Complications in colorectal surgery: risk factors and preventive strategies

Backround: Open or laparoscopic colorectal surgery comprises of many different types of procedures for various diseases. Depending upon the operation and modifiable and non-modifiable risk factors the intra- and postoperative morbidity and mortality rate vary. In general, surgical complications can be divided into intraoperative and postoperative complications and usually occur while the patient is still in the hospital. Methods: A literature search (1980-2009) was carried out, using MEDLINE, PubMed and the Cochrane library. Results: This review provides an overview how to identify and minimize intra- and postoperative complications. The improvement of different treatment strategies and technical inventions in the recent decade has been enormous. This is mainly attributable to the increase in the laparoscopic approach, which is now well accepted for many procedures. Training of the surgeon, hospital volume and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise and cost effectiveness. In addition, standardization of perioperative care is essential to minimize postoperative complications. Conclusion: This review summarizes the main perioperative complications of colorectal surgery and influencable and non-influencable risk factors which are important to the general surgeon and the relevant specialist as well. In order to minimize or even avoid complications it is crucial to know these risk factors and strategies to prevent, treat or reduce intra- and postoperative complications

Predictive Risk Factors for Intra- and Postoperative Complications in 526 Laparoscopic Sigmoid Resections due to Recurrent Diverticulitis: A Multivariate Analysis

Background: Laparoscopic sigmoid resection is a feasible and frequent operation for patients who suffer from recurrent diverticulitis. There is still an ongoing debate about the optimal timing for surgery in patients who suffer from recurrent diverticulitis episodes. In elective situations the complication rate for this procedure is moderate, but there are patients at high risk for perioperative complications. The few identified risk factors so far refer to open surgery. Data for the elective laparoscopic approach is rare. The objective of this study was to identify potential predictive risk factors for intra- and postoperative complications in patients who underwent laparoscopic sigmoid resection due to diverticular disease. Methods: Uni- and multivariate analyses of a prospectively gathered database (1993-2006) were performed on a consecutive series of 526 patients who underwent laparoscopic sigmoid resection due to recurrent diverticulitis in a single institution. Patients were assessed for demographic data, operative indications, and intra- and postoperative complications. Altogether, we analyzed 17 potential risk factors to identify significant influence on the intra- and postoperative outcome, including timing of surgery. Results: Statistical analysis of specific medical and surgical complications revealed anemia, previous myocardial infarction, heart failure, experience of the surgeon, and male gender, as independent predictive risk factors for postoperative complications. Patients older than age 75years was the only independent risk factor for intraoperative complications in a multiple logistic regression model. Early elective surgery led to increased conversion rate but did not influence the postoperative complication rate. Conclusions: This large, single-center study provides first evidence of the significance of specific predictive risk factors for intra- and postoperative complications in laparoscopic sigmoid resection for diverticular diseas

Hidden regularity in singular optimal control of port-Hamiltonian systems

We study the problem of state transition on a finite time interval with minimal energy supply for linear port-Hamiltonian systems. While the cost functional of minimal energy supply is intrinsic to the port-Hamiltonian structure, the necessary conditions of optimality resulting from Pontryagin's maximum principle may yield singular arcs. The underlying reason is the linear dependence on the control, which makes the problem of determining the optimal control as a function of the state and the adjoint more complicated or even impossible. To resolve this issue, we fully characterize regularity of the (differential-algebraic) optimality system by using the interplay of the cost functional and the dynamics. In case of the optimality DAE being characterized by a regular matrix pencil, we fully determine the control on the singular arc. In case of singular matrix pencils of the optimality system, we propose an approach to compute rank-minimal quadratic perturbations of the objective such that the optimal control problem becomes regular. We illustrate the applicability of our results by a general second-order mechanical system and a discretized boundary-controlled heat equation.Comment: 21 page

A real-time capable dynamic partial reconfiguration system for an applicationspecific soft-core processor

Modern FPGAs (Field Programmable Gate Arrays) are becoming increasingly important when it comes to embedded system development. Within these FPGAs, soft-core processors are often used to solve a wide range of different tasks. Soft-core processors are a cost-effective and time-efficient way to realize embedded systems. When using the full potential of FPGAs, it is possible to dynamically reconfigure parts of them during run time without the need to stop the device. This feature is called dynamic partial reconfiguration (DPR). If the DPR approach is to be applied in a real-time application-specific soft-core processor, an architecture must be created that ensures strict compliance with the real-time constraint at all times. In this paper, a novel method that addresses this problem is introduced, and its realization is described. In the first step, an application-specializable soft-core processor is presented that is capable of solving problems while adhering to hard real-time deadlines. This is achieved by the full design time analyzability of the soft-core processor. Its special architecture and other necessary features are discussed. Furthermore, a method for the optimized generation of partial bitstreams for the DPR as well as its practical implementation in a tool is presented. This tool is able to minimize given bitstreams with the help of a differential frame bitmap. Experiments that realize the DPR within the soft-core framework are presented, with respect to the need for hard real-time capability. Those experiments show a significant resource reduction of about 40% compared to a functionally equivalent non-DPR design

