Use of ultraviolet irradiation of the blood in the complex treatment of peritonitis

According to the data of tetrasolium nitroblue test and titer of the blood serum antibodies to the most frequently cultured microflora in complex treatment of 27 patients with diffuse purulent peritonitis, it was established, that the use of ultraviolet irradiation of the blood stimulated the specific and non-specific organism resistance.     

Sanative postoperative laparoscopy using rapid bacteriological methods in comprehensive treatment of patients with diffuse peritonitis]

In treatment of patients with diffuse peritonitis the authors have been using postoperative sanative laparoscopy which proved to provide a means not only for rapid evaluating the dynamics of peritonitis course, but also for carrying out a series of therapeutic manipulations aimed at proper management of infections and inflammatory complications. Sanative laparoscopy was accompanied by taking samples of peritoneal exudate to study sensitivity of microflora to antibiotics and antiseptic substances, ensuring rational antibacterial treatment of peritonitis. This therapeutic method was used in 38 patients who underwent 60 examinations. Sanative laparoscopy was of a planned character in 30 patients, and in 8 cases it was carried out for emergency indications. All the studies were performed within 12-23 hours. A single examination was carried on in 11 subjects, the rest of the patients demanding from 2 to 3 examinations. No complications related to sanative laparoscopy were observed. Positive outcome was noted in the majority of the patients, re-laparoscopy being indicated but for 3 patients. Two patients died due to causes not related to the pathology involved.     

人精子膜结合腺苷脱氨酶单克隆抗体的制备和初步鉴定

本研究以正常人精子，用ｐｅｒｃｏｌｌ分离，经脾直接免疫、细胞融合和克隆化后，以标准ＡＤＡ为抗原筛选，得到２８株单克隆抗体（ＭｃＡｂ）细胞株。其腹水效价均在１：６４００以上（ＥＬＩＳＡ）。免疫球蛋白分类显示，１株为ＩｇＭ，其余各株皆为ＩｇＧ。ＭｃＡｂ对ＡＤＡ活性的抑制实验结果显示，有２２株ＭｃＡｂ对ＡＤＡ有抑制作用而其余６株对ＡＤＡ无抑制作用。初步研究结果显示我们得到的ＭｃＡｂ具有特异性，可用于对精子中ＡＤＡ的性质研究。     

The use of ultraviolet-irradiated plasma in the treatment of peritonitis

Intravenous infusion of the one-group lyophilized donor plasma irradiated with ultraviolet rays was included in the complex treatment of 43 patients with acute purulent peritonitis. The species-specific composition of the microflora was studied in the different groups of patients according to the cause of peritonitis and the degree of microbial contamination of the purulent wounds in patients treated with and without ultraviolet plasma irradiation (UVPI). For prognosticating the course and outcome of the disease the authors used a complex of indices linked with the manifestation of neutrophil bactericidal activity and the level of exogenous intoxication. A positive effect of UVPI in the management of acute purulent appendicitis was noted, which was confirmed by clinical and microbiological tests.     

X线平片及CT检查在急性弥漫性腹膜炎中的诊断价值

影像诊断对自发性急性弥漫性腹膜炎（通过腹膜自身表现：增厚、模糊、渗出）起到提示诊断的作用;对继发性急性弥漫性腹膜炎除了可以发现腹膜本身病变外,还可明确原发病灶及病变累及范围,对临床治疗方案制定、手术与否、预后评估等都有重要价值。CT较X线平片检查更细致、全面,通过优先部位的显示,容易检出病变,定位更加准确和具体。     

Immunization in children with chronic renal failure

Infections jeopardize children on immunosuppression after organ transplantation. Immunization is protective in healthy children. The aims of this study were to analyze the rate and efficacy of immunization in 62 children undergoing dialysis and renal transplantation (RTPL) between 1987 and 2000. The analysis was based on clinical findings, vaccination certificates, and measurement of specific serum antibodies. A member of the renal unit administered vaccinations. All 62 patients were immunized against diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, and hepatitis B. Since introduction in 1991 and 1995, 44 and 42 children were also vaccinated against influenza and Hemophilus influenzae type b, respectively. Of 16 patients with a negative history, 14 were given varicella vaccine; 16 children on peritoneal dialysis (PD) or with nephrotic syndrome were immunized against Streptococcus pneumoniae. All vaccinated patients had detectable serum antibodies against measles, mumps, rubella, varicella, hepatitis B, H. influenzae, and S. pneumoniae. There were 3 infections despite vaccination; 1 patient developed varicella after RTPL and 1 patient on PD had 2 episodes of peritonitis caused by H. influenzae and S. pneumoniae. In conclusion, monitoring and administration of the vaccines by the renal team enabled a high immunization rate. Whether vaccines, as documented by antibody titers, or by the low prevalence in the general population promoted the low prevalence of infections remains open, as there were at least a few vaccination failures.     

