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An uncommon occurrence in which Graves disease (GD) coincides with autonomous functioning thyroid nodules (AFTNs) is termed Marine-Lehnhart syndrome (MLS). While hyperfunctioning nodules in MLS are commonly benign, there exists a rare potential for malignancy. A 41-year-old male patient was initially managed conservatively upon being diagnosed with MLS type 1. However, the emergence of obstructive symptoms prompted a thyroidectomy 4 years after initial presentation. Histological analysis revealed 2 cervical lymph node metastases and papillary thyroid cancer (PTC) within the AFTN., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Endocrine Society.)

Background: Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals., Methods: Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay., Results: Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ., Conclusion: Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

A 23-year-old man and his grandmother with hyperthyroxinemia and hypercortisolemia were heterozygous for an ALB mutation (p. Arg218Pro), known to cause familial dysalbuminemic hyperthyroxinemia (FDH). However, serum-free cortisol levels in these individuals were normal and total cortisol concentrations fell markedly after depletion of albumin from their serum. We conclude that binding of steroid as well as iodothyronines to mutant albumin causes raised circulating cortisol as well as thyroid hormones in euthyroid euadrenal individuals with R218P FDH, with potential for misdiagnosis, unnecessary investigation, and inappropriate treatment.

Technological Innovations in Diabetes Therapy Abstract. In the last few years a whole array of technical innovations has dramatically increased treatment options for patients with diabetes mellitus. Capillary blood glucose measurements are increasingly replaced by continuous glucose monitoring. More and more insulin pump systems are linked up to continuous glucose monitoring, which thereby become ever more self-regulating. Novel ultra-long and ultra-short acting insulins have become available. There will soon be oral alternatives for several anti-diabetic treatments, which hitherto needed to be injected.

Aims: The technique of open complete mesocolic excision (CME) has improved the outcomes of patients with colon carcinoma. Meanwhile it has become an established international standard procedure. It remains unclear if laparoscopic procedures are able to match the high quality of open resections. A video comparison of the two methods gives insight into the different dissection techniques., Indication: Open CME is demonstrated in a 79-year-old female patient with an asymptomatic carcinoma of the ascending colon verified by histopathology. The tumour was diagnosed during routine colonoscopy. No distant metastases were identified during the staging procedure. Laparoscopic CME is performed in a 72-year-old female patient with a biopsy-proven carcinoma of the ascending colon. Similarly this patient was diagnosed during a screening colonoscopy and had no distant metastasis., Methods: During open CME the ascending colon and the duodenum are mobilised by sharp dissection between the parietal and visceral layer of the mesentery. Afterwards the ascending and transverse mesocolon are dissected from the duodenum and pancreas. The parietal and the visceral mesentery are strictly preserved during these procedures. After the exposure of the superior mesenteric artery and vein, a central dissection of the vessels follows. The colon is cut 10 cm distal to the carcinoma. An ileotransversostomy is performed with a running suture. The hole in the mesentery is closed. The laparoscopic CME is performed using the 4-trocar technique with an umbilical camera position following a medial to lateral approach with primary dissection of the superior mesenteric vein. Radicular vessel ligation opens the space dorsal to the mesocolon with the border lamella remaining intact. The space is widened until the ascending colon is entirely mobilised. The mobilised colon is eventrated through an enlarged umbilical midline incision. Colon resection and the subsequent two-layered side-to-side ileotransversostomy are performed in a standard open surgical fashion., Conclusion: Open and laparoscopic CME enable central vessel dissection while preserving the mesenteric layers. However, the laparoscopic procedure is technically demanding and should therefore only be performed by surgeons experienced in laparoscopy., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Surgical treatment of incisional hernia includes implantation of a mesh. The use of synthetic grafts in contaminated fields results in an increased risk of infection. In these cases a potential advantage is described for biological repair material. Evidence for this problem is lacking; therefore, we initiated a survey among surgeons in Germany concerning this question., Material and Method: A survey concerning indications, experience and techniques of using synthetic and biological meshes was sent to 60 surgical departments. The emphasis of the survey was on the differentiation of clean and contaminated fields., Results: The survey was answered by 42 %. The use of biological repair material was preferred in clean-contaminated, contaminated and soiled fields. Synthetic meshes were preferred in clean, rarely in clean-contaminated and not in contaminated or soiled situations. Primary suture repair was chosen in clean fields and barely in contaminated fields. For closure of giant hernias a component separation technique (CST) was favored by the majority of respondents. A single stage repair was preferred by most of the surgeons even in cases with simultaneous stoma takedown. A total of 72 % of the respondents were satisfied with the use of biological repair material, but the reimbursement was considered to be inappropriate., Discussion: Although the response rate was low, this survey gives an idea of the attitude towards the use of synthetic and biological meshes. Biological repair material is favored for hernia repair in contaminated or soiled fields. The advantage of this choice is a one stage repair despite the contamination. As the results of this survey are not able to provide arguments for the use of different meshes this question should be further investigated with a randomized controlled trial.

