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BackgroundWhile enhanced recovery after surgery (ERAS) programs are the standard for perioperative management, special nutritional care has to be administered to malnourished patients and those at metabolic risk with special regard to patients with postoperative complications.MethodsExisting guidelines of the German and European societies of nutritional medicine (DGEM and ESPEN) on enteral and parenteral nutrition in surgery were merged and in accordance with the principles of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, German Association of the Scientific Medical Societies) and Arztliches Zentrum fur Qualitat in der Medizin (AeZQ, German Agency for Quality in Medicine) revised and extended.Results and discussionThe working group developed 41 consensus-based recommendations for perioperative nutrition. The recommendation strength is: 9x A (recommendation based on significant good quality literature containing at least one randomized controlled trial), 12x B (recommendation based on well-designed trial without randomization), 13x C (recommendation based on expert opinions and/or clinical experience of respected authorities) and 7x CCP (clinical consensus point).ConclusionEven in patients without obvious malnutrition perioperative nutritional support is indicated when oral food intake is not feasible or inadequate for a longer period of time.

Fragestellung: Enhanced recovery after surgery (ERAS) Programme sind der Standard im perioperativen Management. Berucksichtigt werden muss der nachgewiesene Einfluss einer krankheitsassoziierten Mangelernahrung auf die postoperative Morbiditat und Letalitat. So bedurfen Patienten mit metabolischem Risiko oder manifester Mangelernahrung sowie solche Patienten mit postoperativen Komplikationen besonderer ernahrungsmedizinischer Aufmerksamkeit. Methodik: Die bestehenden Leitlinien der deutschen und europaischen ernahrungsmedizinischen Fachgesellschaften (DGEM, ESPEN) zur enteralen und parenteralen Ernahrung wurden zusammengefuhrt und in Einklang mit den prozeduralen Vorgaben der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) und des Arztlichen Zentrums fur Qualitat in der Medizin (AZQ) aktualisiert und erweitert. Ergebnisse: Von der Arbeitsgruppe wurden 41 in der Leitlinienkonferenz konsentierte Empfehlungen zur perioperativen Ernahrung mit folgender Empfehlungsstarke erarbeitet: 9-mal A (Empfehlung basiert auf schlussiger Literatur guter Qualitat, die mind. eine randomisierte Studie enthalt), 12-mal B (Empfehlung basiert auf gut durchgefuhrten, nicht randomisierten Studien), 13-mal C (Empfehlung basiert auf Berichten und Meinungen von Expertenkreisen und/oder klinischen Erfahrungen anerkannter Autoritaten) und 7-mal KKP (klinischer Konsenspunkt). Schlussfolgerung: Eine perioperative supplementierende kunstliche Ernahrung ist auch bei Patienten ohne offensichtliche Mangelernahrung indiziert, sofern vorhersehbar ist, dass der Patient fur eine langere postoperative Zeitdauer unfahig zur adaquaten oralen Kalorienzufuhr sein wird.

Estrogen modulates pain perception but how it does so is not fully understood. The aim of this study was to determine if estradiol reduces nociceptive responses in part via hypothalamic-pituitary-adrenal (HPA) axis regulation of cyclooxygenase (COX)-1/COX-2 activity. The first study examined the effects of estradiol (20%) or vehicle with concurrent injection nonsteroidal antiinflammatory drugs (NSAIDs) on formalin-induced nociceptive responding (flinching) in ovariectomized (OVX) rats. The drugs were ibuprofen (COX-1 and COX-2 inhibitor), SC560 (COX-1 inhibitor), or NS398 (COX-2 inhibitor). In a second study, estradiol's effects on formalin-induced nociception were tested in adrenalectomized (ADX), OVX, and ADX+OVX rats. Serum levels of prostaglandins (PG) PGE(2) and corticosterone were measured. Estradiol significantly decreased nociceptive responses in OVX rats with effects during both the first and the second phase of the formalin test. The nonsteroidal antiinflammatory drugs (NSAIDs) did not alter nociception at the doses used here. Adrenalectomy neither altered flinching responses in female rats nor reversed estradiol-induced antinociceptive responses. Estradiol alone had no effect on corticosterone (CORT) or prostaglandin levels after the formalin test, dissociating the effects of estradiol on behavior and these serum markers. Ibuprofen and NS398 significantly reduced PGE2 levels. CORT was not decreased by OVX surgery or by estradiol below that of ADX. Only IBU significantly increased corticosterone levels. Taken together, our results suggest that estradiol-induced antinociception in female rats is independent of COX activity and HPA axis activation.

Alterations in protein kinase (PKA) protein levels have been implicated in the regulation of responses to and development of cocaine addiction. However, the contribution of differences in PKA intracellular cascade to the known sex differences in responses to cocaine is not well understood. This study examined whether there are intrinsic or cocaine-induced alterations in PKA-mediated responses, such as phosphorylation of cyclic AMP response element binding protein, in male and female rats. To this end, protein levels of PKA and phosphorylated CREB (pCREB) in the caudate putamen (CPu) and nucleus accumbens (NAc) of male and female rats were measured basally or after acute (one 30-mg/kg intraperitoneal injection) or chronic (twice-daily 15-mg/kg injections for 14 days) cocaine administration. Behavioral responses to both cocaine administration paradigms were also studied. Similar to previous findings, ambulatory, rearing, and stereotypic activities were higher in female rats after acute cocaine administration. Sex differences in cocaine-induced responses were also observed after chronic cocaine administration: While males developed a robust sensitization in ambulatory activities to cocaine, females developed tolerance in cocaine-induced rearing and stereotypic activities. In the basal group, females had significantly higher PKA protein levels in the NAc. Regardless of the cocaine administration paradigm, PKA protein levels in the NAc were higher overall in females than in males. Furthermore, after cocaine administration, while pCREB protein levels in male rats were induced for a longer amount of time than in female rats, the magnitude of change on pCREB levels were higher in female than male rats. However, in the CPu, no sex differences in PKA or pCREB protein levels were observed either in the basal group or after acute or chronic cocaine administration. Taken together, these findings suggest that sex differences in basal and cocaine-induced alterations in the PKA signaling regulation in the NAc may contribute to sex differences in the psychomotor responses to cocaine.

