die Lymphoszintigraphie zeigte einen Abfluss in die Mammaria interna-Lymphknoten in 2 von 28 Fällen (7%). Schlussfolgerung: Unsere Validierungsstudie zeigt die Reproduzierbarkeit und Verlässlichkeit des SLN-Verfahrens. Ein multidisziplinäres Vorgehen ist dabei unerlässlich. Das SLN-Verfahren hat die Potenz zum Selektionskriterium für oder gegen eine ALND. Serielle Schnitte und die Immunhistochemie erhöhen die Nachweisrate von metastatischem Befall der Lymphknoten. Langzeit-Untersuchungen werden den Einfluss auf das Gesamtüberleben zeigen müssen. Unsere eigenen Daten werden zusammen mit einer ausgedehnten Review der Literatur dargestellt.

Hintergrund: Um die Dignität mammographisch verdächtiger, nicht-palpabler Befunde zu überprüfen verdrängen stereotaktische Biopsietechniken zusehends die offene Biopsie nach konventionell mammographisch gesteuerter Drahtlokalisation. Die advanced breast biopsy instrumentation (ABBI) erlaubt eine stereotaktisch gesteuerte Exzision eines Gewebestückes von 5 bis 20mm Durchmesser ambulant in Lokalanästhesie durchzuführen. Methode: Von 144 mammographisch verdächtiger, nicht-palpabler Befunde, bei denen eine stereotaktische Abklärung mittels ABBI geplant war, wurde die Durchführbarkeit, Sensitivität, Spezifität der ABBI Biopsietechnik, sowie auch die weitere Behandlung der malignen Befunde untersucht. Resultate: Die stereotaktische ABBI Biopsietechnik konnte in 93.8% (135/144) durchgeführt werden. Die korrekte Diagnose wurde in 99.3% (134/135) gestellt, die Sensitivität für maligne Befunde liegt bei 96.9% (31/32); die Morbidität der ABBI Biopsie beträgt nur 1.5%. In Übereinstimmung mit anderen publizierten Serien reichte das Tumorgewebe in 83.9% (26/31) bis an den Biopsierand. Schlussfolgerung: Die stereotaktische Biopsietechnik mittels ABBI erlaubt eine zuverlässige Diagnostik, hat aber nur bei kleinen malignen Befunden eine therapeutische Bedeutung.

Oncologic follow-up and surveillance after curative therapy for invasive breast cancer serves as a quality control of the primary treatment results, enables the early diagnosis and immediate treatment in case of recurrent disease, the detection and therapy of treatment-related side effects and late sequelae, and finally includes the psychologic support of tumor-free patients over decades, during which they are at risk for recurrent disease.

The sentinel lymph node (SLN) procedure has the potential to provide relevant improvement in nodal staging in colon cancer patients. However, there remains room for improvement for SLN identification and sensitivity. Therefore, the objective of the present investigation was to analyze factors influencing the success of the SLN procedure in colon cancer patients.One hundred seventy-four consecutive colon cancer patients were prospectively enrolled in this multicenter study and underwent in vivo SLN procedure with isosulfan blue 1 % followed by open standard oncologic colon resection. Several patient-, tumor-, and procedure-related factors possibly influencing the SLN identification and sensitivity were analyzed.Sentinel lymph node identification rate and accuracy were 89.1 and 83.9 %, respectively. Successful identification of SLN was significantly associated with the intraoperative visualization of blue lymphatic vessels (p0.001) and with female gender (p = 0.024). True positive SLN results were significantly associated with higher numbers of SLN (p = 0.026) and with pN2 stage (p = 0.004). There was a trend toward better sensitivity in patients with lower body mass index (BMI) (p = 0.050).The success of the SLN procedure in colon cancer patients depends on both procedure-related factors (intraoperative visualization of blue lymphatic vessels, high number of SLN identified) and patient factors (gender, BMI). While patient factors can not be influenced, intraoperative visualization of blue lymphatics and identification of high numbers of SLN are key for a successful SLN procedure.

