The anatomical limits of the posterior vaginal vault toward its use as route for intra-abdominal procedures

Background: The use of natural openings for abdominal surgery started at the beginning of the 21th century. A trans-Douglas endoscopic device has been designed to perform most of the intra-abdominal operations in women through the pouch of Douglas. The posterior vaginal vault is limited in size and could be damaged by an oversized instrument. This study investigates the optimal dimensions of the instrument by measuring the limiting factor in the passage. Methods: In ten female embalmed bodies the transversal and sagittal diameter of the fornix posterior vaginalis was measured by two observers. The pouch of Douglas was filled to its maximal capacity with mouldable latex through an open abdomen. By internal vaginal examination the connective tissue borders of the fornix posterior were palpated and the impression in the cast was measured. The mean value of these two diameters was evaluated in this study. The level of agreement between the observers was calculated. Results: The mean fornix posterior diameter was 2.6 cm (standard deviation, SD 0.5 cm) with a range of 2.0-3.4 cm. The mean difference between the two observers of all measurements was 0.08 cm (not significant). Both observers had an acceptable intraobserver variation. The interobserver agreement was excellent. Conclusion: Instruments with dimensions within the measured limits can be used safely for intra-abdominal operations via the natural orifice of the vagina

Platelets Boost Recruitment of CD133+ Bone Marrow Stem Cells to Endothelium and the Rodent Liver-The Role of P-Selectin/PSGL-1 Interactions

Lehwald N, Duhme C, Pinchuk I, et al. Platelets Boost Recruitment of CD133+ Bone Marrow Stem Cells to Endothelium and the Rodent Liver-The Role of P-Selectin/PSGL-1 Interactions. International journal of molecular sciences. 2020;21(17): 6431.We previously demonstrated that clinical administration of mobilized CD133+ bone marrow stem cells (BMSC) accelerates hepatic regeneration. Here, we investigated the potential of platelets to modulate CD133+BMSC homing to hepatic endothelial cells and sequestration to warm ischemic livers. Modulatory effects of platelets on the adhesion of CD133+BMSC to human and mouse liver-sinusoidal- and micro- endothelial cells (EC) respectively were evaluated in in vitro co-culture systems. CD133+BMSC adhesion to all types of EC were increased in the presence of platelets under shear stress. This platelet effect was mostly diminished by antagonization of P-selectin and its ligand P-Selectin-Glyco-Ligand-1 (PSGL-1). Inhibition of PECAM-1 as well as SDF-1 receptor CXCR4 had no such effect. In a model of the isolated reperfused rat liver subsequent to warm ischemia, the co-infusion of platelets augmented CD133+BMSC homing to the injured liver with heightened transmigration towards the extra sinusoidal space when compared to perfusion conditions without platelets. Extravascular co-localization of CD133+BMSC with hepatocytes was confirmed by confocal microscopy. We demonstrated an enhancing effect of platelets on CD133+BMSC homing to and transmigrating along hepatic EC putatively depending on PSGL-1 and P-selectin. Our insights suggest a new mechanism of platelets to augment stem cell dependent hepatic repair

A randomised, multi-centre, prospective, double blind pilot-study to evaluate safety and efficacy of the non-absorbable Optilene® Mesh Elastic versus the partly absorbable Ultrapro® Mesh for incisional hernia repair

<p>Abstract</p> <p>Background</p> <p>Randomised controlled trials with a long term follow-up (3 to 10 years) have demonstrated that mesh repair is superior to suture closure of incisional hernia with lower recurrence rates (5 to 20% versus 20 to 63%). Yet, the ideal size and material of the mesh are not defined. So far, there are few prospective studies that evaluate the influence of the mesh texture on patient's satisfaction, recurrence and complication rate. The aim of this study is to evaluate, if a non-absorbable mesh (Optilene^®Mesh Elastic) will result in better health outcomes compared to a partly absorbable mesh (Ultrapro^®Mesh).</p> <p>Methods/Design</p> <p>In this prospective, randomised, double blind study, eighty patients with incisional hernia after a midline laparotomy will be included. Primary objective of this study is to investigate differences in the physical functioning score from the SF-36 questionnaire 21 days after mesh insertion. Secondary objectives include the evaluation of the patients' daily activity, pain, wound complication and other surgical complications (hematomas, seromas), and safety within six months after intervention.</p> <p>Discussion</p> <p>This study investigates mainly from the patient perspective differences between meshes for treatment of incisional hernias. Whether partly absorbable meshes improve quality of life better than non-absorbable meshes is unclear and therefore, this trial will generate further evidence for a better treatment of patients.</p> <p>Trial registration</p> <p>NCT00646334</p

Multimodale Therapiekonzepte beim Oesophaguskarzinom

Once the diagnosis of esophageal cancer is established, the decision on treatment will depend on the stage of the disease. Since improvement of prognosis can only be expected in patients with complete removal of their tumor, preoperative staging plays a pivotal role in the decision-making process. En bloc esophagectomy together with the regional lymph nodes remains the treatment of choice in medically fit patients with localized esophageal carcinoma (Stage I-IIB, T 1-T 2/N 0-N 1/M 0). Due to early involvement of mediastinal structures, curative resection is unlikely to be achieved in patients with locally advanced esophageal carcinoma (Stage III, T 3-T 4/N 0-N 1/M 0). Most available data indicate that neoadjuvant radiochemotherapy leads in a significant number of patients to downstaging of the tumor, increases the rate of R0 resection, improves local tumor control, and prolongs the recurrence free interval. However, neoadjuvant radiochemotherapy resulted in a marked increase of morbidity and postoperative mortality and survival without improvement of survival. At present, neoadjuvant therapy is still experimental and there is no consensus for an optimal treatment regimen. Its use outside of an investigational setting can not be recommended. Future research must focus on more effective and less toxic neoadjuvant modalities (e.g. new chemotherapy agents, hyperthermia)

The management of locally advanced (pT4) esophageal carcinoma

Background: The dismal prognosis of patients with an esophageal carcinoma can only be improved by R0 resection. However, this condition is very difficult to be achieved in cases with locally advanced (pT4)-tumors. Methods: This paper reviews the result of diagnostics and neoadjuvant therapeutic modalities in patients with esophageal carcnioma that invades adjacent organs. Results: Endosonography (7,5 and 12 MHz frequencies) is with an accuracy rate of approximately 86% actually the most accurate method for staging esophageal carcinoma. Randomized clinical trials indicate that neoadjuvant radiotherapy does not increase the resection rate or prolong survival (5-year survival rate 9,5 to 16%) compared to surgical resection alone. Data from several series suggest that preoperative cisplatin-based chemotherapy is effective, but it is associated with a high perioperative morbidity (>45%) and mortality(>15%) rate. Neoadjuvant radio-chemotherapy appears to improve the prognosis only in those patients with objective clinical or histopathologic response. Due to a high postoperative mortality, combined resection of the tracheobronchial tree and aorta is considered too invasive and therapeutically not worthwhile. When patients are appropriately selected, a combined pulmonary (including lobectomy), pericard and esophageal resection is a relatively safe procedure. The survival curve seems to be better in there patients groups. Conclusion: Paritens with locally advanced esophageal carcinoma should undergo neoadjuvant treatment. This should be performed on appropriately selected cases and in experienced center within the context of clinical trials. The available data on the role of neoadjuvant radio-chemotherapy are not conclusive and recommendation can not yet be given. Multivisceral resection should be performed only if complete tumor resection can be anticipated and only in those patients who respond to neoadjuvant treatment modalities