For diagnosis of instability in case of ruptures of the lateral ankle joint ligaments a special ultrasound examination technique was established. In 41 patients with acute ruptures and 8 patients with chronic instabilities a prospective preoperative sonographic instability-testing was performed and compared to intraoperative result. A sensitivity of 0.96 for injuries of the lig. fib. tal. ant. and 0.79 for the lig. fib. calc. proves the exactness of this method. This technique is easy to perform and the result can be documented. This examination is accepted by the patients.

Decrease in gall-bladder volume after intake of a test meal was assessed by ultrasound in 30 patients (24 females, 6 males; mean age 55 [22-82] years) with indications for elective or early elective cholecystectomy for cholelithiasis. Patients were assigned to three groups, based on intraoperative and histological gall-bladder changes: group 1 (n = 17), without changes or with mild chronic cholecystitis; group 2 (n = 4), with severe chronic inflammatory changes; group 3 (n = 9), with acute cholecystitis or cystic duct occlusion. A volume decrease of at least 30% after the test meal excluded only acute wall inflammation (negative predictive value 95.5%), while a volume reduction of at least 50% made it possible in a high percentage of cases (negative predictive value 88.2%) to predict correctly an absence of severe chronic wall changes. Before organ-preserving treatment (extracorporeal lithotripsy or local litholysis) is undertaken, gall-bladder volume reduction of at least 50% should be documented.

HISTORY AND ADMISSION FINDINGS A 55-year-old woman had for 5 years been suffering from severe burning thoracic pain. She had typical risk factors for cardiovascular disease, namely hypertension, chronic smoking, obesity and hypercholesterolaemia. She had been hospitalized several times for suspected myocardial infarction, but coronary heart disease had been excluded by cardiac examination, including angiocardiography. The only contributory admission finding was epigastric pain on pressure. INVESTIGATION Gastroscopy revealed a non-erosive duodenitis and chronic antral gastritis. The cardia was tightly closed and there were no signs of reflux oesophagitis. Manometry in the oesophagus showed frequent simultaneous contractions and marked increase in pressure amplitude, predominantly in the distal segment, indicating diffuse oesophageal spasms. TREATMENT AND COURSE Drug treatment with calcium channel blockers gave only brief relief from the thoracic pain. But longitudinal oesophageal myotomy via thoracoscopy brought about complete pain relief, which has now persisted for 3 years. CONCLUSION Thoracoscopic longitudinal oesophageal myotomy can provide a therapeutic alternative in patients with oesophageal spasms when drug therapy and pneumatic oesophageal dilatation have failed.

Four days after an operation for fusion of lumbar and sacral vertebrae a 30-year-old man developed bilateral deep-vein thrombosis in the legs, extending on the left from the fibular group of veins to the popliteal vein. On the right all deep veins of the lower leg were occluded, including the confluence of the popliteal vein. As systemic fibrinolysis was contraindicated, surgical thrombectomy was undertaken. After incomplete removal of the thrombi, regional hyperthermic perfusion with streptokinase was performed using a heart-lung machine. After a compression bandage had been applied to the right leg above the veins the leg was perfused via the common femoral vein at 40 degrees C from the heart-lung machine, at a flow rate of 600-800 ml/min, for 60 min with a solution containing 1 million IU streptokinase. Measurement of various components in the perfusate indicated marked fibrinolysis (fibrinogen: not measurable; fibrinogen breakdown products: > 80 micrograms; streptokinase: 100 FU/ml after 30 min, 62 FU/ml after 60 min). At the same time there was no demonstrable fibrinolytic activity in the systemic circulation. Fibrinogen concentration fell from 340 mg/dl 30 min before the onset of perfusion to 245 mg/dl 90 min after it. After 60 min of perfusion the blood from the right leg was discarded and the leg flushed through with 1.5 l of an electrolyte solution and then filled up with previously obtained and stored patient's own blood concentrate. Subsequent phlebography and venous occlusion plethysmography demonstrated complete recanalization of the deep-vein system with normal venous valve function.

Gallbladder volume and contraction after a fatty meal was determined in 14 patients with gastric cancer before and 3-4 months after gastrectomy (7 total and 7 subtotal gastrectomies) with Roux-en-Y anastomosis. All patients had an increased gallbladder resting volume (p less than 0.001) and 10 of 14 patients (6 after total gastrectomy and 4 after subtotal gastrectomy) had an increased minimal residual volume after fatty meal stimulation (p less than 0.01) in the postoperative state, when compared to the preoperative values. It can be concluded that gastrectomy is followed by an impairment of gallbladder tone and contraction, both possibly increasing the risk of gallstone formation.