BACKGROUND A new diagnostic system, called one-step nucleic acid amplification (OSNA), has recently been designed to detect cytokeratin 19 mRNA as a surrogate for lymph node metastases. The objective of this prospective investigation was to compare the performance of OSNA with both standard hematoxylin and eosin (H&E) analysis and intensive histopathology in the detection of colon cancer lymph node metastases. METHODS In total, 313 lymph nodes from 22 consecutive patients with stage I, II, and III colon cancer were assessed. Half of each lymph node was analyzed initially by H&E followed by an intensive histologic workup (5 levels of H&E and immunohistochemistry analyses, the gold standard for the assessment of sensitivity/specificity of OSNA), and the other half was analyzed using OSNA. RESULTS OSNA was more sensitive in detecting small lymph node tumor infiltrates compared with H&E (11 results were OSNA positive/H&E negative). Compared with intensive histopathology, OSNA had 94.5% sensitivity, 97.6% specificity, and a concordance rate of 97.1%. OSNA resulted in an upstaging of 2 of 13 patients (15.3%) with lymph node-negative colon cancer after standard H&E examination. CONCLUSIONS OSNA appeared to be a powerful and promising molecular tool for the detection of lymph node metastases in patients with colon cancer. OSNA had similar performance in the detection of lymph node metastases compared with intensive histopathologic investigations and appeared to be superior to standard histology with H&E. Most important, the authors concluded that OSNA may lead to a potential upstaging of >15% of patients with colon cancer. Cancer 2012. © 2012 American Cancer Society.

Background: Duration of surgery is a main cost factor of surgical training. The purpose of this analysis of operative times for laparoscopic cholecystectomies (LC) was to quantify the extra time and related costs in regards to the surgeons' experience in the operating room (OR). Methods: All LC performed between January 01, 2005 and December 31, 2008 in 46 hospitals reporting to the database of the Swiss Association for Quality Management in Surgery (AQC) were analyzed (n=10,010). Four levels of seniority were specified: resident (R), junior consultant (JC), senior consultant (SC), and attending surgeon (AS). The differences in operative time according to seniority were investigated in a multivariable log-linear and median regression analysis controlling for possible confounders. The OR costs were calculated by using a full cost rate in a teaching hospital. Results: A total of 9,208 LC were available for analysis; 802 had to be excluded due to missing data (n=212) or secondary major operations (n=590). Twenty-eight percent of the LC were performed by R as teaching operations (n=2,591). Compared with R, the multivariable analysis of operative time showed a median difference of −2.5min (−9.0; 4.8) for JC and −18min (−25; −11) for SC and −28min (−35; −10) for AS, respectively. The OR minute costs were €17.57, resulting in incremental costs of €492 (159; 615) per operation in case of tutorial assistance. Conclusions: The proportion of LC performed as tutorial assistance for R remains low. Surgical training in the OR causes relevant case-related extra time and therefore costs

The value of the sentinel lymph node (SLN) procedure in colon cancer patients remains a matter of debate. The objective of this prospective, multicenter trial was 3-fold: to determine the identification rate and accuracy of the SLN procedure in patients with resectable colon cancer; to evaluate the learning curve of the SLN procedure; and to assess the extent of upstaging due to the SLN procedure.One hundred seventy-four consecutive colon cancer patients were enrolled onto this prospective trial. They underwent an intraoperative SLN procedure with isosulfan blue 1% injected peritumorally followed by open standard colon resection with oncologic lymphadenectomy. Three levels of each SLN were stained with hematoxylin and eosin (HE) and immunostained with the pancytokeratin marker AE1/AE3 if HE was negative.SLN identification rate and accuracy were 89.1% and 83.9%, respectively. SLN were significantly more likely to contain tumor infiltrates than non-SLN (P0.001). Both SLN identification rate (P = 0.021) and the sensitivity of the procedure (P = 0.043) significantly improved with experience. The use of immunohistochemistry in SLN resulted in an upstaging of 15.4% (16 of 104) stage I and II patients considered node-negative in initial HE analysis.The SLN procedure for colon cancer has good identification and accuracy rates, which further improve with increasing experience. Most importantly, the SLN procedure results in upstaging of15% of node-negative patients. The potential advantage of performing the SLN procedure appears to be particularly important in these patients because they may potentially benefit from adjuvant therapy.

