Anastomotic insufficiency in small bowel surgery —incidence and treatment

Summary In the period 1977–1981 234 small bowel anastomoses were constructed in 143 patients. Eight anastomoses showed leakage (3.4%) and from nine anastomoses a fistula developed (3.8%): a total rate of disturbed healing of small bowel anastomoses (7.3%). In the presence of intra-abdominal infection this rate was 14.8%, in the absence of infection 0.8%. The results of treatment with oversewing and with resection and immediate anastomosis were disappointing. Better results were obtained by dismantling of the anastomosis, establishment of a split-enterostomy and reestablishment of continuity in a second stage. Mortality was 3/17 (18%). The literature is reviewed.

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Insuffizienz von Dünndarmanastomosen — Ineidenz und Therapie

Zusammenfassung In dem Zeitraum 1977–1981 wurden bei 143 Patienten 234 Dünndarmanastomosen angelegt. Acht Anastomosen zeigten eine Nahtleckage (3,4%), bei neun entwickelte sich eine Fistel (3,8%): die Gesamthäufigkeit von Wundheilungsstörungen bei Dünndarmanastomosen war 7,3%. Bei gleichzeitigem Vorliegen intraabdominaler Infektionen betrug die Häufigkeit 14,8%, ohne diese 0,8%. Die Resultate einer Therapie durch Übernähung oder Resektion mit sofort anschließender Reanastomosierung waren enttäuschend. Befriedigendere Ergebnisse wurden durch Aufheben der Anastomosen, Anlage einer split enterostomy unter Wiederherstellung der Kontinuität in einer zweiten Sitzung erzielt. Die Mortalität betrug 3/17 (18%). Ein Literaturüberblick wird gegeben.

     

173. Gibt es bakteriologische Diagnosekriterien des perforierten Gastroduodenalulcus?

Zusammenfassung Die entscheidenden Kriterien für die Prognose einer Ulcusperforation sind Alter, die Zeitdauer bis zur operativen Versorgung sowie das Geschlecht der Patienten. In der eigenen Klinik wurden von 1974 bis 1985 85 Patienten versorgt. Dies erfolgte mit der Tendenz zum kleinstmöglichen Eingriff. Eine synchrone definitive Operation der jeweiligen Ulcuskrankheit war die Ausnahme. In einer seit 1981 durchgeführten prospektiven Studie wurden Keimart, Keimzahl, Zellzahl, pH-Wert sowie der Nachweis von Toxinen untersucht. Es ergab sich keine Relation zur Letalität des Einzelfalles.     

Correction to: How to support dental students in reading radiographs: effects of a gaze‑based compare‑and‑contrast intervention

Advances in Health Sciences Education -     

Role of x-ray computed tomography in the preoperative evaluation of aneurysm of the abdominal aorta

The authors have studied the files of 50 consecutive patients (1987-89) operated for abdominal aortic aneurysm (AAA) and examined with CT. The criteria for inclusion were surgical features. CT can be made more accurate for the study of AAA: Thus the location of the neck of the aneurysm relative to the renal arteries was defined in 94% of all cases. In addition, CT yields information about the wall of the aneurysm, whether it be thickened (3 inflammatory aneurysms were properly diagnosed) or, mor importantly, weakened (solution of continuity in the wall in the "prior-to-rupture" appearance). Owing to the quality of its performances and to its noninvasive character, the authors regard CT with contrast injection as an essential technique for the preoperative assessment of abdominal aortic aneurysm in most cases. The examination must be carried out strictly, especially for the contiguous sections of the renal arteries and their extension to the crural arch. As it demonstrates weakened areas more easily, a more accurate study of the aneurysmal wall with CT might increase the surgical indications for some smaller aneurysms, the potential evolution of which does not seem to be associated with their diameter only.     

Human intestinal diamine oxidase (DAO) activity in Crohn's disease: A new marker for disease assessment?

The key-enzyme for the metabolism of diamines in man is diamine oxidase (DAO). Its highest activities are in the intestinal mucosa, localized in the cytoplasm of the mature enterocytes of the small and large bowel. If the gut is affected by inflammation in Crohn's disease macroscopical changes are observed. This prospective study investigated if these mucosal alterations are also reflected in changes of mucosal diamine oxidase activity and/or mucosal histamine content respectively. Twenty patients (12 female, 8 male; age: , range 18 49 years) undergoing gut resection because of complications in Crohn's disease (Jan.–Dec. 1988) formed the basis of the study. Tissue samples of the resected material from areas inflamed and histologically not involved in the disease were investigated for diamine oxidase activities and histamine content. Diamine oxidase activities in the mucosa obtained from the macroscopically normal proximal (155.6; (76–393) mU/g ( range)) and distal (132; (58.5–295) mU/g) resection margins were similar to our previous findings. In all patients, however, samples from the diseased mucosa had significantly (ca. 50%) lower diamine oxidase activities (74.5; (5–262) mU/g) compared to the healthy tissue. Similar differences were found in material obtained either from whole intestinal wall or from the mucosa. The determination of diamine oxidase activity constitutes possibly a more unambiguous and earlier parameter for assessing the extent of the inflamed area than histological disease presentations. Using biopsies the necessary extent of resection could be estimatedbefore operation: this may influence operative strategies and help in the definition of the minimum amount of inflamed gut to be removed.Supported by grant of Deutsche Forschungsgemeinschaft (Lo 199/15-2).     