In 2002 screening colonoscopy was introduced in Germany for the prevention of colorectal cancer (CRC) and CRC mortality. Individuals took part in a prospective study from October 2002 until September 2005 performed at a single centre for gastroenterology. Histopathological data, surgical-pathological stages and further follow-up events were recorded until 31st of December 2006. For screened individuals without symptoms, the data obtained were compared to those from age-matched patients who presented with clinical symptoms/signs and who underwent colonoscopy during the same period in time. A total of 5066 individuals underwent screening colonoscopy. In this group, colorectal cancer was detected in 46 individuals (0.9%). Endoscopic treatment was considered adequate for 21 cancers. In this group of 46 patients, 94.5% were classified into UICC stages I-II by pathological staging. In 504 screened individuals, colorectal polyps were detected (12.2%) and removed by polypectomy. Of these polyps, 16 were classified as cancer, 496 as adenomas and 1 as a carcinoid tumour. High grade dysplasia was noted in 41 polyps (8.3% of adenomas). In comparison, 4099 symptomatic patients underwent colonoscopy. In this group 100 cancers (2.4%) were detected. Advanced malignant tumours were noted in 39% of these; endoscopic treatment was feasible in 16% of the cancers. As of December 2006, cancer-related deaths were observed in 20% of symptomatic patients with CRC. Screening colonoscopy detects colorectal cancers in the early stages. Given the favourable prognosis in these stages, screening can reduce CRC-related mortality.

In der Chirurgie ist die Bedeutung des Ernah−rungsstatus fur die postoperative Morbiditatund Letalitat bei verschiedenen Krankheitsbil−dern retrospektiv [1±6] und auch prospektiv[7±22] gezeigt worden.Haufig ist das Bestehen einer MangelernahrungAusdruck der Grunderkrankung z.B. eines Tu−morleidens oder einer chronischen Organinsuffi−zienz [22±31] (s. auch entsprechende Kapitel).So ist die Mangelernahrung besonders relevantfur die Prognose nach Organtransplantation[32±41]. Der Ernahrungsstatus beeinflusst auchwesentlich die Morbiditat in der Chirurgie alterMenschen [42].Rasche Rekonvaleszenz nach chirurgischen Ein−griffen (¹Enhanced Recovery after Surgery =ERAS“) ist die Voraussetzung fur die auch okono−misch gebotene Senkung der Krankenhausver−weildauer. Insbesondere nach Koloneingriffen istder sog. ¹Fast Track“ zum Masstab des postope−rativen Managements geworden. Grundlage istim multimodalen Vorgehen die perioperativsparsame Volumenzufuhr, adaquate Schmerz−therapie vor allem mittels epiduraler Anasthesieunter Minimierung der Gabe von Opioiden, Gabevon Antiemetika und Peristaltika. Ziel ist der fru−hestmogliche orale Kostaufbau mit Vollmobili−sierung.Die Indikationen fur eine kunstliche Ernahrungsind auch in der Chirurgie die Prophylaxe und Be−handlung von Katabolie und Mangelernahrung.Dies betrifft vor allem perioperativ ¹substitutiv“den Erhalt des Ernahrungszustandes zur Verhin−derung einer Mangelernahrung. Kriterien des Er−folgs fur die ¹therapeutische“ Indikation einer PEsind unter Berucksichtigung okonomischer Im−plikationen, die sogenannten OutcomeparameterMorbiditat, Krankenhausverweildauer und Leta−litat. Bei ¹palliativer“ Indikation und poststatio−nar steht neben der Verbesserung des Ernah−rungsstatus die Lebensqualitat im Vordergrund[43±55].

Although it is established that female rats have a more robust behavioral response to acute cocaine administration than male rats, the neurobiological mechanisms underlying these differences remain unclear. The purpose of the present study was to determine whether dopamine (DA) receptor activation influences sex differences in cocaine-induced behaviors. A second study was performed to determine sex differences in D1/D2 receptor levels prior to and post-cocaine administration. Male and female Fischer rats were pre-treated with the D1 antagonist SCH-23390 (0.05, 0.1, and 0.25 mg/kg, i.p.), the D2 antagonist eticlopride (0.03, 0.1 mg/kg, i.p.), or vehicle (saline) 15 min before acute cocaine (20 mg/kg, i.p.) or saline administration. Cocaine-induced ambulatory and rearing activity was greater in female than male rats. Pre-treatment with SCH-23390 affected cocaine-induced ambulatory, rearing, and stereotypic activity in a sex-dependent manner; cocaine-induced ambulatory and stereotypic behavior in female rats was reduced by the lowest dose of SCH-23390. Eticlopride did not alter behavioral responses to cocaine in male or female rats. These results suggest that in both male and female rats, activation of the D1, but not the D2, receptor modulates cocaine's motor effects. There were no sex differences in baseline levels of D1, D2, and DA transporter binding in the caudate putamen (CPu) and the nucleus accumbens (NAc). Cocaine administration reduced D1 binding levels in the CPu only in male rats. Our findings suggest that the regulation of striatal D1 binding levels after acute cocaine administration is a sexually dimorphic process. We also hypothesize that the greater sensitivity to D1 receptor blockade in female rats, as compared to male rats, may contribute to their overall increased hyperactivity in response to acute cocaine. Taken together, the D1 receptor may be an important substrate in the regulation of sex differences to cocaine-induced locomotor activity.

Female rats demonstrate higher pain sensitivity than do males in various nociceptive assays of inflammation. In the present study, we found that estradiol (20%) replacement in ovariectomized rats attenuated the chronic phase of the formalin response but only at high formalin concentrations thought to rely on peripheral inflammation. An inactive isomer of estradiol, alpha-estradiol, failed to result in the same attenuation (P > 0.05). Our results suggest that estradiol's actions in inflammatory responses are mediated through genomic estrogen receptor-mediated mechanisms.