The prognostic value of sentinel lymph node (SLN) micro-metastases and the question whether patients with SLN micro-metastases should undergo axillary lymph node dissection remain a matter of great debate. Based on the current literature and on our own data, we provide suggestive evidence that SLN micro-metastases in early stage breast cancer patients appear to have prognostic value and should impact the decision-making regarding adjuvant therapy, however, do not necessarily require further surgical treatment.

Suggested citation for this article: Ogredici O, Erb S, Langer I, Pilo P, Kerner A, Haack HG,.et al. Brucellosis reactivation after 28 years. Emerg Infect Dis [serial on the Internet]. 2010 Dec [date cited]. http://dx.doi.org/10.3201/eid1612.100678

To evaluate the long-term disease-free and overall survival of patients with sentinel lymph node (SLN) micrometastases, in whom a completion axillary lymph node dissection (ALND) was systematically omitted.The use of step sectioning and immunohistochemistry for SLN analysis results in a more accurate histopathologic examination and a higher detection rate of micrometastases. However, the clinical relevance and therapeutic implications of SLN micrometastases remain a matter of debate.In this prospective study, 236 SLN biopsies were performed in 234 consecutive early-stage breast cancer patients (T1, T2or= 3 cm, cN0 M0) between 1998 and 2002. The SLN were examined by step sectioning and stained with hematoxylin and eosin and immunohistochemistry. None of the patients with negative SLN or SLN micrometastases (International Union Against Cancer classification,.2 mm toor=2 mm) underwent a completion ALND or radiation to the axilla. Long-term overall and disease-free survivals were compared between patients with negative SLN and those with SLN micrometastases by log rank tests.The SLN was negative in 55% of patients (123 of 224). SLN micrometastases were detected in 27 patients (27 of 224, 12%). After a median follow-up of 77 months (range, 24-106 months), neither locoregional recurrences nor distant metastases occurred in any of the 27 patients with SLN micrometastases. There were no statistically significant differences for overall (P = .656), locoregional (P = .174), and axillary and distant disease-free survival (P = .15) between patients with negative SLN and SLN micrometastases.This analysis of unselected patients provides evidence that a completion level I and II ALND may be safely omitted in early-stage breast cancer patients with SLN micrometastases.

Objective To assess the accuracy of sentinel lymph node (SLN) frozen section in a prospective multicenter study of early-stage breast cancer patients. Summary background data The decision to perform an immediate completion axillary node dissection (ALND) is based on results of SLN frozen section. However, SLN frozen sections are not routinely performed in all centers. Moreover, the accuracy of SLN frozen section remains a matter of great debate. Methods Prospective multicenter trial analyzing 659 early stage breast cancer patients (pT1 and pT2 ≤ 3 cm, cN0) enrolled between January 2000 and December 2003. SLN were intraoperatively examined by frozen section. Final histopathology consisted in performing step sectioning as well as staining with H&E and immunohistochemistry. Results SLN were identified in 98.3% (648/659) of all patients. The accuracy of frozen section was 90.1% (584/648), the sensitivity for SLN macro-metastases 98% (142/145), and the specificity 100%. A total of 47 patients with SLN micro-metastases (n = 36) or isolated tumor cells (n = 11) underwent a delayed completion ALND. In 96% (45/47) of these patients the ALND specimens were free of macro-metastases. Conclusions SLN frozen section provides highly accurate information regarding identification of SLN macro-metastases, a delayed completion ALND can be avoided in 98% of these patients. More importantly, in the present investigation the vast majority (96%) of patients with SLN micro-metastases or isolated tumor cells undergoing delayed completion ALND did not benefit from the second operation as ALND specimens were free of macro-metastases. We strongly recommend the routine use of SLN frozen section in early stage breast cancer patients.

Oncologic follow-up and surveillance after curative therapy for invasive breast cancer serves as a quality control of the primary treatment results, enables the early diagnosis and immediate treatment in case of recurrent disease, the detection and therapy of treatment-related side effects and late sequelae, and finally includes the psychologic support of tumor-free patients over decades, during which they are at risk for recurrent disease.