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??Value of modern imaging technology in the diaghosis of acute diffuse peritonitis LI Ming-hua??ZHAO Jun-gong. Department of Radiology, the Sixth People’s Hospital of Shanghai Jiao Tong University, Shanghai 200233??China Corresponding author??LI Ming-hua??E-mail??liminghua@online.sh.cn Abstract The imaging diagnosis of spontaneous acute diffuse peritonitis (including peritoneal thickness, fuzzy, effusion) plays the role of prompt diagnosis. Peritoneal changes as well as direct findings of original lesions obtained on contrast enhanced CT are manifestations for the diagnosis of secondary acute diffuse peritonitis, which are important to decide the treatment protocol. CT is a more valuable method than the X-ray film in the diagnosis of acute diffuse peritonitis.     

Peritonitis in diverticulitis: the Bern concept

INTRODUCTION: The colon is the most frequent origine for a diffuse peritonitis and diverticular perforation is again the most common source of a spontaneous secondary peritonitis. This paper first focuses on the treatment of peritonitis and secondly on the strategies of source control in peritonitis with special emphasis on the tactics (primary anastomosis vs. Hartmann procedure with colostomy) for surgical source control. PATIENT AND METHODS: Prospective analysis of 404 patients suffering from peritonitis (11/93-2/98), treated with an uniform treatment concept including early operation, source control and extensive intraoperative lavage (20 to 30 liters) as a standard procedure. Other treatment measures were added in special indications "on demand" only. Peritonitis was graded with the Mannheim Peritonitis Index (MPI). Tactics of source control in peritonitis due to diverticulitis were performed according to "general condition" respectively the MPI of the patient. RESULTS: The 404 patients averaged a MPI of 19 (0-35) in "local" peritonitis and a MPI of 26 (11-43) in "diffuse" peritonitis. The colon as a source of peritonitis resulted in MPI of 16 (0-33) in the case of "local" respectively 27 (11-43) in "diffuse" peritonitis. From 181 patients suffering from diverticulitis 144 needed an operation and in 78 (54%) peritonitis was present. Fourty-six percent (36) of the patients suffered from "local", 54% (42) from "diffuse" peritonitis. Resection with primary anastomosis was performed in 26% (20/78) whereas in 74% (58/78) of the patients a Hartmann procedure with colostomy was performed. The correlating MPI was 16 (0-28) vs. 23 (16-27) respectively. The analysis of complications and mortality based on the MPI showed a decent discrimination potential for primary anastomosis vs Hartmann procedure: morbidity 35% vs. 41%; reoperation 5% vs. 5%; mortality 0% vs. 14%. CONCLUSION: In case of peritonitis due to diverticulitis the treatment of peritonitis comes first. Thanks to advances in intensive care and improved anti-inflammatory care, a more conservative surgical concept nowadays is accepted. In the case of diverticulitis the MPI is helpful to choose between primary anastomosis vs. Hartmann procedure with colostomy as source control. The MPI includes the "general condition" of the patient into the tactical decision how to attain source control.     