Female rats display a more robust behavioral response to acute cocaine administration than do male rats. However, a clear understanding of the biological mechanisms underlying these differences remains elusive. The present study investigated whether sexual dimorphisms in cocaine-induced motor behavior might be based on monoaminergic levels and/or cocaine pharmacokinetics. An acute injection of cocaine (5, 15, 20 or 30 mg/kg) or saline was administered to male and female rats, and behavioral activity was monitored for 3 h. Following acute cocaine or saline administration motor behavior varied according to dose and sex; overall, female rats displayed greater rearing counts and stereotypic scores, greater total locomotor counts at 15, 20, and 30 mg/kg of cocaine, and greater ambulatory counts at 20 and 30 mg/kg of cocaine than did male rats. Neurochemical determinations in post-mortem tissue showed that both male and female rats had increases in total dopamine (DA) in the caudate putamen (CPu) 15 min following cocaine administration. Additionally, male rats had a decrease in dihydroxyphenylacetic acid (DOPAC)/DA turnover. Female rats showed significant reductions in total levels of DA, DOPAC, HVA, serotonin (5-HT), 5-hydroxyindole acetic acid (5-HIAA), and DOPAC/DA turnover in the nucleus accumbens (NAc). Male rats displayed a reduction only in DOPAC/DA turnover and increases in 5-HT in the NAc following cocaine administration. Furthermore, sex differences in cocaine metabolism were observed where females had greater brain/blood levels of norcocaine and ecgonine methyl ester while male rats had higher blood levels of benzoylecgonine. These results suggest that sex differences in the behavioral responses to cocaine administration could be explained in part by intrinsic differences in both monoaminergic levels and metabolic processes.

Summary The main problem in enteral nutrition is still the occurrence of diarrhea and other gastrointestinal side effects during nutrition. There are reports about the diarrhea rate between 2% and 67% of patients receiving enteral nutrition [Gastroenterol. Nurs. 25(3) (2002) 95] In a randomized, double blinded clinical trial, the influence of a soluble fibre, partially hydrolyzed guar gum (PHGG), on diarrhea rate in medical and surgical patients, was evaluated. Thirty of the 100 patients received a total enteral nutrition (TEN) following upper gastrointestinal surgery, 70 patients received a supplemental enteral nutrition of 1000 ml/d. Diarrhea occurred in 15 of the fibre free fed patients (30%) and in 6 of the fibre fed patients (12%) ( P 0.05 ). In the fibre free diet group, there were 40.6 days noted where patients suffered from diarrhea, and 10.2 days were noted in the supplemented group ( P 0.05 ). Discharge of enteral nutrition because of GI-side effects was significantly more often in the fibre free group of patients who received TEN than in totally enteral fed patients with fibre. Use of PHGG lowered the rate of diarrhea occurrence in patients with total as well as supplemental enteral nutrition. When diarrhea occurred in patients with fibre supplemented enteral nutrition, it lasted significantly shorter.

Several recent reports have demonstrated sex differences in the behavioral and neurochemical response to cocaine. However, it is not clear whether differences exist in cocaine reward or the extent to which adrenal hormones regulate cocaine-induced conditioned place preference (CPP) in either sex. To address these questions, side-by-side comparisons were conducted to determine the effects of conditioning length, cocaine dose and adrenalectomy on cocaine CPP in male and female rats. Female rats demonstrated cocaine CPP after four pairing sessions, while male rats required eight pairing sessions to develop CPP for cocaine. Also, female rats developed CPP at cocaine doses of 5 and 10 mg/kg while male rats required higher cocaine doses (20 mg/kg). Overall, females had higher blood serum levels of corticosterone. Furthermore, a dose-dependent effect on serum levels of corticosterone was observed only in female rats, where rats conditioned with 20 mg/kg cocaine had significantly higher serum levels of corticosterone than rats conditioned with 5 mg/kg cocaine. However, adrenalectomy did not affect CPP for cocaine in either sex. These results suggest that a female's higher sensitivity to cocaine's rewarding effects is not completely mediated by the hypothalamic-pituitary-adrenal axis. Therefore, sex differences in the acquisition and/or expression of cocaine CPP may be regulated by other mechanisms, such as the hypothalamic-pituitary-gonadal axis.

Major surgery leads to post-traumatic immune dysregulation which is driven by the activation of potent proinflammatory mediators including the leukotrienes (LTs). The LTs of the four-series derive from arachidonic acid (an omega-6 fatty acid). In contrast, LTs of the five-series are metabolic products of eicosapentaenoic acid (an omega-3 fatty acid) and exert less biological activities. Therapeutical strategies to attenuate proinflammatory signals include the provision of omega-3 fatty acids. Thirty patients with major elective abdominal surgery and an indication for total parenteral nutrition (TPN) were compared in a prospective, double blind, randomized study of two parallel groups. Group 1 (n=14) received an omega-3 fatty acid enriched 20% lipid emulsion (MCT:LCT:fish oil = 5:4:1, MLF541; Lipoplus) for 5 days postoperatively. Group 2 (n=16) received a standard 20% fat emulsion (LCT; Intralipid). The LT release from whole blood leukocytes stimulated with Ca-ionophore was analyzed preoperatively and on postoperative days 1, 6 and 8 by HPLC. There was a significant increase in the generation of LTB(5) (P=0.0035) and in the ratio of LTB(5)/LTB(4) (P=0.0017) the omega-3 group, but not in the reference group after 5 days infusion of the lipid emulsions. The omega-6/omega-3 fatty acid ratio 3:1 of the newly developed MLF541 lipid emulsion is appropriate to increase the synthesis of the biologically less active leukotrienes of the five-series. Nutritive enrichment with omega-3 fatty acids in a balanced ratio with omega-6 fatty acids is an important step to avoid hyperinflammatory situations in patients after major surgery.

Benign strictures of the common bile duct after surgery or due to gallstones may lead to obstruction and derangement of bile drainage in the extrahepatic biliary system. Although the treatment of choice in these situations is the endoscopic dilatation, in some cases with stenosis of a long segment of the bile duct a partial replacement with a vascularised jejunal patch may be possible and useful. To our knowledge, there are no reports on long-term results of the procedure. We describe the course, the surgical technique and long-term results of four patients with a jejunal patch reconstruction of the common bile duct. Ten years after surgery there were no radiologic or laboratory signs of a restenosis of the common bile duct.