Objective: The few long-term follow-up data for sentinel lymph node (SLN) negative breast cancer patients demonstrate a 5-year diseasefree survival of 96e98%. It remains to be elucidated whether the more accurate SLN staging defines a more selective node negative patient group and whether this is associated with better overall and disease-free survival compared with level I & II axillary lymph node dissection (ALND). Methods: Three-hundred and fifty-five consecutive node negative patients with early stage breast cancer (pT1 and pT2 � 3 cm, pN0/pNSN0) were assessed from our prospective database. Patients underwent either ALND (n ¼178) in 1990e1997 or SLN biopsy (n ¼177) in 1998e2004. All SLN were examined by step sectioning, stained with H&E and immunohistochemistry. Lymph nodes from ALND specimens were examined by standard H&E only. Neither immunohistochemistry nor step sections were performed in the analysis of ALND specimen. Results: The median follow-up was 49 months in the SLN and 133 months in the ALND group. Patients in the SLN group had a significantly better disease-free (p ¼ 0.008) and overall survival (p ¼0.034). After adjusting for other prognostic factors in Cox proportional hazard regression analysis, SLN procedure was an independent predictor for improved disease-free (HR: 0.28, 95% CI: 0.10e0.73, p ¼ 0.009) and overall survival (HR: 0.34, 95% CI: 0.14e0.84, p ¼ 0.019). Conclusions: This is the first prospective analysis providing evidence that early stage breast cancer patients with a negative SLN have an improved disease-free and overall survival compared with node negative ALND patients. This is most likely due to a more accurate axillary staging in the SLN group. 2008 Elsevier Ltd. All rights reserved.

Breast conserving surgery followed by radiation therapy is the treatment of choice for early breast cancer. For patients who choice or need a mastectomy, breast reconstruction provides an acceptable alternative. Breast cancer surgery has been evolving through minimally invasive approaches. Sentinel node biopsy has already remplaced axillary lymph node dissection in the evaluation of the axilla. Local ablation of the tumor may be a valuable alternative to surgery in the future.

Personality traits and coping strategies are regarded as determinants of post-traumatic stress disorder (PTSD) symptoms in persons who have experienced a traumatic event. The purpose of the study was to investigate the relationship between type D personality, coping strategies, and PTSD symptoms.A group of 190 firefighters of life-saving units of the State Fire Brigade, Łódź, participated in the study. Their mean age was 33.5 years and their mean duration of employment was 9.2 years. Survey, the Impact Event Scale, the DS14 scale, and Mini-COPE were used as the study techniques.The data obtained from the study confirm the relationship of both dimensions, comprising type D personality and maladaptive strategies with the increased level of PTSD symptoms.A tendency to experience strong negative emotions (negative affectivity) and coping strategies, such as self-distraction and behavioral disengagement increase the intensity of PTSD symptoms, intrusion in general, and hyperarousal in particular.

Objective: To assess the morbidity after sentinel lymph node (SLN) biopsy compared with SLN and completion level I and II axillary lymph node dissection (ALND) in a prospective multicenter study. Summary Background Data: ALND after breast cancer surgery is associated with considerable morbidity. We hypothesized: 1) that the morbidity in patients undergoing SLN biopsy only is significantly lower compared with those after SLN and completion ALND level I and II; and 2) that SLN biopsy can be performed with similar intermediate term morbidity in academic and nonacademic centers. Methods: Patients with early stage breast cancer (pT1 and pT2 3 cm, cN0) were included between January 2000 and December 2003 in this prospective Swiss multicenter study. All patients underwent SLN biopsy. In all patients with SLN macrometastases and most patients with SLN micrometastases (43 of 68) or isolated tumor cells (11 of 19), a completion ALND was performed. Postoperative morbidity was assessed based on a standardized protocol. Results: SLN biopsy alone was performed in 449 patients, whereas 210 patients underwent SLN and completion ALND. The median follow-ups were 31.0 and 29.5 months for the SLN and SLN and completion ALND groups, respectively. Intermediate-term follow-up information was available from 635 of 659 patients (96.4%) of enrolled patients. The following results were found in the SLN versus SLN and completion ALND group: presence of lymphedema (3.5% vs. 19.1%, P 0.0001), impaired shoulder range of motion (3.5% vs. 11.3%, P 0.0001), shoulder/arm pain (8.1% vs. 21.1%, P 0.0001), and numbness (10.9% vs. 37.7%, P 0.0001). No significant differences regarding postoperative morbidity after SLN biopsy were noticed between academic and nonacademic hospitals (P 0.921). Conclusions: The morbidity after SLN biopsy alone is not negligible but significantly lower compared with level I and II ALND. SLN biopsy can be performed with similar short- and intermediate-term morbidity in academic and nonacademic centers. (Ann Surg 2007;245: 452‐461)

