Biomedical subjects

Carsten N Gutt

Publications and source records attributed to Carsten N Gutt.

12 recordsLinked to original sources

PubMed2006

Preoperative bowel preparation: surgical standard or past?

BACKGROUND: Preoperative bowel preparation is still routinely used prior to colorectal surgery. This concept is based on traditional and personal empiricism and usually not evidence based. The objective of the present review was to reassess this dogma against the background of the highest level of evidence published thus far. METHODS: The Medline database was searched using the search terms 'preoperative', 'bowel' and 'preparation' limited to 'randomized controlled trials' and 'meta-analyses'. Ten randomised controlled trials and seven meta-analyses comparing orthograde bowel cleansing to no preoperative bowel preparation were considered for rates of anastomotic leakages, surgical infections and other types of complications, reoperations and mortality. RESULTS: All the most recent meta-analyses showed a significant increase of anastomotic dehiscences in patients with preoperative orthograde bowel cleansing. Additionally, a trend towards higher rates of surgical infectious complications and re-operations was revealed. Mortality remained unchanged by preoperative orthograde bowel cleansing. CONCLUSION: Routine preoperative orthograde bowel cleansing is no longer justified prior to colorectal surgery in general due to increased risk of anastomotic leakages. Further investigations should focus on different types of bowel preparation in situations where preoperative bowel preparation still may have a role such as total mesorectal resection with low anastomosis and protective ileostomy.

Cathartics↗

PubMed2006

Totally laparoscopic versus conventional ileoanal pouch procedure--design of a single-centre, expertise based randomised controlled trial to compare the laparoscopic and conventional surgical approach in patients undergoing primary elective restorative proctocolectomy--LapConPouch-Trial.

BACKGROUND: Restorative proctocolectomy is increasingly being performed minimal invasively but a totally laparoscopic technique has not yet been compared to the standard open technique in a randomized study. METHODS/DESIGN: This is a two armed, single centre, expertise based, preoperatively randomized, patient blinded study. It is designed as a two-group parallel superiority study. Power calculation revealed 80 patients per group in order to recruit the 65 patients to be analysed for the primary endpoint. The primary objective is to investigate intra-operative blood loss and the need for blood transfusions. We hypothesise that intra-operative blood loss and the need for peri-operative blood transfusions are significantly higher in the conventional group. Additionally a set of surgical and non-surgical parameters related to the operation will be analysed as secondary objectives. These will include operative time, complications, postoperative pain, lung function, postoperative length of hospital stay, a cosmetic score and pre-and postoperative quality of life. DISCUSSION: The trial will answer the question whether there is indeed an advantage in the laparoscopic group in regard to blood loss and the need for blood transfusions. Moreover, it will generate data on the safety and potential advantages and disadvantages of the minimally invasive approach.

Adenomatous Polyposis Coli↗

PubMed2006

Surgical palliation in patients with pancreatic cancer.

BACKGROUND: The aim of palliative strategies in patients with pancreatic cancer is the relief of tumor-associated symptoms such as biliary and duodenal obstruction and tumor growth. Due to high mortality and morbidity rates of surgery, treatment of patients with advanced pancreatic cancer is mainly in the hand of gastroenterologists. RATIONALE: In recent years, surgery of pancreatic cancer in specialized centres developed strongly, which makes it a viable option even in the treatment of advanced disease. CONCLUSION: We advocate for an aggressive strategy in the treatment of pancreatic cancer with surgical exploration and tumor resection whenever possible.

Abdominal Pain↗

PubMed2006

Management of early hemorrhage from pancreatic anastomoses after pancreaticoduodenectomy.