While enhanced recovery after surgery (ERAS) programs are the standard for perioperative management, special nutritional care has to be administered to malnourished patients and those at metabolic risk with special regard to patients with postoperative complications.Existing guidelines of the German and European societies of nutritional medicine (DGEM and ESPEN) on enteral and parenteral nutrition in surgery were merged and in accordance with the principles of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, German Association of the Scientific Medical Societies) and Ärztliches Zentrum für Qualität in der Medizin (AeZQ, German Agency for Quality in Medicine) revised and extended.The working group developed 41 consensus-based recommendations for perioperative nutrition. The recommendation strength is: 9x A (recommendation based on significant good quality literature containing at least one randomized controlled trial), 12x B (recommendation based on well-designed trial without randomization), 13x C (recommendation based on expert opinions and/or clinical experience of respected authorities) and 7x CCP (clinical consensus point).Even in patients without obvious malnutrition perioperative nutritional support is indicated when oral food intake is not feasible or inadequate for a longer period of time.

Between October 1995 and April 2000 we performed 30 aortic laparoscopic reconstructions and 13 procedures on the iliac vessels. Severe aortic calcifications, poor cardiac and pulmonary status, and extensive intraabdominal adhesions were considered as contraindications for the laparoscopic procedure. Operative time, conversion rate, surgical and cardiopulmonary complications were recorded for an intention- to treat-analysis. Clinical criteria and Duplex ultrasound scans were used to document the patency of the grafts. The duration of analgetic therapy, nursing care, and hospital stay characterized the postoperative recovery. Mean surgical time was 302 minutes (min) in the aortic group (Ao) and 251 min in the iliac group (Ia). Seven conversions (5 in the aortic and 2 in the iliac group) occurred for clamping problems (n = 3), aortic lesion (n = 1), iliac vein lesion (n = 1), time consuming dissection (n = 1), and suturing failure (n = 1). Cardiac morbidity rate was 6.6% (Ao) and 7.7% (Ia). Two patients suffered pulmonary complications after aortic surgery (6.6%). Mean duration of analgetic therapy was 2.4 d (Ao) and 2.5 d (Ia). Nursing care was necessary for 4.4 d (Ao) and 3.1 d (Ia). At discharge the reconstructions were patent and ischemia symptoms subsided in all cases. Mean hospital stay was 9.1 d (Ao) and 6.7 d (Ia). At follow-up after a mean interval of 5.2 months (Ao) and 8.3 mo (Ia) patency was documented in all cases. Disease progression in the adjacent native vessels (n = 3) and beyond the graft (n = 1) was revealed by ultrasound scan, requiring a further vascular procedure. In our laparoscopic experience cardiac and pulmonary morbidity proved similar to traditional vascular surgery. The advantage of the minimally invasive approach seemed to be a more comfortable recovery. However, operative time and conversion rate emphasize the technical challenge of the procedure, which should be performed only in highly selected cases.

PURPOSE The evaluation of multiple intra- and early postoperative parameters in patients undergoing laparoscopic aortobifemoral bypass grafting. METHODS The charts of 22 patients who underwent laparoscopic aortobifemoral grafting between February 2nd, 1996 and April 30th, 1999 were retrospectively reviewed. RESULTS All patients were men. The mean age was 54 +/- 7.2 years with the mean body weight being 76.3 +/- 10.9 kg and the Body-Mass-Index (BMI) 23 +/- 2.8. Claudication was present in 20 patients; one patient had rest pain and one patient suffered from tissue loss. The mean Ankle-Brachial-Index (ABI) was 0.57 +/- 0.1. In four cases conversion to open technique became necessary. The mean operation time was 316 +/- 73 min and the mean aortic cross-clamp time was 73 +/- 20 min. The mean intraoperative blood-loss reached 689 +/- 461 ml. The mean duration of postoperative ventilator support was 6.0 +/- 5.8 hours and the patients left the ICU after 2.2 +/- 3.2 days. Oral intake was allowed after a mean of 2.6 +/- 2.9 days and the central venous lines were removed after 3.8 +/- 3.9 days. The administration of analgetic drugs was required for 2.9 +/- 3.9 days. The mean length of stay in the hospital was 9.6 +/- 5.5 days. CONCLUSIONS Laparoscopic aortobifemoral bypass grafting is feasible in a selected group of patients. Despite relatively long operation times and the use of a pneumoperitoneum, we did not encounter significant cardiopulmonary adverse effects.

Traumatic arterioportal fistulas (APF) are very rare. The most common reasons are liver biopsy and liver injuries. They are also caused by liver tumours and vessel anomalies. This is a case-report of a patient who developed an APF after blunt abdominal trauma. The fistula bearing part of the liver was resected in two sessions. In cases of large APFs with a flow from multiple collaterals the therapy of choice is the embolization. If not possible a selective excision of the fistulous sac or the resection of the fistula containing liver segment are recommended.

The aim was to perform a totally laparoscopic thrombendarterectomy (TEA) of the infrarenal aorta to reduce the trauma connected to the surgical approach. A 52-year-old man was referred to our institution with severe claudication. Angiography revealed a subtotal stenosis of the infrarenal aorta. Because the lesion was not suitable for an interventional procedure, a TEA was planned. The surgery was performed through six ports using a transperitoneal approach with pneumoperitoneum. The laparoscopic TEA was carried out according to the standards of open vascular surgery. The surgery time was 285 minutes, the crossclamping lasted 105 minutes, and the blood loss was 100 mL. The angiographic and functional results were excellent. The patient experienced a rapid recovery and was discharged after 6 days. This case report shows the feasibility of totally laparoscopic TEA of the infrarenal aorta. The well-known advantages of minimally invasive techniques in abdominal surgery with regard to the decrease of surgical trauma may also be valid in aortic surgery for occlusive disease.