Purpose: Wound infections affect not only the individual patient but lead to an increase in medical costs. After ileostomy reversal, surgical site infections are a common problem. The objective of the study was to compare the infection rates of purse-string and conventional skin closure techniques in a high volume setting., Methods: Patients undergoing ileostomy reversal at the Goethe University Hospital between January 2009 and August 2012 were retrospectively analysed regarding surgical site infections and associated risk factors. Patients received either conventional skin closure (running, interrupted or stapled suturing; group C) or subcuticular purse-string suture (group PS)., Results: In total, 114 patients have been analysed. Conventional wound closure was performed in 81 patients and 33 patients received purse-string skin closure. The groups did not differ regarding age, gender, indication for ileostomy, previous chemotherapy, and operation time. Median hospital stay was 7 days (3-34) in group PS and 8 (3-53) in group C (p = 0.15). Wound infections only occurred in groups C (n = 10, 12 %) compared to group PS (n = 0; 0 %; p = 0.034), and the wound closure technique was the only significant factor associated with surgical site infection. Surgery performed by a resident under supervision was not a risk factor for complications compared to the procedure done by a senior surgeon (p = 0.73)., Conclusion: This study reveals an advantage of the purse-string skin closure technique in ileostomy reversals analysing a large cohort of patients. Therefore, we recommend the use of the purse-string skin closure in ileostomy reversals as one way to lower wound infection rates.

Background: Regions of decreasing medical supply with long distances to pharmacy or practice require a good collaboration between practitioners and pharmacists., Objective: To determine and compare the attitudes of community pharmacists and practitioners towards each other regarding collaboration. Setting Mecklenburg-Western Pomerania in Germany., Method: 749 general practitioners and practitioners specialized in diabetes care as well as 344 community pharmacists received a 38-item survey regarding their interrelations and attitudes towards each other., Main Outcome Measure: Descriptive statistics of the practitioners' attitudes towards pharmacists in comparison to the pharmacists' attitudes towards practitioners in terms of perception of their role, reliability, functions, frequency and helpfulness of contact, cooperation in promoting medication adherence and quality of communication., Results: Response rates were 19.4 % (n = 145) for practitioners and 24.4 % (n = 84) for pharmacists. 144 (76.6 %) of practitioners and 79 (71.5 %) of pharmacists strongly trusted the other health care providers' statements and expertise (p = 0.0076). Practitioner-pharmacist interactions on average were of low frequency. They were, however, perceived to be helpful. The majority of pharmacists (62.7 %) regard their responsibility to ensure adherence with long-term medication to be equal to that of general practitioners. In contrast, the vast majority of practitioners (90.1 %) estimated their proportion of responsibility for adherence to long-term medication to be 75 % or more. At the same time, practitioners perceived the pharmacists' current influence on patient adherence to long-term medication as generally positive (65.0 %). This is in line with the pharmacists' self-perception (94.7 %)., Conclusion: The general trust of both health care providers towards each other is a good pre-condition for further collaborations. However, increased frequency in practitioner-pharmacist-interactions is necessary. Additionally, the role perceptions of pharmacists and practitioners should be harmonised as there are still misunderstandings in the responsibilities of both parties.