BACKGROUND: Pancreatic surgery remains a challenge with considerable morbidity rates. The leading cause of emergency reexploration is early postoperative hemorrhage due to technical failure of hemostasis. Failure of hemostasis is usually tackled without difficulty, except when the bleeding arises from pancreatic anastomosis, since it poses a unique surgical challenge of preserving its integrity and also controlling the hemorrhage. The practical aspects and outcomes of management of this complication are unclear, with limited data. METHODS: Data from 458 patients undergoing pancreaticoduodenectomy were analyzed. Early hemorrhage emanating from pancreatic anastomoses resulting in a relaparotomy was identified. RESULTS: Eight patients (1.7%) had pancreatic anastomotic bleeding. The initial 2 patients underwent completion pancreatectomy, and the latter 6 patients underwent enterotomy with control of bleeding without disturbing the pancreatic anastomosis. The median interval between primary surgery and relaparotomy was 30.5 h, with a median overall hospital stay of 26.5 days; the 90-day mortality was zero. Based on these results, a step-by-step illustrated approach is described. CONCLUSIONS: This uncommon complication of early hemorrhage from pancreaticojejunostomy after pancreaticoduodenectomy can be successfully managed by an enterotomy without endangering the pancreatic anastomosis. By this approach, a completion pancreatectomy may be prevented and the integrity of the anastomosis preserved.

Adult↗

PubMed2006

Robotic-assisted transhiatal esophagectomy.

BACKGROUND: Despite its reduced aggressiveness and excellent results obtained in certain diseases, minimally invasive surgery did not manage to significantly lower the risks of esophageal resections. Further advances in technology led to the creation of robotic systems with their unique maneuverability of the instruments and exceptional view on the operative field, thus setting the prerequisites for performance in complex surgical procedures and offering new possibilities to a disease notorious for its dismal prognosis. MATERIALS AND METHODS: The robotic-assisted transhiatal esophagectomy technique was used in a patient with squamous cell carcinoma of the lower esophagus that had high medical risk for surgical therapy. RESULTS: Esophageal resection and reconstruction were possible through a robotic-assisted minimally invasive transhiatal approach. There were no intraoperative incidents, blood loss was minimal, and lymph node dissection and removal was possible during the procedure. Early ambulation and conservative treatment of the mild complications that occurred offered a favorable postoperative outcome. CONCLUSION: The robotic-assisted transhiatal esophagectomy technique is feasible and safe. Complex procedures become less technically demanding with the help of the robotic system and, thus, the minimally invasive approach can be offered for the benefit of selected patients. Further studies are required to confirm these observations and to establish the role of this procedure in the future.

Aged↗

PubMed2005

Negative impact of systemic catecholamine administration on hepatic blood perfusion after porcine liver transplantation.

Catecholamines are often administered during and after liver transplantation (LTx) to support systemic perfusion and to increase organ oxygen supply. Some vasoactive agents can compromise visceral organ perfusion. We followed the hypothesis that the vasculature of transplanted livers presents with a higher sensitivity, which leads to an increased vulnerability for flow derangement after application of epinephrine (Epi) or norepinephrine (NorEpi). Hepatic macroperfusion and microperfusion during systemic Epi or NorEpi infusion were measured by Doppler flow and thermodiffusion probes in porcine native, denervated, and transplanted livers (n = 16 in each group). Epi or NorEpi were infused (n = 8 in each subgroup) in predefined dosages (low dose = 5 microg/kg/minute and high dose = 10 microg/kg/minute) over 240 minutes. Systemic cardiocirculatory parameters were monitored continuously. Hepatic perfusion data were compared between all groups at comparable time points and dosages. In all native, denervated, and transplanted liver groups, Epi and NorEpi induced an inconsistent rise of mean arterial pressure and heart rate shortly after onset of infusion in both dosages compared with baseline. No significant differences of cardiovascular parameters at comparable time points were observed. In native livers, Epi and NorEpi induced only temporary alterations of hepatic macrocirculation and microcirculation, which returned to baseline 2 hours after onset of infusion. No significant alterations of hepatic blood flow were detected after isolated surgical denervation of the liver. By contrast, transplanted livers showed a progressive decline of hepatic macrocirculation (33-75% reduction) and microcirculation (39-58% reduction) during catecholamine infusions in a dose-dependent fashion. Characteristics of liver blood flow impairment were comparable for both vasoactive agents. In conclusion, pronounced disturbances of hepatic macrocirculation and microcirculation were observed during systemic Epi and NorEpi infusion after LTx compared with native and denervated livers. Microcirculation disturbances after LTx might be explained by impairment of hepatic blood flow regulation caused by an increased sensitivity of hepatic vasculature after ischemia-reperfusion and by lengthening of vasopressor effects caused by reduced hepatocyte metabolism. Clinicians should be aware of this potentially hazardous effect. Therefore, application of catecholamines after clinical LTx should be indicated carefully.