Heart transplantation across antibodies against human leukocyte antigen and ABO-post-transplant follow-up of donor reactive antibodies

BACKGROUND: We have successfully performed heart transplantation despite the most unfavourable risk factors for graft and patient survival: the presence of a high level of antibodies (Abs) against the donor's human leukocyte antigens (HLA) class I/II and blood group A1 antigens. The present study concerns post-transplant follow-up and characterization of donor reactive antibodies (DRA). METHODS: Pre-transplant treatment consisted of mycophenolate mofetil (MMF), prednisolone, tacrolimus, intravenous immunoglobulin (IVIG), rituximab, protein-A immunoadsorption (PAIA) and per-operative plasma exchange. A standard triple-drug immunosuppressive protocol was used post-operatively. Abs were analyzed by the complement dependent cytotoxicity (CDC) test against donor and panel B/T cells and by flow cytometry (FlowPRA tests detecting isolated HLA class I/II antigens). Abs against the donor's erythrocytes were analyzed using a standard direct agglutination test for immunoglobulin M (IgM) Abs and a Bio-Rad AHG gel card test detecting IgG Abs and C3d. RESULTS: Pre-transplant treatment reduced Ab titers against the donor's lymphocytes from 128 to 16 and against the donor's blood group A1 antigen from 256 to 0. The patient was emergently transplanted with a heart from a blood group incompatible donor (A1 secretor to O). No hyperacute rejection was seen. DRA were present against all mismatched HLA class I and class II antigens at the time of transplantation; two of these DRA Abs disappeared within the first year post-transplant (anti-B62 and anti-DR4), one showed weakened reactivity (anti-A24) and one is still strongly reactive (anti-DQ3). The donor-specific CDC cross-match is still positive (titers 2 to 8). The level of panel reactive antibodies (PRA) remained unchanged from 6 months on post-transplant. Rising anti-A1 blood group Abs preceded the second rejection and were adsorbed by two blood group specific immunoadsorptions (Glycosorb)-ABO) and remained at a low level. IgM anti-A1 blood group Abs disappeared at 1 yr post-transplant and IgG Abs are still reactive with blood group A1 erythrocytes but at low titers (1 to 2). CONCLUSIONS: The patient is clinically well 2 years after heart transplantation despite the constant persistence of donor reactive IgG Abs against blood group A1 and HLA-DQ antigens. The reactivity of DRA against other mismatched HLA antigens disappeared or weakened during the follow-up period.     

腹腔穿刺术在急性弥漫性腹膜炎鉴别诊断中的应用

急性弥漫性腹膜炎是一种常见的外科急症,病因复杂,鉴别诊断较为困难。腹腔穿刺术作为一项常用的外科技术,在急性弥漫性腹膜炎的鉴别诊断中发挥着不可替代的作用,常能迅速地判断病因,从而指导快速有效的治疗。     

急性弥漫性腹膜炎手术时机及术式选择

急性弥漫性腹膜炎是腹部外科较为常见的急症,起病急、变化快、病情重且复杂。外科手术能有效的阻断病情进展,在治疗中起至关重要的作用,直接决定疾病的转归。如何准确掌握急性弥漫性腹膜炎的手术时机、手术方式非常重要。     

Kinetics and character of xenoantibody formation in diabetic patients transplanted with fetal porcine islet cell clusters

Abstract: Porcine fetal islet-like cell clusters (ICC) were transplanted to 10 renal transplant patients suffering from long-standing type I diabetes. Since they had renal grafts, they were given immunosuppression with cyclosporine, prednisolone and azathioprine. Eight patients had the ICC injected intraportally and two had the ICC placed under the renal graft capsule. At the time of the xenotransplantation, ATG or 15-deoxyspergualin was given as an adjunct. Evidence of engraftment, as reflected by excretion of small amounts of porcine C-peptide into the urine, was observed in four of the patients. In all patients, irrespective of the type of immunosuppression given and whether graft function was established or not, specific xenoantibodies were formed. Titer increases in lymphocytotoxic antibodies occurred after 10 to 14 days with peak reactivity after 30 to 50 days. High titers of ADCC activity measured against porcine lymphoblasts were found in all patients. Titers were maintained at a high level for at least 100 days. Antibody titers were monitored against pig lymphocytes, erythrocytes and against pig membrane antigens solubilized from peripheral blood mononuclear cells, platelets and erythrocytes. Both IgM and IgG antibodies were formed with identical kinetics. There was no increase in the titers of alloantibodies, as evidenced by panel-reactive lymphocytotoxic antibodies. In all patients an increase in titers of isohemagglutinins was recorded, especially against blood group B antigens. Absorption studies showed that xenoreactivity present in healthy individuals could not be blocked by absorption with human RBC. However, in all transplanted patients, xenoreactivities against pig antigens were inhibited by absorption with human RBC, in particular with B-type RBC. These data show that the increase in isohemagglutinins was probably due to cross-reactivity with xenogeneic antigens. Using an ELISA assay, increased antibody titers were also recorded against purified pig MHC class I antigens. However, as is shown in the accompanying paper (next issue), these antibodies were probably not directed against protein determinants on the MHC molecules but rather against glycosylated side chains of these molecules.     

