43. Trasylol und peritonitis

Zusammenfassung Die schwerste Komplikation und damit das zentrale Problem der septischen Peritonitis sind die Kreislaufinsuffizienz und die Allgemein-Intoxikation durch den paralytischen Begleitileus. Neben der Frühdiagnose und dem Zeit punkt der chirurgischen Intervention hängt die Prognose entscheidend ab von der Behandlung der Peritonitisfolgezustände. Die Hauptursache dafür muß in einer vasotoxischen Schädigung des Kreislaufs und der von ihm abhängigen lebenswichtigen Funktionskreise gesucht werden. Hierfür kommen pathogenetisch und pathophysiologisch auch durch Endotoxininvasion, Entzündung und Autolyse freiwerdende Proteasen in Frage, die permeabilitätssteigernde Plasmakinine liberieren können. Nach früheren Untersuchungen zur Wirkung des Trasylol bei der experimentellen und klinischen Perforationsperitonitis wurden beim experimentellen und klinischen Ileus mit Durchwanderungsperitonitis Kallikreinbestimmungen im mesenterialen und peripheren Venenblut durchgeführt. Dabei fanden sich erhöhte Kallikreinaktivitäten besonders im mesenterial-portalen Venenblut, abhängig von der zeitlichen Entwicklung, dem Schweregrad, den metabolischen Störungen und der Peritonitisursache. Nach operativer Behandlung und Proteaseinhibitortherapie trat ein Abfall der erhöhten Kallikreinwerte ein. Auch bei einigen Patienten mit intestinaltoxischen und septischen Krankheitsbildern anderer Ursache war ein Protcolysestress erkennbar. Bei protrahierten Schockzuständen darf vom Trasylol keine kausale Wirkung erwartet werden, da es in seiner Natur als Proteaseninhibitor, in einen multienzymatischen und multifaktoriellen pathophysiologischen Prozeß eingeschaltet ist.

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Summary The most severe complications and thus the central problems of septic peritonitis are circulatory failure and general intoxication due to the accompanying paralytic ileus. The prognosis depends on early diagnosis, the point in time of surgical intervention, and chiefly, upon the treatment of the sequalae of peritonitis. This is because of the vasotoxic damage to the circulation and the vital functional areas dependent upon it. From the point of view of pathogenesis and pathophysiology proteases that have been liberated by invasion of endotoxins, by inflammation, and by autolysis, are involved, which are able to liberate plasma kinins, which in turn increase permeability. Following on earlier investigations of Trasylol in experimental and clinical peritonitis due to perforations, kallikrein was determined in mesenteric and peripheral venous blood in cases of experimental and clinical ileus with transmigration peritonitis. Increased kallikrein activities were found especially in mesenteric-portal venous blood, depending upon the duration, the severity, the metabolic disturbances, and the cause of the peritonitis. After operation and treatment with protease inhibitors these kallikrein values fell. In several patients who had intestinal-toxic and septic syndromes that were due to other causes, proteolytic stress was also recognizable. No causal effect should be expected from Trasylol in protracted shock, because by its very nature as a protease inhibitor it acts only as part of a multienzymatic and multifactorial pathophysiological process.

     

73. Fehler bei der Indikation zur Relaparotomie nach Operationen wegen Duodenalileus

Zusammenfassung Die postoperative Phase nach Korrektur eines congenitalen Duodenalverschlusses wird von einem duodenalen Subileus beherrscht, der als dynamischer Ileus seine Ursache in der mangelhaften Kontraktion des Duodenums hat. Das Duodenum, das bei der Operation nicht mitreseziert wird, braucht in der Regel 14 Tage bis 3 Wochen. Eine zu frühe Operation ist fehlindiziert.

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Summary The postoperative phase after correction of a congenital duodenal occlusion is dominated by duodenal subileus which, being a dynamic ileus, is caused by deficient contraction of the duodenum. The part of the duodenum not resected during the operation generally requires 14 days to 3 weeks. Premature operation is contraindicated.

     

Drainage in treatment of perforated appendicitis

In treatment of peritonitis drainage of the peritoneal cavity, abdominal wall, and intestinal lumen, may be carried out.Attention is directed to the value of the third type which may prevent the establishment of ileus and a fatal outcome, if performed early after perforation.The effect of tension upon the intestinal capillaries is contrasted with that of pressure on the somatic capillaries.A small series of unselected cases in which enterostomy was added to appendectomy is summarized.     