Background: The over-the-scope clip (OTSC) system was first used to close the access route in natural orifice transluminal endoscopic surgery and is increasingly used for other indications., Objective: We analyzed the use of the OTSC in intestinal bleeding and in closure of GI tract leaks., Design: Analysis of a consecutive series of patients., Setting: University hospital., Patients: Nineteen patients (group A: closure of GI leak site, n = 12; group B: complex GI bleeding, n = 7) were retrospectively enrolled in this study. We analyzed outcome and follow-up (6-68 weeks; group A: mean 37 weeks, standard deviation 24) in terms of treatment success (closure of the GI tract leak/durable hemostasis)., Intervention: Endoscopic application of OTSCs., Main Outcome Measurements: Resolution of leaks, closure of fistula (group A), or stopping bleeding (group B)., Results: In group A, durable closure was achieved in 8 of 12 patients. Sealing a postoperative/postinterventional leak was successful in 6 patients and failed in 3. A gastrocutaneous fistula was primarily closed successfully in 2 patients, but recurred in 1 of these patients. A gastric wall dehiscence in necrotizing pancreatitis was successfully closed in another patient. Group B patients had previous endoscopic treatment failure in 4 of 7 patients (through-the-scope clips, injection of Suprarenin or fibrin glue, others) and were deemed not treatable by through-the-scope clips in 3 of 7 patients. The primary success rate was 100% (7 of 7 patients); durable hemostasis was achieved in 4 of 7 patients, whereas surgery or angiography was necessary in the remaining patients., Limitations: Retrospective analysis., Conclusions: Leaks and fistulae are reliably closed with OTSCs in tissue flexible enough to be sucked into the attached cap (eg, in lesions caused <1 week before). GI bleeding may be stopped by OTSCs with reliable transient hemostasis, but durable hemostasis is less frequent., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Today, mesh repair is the preferred technique in surgery of inguinal hernia. Whether the mesh should be placed laparoscopically or by open techniques is still controversial., Methods: A comparison of open mesh and laparoscopic techniques was made with the help of meta-analyses and prospective trials. Outcome variables analysed were recurrence, chronic pain, recovery, morbidity and costs., Results: With regard to recurrence rates, both techniques gave comparable results. The laparoscopic technique shows advantages in terms of morbidity, recovery and especially a lower rate of chronic pain. Open mesh repair has the advantage of a lower risk of some rare severe intra-abdominal complications and seems to be more cost-effective., Conclusion: Both techniques of inguinal hernia repair are effective and safe. Each technique has its advantages and disadvantages. Therefore, today no single technique can be recommended as a gold standard.

Objective: To illustrate the influence of pregnancy on primary umbilical endometriosis., Design: Case report., Setting: Gynecologic endocrinology outpatient department of a university hospital., Patient(s): 27-year-old nulliparous woman., Intervention(s): Surgical treatment with total excision of the umbilicus during early pregnancy., Main Outcome Measure(s): Progressive enlargement of endometriotic umbilical lesions during pregnancy., Result(s): At 3-month follow-up evaluation, there were no signs of recurrence of the disease., Conclusion(s): Spontaneous umbilicus endometriosis is a rare disease that can worsen during pregnancy.

Isolated human hepatocytes are of great value in investigating cell transplantation, liver physiology, pathology, and drug metabolism. Though hepatocytes possess a tremendous proliferative capacity in vivo, their ability to grow in culture is severely limited. We postulated that repeated medium change, common to most in vitro systems, may prevent long-term maintenance of hepato-specific functions and growth capacity. To verify our hypotheses we compared the DNA synthesis and differentiation status of isolated human hepatocytes, cultured in medium which was renewed every day or was not changed for 3 weeks ('autocrine' setting). Daily medium change led to rapid hepatocellular de-differentiation without any signs of DNA replication. In contrast, the autocrine setting allowed hepatocytes to become highly differentiated, demonstrated by an elevated ASGPr expression level, and increased albumin and fibrinogen synthesis and release. Cytokeratin 18 filaments were stably expressed, whereas cytokeratin 19 remained undetectable. Hepatocytes growing in an autocrine fashion were activated in the presence of hepatocyte growth factor (HGF), evidenced by c-Met phosphorylation. However, HGF response was not achieved when the culture medium was renewed daily. Furthermore, the autocrine setting evoked a late but strong interleukin 6 release into the culture supernatant, reaching maximum values after a 10-day cultivation period, and intense BrdU incorporation after a further 5-day period. Our data suggest that preservation of the same medium creates environmental conditions which allow hepatocytes to control their differentiation status and DNA synthesis in an autocrine fashion. Further studies are necessary to identify the key mediators involved in autocrine communication and to design the optimal culture configuration for clinical application.