Effect of endolymphatic antibiotic therapy on the status of cellular immunity in peritonitis

The immune status in 68 patients with diffuse and generalized peritonitis was studied. It was established, that a degree of the impairment in immune response depended on peritonitis spreading. Endolymphatic antibiotic therapy had immunostimulating effect in patients with diffuse peritonitis, in generalized peritonitis, this was not observed. In patients with generalized peritonitis, it is necessary to include into the complex of treatment the other methods of immunologic correction.     

Association of endotoxemia and production of antibodies against endotoxins after multiple injuries

BACKGROUND: Endotoxemia after injury has been a controversial issue. Endotoxins stimulate the innate and adaptive immune system. OBJECTIVE: To investigate endotoxemia and its effects on the production of antiendotoxin antibodies of cultured mononuclear cells of patients with multiple injuries. METHODS: Blood samples of 20 patients with multiple injuries were collected up to 12 days after trauma. The endotoxin concentration was measured in the plasma, and mononuclear cells were isolated and cultured. Specific antibodies against two lipopolysaccharides, one lipid A preparation, and alpha-hemolysin of Staphylococcus aureus were measured in the cell culture supernatant by an enzyme-linked immunosorbent assay. RESULTS: Endotoxemia peaked at admission of the patients, decreasing thereafter to almost normal values within 5 days. Isolated mononuclear cells synthesized antibodies against all tested antigens with a peak at or between day 5 and day 7. The increase was significant for immunoglobulin (Ig)A and IgM specific to all endotoxins tested and for IgA specific to alpha-hemolysin. However, there were no significant changes of the concentrations of total IgM, IgA, and IgG. All specific IgG remained unaffected. CONCLUSION: Patients with multiple injuries initially have temporary endotoxemia. Endotoxin may be suggested as a stimulator of the synthesis of antiendotoxin antibodies, in particular of the IgA and IgM class in patients with multiple injuries.     

The use of magnetic resonance imaging in the differential diagnosis between starch and fecal peritonitis

Granulomatous peritonitis, caused by the starch from the surgeons' gloves, is a hypersensitivity reaction that can complicate abdominal surgery and mimic other causes of peritonitis. The diagnosis of this entity is difficult to make, and relies on a high index of suspicion. We suggest the use of magnetic resonance imaging to facilitate the diagnosis of this condition, based on an experimental animal model. 84 rats were subjected to laparotomy, and the abdominal cavity was exposed to either saline solution, talc solution, starch solution or fecal material by creating a cecal perforation. TI-weighted magnetic resonance images, with and without gadolinum enhancement, were taken after 3, 5 and 10 days. The animals were then sacrificed and the abdominal contents were evaluated both macroscopically and microscopically. Both talc and starch caused gross adhesions involving the entire abdominal viscera, and microscopy revealed signs of inflammation and fibrosis. Starch induced reactive granulomas. The adhesions in the cases of fecal peritonitis were confined to the area of the perforation. MR images of the starch peritonitis group was remarkable for a diffuse pathological process with enhancement of the omentum and the peritoneum after gadolinum injection. The MR readings of the fecal peritonitis group showed a localized process with no diffuse enhancement of the peritoneum. The striking differences between the magnetic resonance images of starch and fecal peritonitis in rats suggest that this modality is both sensitive and specific in diagnosing starch peritonitis in a rat model. Early non-invasive diagnosis of these separate entities would ease the establishment of the appropriate treatment. We are currently investigating the use of MRI imaging in suspected starch peritonitis in humans.     

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??Choice of operative timing and method on acute diffuse peritonitis SUO Jian. Department of General Surgery??the First Hospital of Jilin University, Changchun 130021??China Abstract Acute diffuse peritonitis is a common surgical emergency, which has acute onset and rapid progression, usually with severe and complicated clinical situations. Surgery interventions play an important role in treatment of acute diffused peritonitis, which can control the progression of such condition efficiently, thus affect the prognosis of the disease strongly. In the paper, as a hot topic, it discussed choice of operative timing and method applied to a certain case.     