Background: Gastric necrosis after Nissen fundoplication is a rare and life-threatening complication described in paediatric surgery and in some experimental models. Prompt diagnosis and appropriate therapy of acute gastric dilatation is mandatory to avoid potentially fatal gastric necrosis. Case report: This case report is the first one to describe a gastric necrosis in an adult as a late and very severe complication after Nissen fundoplication. Gastric dilatation and subsequent necrosis occurred 14years after Nissen fundoplication because of small bowel obstruction based on adhesions. Conclusion: Early diagnosis and treatment of gastric dilatation after Nissen fundoplication are essential to prevent from severe secondary complications but can be difficult to establish because of atypical symptoms

The sentinel lymph node (SLN) status has proven to accurately reflect the remaining axillary lymph nodes and represents the most important prognostic factor. It is unknown whether an association exists between the SLN status and the presence of bone marrow (BM) micrometastases. The objective of the present investigation was to evaluate whether or not such an association exists.In the present investigation 410 patients with early stage breast cancer (pT1 and pT2or=3 cm, cN0) were prospectively enrolled between 1/2000 and 12/2003. All patients underwent SLN biopsy and bone marrow aspiration. The histological examination of the SLN consisted of step sectioning, HE, and immunohistochemistry (Lu-5, CK 22) staining. Cancer cells in the BM were stained with monoclonal antibodies A45-B/B3 against cytokeratin and counted by an automated computerized digital microscope.BM micrometastases were detected in 28.8% (118/410) of all patients. The SLN contained metastases in 32.4% (133/410). Overall 51.2% of the patients (210/410) were SLN negative/BM negative and 12.4% (51/410) SLN positive/BM positive. Of all patients, 16.4% (67/410) were SLN negative/BM positive and 20.0% (82/410) SLN positive/BM negative. There was a statistically significant association between the SLN and BM status, both in unadjusted (Fisher's exact test: P = .004) and multiple logistic regression analysis (P = .007).In the present investigation a significant association was found between a positive SLN status and the presence of BM micrometastases. Nonetheless, the percentage of non-concordance (SLN negative/BM positive and SLN positive/BM negative) was considerable. The prognostic impact of BM micrometastases in our patient sample remains to be evaluated.

BACKGROUND Because of the considerable heterogeneity in breast carcinoma with noninflammatory skin involvement (T4b/Stage IIIB), a revision was proposed of the TNM staging system that would classify these tumors exclusively based on their tumor size and lymph node status. In the current study, the authors evaluated how implementation of this proposal will affect Stage III noninflammatory breast cancer. METHODS Two hundred seven patients who were classified with noninflammatory Stage III breast cancer were treated consecutively between 1990 and 1999 at the University Hospital Basel, Switzerland. To assess the extent of T4b/Stage IIIB tumors independent of the clinicopathologic feature of skin involvement, the reclassification was undertaken. RESULTS Of 68 patients who had nonmetastatic T4b breast cancer, 37 patients (54.4%) had a tumor extent in accordance with Stage I/II and had improved disease-specific survival (DSS) compared with patients who had Stage III breast cancer (P = .008). Excluding those patients from Stage III led to a 17.9% reduction of the number of patients in this group (n = 170 patients). The 10-year DSS declined from 48.5% to 42.9%. CONCLUSIONS Considerable numbers of patients who are classified with noninflammatory Stage IIIB breast cancer show only a limited disease extent. Through a revision of the T4 category, these low-risk patients were excluded from the highest nonmetastatic TNM stage, and overstaging could be avoided. This procedure decreased the degree of heterogeneity of the entire Stage III group and may result in a more precise assessment of this disease entity. Cancer 2006. © 2006 American Cancer Society.