An amino acid transporter involved in gastric acid secretion

Gastric acid secretion is regulated by a variety of stimuli, in particular histamine and acetyl choline. In addition, dietary factors such as the acute intake of a protein-rich diet and the subsequent increase in serum amino acids can stimulate gastric acid secretion only through partially characterized pathways. Recently, we described in mouse stomach parietal cells the expression of the system L heteromeric amino acid transporter comprised of the LAT2-4F2hc dimer. Here we address the potential role of the system L amino acid transporter in gastric acid secretion by parietal cells in freshly isolated rat gastric glands. RT-PCR, western blotting and immunohistochemistry confirmed the expression of 4F2-LAT2 amino acid transporters in rat parietal cells. In addition, mRNA was detected for the B0AT1, ASCT2, and ATB(0+) amino acid transporters. Intracellular pH measurements in parietal cells showed histamine-induced and omeprazole-sensitive H+-extrusion which was enhanced by about 50% in the presence of glutamine or cysteine (1mM), two substrates of system L amino acid transporters. BCH, a non-metabolizable substrate and a competitive inhibitor of system L amino acid transport, abolished the stimulation of acid secretion by glutamine or cysteine suggesting that this stimulation required the uptake of amino acids by system L. In the absence of histamine glutamine also stimulated H+-extrusion, whereas glutamate did not. Also, phenylalanine was effective in stimulating H+/K+-ATPase activity. Glutamine did not increase intracellular Ca2+ levels indicating that it did not act via the recently described amino acid modulated Ca2+-sensing receptor. These data suggest a novel role for heterodimeric amino acid transporters and may elucidate a pathway by which protein-rich diets stimulate gastric acid secretio

The Stomach Divalent Ion-sensing Receptor SCAR Is a Modulator of Gastric Acid Secretion

Divalent cation receptors have recently been identified in a wide variety of tissues and organs, yet their exact function remains controversial. We have previously identified a member of this receptor family in the stomach and have demonstrated that it is localized to the parietal cell, the acid secretory cell of the gastric gland. The activation of acid secretion has been classically defined as being regulated by two pathways: a neuronal pathway (mediated by acetylcholine) and an endocrine pathway (mediated by gastrin and histamine). Here, we identified a novel pathway modulating gastric acid secretion through the stomach calcium-sensing receptor (SCAR) located on the basolateral membrane of gastric parietal cells. Activation of SCAR in the intact rat gastric gland by divalent cations (Ca(2+) or Mg(2+)) or by the potent stimulator gadolinium (Gd(3+)) led to an increase in the rate of acid secretion through the apical H+,K+ -ATPase. Gd(3+) was able to activate acid secretion through the omeprazole-sensitive H+,K+ -ATPase even in the absence of the classical stimulator histamine. In contrast, inhibition of SCAR by reduction of extracellular cations abolished the stimulatory effect of histamine on gastric acid secretion, providing evidence for the regulation of the proton secretory transport protein by the receptor. These studies present the first example of a member of the divalent cation receptors modulating a plasma membrane transport protein and may lead to new insights into the regulation of gastric acid secretion

X-ray reflectivity measurement of interdiffusion in metallic multilayers during rapid heating

A technique for measuring interdiffusion in multilayer materials during rapid heating using X-ray reflectivity is described. In this technique the sample is bent to achieve a range of incident angles simultaneously, and the scattered intensity is recorded on a fast high-dynamic-range mixed-mode pixel array detector. Heating of the multilayer is achieved by electrical resistive heating of the silicon substrate, monitored by an infrared pyrometer. As an example, reflectivity data from Al/Ni heated at rates up to 200 K s^(−1) are presented. At short times the interdiffusion coefficient can be determined from the rate of decay of the reflectivity peaks, and it is shown that the activation energy for interdiffusion is consistent with a grain boundary diffusion mechanism. At longer times the simple analysis no longer applies because the evolution of the reflectivity pattern is complicated by other processes, such as nucleation and growth of intermetallic phases

No association between the common calcium-sensing receptor polymorphism rs1801725 and irritable bowel syndrome

Background The calcium-sensing receptor (CaSR) is a calcium (Ca2+) sensitive G protein-coupled receptor implicated in various biological processes. In particular, it regulates Ca2+/Mg2+- homeostasis and senses interstitial Ca2+ levels and thereby controls downstream signalling cascades. Due to its expression in the gut epithelium, the enteric nervous system and smooth muscles and its key function in regulation and coordination of muscular contraction and secretion, it represents an excellent candidate gene to be investigated in the pathophysiology of irritable bowel syndrome (IBS). Disturbed CaSR structure and function may impact gastrointestinal regulation of muscular contraction, neuronal excitation and secretion and consequently contribute to symptoms seen in IBS, such as disordered defecation as well as disturbed gut motility and visceral sensitivity. Methods We have therefore genotyped the functional CASR SNP rs1801725 in three case control samples from the UK, Belgium and the USA. Results Genotype frequencies showed no association in the three genotyped case–control samples, neither with IBS nor with IBS subtypes. Conclusions Although we could not associate the SNP to any of the established bowel symptom based IBS subtypes we cannot rule out association to altered Ca2+ levels and disturbed secretion and gut motility which were unfortunately not assessed in the patients genotyped. This underlines the necessity of a more detailed phenotyping of IBS patients and control individuals in future studies