Fragestellung: Entwicklung einer laparoskopischen Technik zur transperitonealen Anlage einer aortobifemoralen Bifurkationsprothese bei AVK. Methode und Patienten: In der Zeit vom 1. 2. 96 bis zum 1. 2. 98 wurden 16 Patienten der laparoskopischen Anlage einer aortofemoralen Bifurkationsprothese zugefuhrt. Uber 6 5–12 mm grose Arbeitszugange konnten Exposition, Ausklemmung und Arteriotomie des infrarenalen Aortensegmentes mittels laparoskopischer Instrumente ausgefuhrt werden. Der fortlaufende End-zu-Seit-Anschlus der primar dichten Dacronprothese erfolgte ebenso vollstandig laparoskopisch. Nach retroperitonealem Durchzug der Prothesenschenkel, wurden diese konventionell an den Leistenschlagadern angeschlossen. Ergebnisse: Der Eingriff konnte 13mal auf laparoskopischem Wege beendet werden; 3mal war eine Konversion zur konventionellen Operationstechnik erforderlich. Ein Patient erfuhr eine 16tagige intensivmedizinische Behandlung wegen einer respiratorischen Insuffizienz. Die mittlere Operationsdauer betrug 292±60 min bei einer Abklemmzeit von 74 ±18 min. Der Blutverlust lag bei 566±434 ml, bei 2 Patienten erfolgte eine Fremdbluttransfusion. Die regelrechte Lage und Durchgangigkeit der Bypasse wurde angiographisch dokumentiert. Die Patienten konnten durchschnittlich 9±5,8 Tage nach dem Eingriff entlassen werden. Bisher wurden 15 von 16 Patienten im nicht-invasiven Gefaslabor nachuntersucht, alle Rekonstruktionen waren offen. Wegen einer hochgradigen Stenose am femoralen Anschlus, war in einem Fall eine Revision erforderlich. Schlusfolgerung: Die laparoskopische Anlage einer aortofemoralen Bifurkationsprothese ist moglich, sicher und effektiv. Der technisch anspruchsvolle Eingriff wird mit speziellem Instrumentarium durchgefuhrt, die Entwicklung eines Klammernahtgerats sowie eines Retraktors fur den Darm wird voraussichtlich den Schwierigkeitsgrad sowie die Dauer der Operation wesentlich verringern konnen. Moglicherweise wird diese Methode einen Beitrag zur Minimierung des Operationstraumas bei aortofemoralen Rekonstruktionen leisten konnen.

In an in-vitro study standardized test thrombi were incubated at different temperatures between 25 degrees and 43 degrees C in a constant test mixture in which all reagents necessary for fibrinolysis including streptokinase were contained in excess. At each temperature step the dilution of the standard streptokinase solution (1:1000 IU/ml) was measured at which the test thrombus dissolved in exactly 15 min (clot lysis test). The highest fibrinolysis activity (dilution of 1:1140 of the standard) was obtained at 40 degrees C, lower activities having been recorded at both higher and lower temperatures (43 degrees C:1:1000; 37 degrees C:1:900; 34 degrees C:1:550; 30 degrees C:1:255; 25 degrees C:1:90). Related to the optimal temperature of 40 degrees C (100%), the fibrinolytic activity at 25 degrees C was only 7.9%. In view of the axial temperature gradients existing in the limbs, the internal temperature in their peripheral parts lies well below the optimal temperature for fibrinolysis. This situation should be taken into account during fibrinolysis procedures for thrombotic occlusions in the limbs.

Dieser Beitrag referiert die Ergebnisse einer Diskussion von Experten zur kunstlichen Ernahrung, welche wahrend der 6. Fortbildungsveranstaltung der Deutschen Gesellschaft fur Ernahrungsmedizin in Norddeutschland in der Evangelischen Akademie Loccum vom 7. – 8.5.97 gefuhrt wurde. Bei der Durchfuhrung einer Ernahrungstherapie mussen kritisch Kranke und klinisch ,,stabile`` stationare oder ambulante Patienten unterschieden werden. Der Ernahrungsstatus kann adaquat mittels klinischer Einschatzung (,,Subjective Global Assessment``) beurteilt werden. Grundlegend fur die Uberwachung nach Beginn einer kunstlichen Ernahrung ist die klinische Beobachtung. Laborparameter der klinischen Routine (wie z. B. Serumelektrolyte, -glukose, -harnstoff, -triglyzeride) mussen auch unter Aspekten der Ernahrungstherapie interpretiert werden. Fur ,,stabile`` stationare und ambulante Patienten wird die Korperimpedanzanalyse (B. I. A.) zur Berechnung von Korperzell- und Extrazellularmasse weit verbreitet eingesetzt. Zur langerfristigen Verlaufskontrolle insbesondere von Patienten unter heimparenteraler oder -enteraler Ernahrung hat auch die Hautfaltenmessung noch Bedeutung. Beim kritisch Kranken sind aufgrund der extremen Flussig-keitseinlagerung und Erweiterung des Extrazellularraums mit der monofrequenten B. I. A. unter Ver-wendung der derzeit zur Verfugung stehenden Formeln keine zuverlassigen Berechnungen der Korperzusammensetzung moglich. Allerdings ist der Wert einer differenzierten Ernahrungsdiagnostik mit Analyse der Korperzusammensetzung in der Verlaufsbeobachtung Schwerkranker durchaus strittig. Der Energiebedarf kann fur ,,stabile`` Patienten anhand des Korpergewichts mittels der Formel von Harris-Benedict berechnet werden. Dies mus fur kritisch Kranke als problematisch angesehen werden. Die Messung des Energieverbrauchs mit Hilfe der indirekten Kalorimetrie ist der Schatzung vorzuziehen. Diese Methode liefert uber die Erfassung des Respiratorischen Quotienten (RQ) genauere Daten zum Substratbedarf. Selbst beim kritisch Kranken sind tagliche Messungen in der Regel nicht erforderlich. Gerade bei diesen Patienten sollten Energie- und Substratzufuhr vor allem an der metabolischen Aktivitat und Substrattoleranz ausgerichtet werden.