Acute gastro-mesenteric ileus

Acute gastro-mesenteric ileus is the cause of death in numerous medical and surgical conditions. The essential pathology is the compression of the lower duodenal segment by the mesenteric root. The clinical manifestations consist of marked dilatation of the stomach, the accumulation of toxic fluids in the stomach, greatly in excess of the fluid ingested, dehydration, toxic nephritis and a tendency toward alkalosis.The treatment should consist of frequent evaluation of the stomach, postural changes to lessen the compression of the duodenum, and the introduction of large quantities of saline solution to combat dehydration and alkalosis.The use of alkalies and surgical intervention is contraindicated.     

Enteral insufficiency syndrome in acute ileus and ways for its correction]

Based on experimental investigations in 26 mongrel dogs, we established that due to acute ileus (AI) proximal and distal regions of small intestine are colonized by pathogenic aerobic and anaerobic microorganisms, which causes occurrence of enteral insufficiency syndrome (EIS). Absorption of microorganisms and their toxins through intestinal wall leads to bacteriemia, endotoxemia and morphological insufficiency of parenchymatous organs. The results of treatment of 486 patients with AI of different etiology are studied. Based on clinical and diagnostical changes 4 stages of EIS are separated. The rate of post-operative complications depends on severity of EIS. When treating the patients with AI the severity of EIS should be taken into consideration. Specific pre-operative preparation, the relevant technology of surgical intervention and post-operative treatment should be used differently at every stage of the disease.     

Pathogenesis of paralytic intestinal obstruction in peritonitis

The author believes that the vascular spasm does not play any part in the occurrence of functional ileus in peritonitis. Humoral factors, such as the loss of electrolytes and serotonin, which is of a specific mediatory effect upon the intestine in particular, are by far more important. It seems that some other humoral factors, e.g. bacterial toxins and endotoxins, formed during the inflammatory process, play their part too. The article is published for purposes of discussion in connection with the paper by Yu. L. Shal'kov. a coll. (Vestnik Khirurgii, 1976, N 4, p. 55).     

Internal intubation of the small intestine for preventing ileus in peritonitis and recurrent adhesions

Preventive intestinal intubation for ileus prophylaxis in cases of diffuse peritonitis and extended adhesion ileus had often been discredited for the technically demanding and thus time-consuming technique involved. Yet, tube-related complications in the context of tube insertion or removal can be minimised by the experienced surgeon who stringently observes a number of precautions and provided that the indication had been accurate. Fifty-three intestinal intubations on 49 patients were accompanied by three iatrogenic perforations intraoperatively and by four instances of postoperative fistulation of the small intestine which, however, were all properly controlled by suturing or conservative action. Ileus recurred in three patients because of too early tube removal and due to progressive peritonitis against the background of inadequately cured primary disease and due to peritoneal mesothelioma in one case. Periods of intestinal intubation ranged from six to 14 days. Postoperative lethality was relatively high (30.6 per cent) and had been exclusively caused by progressive sepsis or cardiopulmonary insufficiency. It amounted to 50 per cent of all cases of diffuse peritonitis and only to 4.7 per cent of patients with recurrent adhesion ileus.     

Peritonitis. Problems and prospects

Based upon studying the literature data and his personal clinical material including the 10-year experience with 2249 patients with peritonitis the author discusses the present-day state of the problem and prospects of its further investigation. Main attention is given to the syndrome of endogenous intoxication in peritonitis and to regulating mechanisms of the inflammatory reaction at early stages of forming the "program" of the pathological process.     

Postoperative small bowel obstruction in infants and children.

In the Pediatric Surgical Department of The St Radboud Hospital, Nijmegen, The Netherlands, between January 1970 and December 1980, 1476 laparotomies were performed on neonates, infants, and children. In 33 of these patient the abdominal surgery was complicated by a postoperative small bowel obstruction (SBO), for which a second laparotomy had to be performed. In 80% of patients this SBO developed within three months of the prior operation. The risk of developing an adhesive SBO was greater when there was more than one prior peritoneal procedure, and when, during this prior procedure, there was already a peritonitis. There was no obvious relation with the nature of the original operation. In more than 70% of patients a single adhesion caused the obstruction, while in many of these cases there were already circulatory disturbances, even by early reintervention. The mortality was 6%.     