Summary A retrospective review was performed to investigate the prognostic significance and validity of the pathological and clinical TNM staging of noninflammatory skin involvement in breast cancer. In 128 tumors with histologically proven skin involvement and a size up to 5 cm (64% of the entire group), we distinguished clearly between group A) cases showing the classical clinical signs (cT4b) and those that do not, and between group B) carcinomas infiltrating the epidermis (pT4b) and those infiltrating only the dermis. We found only moderate concordance ( κ = 0.44) between the pathological and clinical TNM staging system. In the analysis of 80 patients with a tumor size from 2.1 to 5.0 cm, neither the appearance of classical clinical signs nor the histological diagnosis of infiltration of the epidermis was shown to be a relevant factor. In comparison to the control groups, similar clinicopathologic entities without significant differences in long-term outcome were observed. After regrouping of the patients having tumor infiltration of the papillary dermis from the control group into the study group (pT4), the study group showed a significant higher number of involved axillary lymph nodes ( P = .014) and a more extensive lymph node involvement (pN3; P = .025). The combination epidermis-papillary dermis seems to be more a functional unit than the epidermis alone that is defined as the crucial and delineating factor in the TNM Classification. Our results challenge the validity of the TNM rules and recommendations concerning T4b breast cancer because it leads, in the majority of cases, to tumors of comparable extent and prognosis being placed in different categories.

Aim To assess the influence of tumour location on axillary lymph node involvement (ALNI) and prognosis in breast cancer by evaluating the signficance of the sagittal/horizontal alignment. Methods We compared 57 patients with superficially located breast carcinomas up to 3.0cm with patients having lesions in posterior planes of the breast. Both groups were matched according to age, time of diagnosis, tumour size, grade, hormonal receptor status and tumour site within the frontal plane. Histologic evidence of skin involvement, excluding tumours fulfilling the criteria for pT4b, was defined as inclusion criteria and reference plane for superficial tumour location. Results Tumours situated in the superficial region of the breast, compared to those located in deeper planes, have an increased risk of ALNI ( p =0.023), whereas no difference was observed with reference to disease-specific survival ( p =0.203). Conclusion This study shows that ALNI is dependent on sagittal/horizontal as well as frontal tumour location. Clinicians should be aware that tumours lying posteriorly may be at increased risk of occult spread outside axillary lymph nodes.

BACKGROUND In this study, the authors evaluated the clinical presentation of patients with T4b breast carcinoma, analyzed the impact of noninflammatory skin involvement on long-term survival, and addressed the question whether the T4 tumor category still has any justification. METHODS The clinical course of a study group of 119 patients with skin involvement was compared with the outcome of a control group of 299 consecutive patients who had tumors of the same size but without skin involvement. All tumors were stratified into 1 of 4 subsets according to greatest tumor dimension, as follows: Group A, ≤ 3.0 cm; Group B, 3.1–5.0 cm; Group C, 5.1–10.0 cm; and Group D, > 10.0 cm. RESULTS The study group distribution of patients within the size subsets were as follows: Group A, 26.1%; Group B, 24.3%; Group C, 26.1%; and Group D, 23.5%. Differences in disease-specific survival between the tumor size subsets were significant (Groups A and B vs. Groups C and D; P 5.0 cm), carcinomas ≤ 5.0 cm showed no statistical significant differences in disease-specific survival between study group patients and control group patients (Group A: P = 0.17; Group B: P = 0.31). CONCLUSIONS There is a broad range of clinicopathologic breast carcinoma entities within the T4b category. For > 50% of patients with T4b breast carcinoma, the feature noninflammatory skin involvement had no significant prognostic impact. Approximately 25% of patients had an extent of disease similar to that observed in patients with Stage I–II disease and, thus, falsely were considered to have more advanced disease. Heterogeneity and a lack of prognostic significance suggest that a revision of the T4 category, a relic of historic tumor classifications, is necessary. Cancer 2005. © 2005 American Cancer Society.

