Die Rolle des Junktionalen Adhäsionsmoleküls 1 während der posttraumatischen Schrankenstörung

Das Polytrauma stellt eine häufige Todesursache bei Erwachsenen dar. Posttraumatisch kann eine starke, systemische Entzündungsreaktion mit Komplementaktivierung zu weiteren Schäden im Körper führen. Hierbei hat die Schrankenstörung einen großen Beitrag zum Multiorganversagen. Mit HBMEC-60-Endothelzellen konnte ein Modell für eine Schranke nachgebildet werden. Nach Exposition mit den Komplementspaltprodukten C5a änderte sich die parazelluläre Permeabilität. Die Menge an Junktionalem Adhäsionsmolekül 1 (JAM-1) in der Zelle änderte sich hierunter nicht. In einem Polytraumamausmodell konnte JAM-1 besonders im Lungengewebe 2 h nach Trauma reduziert detektiert werden. Im Plasma fand sich dagegen JAM-1, das bei Trauma nach 2 h stark erhöht war. Die Höhe der JAM-1-Konzentration korrelierte dabei mit dem Ausmaß der Schrankenstörung in der Lunge. Im Falle eines zusätzlichen hämorrhagischen Schocks im Polytraumamodell der Maus wurde JAM-1 im Plasma nachgewiesen. Im Großtierpolytraumamodell an der Universitätklinik Aachen konnten insgesamt erhöhte JAM-1-Konzentrationen gefunden werden, jedoch keine signifikanten Differenzen zwischen den unverletzten Tieren und den Tieren mit Polytrauma. In einer an der Universitätsklinik Ulm durchgeführten prospektiven Observationsstudie mit Einschluss von n = 8 Polytraumapatienten mit einem Injury Severity Score (ISS) von 29 ± 1,5 (SEM) konnte erstmalig im Plasma der Patienten signifikant erhöhte zeitabhängie JAM-1Konzentrationen nachgewiesen werden. Die Freisetzung von JAM-1 ins Plasma korrelierte mit der Kreatinin-, Laktat- und CRP-Konzentrazion als mögliche Zeichen eines posttraumatischen Nierenversagens, Gewebehyposie und systemischen Entzündung. Zusätzlich korrelierten die JAM-1-Konzentrationen teilweise mit der Gesamtein- und ausfuhr an Flüssigkeiten. Signifikante Korrelationen ergaben sich mit klinischen Scores, besonders dem APACHE-II-Score für den Erkrankungsschweregrad, und dem SOFAScore für das Auftreten eines Multiorganversagens. Zusammenfassend kann der Nachweis von JAM-1 im Serum und Plasma von Traumapatienten als möglicher Marker zur Überwachung von Patienten bezüglich der Entwicklung einer Schrankenstörung und dem assoziierten Multiorganversagen verwendet werden. Wissenschaftliche Studien mit höheren Fallzahlen müssen die Reliabilität dieses neuen Markers einschätzen

Impact of Resection Volume/Stapler Firings-Ratio on Perioperative Complications and Weight Loss After Laparoscopic Sleeve Gastrectomy

Background!#!Major postoperative morbidity after laparoscopic sleeve gastrectomy (LSG) is often related to staple line leaks (SLL). Of note, a recent study suggested a central role of the absolute numbers of stapler firings as a predictive factor for postoperative morbidity due to SLL. In addition, a larger gastric remnant volume could be responsible for lower weight loss after LSG, and nevertheless, the gastric resection volume (GRV) is strictly related to the residual volume.!##!Methods!#!Prospectively, collected data of 384 consecutive patients with complete follow-up at 12 months after LSG at our institution were retrospectively analyzed. Patients were stratified according to three different variables (i.e., number of stapler firings, GRV, and GRV/stapler firings-ratio), and respective impact on postoperative complications and weight loss was analyzed.!##!Results!#!High absolute number of stapler firings was linked to increased intraoperative and postoperative bleeding and prolonged hospitalization, but was not associated with SLL, transfusion rate or revisional procedures. Absolute GRV showed no impact on both complications and outcome after LSG. Interestingly, higher ratio of GRV/stapler firings was not only linked to decreased intraoperative bleeding and shorter hospital stay but also to higher Excess Body Mass Index Loss (EBMIL) at 12 months after LSG.!##!Conclusions!#!Here, we introduce GRV/stapler firings-ratio as a simple predictive factor for identifying patients at risk for postoperative complications and impaired weight loss that is superior compared with absolute number of stapler firings or GRV alone

Role of Rendezvous-Procedure in the Treatment of Complications after Laparoscopic Sleeve Gastrectomy