Animals↗

PubMed2005

Taurine improves graft survival after experimental liver transplantation.

Relevant mechanisms of reperfusion injury after liver transplantation are most likely mediated by activated Kupffer cells. Recently, it has been demonstrated that taurine prevents Kupffer cell-activation in vitro. Thus, this study was designed to assess the effects of taurine after liver transplantation. Female Sprague-Dawley rats (210-240 g) were infused with taurine dissolved in normal saline, before organ harvest. Controls were infused with the same volume of normal saline without taurine. Following 4 hours of cold ischemia, liver transplantation was performed. Graft and animal survival, serum transaminases, liver histology, perfusion data of intravital microscopy, blood distribution at reperfusion, and both phagocytosis of Kupffer cells and expression of tumor necrosis factor alpha (TNF-alpha) to index cellular activation were investigated. For comparison, both, analysis of variance (ANOVA) and Fisher's exact test were used as appropriate. Results are presented as mean +/- SEM. Controls survived in 60% of cases. Taurine improved survival in a dose-dependent manner to 100% (P < 0.05). In controls, mean aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactic dehydrogenase (LDH) serum levels increased to 3,260 +/- 814; 1,703 +/- 432; and 14,071 +/- 3,177 U/L, respectively, after transplantation. In contrast, these values were between 20 and 45% of control values after taurine (P < 0.05). Histology taken after transplantation confirmed the significant protective effects of taurine, including the reduction of TNF-alpha expression. Time until homogeneous reperfusion of the graft improved to 50% of control values (P < 0.05). Further, taurine significantly decreased both phagocytosis of latex beads by Kupffer cells and leukocyte-endothelial cell interaction. In parallel, flow velocity of red blood cells as well as acinar and sinusoidal perfusion improved (P < 0.05). In conclusion, these data show for the first time in vivo that taurine minimizes reperfusion injury after liver transplantation. Decreased leukocyte-endothelial cell interaction and improved microcirculation are the proposed mechanisms, which are most likely Kupffer cell-dependent.

Animals↗

PubMed2005

Prophylaxis and treatment of deep vein thrombosis in general surgery.

BACKGROUND: Patients undergoing general surgery present an inherent risk of deep vein thrombosis (DVT). Evidence-based strategies for prevention and treatment of DVT should be continuously upgraded on the basis of good-quality recent trials. DATA SOURCES: Articles were identified using MEDLINE, EMBASE, and the Cochrane Library databases (January 1980 to July 2003). Randomized clinical trials and meta-analyses in which different prophylactic and treatment methods were compared for general surgery patients were selected. CONCLUSIONS: In general surgery, low-molecular weight heparins (LMWHs) are relied upon more and more for prophylaxis and initial anticoagulant treatment of DVT, because of their multiple advantages in efficacy, safety, and convenience in handling. For cost-effective reasons, full-dose vitamin K antagonists are still preferred as the standard long-term anticoagulation method, while LMWHs represent the exception. Long-term use of low-intensity warfarin should be considered a new standard of care for the management of venous thrombosis. Compared to LMWH, the new anticoagulant molecules fondaparinux and ximelagatran seem to have similar efficacy in the treatment of venous thromboembolism, but they have a 2-fold increased efficacy in its prophylaxis. Clinical implementation of these new anticoagulant molecules depends on their cost-effectiveness; however, they have the potential to become the treatment of choice in the next decade. Thrombolysis has an unacceptable risk of hemorrhagic complications when used in the treatment of postoperative DVT. Furthermore, there are no data to prove that thrombolysis reduces the incidence of postthrombotic syndrome (PTS), despite early and complete recanalization achieved by thrombolysis. Surgical thrombectomy is only meant to decompress the venous hypertension consecutive to massive thrombosis (phlegmasia cerulea dolens) and thus to avoid venous gangrene. Other mechanical percutaneous thrombectomy devices are under evaluation. In selected cases, a combination treatment consisting of locoregional thrombolysis of the crurofemoral venous axis and mechanical thrombectomy of the pelvic venous axis achieves high rates of complete desobliteration.