Phagocytosis by emigrated,intra-abdominal neutrophils is depressed during human secondary peritonitis

The phagocytic function of neutrophils is a crucial element in host defense against invading microorganisms. Patients with diffuse peritonitis depend on adequate reactivity of neutrophils, in particular locally in the peritoneal cavity as well as in the circulation. This study examined phagocytosis as well as numerical expression of Fcgamma I-III (CD16, CD32, CD64) and complement receptors (CD18, CD35) of emigrated, intra-abdominal and circulating neutrophils during human secondary peritonitis using fluorescence-activated cell analysis. Optimally opsonized E. coli bacteria were used independently of the well-known low level of opsonic molecules during peritonitis. Compared with controls (abdominal surgery without peritonitis), the percentage of emigrated neutrophils which engulfed E. coli bacteria was significantly depressed until 48 h after diagnosis of, and surgery for, peritonitis. When patients with complicated peritonitis (septic shock, multiple organ failure) were compared with patients without complications, phagocytosis was even more depressed in patients with complications. Numerical expression of CD64 (Fcgamma RI) and CD35 (CR1) increased significantly on emigrated polymorphonuclear leukocytes (PMNs) during peritonitis when compared to controls. There was no difference in CD18 and CD32 (Fcgamma RII) expression between the two groups. Numerical expression of CD16 (Fcgamma RIII) on emigrated PMNs decreased significantly in peritonitis. This was more pronounced in patients with complicated peritonitis. We conclude that there is a long-lasting depression of phagocytosis by emigrated PMNs during peritonitis, independent of the opsonic activity. Our data suggest that decreased phagocytosis might be correlated to the profound drop in CD16 on these cells.     

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??Role of abdominal paracentesis in the differential diagnosis of acute diffuse peritonitis LIU Lian-xin, MENG Xian-zhi. Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, China Corresponding author: LIU Lian-xin, E-mail: liulianxin@medmail.com.cn Abstract Acute diffuse peritonitis is a common surgical emergency with complex etiology, which makes its differential diagnosis very difficult. Abdominal paracentesis, a commonly used surgical technique, plays an irreplaceable role in the differential diagnosis of acute diffuse peritonitis. It usually leads to quick judgement of etiology as well as timely and effective treatment.     

Elective relaparotomy as a method of treatment and prevention of complications of diffuse suppurative peritonitis

The results of treatment of 41 patient with diffuse purulent peritonitis, who underwent 2 and more relaparotomies are analysed. It has been proved that performance of the elective relaparotomy for preventing the development of intraabdominal complications of peritonitis were superior to the existing methods of treatment. It permitted to reduce lethality in diffuse purulent peritonitis 3.6-fold.     

Antibiotic treatment during surgery for diffuse peritonitis: a prospective randomized study comparing the effects of cefuroxime and of a cefuroxime and metronidazole combination

In a prospective randomized open study of patients operated upon for diffuse peritonitis, the effects of two different antibiotic regimens were evaluated. Cefuroxime given as a single drug (Group I; n = 59) was compared with a combination of cefuroxime and metronidazole (Group II; n = 63). Bacteriological cultures, both aerobic and anaerobic, were obtained peroperatively and in the event of any complication. The antibiotic sensitivities of isolated bacteria, and the serum and tissue concentrations of cefuroxime were determined. Postoperative infectious complications occurred in 22 per cent of Group I patients (cefuroxime), and in 17.5 per cent of Group II (cefuroxime plus metronidazole). The mortality rates were 5 per cent for Group I and 8 per cent for Group II. Tissue concentrations of cefuroxime were well above the MIC (minimal inhibiting concentration) values for most of the bacteria isolated. From a few patients in Group I, however, cultures were obtained with isolates sensitive to metronidazole but resistant to cefuroxime. Our findings suggest that, in the antibiotic treatment of patients operated for diffuse peritonitis, an agent which is primarily effective against aerobic bacteria (but not entirely without effect on anaerobes) is as effective as combination therapy covering both aerobic and anaerobic bacteria.