Introduction: Laparoscopic sleeve gastrectomy is one of the most commonly performed bariatric procedures worldwide with good results, high patient acceptance, and low complication rates. The most relevant perioperative complication is the staple line leak. For the treatment of this complication, endoscopic negative pressure therapy has proven particularly effective. The correct time to start endoscopic negative pressure therapy has not been the subject of studies to date. Methods: Twelve patients were included in this retrospective data analysis over three years. Endoscopic negative pressure therapy was carried out using innovative open pore suction devices. Patients were treated with simultaneous surgery and endoscopy, so called rendezvous-procedure (Group A) or solely endoscopically, or in sequence surgically and endoscopically (Group B). Therapy data of the procedures and outcome measures, including duration of therapy, therapy success, and change of treatment strategy, were collected and analysed. Results: In each group, six patients were treated (mean age 52.96 years, 4 males, 8 females). Poor initial clinical situation, time span of endoscopic negative pressure therapy (Group A 31 days vs. Group B 18 days), and mean length of hospital stay (Group A 39.5 days vs. Group B 20.17 days) were higher in patients with rendezvous procedures. One patient in Group B died during the observation time. Discussion: Rendezvous procedures for patients with staple line leaks after sleeve gastrectomy is indicated for serious ill patients with perigastric abscesses and in need of laparoscopic lavage. The one-stage complication management with the rendezvous procedure seems not to result in an obvious advantage in the further outcome in patients with staple line leaks after laparoscopic sleeve gastrectomy

Endoscopic Negative Pressure Therapy (ENPT) Is Superior to Stent Therapy for Staple Line Leak After Sleeve Gastrectomy: a Single-Center Cohort Study

Purpose!#!Staple line leak (SLL) is a serious complication after sleeve gastrectomy (SG). Common endoscopic treatment options include self-expandable metallic stent (SEMS), endoscopic internal drainage (EID), and endoscopic closure. The endoscopic negative pressure therapy (ENPT) is a promising treatment option combining temporary sealing of the defect with drainage of the inflammatory bed. In this study, we compare the outcome of ENPT and SEMS for the treatment of SLL following SG.!##!Materials and methods!#!A retrospective cohort of 27 patients (21 females) treated at a single center for SLL after SG was included. ENPT was primary therapy for 14 patients and compared with 13 patients treated primarily using SEMS.!##!Results!#!ENPT was associated with a significant reduction of hospital stay (19 ± 15.1 vs. 56.69 ± 47.21 days, p = 0.027), reduced duration of endoscopic treatment (9.8 ± 8.6 vs. 44.92 ± 60.98 days, p = 0.009), and shorter transabdominal drain dwell time (15 (5-96) vs. 45 (12-162) days, p = 0.014) when compared to SEMS. Whereas endoscopic management was successful in 12/14 (85.7%) of patients from the ENPT group, SEMS was successful in only 5/13 (38.5%) of patients (p = 0.015). Furthermore, ENPT was associated with a significant reduction of endoscopic adverse events compared with SEMS (14.3% vs. 76.92% p = 0.001).!##!Conclusion!#!Compared with SEMS, ENPT is effective and safe in treating SLL after SG providing higher success rates, shorter treatment duration, and lower adverse events rates

Complement C5a Alters the Membrane Potential of Neutrophils during Hemorrhagic Shock

Background. Polymorphonuclear granulocytes (PMN) play a crucial role in host defense. Physiologically, exposure of PMN to the complement activation product C5a results in a protective response against pathogens, whereas in the case of systemic inflammation, excessive C5a substantially impairs neutrophil functions. To further elucidate the inability of PMN to properly respond to C5a, this study investigates the role of the cellular membrane potential of PMN in response to C5a. Methods. Electrophysiological changes in cellular and mitochondrial membrane potential and intracellular pH of PMN from human healthy volunteers were determined by flow cytometry after exposure to C5a. Furthermore, PMN from male Bretoncelles-Meishan-Willebrand cross-bred pigs before and three hours after severe hemorrhagic shock were analyzed for their electrophysiological response. Results. PMN showed a significant dose- and time-dependent depolarization in response to C5a with a strong response after one minute. The chemotactic peptide fMLP also evoked a significant shift in the membrane potential of PMN. Acidification of the cellular microenvironment significantly enhanced depolarization of PMN. In a clinically relevant model of porcine hemorrhagic shock, the C5a-induced changes in membrane potential of PMN were markedly diminished compared to healthy littermates. Overall, these membrane potential changes may contribute to PMN dysfunction in an inflammatory environment