To assess the axillary recurrence rate in breast cancer patients with negative sentinel lymph node (SLN) or SLN micrometastases (0.2 mm toor=2.0 mm) after breast surgery and SLN procedure without formal axillary lymph node dissection (ALND).Under controlled study conditions, the SLN procedure proved to be a reliable method for the evaluation of the axillary nodal status in patients with early-stage invasive breast cancer. Axillary dissection of levels I and II can thus be omitted if the SLN is free of macrometastases. The prognostic value and potential therapeutic consequences of SLN micrometastases, however, remain a matter of great debate. We present the follow-up data of our prospective SLN study, particularly focusing on the axillary recurrence rate in patients with negative SLN and SLN micrometastases.In this prospective study, 236 SLN procedures were performed in 234 patients with early-stage breast cancer between April 1998 and September 2002. The SLN were marked and identified with 99m technetium-labeled colloid and blue dye (Isosulfanblue 1%). The excised SLNs were examined by step sectioning and stained with hematoxylin and eosin and immunohistochemistry (cytokeratin antibodies Lu-5 or CK 22). Only patients with SLN macrometastases received formal ALND of levels I and II, while patients with negative SLN or SLN micrometastases did not undergo further axillary surgery.The SLN identification rate was 95% (224/236). SLN macrometastases were found in 33% (74/224) and micrometastases (0.2 mm toor=2 mm) in 12% (27/224) of patients. Adjuvant therapy did not differ between the group of SLN-negative patients and those with SLN micrometastases. After a median follow-up of 42 months (range 12-64 months), 99% (222/224) of evaluable patients were reassessed. While 1 patient with a negative SLN developed axillary recurrence (0.7%, 1/122), all 27 patients with SLN micrometastases were disease-free at the last follow-up control.Axillary recurrences in patients with negative SLN or SLN micrometastases did not occur more frequently after SLN biopsy alone compared with results from the recent literature regarding breast cancer patients undergoing formal ALND. Based on a median follow-up of 42 months-one of the longest so far in the literature-the present investigation does not provide evidence that the presence of SLN micrometastases leads to axillary recurrence or distant disease and supports the theory that formal ALND may be omitted in these patients.

Somatostatin (SRIF) is a well-known neuroendocrine secretion product. SRIF expression and secretion are induced after inflammation in murine macrophages and in endotoxin-injected sheep and pigs. Because adipocytes have been demonstrated to produce numerous cytokines and peptide hormones, we investigated the expression of SRIF and its receptors (SSTR1-5) in human adipose tissue after inflammatory stimulation in vitro and in tissues from patients with septic disease.Preadipocyte-derived adipocytes, mesenchymal stem cell-derived adipocytes, and mature explanted adipocytes expressed SRIF-mRNA after endotoxin [lipopolysaccharide (LPS)] or IL-1beta treatments. LPS- and IL-1beta-mediated SRIF-mRNA induction was blocked by pretreatment with dexamethasone. Using cocultures and quantitative real-time PCR, we demonstrate adipocyte SRIF induction by secretion factors from activated peripheral blood mononuclear cell-derived macrophages. In contrast to basal adipocytes, SRIF protein was detected in culture supernatants of LPS-treated and of combined TNFalpha/IL-1beta/LPS-treated adipocytes. SRIF protein was visualized by immunohistochemistry in explanted minced adipose tissue after overnight incubation in culture medium supplemented with combined IL-1beta and LPS. In septic patients, expression of SRIF-mRNA and SRIF protein was found in visceral, but not in sc, adipose tissue. Adipocyte mRNA abundance of SSTR 1-5 was differentially regulated by inflammatory treatments.Thus, human visceral adipose tissue secretes SRIF during inflammation and sepsis and expresses several SSTRs. It is tempting to speculate that visceral adipose tissue-derived SRIF plays a modulatory role in the immunological and metabolic response to inflammation.