A 22-year-old woman was treated for a hepatic lesion with a high suspicion of a liver adenoma at another hospital. The patient presented with unspecific abdominal pain. Further physical examination was unremarkable. A biopsy of the liver lesion revealed hepatic adenoma. Because of the increasing tumour size over a one-year period the patient was referred to our department for surgical therapy. On MRI scan, the liver mass measured 10 x 9 x 9 cm in the right liver lobe with contact to the right hilum. Because of the histological signs of adenoma a right hepatic lobectomy was performed. Postoperative follow-up was uneventful. The pathological diagnosis of hepatic angiomyolipoma was obtained. Angiomyolipoma of the liver is a rare benign mesenchymal tumour often mimicking other hepatic lesions. Histological features are thick-walled blood vessels, mature fat and smooth muscle in various proportions. The biological behaviour of the tumour is benign, although distant metastases are occasionally possible. Due to the potential for malignant transformation, tumour resection should be performed.

Surgery inevitably leads to bleeding, and hemostasis aims at reducing the amount of blood loss and the need for transfusion as well as preventing rebleeding, hematoma formation, and the need for repeat surgery. Various locally applicable agents are in use including bone wax, gelatin, collagen, oxidized regenerated cellulose, fibrin sealant glues, and synthetic glues. Some evidence from randomized controlled trials (RCT) exists regarding the use of fibrin sealants on their own or combined with collagen fleece. Systemic hemostasis may be achieved with lysine analogs such as epsilon-aminocaproic acid or tranexamic acid and aprotinin, which are inhibitors of fibrinolysis. There is much albeit sometimes conflicting evidence from RCT regarding the use of these substances in surgery. The role of recombinant activated factor VII in achieving systemic hemostasis is being investigated.

Flavonoids are naturally occurring plant compounds with established in vitro antioxidant properties and potential cardioprotective effects. We carried out a 12-week pilot study on the effects of dietary supplementation with an extract of bioflavonoids prepared from the bark of Pinus radiata trees [Enzogenol] containing added vitamin C. Data was collected from 24 healthy subjects aged between 55-75 years at baseline and at 6 and 12 weeks and included, routine biochemical and haematological indices, and anthropometric, blood pressure, forearm blood flow and haemorheological measurements. Enzogenol supplementation at a dosage of 480 mg/day of pine bark extract and 240 mg/day vitamin C did not result in changes in any biochemical or haematological indice and was associated with a significant reduction in the means of body weight, percentage body fat, systolic blood pressure and plasma viscosity. Basal and hyperaemic blood fl ow in forearm resistance vessels measured by plethysmography increased significantly during the study. The findings of this pilot study indicate that dietary supplementation with Enzogenol is safe and well tolerated and is associated with a number of beneficial effects on a range of established cardiovascular risk factors. These changes need to be validated by a placebo-controlled study but are consistent with other studies that have reported beneficial clinical effects following supplementation with bioflavonoids., (Copyright 2003 John Wiley & Sons, Ltd.)

Background: Patients with Wilson's disease may present with cirrhosis, acute hepatitis or fulminant hepatic failure. Without urgent orthotopic liver transplantation, a fulminant Wilson crisis has a mortality of 100%. We report on an 18-year-old female patient with fulminant hepatic failure due to Wilson crisis., Methods: The molecular adsorbent recirculating system (MARS) was used to eliminate albumin-bound toxins and to bridge waiting until an organ became available., Results: A total of 18 MARS sessions and 4 plasma exchange sessions were performed. Bilirubin levels and hepatic encephalopathy improved under MARS therapy. A total of 75 mg copper was removed until serum copper levels were within the normal range. Copper elimination was measured in 15 MARS treatments, which removed a total of 12.9 mg copper. Four plasma exchange sessions, with a total exchange of 11 liters of plasma, removed 12 mg copper. Urinary copper elimination with penicillamine was 50 mg., Conclusion: MARS was an effective method to stabilize a patient with Wilson crisis, contributed to copper elimination and gained time for liver transplantation. The risk of high-urgency transplantation could be avoided. Liver support was easy in the hands of nephrologists familiar with extracorporeal therapy., (Copyright 2003 S. Karger AG, Basel)