Therapy of primary breast cancer in the 21st century: A prediction

Biology

New treatment selection criteria will arise from molecular biology parameters of growth and treatment response, most probably coupled with the increasing use of initial chemotherapy and repeated minimally invasive surgery.

Prevention

Secondary and hopefully also primary prevention of breast cancer will become more and more successful in the era of molecular genetics, and such interventions will be more directed to individuals and groups at defined higher risk.

Surgery

Surgery will increasingly tend towards “minimally invasive surgery,” which favors not only cosmetics and quality of life, but also more appropriate imaging follow-up.

Chemotherapy

Primary (preoperative) chemo- and endocrine therapy will become the standard initial form of breast cancer treatment, with the intent of down-staging of the tumors to allow later breast-conserving procedures, but also to use the tumor as a biological response parameter and hopefully also for better clinical outcome.

Cost — Effectiveness

Economical parameters might become more and more decisive, as we will have to live with much more “evidence based medicine” and with much more restricted allocation of resources in the future. This might mean, that we will have to diligently develop more simple and cheaper, but not prognostically worse treatment strategies in years to come. More specifically: Do we still need all of the traditional steps in diagnosis and treatment of breast cancer in order to achieve the same results?

Gain of Life

Finally in all of this, we have to make clearcut assumptions, supported also by society and people involved: How do we value “gained years of life” in breast cancer adjuvant and prevention trials? This certainly is not predominantly a medical or economical, but rather an ethical, social and political problem, which has to be finally answered by our socio-cultural environment, and not by doctors alone.     

Acid-base balance and substitution fluid during continuous hemofiltration

Critically ill patients with acute renal failure usually present with an unstable acid-base balance, often leading to cardiovascular complications and multi-organ failure. Therefore, to prevent metabolic acidosis, acid-base balance must be normalized and maintained; these patients are primarily treated with continuous hemofiltration techniques using different replacement fluids to influence the acid-base values. Dialysate solutions can be an acetate-based, lactate-based, citrate-based or bicarbonate-based buffer. This article discusses the strengths and weaknesses of each type of hemofiltration replacement fluid.     

A method for the follow-up of clusters of adverse reproductive outcomes

Clusters of adverse reproductive outcomes are reported with increasing frequency to public health authorities. Most are random events and only a very small proportion is likely due to identifiable environmental agents. Often, a preliminary study confirms the existence of a spatial and temporal excess but no biologically plausible cause is found. These cases require a follow-up of incidence to identify any continuing excess. A conceptually simple fixed window technique of follow up is proposed. The power of the test is mainly influenced by the magnitude of the increase in rate, the number of adverse outcomes selected for observation and the acceptable false alarm rate. This technique has several advantages compared with other currently used methods. From a public health point of view, two important factors are to be considered in setting the parameters of the test: the delay in providing an answer for the community and the availability of resources for conducting environmental investigations.     

Bilateral cystoid macular edema following successful treatment of AIDS-associated CMV retinitis

Background: Cystoid macular edema (CME) in AIDS patients with inactive cytomegalovirus (CMV) retinitis is an uncommon but potentially sight-threatening complication. The pathogenesis of CME in these patients is unclear. This study tries to identify possible risk factors by analyzing the charts of five patients. Methods: Ten eyes of 5 patients that finally developed CME were followed for an average of 18 months. The initial retinal lesions, their response to antiviral treatment, the development of CME, and the patients' immune status were prospectively monitored. Results: CMV retinitis was diagnosed at a median CD4+ count of 3 cells/mm³ (range 0–11). All eyes responded to the initial systemic anti-viral treatment. At the onset of CME, CMV retinitis was controlled by antiviral maintenance therapy in all patients [ganciclovir (n = 2), cidofovir (n = 2), foscarnet (n = 1)]. The median time between diagnosis of CMV retinitis and onset of CME was 11.5 months (range 5–24). Development of CME was associated with significant visual loss: acuity ranged from 0.05 to 0.7 when CME was first noticed, compared to 0.8–1.25 at diagnosis of CMV retinitis. Duration of inflammation, size or zone of retinal necrosis did not favor the development of CME, neither did the antiviral therapy. A weak correlation of CME development and immune status (expressed as increase of CD4+ cells) was found. Due to systemic corticosteroids CME resolved. Conclusions: CME is a new visual threat to AIDS-patients with CMV retinitis whose immune status improved under the latest combined antiretroviral therapy. Therapy with oral corticosteroids may positively influence this condition.