Weight loss reduces bone mass and increases the risk of osteoporosis. This study was undertaken to assess changes of bone metabolism following Roux-en-Y gastric bypass (RYGB) and adjustable silicone gastric banding (ASGB) as compared to nonoperated controls of morbidly obese subjects. Fourteen female and 5 male patients with a mean (+/-SEM) age of 44.3 +/- 1.8 years participated in the 24-month prospective study. Nine patients underwent ASGB, 4 patients RYGB operation, and 6 patients were included in the control group. Bone metabolism was assessed by determination of serum parathyroid hormone (PTH), osteocalcin, urinary deoxypyridinoline, and dual energy x-ray absorptiometry (DXA) before, and 6, 12, and 24 months after intervention. The body mass index (BMI) decreased from 41.0 +/- 1.1 to 34.0 +/- 1.4 kg/m2 in the ASGB group (P = .001), from 42.7 +/- 2.2 to 30.5 +/- 2.2 kg/m2 in the RYGB group (P = .006), and remained unchanged in the control group (from 41.2 +/- 1.2 to 41.4 +/- 1.4 kg/m2) after 24 months. Bone mineral content (BMC) showed no significant change in the ASGB group (from 3,079 +/- 140 to 3,064 +/- 129 g) and in the control group (from 2,945 +/- 130 to 2,940 +/- 111 g), whereas it decreased from 2,968 +/- 111 to 2,621 +/- 139 g in the RYGB group (P = .005). The loss in BMC was accompanied by significant increases in urinary deoxypyridinoline (P < .05) and in serum osteocalcin (P < .01) after RYGB, suggesting both, increased bone resorption and increased bone formation. The authors were aware of the fact that the study groups were small and conclusions need to be regarded as preliminary. However, the RYGB operation resulted in enhanced weight loss and significant net loss of bone mass in comparison to ASGB and obese control subjects. Patients losing large amounts of body weight should be monitored regularly regarding prevention of osteoporosis.

The wish for a minimally invasive procedure is one of the utmost demands by all persons undergoing living-donor nephrectomies. The retroperitoneoscopic access for this procedure has proven to be a safe, minimally invasive, and efficient approach accompanied by early mobilization and a fast return to general daily activities. The incidence of complications during and after this technically demanding operation is comparable to that of other approaches. Because of the direct anatomic approach, retroperitoneoscopic living-donor nephrectomy has become the preferred access at our institution for both donors and surgeons.

Objective: Ghrelin is an enteric peptide with strong orexigenic and adipogenic effects. Plasma ghrelin levels are decreased in obese subjects but increase after weight loss; this increase is not observed after Roux-en-Y gastric bypass (RYGB). Prospective and comparative data after adjustable silicone gastric banding (ASGB) have not been reported previously. Research Methods and Procedures: Overnight fasting plasma ghrelin concentration was measured in morbidly obese subjects at baseline and 3, 6, 12, and 24 months after ASGB (n = 8) or RYGB (n = 5) and in nonoperated controls (n = 7). Results: After RYGB, body weight (BW) decreased by 29.5 ± 5.5 kg (mean ± SE, p < 0.001), whereas plasma ghrelin failed to increase significantly (+167 ± 119 pg/mL, not significant). In contrast, after ASGB, BW decreased less (by 22.8 ± 5.9 kg; p < 0.001), and plasma ghrelin significantly increased by 377 ± 201 pg/mL (p = 0.025). Neither BW nor plasma ghrelin changed in nonoperated controls. Plasma leptin decreased in both operated groups (similarly p < 0.05) but not in nonoperated controls. Plasma growth hormone and insulin-like growth factor 1 were not correlated with changes in plasma ghrelin concentrations. Discussion: Plasma ghrelin levels failed to increase during substantial weight loss after RYGB, but did increase in response to lesser weight loss after ASGB. These findings suggest that the plasma ghrelin response after weight loss is impaired after exclusion of major parts of the stomach and the duodenum (RYGB), and the smaller long-term weight loss after ASGB compared with RYGB may be due, at least in part, to an absent increase in plasma ghrelin after RYGB.