Anticoagulants↗

PubMed2004

Different impact of normo- and hypotensive brain death on renal macro- and microperfusion--an experimental evaluation in a porcine model.

BACKGROUND: Despite the growing use of kidneys from living donors, organs harvested from brain dead donors are the dominant graft types used in renal transplantation. It is accepted that brain death (BD) has a damaging effect on the renal allograft, with a lower graft survival. Amongst various causes, changes in renal microperfusion could be responsible. Renocortical microperfusion was assessed during BD using thermal diffusion in a porcine model. METHODS: Two types of BD were induced in two groups of pigs [hypotension (Hypo-BD): n = 11; normotension (Normo-BD): n = 10] and compared to controls (n = 5) over a period of 210 min. We analysed systemic parameters [heart rate (HR), mean arterial blood pressure (MAP)], aortic blood flow (ABF) and renal perfusion [renal artery blood flow (RABF) and renocortical blood flow (RCBF)]. RESULTS: Following the two distinct forms of BD induction, a stable normo- or hypotension was observed. Haemodynamic parameters were only slightly changed (control group: MAP, 62+/-2 mmHg; HR, 95+/-3/min; Normo-BD: MAP, 56+/-4 mmHg; HR, 104+/-8/min; Hypo-BD: MAP, 43+/-3 mmHg; HR, 112+/-7/min). Solely dependent on systemic haemodynamics, RABF and RCBF decreased in the Hypo-BD (RABF: 142+/-19 to 94+/-9 ml/100 g/min; RCBF: 80+/-4 to 52+/-2 ml/100 g/min), while in Normo-BD group RABF mildly changed (158+/-13 ml/100 g/min) and RCBF decreased slightly from 76+/-3 to 70+/-6 ml/100 g/min. As opposed to the Normo-BD group, animals with Hypo-BD showed a significant decrease in RABF (reduction of 34%) and RCBF (reduction of 35%) with a sharp drop of MAP (reduction of 25%), however ABF remained relatively constant. CONCLUSIONS: In this model, a reduction of renocortical microperfusion in brain dead pigs was only found during haemodynamic instability (hypotension) and could not be attributed to BD as such. Our findings would support intensive cardiocirculatory stabilization for potential BD donors in order to minimize kidney preservation damage.

Animals↗

PubMed2002

Impact of laparoscopic and conventional surgery on Kupffer cells, tumor-associated CD44 expression, and intrahepatic tumor spread.