Complication of spontaneous internal biliary fistulae (experiences in 46 cases)]

Spontaneous internal biliary fistulas are complications of biliary disease and may themselves be the source of further complications. Instances of the latter observed in a series of 28 bilio-digestive and 18 bilio-biliary forms are described: angiocolitis, biliary peritonitis, cholangitic cirrhosis, diarrhoea and malabsorption syndrome, haemorrhage, biliary ileus and Bouveret syndrome. Stress is laid on the need for early diagnosis and early surgery. It is pointed out that there is no such thing as an innocuous biliary calculus.     

Importance of lactacidemia for evaluation of severe postoperative condition of patients with peritonitis]

Based on the analysis of a number of organic acids, blood pH in the early postoperative period in 56 patients with diffuse peritonitis, it is concluded that the level of lactic acid depends both on the intensity of the inflammatory process in the peritoneum and on the degree of tissue perfusion disorders. During the intensive therapy these microcirculatory disturbances are liquidated during initial two postoperative days, whereas the kinetics of blood organic acids reduction allow characterization of the degree of pathophysiological shifts in diffuse peritonitis and possible issues of the disease.     

A bacteriological study of perforated duodenal ulcers

Peritoneal fluid sampling and bacteriological examination were performed in 63 patients with perforated duodenal ulcers, and the results compared with those in 175 patients with other perforations. Bacterial culture was positive in 100 per cent of the patients whose perforations occurred in the colon, whereas it was positive in only 44.4 per cent of those with duodenal perforations, being negative in many cases when the interval from perforation to surgery was short. A mixed contamination with both aerobes and anaerobes was usually found in the cases of lower digestive tract perforation, and the isolates from duodenal perforations were uniquely aerobes in most cases. It is suggested that bacteria play a minor role in the pathogenesis of early stage duodenal perforation, which supports the technique of primary closure without indwelling drainage tubes during early stage operations following sufficient peritoneal lavage. Moreover, if the stomach is empty at the time of perforation and the peritonitis is localized, even conservative therapy seems possible, provided it is begun shortly after the perforation.     

A bacteriological study of perforated duodenal ulcers

Peritoneal fluid sampling and bacteriological examination were performed in 63 patients with perforated duodenal ulcers, and the results compared with those in 175 patients with other perforations. Bacterial culture was positive in 100 per cent of the patients whose perforations occurred in the colon, whereas it was positive in only 44.4 per cent of those with duodenal perforations, being negative in many cases when the interval from perforation to surgery was short. A mixed contamination with both aerobes and anaerobes was usually found in the cases of lower digestive tract perforation, and the isolates from duodenal perforations were uniquely aerobes in most cases. It is suggested that bacteria play a minor role in the pathogenesis of early stage duodenal perforation, which supports the technique of primary closure without indwelling drainage tubes during early stage operations following sufficient peritoneal lavage. Moreover, if the stomach is empty at the time of perforation and the peritonitis is localized, even conservative therapy seems possible, provided it is begun shortly after the perforation.     

Surgical treatment of "difficult" duodenal ulcers

So-called "difficult" ulcers have a significant occurrence among complicated duodenal ulcers. Scar process and anatomic disturbances in the zone of duodenal bulb lead to technical difficulties during resection of the stomach with Gofmeister-Finsterer method. Eighty-nine resections of the stomach by Bilrot-I with creation of end-to-end one-row gastro-duodeno-anastomosis were performed under conditions of "difficult" duodenal ulcer with good early and long-term results.     

Retroperitoneal hemorrhage: With special reference to the accompanying paralytic ileus

Nine patients with retroperitoneal hemorrhage are reported. One hemorrhage occurred after an appendectomy, another after a vaginal hysterectomy, and seven as a result of a ruptured abdominal aortic aneurysm.Retroperitoneal hemorrhage may be classified into hemorrhage due to nontraumatic and traumatic causes. The signs and symptoms are quite similar in both groups but may vary with the underlying cause of the hemorrhage.The treatment of the retroperitoneal hemorrhage will depend upon the etiology of the condition.At the onset of the hemorrhage there is an abdominal syndrome simulating a generalized peritonitis and is due to a reflex, most likely from an irritation of the sympathetic and parasympathetic nervous systems.After this acute stage, a paralytic ileus usually develops. The ileus may occur from twenty-four hours to five days after the onset of the hemorrhage. It is probably due to a paralysis of the sympathetic and parasympathetic systems, rather than a reflex irritation of the splanchnic system.The prognosis in patients with retroperitoneal hemorrhage will vary and depend entirely upon the etiology of the condition.     