Nutritive immunomodulation of patients after major surgery.Prospective, randomized controlled double-blind study.Forty patients undergoing major intestinal surgery. Patients were divided into two groups: one received a total parenteral nutrition enriched with omega-3 fatty acids for 5 days postoperatively, the other an isocaloric, control nutrition.We analyzed the leukocyte ability to release leukotrienes from whole blood leukocytes stimulated with the calcium ionophore A23187 (5 micromol/L) by reverse phase high-performance liquid chromatography and circulating cytokines by enzyme-linked immunosorbent assay.Leukocytes from patients of the omega-3 fatty acids group generated significantly higher amounts of less biologically active leukotriene B5 as compared to the control group (por = 0.001). This was accompanied by a significant decrease in the generation of proinflammatory leukotriene B4 (por = 0.006) in the study group. In contrast to interleukin-1beta, interleukin-6, and interleukin-10 systemic levels of tumor necrosis factor-alpha (por = 0.05) were postoperatively decreased in the study group.Our data provide evidence that a total parenteral nutrition enriched with omega-3 fatty acids modulates the lipid mediator pattern and systemic tumor necrosis factor-alpha levels.

Die Indikation zur postoperativen enteralen Ernahrung stellt sich vor allem bei groβen resezierenden Oberbaucheingriffen. Neben der Anwendung eines fruhpostoperativen enteralen Ernahrungs-regimes ist

Objective: To evaluate the effect of early postoperative feeding with a nutritionally complete enteral diet supplemented with the nutrients arginine, ribonucleic acid (RNA), and ω-3 fatty acids on the immune function in patients undergoing surgery for upper gastrointestinal (GI) malignancies. Design: Prospective, randomized, placebo-controlled, double-blind study. Setting: Surgical intensive care unit (ICU) in a German university hospital. Patients: Forty-two consecutive patients receiving an enteral diet via needle catheter jejunostomy after GI surgery for cancer. Interventions: Patients were randomized to receive either the arginine, RNA, and ω-3 fatty acids supplemented diet or an isocaloric and isonitrogenous placebo diet. Early enteral nutrition was started on postoperative day 1 in the surgical ICU with 20 mL/hr and progressed to the optimal goal of 80 mL/hr by postoperative day 5. Measurements and Main Results: Clinical examination and adverse GI symptoms were recorded on a daily basis. Body weight was determined twice weekly. Immunoglobulin concentrations were determined by laser nephelometry. Interferon-γ concentrations were measured with a modified enzyme-linked immunosorbent assay method. Fluorescence-activated cell scan flow cytometry was performed to analyze B cells, T lymphocytes and their subsets. Clinical patient characteristics and mean caloric intake were similar between the two groups and both formulas were well tolerated. The number of T lymphocytes and their subsets, helper T cells (CD4) and activated T cells (CD3, HLA-DR), were significantly higher in the supplemented diet group on postoperative days 10 and 16 (p

Die Indikation zur postoperativen enteralen Ernahrung stellt sich vor allem bei groβen resezierenden Oberbaucheingriffen. Neben der Anwendung eines fruhpostoperativen enteralen Ernahrungsregimes ist hier auch in der spatpostoperativen Phase eine supportive Diatgabe sinnvoll, da die Patienten aufgrund funktioneller Anpassungsschwierigkeiten oft mehrere Wochen lang nicht in der Lage sind, oral ausreichend Nahrung aufzunehmen. Zur Realisierung dieses Ernahrungskonzeptes ist die intraoperativ plazierte Feinnadelkatheterjejunostomie (FNKJ) am besten geeignet. Wir beginnen am 1. postoperativen Tag mit der Gabe einer nahrstoffdefinierten Diat in der Dosis von 20 ml/h und steigern diese langsam bis zur vollen enteralen Ernahrung (27-30 kcal/kg KG) am 5. postoperativen Tag. Zwischen dem 6. und 8. postoperativen Tag wird mit dem oralen Kostaufbau begonnen, und die enterale Applikation wird bis zur Gewichtssteigerung in der Dosierung von 1000 ml/Tag supportiv fortgefuhrt. Zur Uberwachung der enteralen Ernahrungstherapie sind intensive klinische Kontrollen vor allem in der Adaptationsphase notwendig. Bei Auftreten einer Diarrho wird die Diatzufuhr reduziert und nur in Ausnahmefallen abgebrochen. In der spatpostoperativen Phase empfiehlt sich der Einsatz ballaststoffhaltiger Diaten zur Reduktion der Stuhlfrequenz.