BACKGROUND: The oncologic feasibility of laparoscopic surgery for the cure of colorectal cancer is under debate. The effect of laparoscopic colorectal cancer resection on hepatic tumor spread has not yet been clarified. HYPOTHESIS: Laparoscopic surgery affects cell-mediated immune response and hepatic tumor spread dependent on intraperitoneal insufflation. METHODS: Thirty WAG/Rij rats were randomized into 3 operative groups: carbon dioxide (CO( 2)) laparoscopy (n = 10), "gasless" laparoscopy (n = 10), and laparotomy (n = 10). To induce liver metastases, 50 000 CC531 colon carcinoma cells were injected into the portal vein during either laparoscopy or laparotomy. Twenty-eight days after injection, specimens were explanted, sectioned, and examined immunohistochemically for CC531 tumor cells (monoclonal antibody CC52), CD44v5, v6 (monoclonal antibody OX49), and Kupffer cells (monoclonal antibody HIS36). For quantification, a morphometric analysis system was applied. Data were analyzed using the Kruskal-Wallis, Dunn, and Holm tests. RESULTS: No statistically significant differences in hepatic tumor growth were found between CO(2) laparoscopy and laparotomy (P =.37). However, compared with CO(2) laparoscopy and laparotomy, a significant decrease in intrahepatic tumor growth was found after gasless laparoscopy (P =.02). Kupffer cells had significantly decreased after CO(2) laparoscopy and laparotomy compared with after gasless laparoscopy (P<.001 and P =.002, respectively). CD44v5, v6 expression was significantly increased after CO(2) laparoscopy and laparotomy compared with after gasless laparoscopy (P =.002 and P =.05, respectively). CONCLUSIONS: Hepatic resistance to tumor growth is best preserved by gasless laparoscopy as opposed to CO(2) laparoscopy or laparotomy. The amount of intra-abdominal pressure with circulatory changes rather than the used gas may explain this finding. On the other hand, conventional laparoscopy vs laparotomy did not preserve hepatic immune function.

Animals↗

PubMed2002

Training for advanced laparoscopic surgery.

OBJECTIVE: To evaluate the efficiency of training for advanced minimally-invasive surgery in rats. SETTING: Teaching hospital, Germany. SUBJECTS: 10 surgical residents with few laparoscopic training skills had two days laparoscopic microsurgical training using rats. INTERVENTIONS: Increasingly difficult procedures started using a rubber model, followed by 'open' and 'closed' rat models simulating laparoscopic conditions. MAIN OUTCOME MEASURES: The surgical skills of all participants were assessed before and after the laparoscopic training course by applying 5 defined tasks in a simulation trainer. As a control group, 8 surgical residents with the same amount of minimal-invasive training were tested after a 2-day interval. RESULTS: All participants of the laparoscopic training programme significantly improved their surgical skills for all 5 tasks (p < 0.05). In the control group only one of the 5 tasks was significantly improved after repetition. Participants of the complete training programme consistently improved their surgical skills significantly compared with the controls before and after repetition (p < 0.05). CONCLUSION: Surgical training in minimal-invasive techniques in the rat model is effective and reproducible especially to improve laparoscopic skills such as bimanual tissue handling, knot tying and microsurgical suturing.

Animals↗

PubMed2002

Vasoactive intestinal polypeptide and gastrin-releasing peptide attenuate hepatic microvasculatory disturbances following intestinal ischemia and reperfusion.

BACKGROUND/AIMS: In addition to the primarily affected small bowel, intestinal ischemia and reperfusion (IIR) also leads to a marked decrease in hepatic microcirculation. The aim was to determine the potentially protective effect of the vasoactive hormones vasoactive intestinal polypeptide (VIP) and gastrin-releasing peptide (GRP) on hepatic microcirculation following IIR. METHODS: Using a rat model, three animal groups were subjected to 40 min of intestinal ischemia, two of which were infused with either VIP or GRP (n = 12 each). Following reperfusion, hepatic intravital microscopy was performed. Portal venous perfusion, activities of serum glutamate pyruvate transaminase and alkaline phosphatase, mucosal injury in the small intestine and the expression of antioxidant enzymes glutathione peroxidase, copper-zinc-superoxide dismutase (Cu-Zn-SOD), glutathione reductase and catalase (CAT) in the liver were investigated. RESULTS: Infusion of either VIP or GRP improved hepatic microcirculation and bile flow when compared with the untreated IIR group. VIP and GRP increased portal venous blood flow during reperfusion. VIP reduced the extent of mucosal damage resulting from IIR. GRP caused a decrease in expression of CAT and Cu-Zn-SOD, whereas VIP simply reduced CAT expression. CONCLUSION: This study indicates that vasoactive hormones may attenuate intestinal and hepatic injuries and circulatory disturbances following IIR.

Animals↗