Early relaparotomy in postoperative peritonitis

The most frequent reason for relaparotomy is peritonitis, followed by mechanical ileus and secondary hemorrhage. The most common cause of postoperative peritonitis is insufficient anastomosis. The relative proportion of cases of localized peritonitis is increasing. Diffuse peritonitis is still treated by operation, according to instructions of Kirschner 1926, whereas localized peritonitis is more and more treated by percutaneous puncture. The prognosis of postoperative peritonitis is poor.     

Emergency relaparotomies

The authors generalize the experience with 172 repeated operations carried out for severe, dangerous to life complications. Among the latters the most common were peritonitis, bleeding, early adhesive intestinal ileus, eventration etc. The authors believe that a timely diagnosis is possible, almost without exception, in case of a dynamic observation over patients after the first operation.     

Human duodenal myoelectric activity after operation and with pacing

We sought to determine the influence of operation on the pattern of human duodenal myoelectric activity and to assess whether electrical pacing might correct any postoperative disturbances. Three pairs of temporary bipolar serosal electrodes were placed on the duodenums of ten patients undergoing cholecystectomy. Electrical recordings were obtained daily until the patients' discharge, at 3 to 7 days, after operation. On each postoperative day, a regular rhythmic pattern of pacesetter potentials (PPs) was detected in all patients. The PP frequency (mean +/- SEM) was greater at the proximal electrode than at the distal electrode on the first postoperative day (12.3 +/- 0.1 cpm vs 11.9 +/- 0.1 cpm, p less than 0.01) and on the day of feeding (12.0 +/- 0.2 cpm vs 11.6 +/- 0.2, p less than 0.01). Spontaneous periods when spike potentials accompanied each PP (phase III of the migrating myoelectric complex), were found in only one patient on the day after operation, while they were recorded in five patients after 3 to 7 days, when postoperative ileus had resolved (p less than 0.05). Pacing with electric pulses (50 msec, 5 to 15 mA, 11 to 13 cpm) did not alter the pattern of duodenal PPs or entrain them in the duodenum of any patient at any time after operation. In conclusion, the pattern of duodenal pacesetter potentials changed little during the period of postoperative ileus, while the incidence of phase IIIs of the migrating myoelectric complex was greatly decreased.(ABSTRACT TRUNCATED AT 250 WORDS)     

胆囊十二指肠瘘伴胆石性肠梗阻1例分析并文献复习

目的:探讨胆囊十二指肠瘘合并胆石性肠梗阻的术前评估、诊断和手术方式。方法:回顾性分析1例胆囊十二指肠瘘合并胆石性肠梗阻术前及术中的临床资料,并复习相关文献。结果:患者术前CT检查考虑胆囊结石与胆石性肠梗阻。术中探查见回盲部40cm处结石嵌顿,随后成功行肠切开取石、十二指肠瘘口修补、胆囊切除。术后痊愈出院,随访至目前未见相关并发症。结论:胆囊十二指肠瘘合并胆石性肠梗阻临床罕见,早期的明确诊断及精确的评估是关键,应根据患者具体情况选择合适的手术方式。     

Sclerosing peritonitis with gross peritoneal calcification: a case report.

We report the case of a patient on dialysis for 13 years, including continuous ambulatory peritoneal dialysis (CAPD) for 11 years, who developed sclerosing peritonitis with gross peritoneal calcification. The patient first presented with abdominal pain in January 1990, when peritoneal calcification was detected for the first time. Her symptoms settled spontaneously and 1 year later she presented with acute peritonitis and adynamic ileus. The peritonitis settled with antibiotics and Tenchkoff catheter removal, but the ileus persisted. She was commenced on long-term parenteral nutrition, but never recovered useful bowel function. After 8 weeks of hemodialysis and total parenteral nutrition, a further laparotomy for an acute abdomen showed what appeared to be extensive bowel infarction and peritoneal calcification. She died several days later. Of significance, peritoneal calcification was first noted on x-ray and computed tomography (CT) scan while the patient was still largely asymptomatic and before peritoneal ultrafiltration capacity was significantly impaired. Unlike other reported cases of calcifying peritonitis, sclerosing peritonitis was present and calcification was far more extensive. It was not associated with factors such as frequent infective peritonitis or acetate dialysate. Calciphylaxis was not present nor was there any abnormality of calcium-phosphate metabolism. The outcome of this case suggests that patients with recurrent or persistent bowel symptoms on long-term CAPD should have early abdominal x-ray or CT scanning to exclude sclerosing peritonitis or bowel calcification. If present, consideration should be given to transferring the patient to another therapeutic dialysis modality if possible.