Four enteral feeding systems were compared in terms of their ability to limit the chance of introducing microbial contamination during the set up of the systems. The systems incorporated a variety of containers and giving sets, thus resulting in different methods of assembly. The systems were tested under ward conditions in two hospitals and under the worst possible conditions in a simulated ward study. The Steriflo system performed best. Even in the worst possible situation, counts remained very low and the number of Steriflo feeds remaining sterile throughout the feeding period was more than 85% (P< 0.05). The Bag system performed worst: at the end of the recommended feeding period counts of more than 1000 colony forming units/ml were obtained and the number of sterile feeds was significantly lower than for the other systems (P< 0.05). Crown cork bottle and Container performed equally well, but not as well as the Steriflo system. Taking

Little is known about the physiological and behavioral effects of testosterone when co-administered with cocaine during adolescence. The present study aimed to determine whether exogenous testosterone administration differentially alters psychomotor responses to cocaine in adolescent and adult male rats. To this end, intact adolescent (30-days-old) and adult (60-day-old) male Fisher rats were pretreated with vehicle (sesame oil) or testosterone (5 or 10 mg/kg) 45 minutes prior to saline or cocaine (20 mg/kg) administration. Behavioral responses were monitored 1 hour after drug treatment, and serum testosterone levels were determined. Serum testosterone levels were affected by age: saline- and cocaine-treated adults in the vehicle groups had higher serum testosterone levels than adolescents rats, but after co-administration of testosterone the adolescent rats had higher serum testosterone levels than the adults. Pretreatment with testosterone affected baseline activity in adolescent rats: 5 mg/kg of testosterone increased both rearing and ambulatory behaviors in saline-treated adolescent rats. After normalizing data to % saline, an interaction between hormone administration and cocaine-induced behavioral responses was observed; 5 mg/kg of testosterone decreased both ambulatory and rearing behaviors among adolescents whereas 10 mg/kg of testosterone decreased only rearing behaviors. Testosterone pretreatment did not alter cocaine-induced behavioral responses in adult rats. These findings suggest that adolescents are more sensitive than adults to an interaction between testosterone and cocaine, and, indirectly, suggest that androgen abuse may lessen cocaine-induced behavioral responses in younger cocaine users.

Bei 24 Patienten erfolgte ab dem 5. postoperativen Tag nach groβen Oberbaucheingriffen (Gastrektomie, Ösophagusresektion) die enterale Ernährung über eine intraoperativ plazierte Feinnadelkatheterjejunostomie mit einer chemisch definierten Diät. Am 4. postoperativen Tag wurde der jejuno-zökale Transit unter Anwendung des H2-Laktu-lose-Atemtests mit einem Median von 97,5 min bestimmt. Während der enteralen Ernährung zeigte die regelmäβige H2-Exhalationsmessung einen signifikanten Anstieg gegenüber dem Basalwert. Betrachtet man die H2-Exhalation der 8 Patienten (33%), bei denen während der enteralen Ernährung eine Diarrhö auftrat, bestand gegenüber den Patienten ohne Diarrhö ein signifikanter Unterschied. Bereits 6–12 h vor Auftreten der Diarrhö fand sich eine erhöhte H2-Exhalation als Korrelat der zunehmenden Kohlenhydratmalabsorption. Der H2-Atemtest erweist sich als einfache, nicht invasive Methode zur Abschätzung der Kohlenhydratmalabsorption unter enteraler Ernährung und läβt die Entwicklung von Diarrhöen rechtzeitig erkennen.

Growing evidence suggests that sex differences in cocaine reward responses are regulated by endogenous gonadal hormones. However, few studies have addressed the role of testosterone on cocaine reward and psychomotor activation. This study aimed to determine whether testosterone influences the development of psychomotor and reward responses to cocaine. Castrated 8-week-old male Fisher rats received placebo or testosterone via Silastic capsules (1-3 capsules of 100% testosterone) or subcutaneous injections (400, 800, or 1200 microg/kg) concurrent with cocaine administration. Although chronic testosterone administration did not alter cocaine-induced conditioned place preference (CPP), concurrent administration of testosterone and cocaine affected the development of cocaine CPP dose-dependently; 400 microg/kg blocked the expression of cocaine-induced CPP. Testosterone did not affect cocaine-induced locomotor activity. Furthermore, testosterone-saline-treated controls did not develop CPP, suggesting that at these doses, testosterone does not produce rewarding or motor responses. These data suggest that testosterone may play a limited role in cocaine-induced reward associations and locomotor responses and thus has a limited effect in the previously reported sexually dimorphic responses to cocaine.

In order to detect the effects of proximal gastric vagotomy on the gastrointestinal transit time during the early and late postoperative periods, a mixed solid-liquid test meal containing 0.5 mCi

Objective: To prove safety and effectiveness of a lipid emulsion enriched with n-3 fatty acids from fish oil (Lipoplus) within the setting of parenteral nutrition of patients after major abdominal surgery and to determine whether there are effects on outcome parameters. Design: Prospective, randomized, double-blind, multicenter trial. Setting: University and surgical teaching hospitals. Patients: After obtaining informed consent, 256 patients undergoing major abdominal surgery were randomized. Parameters of safety, effectiveness, and outcome were routine laboratory parameters, complication rates, length of stay in the intensive care unit, and length of hospital stay. In addition we determined in patient subgroups of 30 patients each, the changes of the content of selected long-chain polyunsaturated fatty acids, the leukotriene synthetic capacity and the antioxidant -tocopherol. Interventions: Participating patients were randomized to receive either Lipoplus (group I; n 127 patients) or Intralipid (group II; n 129 patients). Parenteral nutrition was initiated immediately after surgery and ended on day 5 after surgery. Measurements and Main Results: No significant differences between groups I and II were observed when comparing routine laboratory parameters during the perioperative period. Plasma levels of eicosapentaenoic acid, leukotriene B5, and antioxidant content were significantly increased in group I. Furthermore, there was a significantly shorter length of hospital stay of 21% (17.2 vs. 21.9 days; p .0061) in group I. Conclusions: Our findings indicate that the administration of Lipoplus in the postoperative period after major abdominal surgery is safe and results in a significantly shorter length of hospital stay. Administration of n-3 polyunsaturated fatty acids in the postoperative period can be considered a valuable choice for patients requiring parenteral nutrition after major abdominal surgery. (Crit Care Med 2007; 35:700‐706)