Fortschritte bei der operativen Therapie der Divertikelerkrankung des Dickdarms

European Surgery - Es werden in einer retrospektiven Studies die Ergebnisse von 101 Patienten, welche wegen einer komplizierten Kolondivertikulitis in den Jahren 1965 bis 1978 operiert wurden, den...     

Combined sclerotherapy and operation for the treatment of bleeding oesophageal varices.

OBJECTIVE--To identify prognostic factors in a consecutive series of patients with bleeding oesophageal varices and develop an optimum regimen of treatment. DESIGN--Retrospective review. SETTING--I Department of Surgery, University Hospital, Vienna, Austria. PATIENTS--301 consecutive patients with bleeding oesophageal varices. OUTCOME MEASURES--Median survival and survival at one year after sclerotherapy alone (n = 213), or sclerotherapy with portosystemic shunt (n = 54), Hassab's devascularisation (n = 29), or liver transplantation (n = 5). RESULTS--Prognosis was dependent on the severity of liver damage at the start of treatment. Median survival for Child's class A was 47 months, for Child's class B 54 months, and for Child's class C 2 months. The overall one year survival for patients in Child's class C was 33%, for sclerotherapy alone 28%, and for sclerotherapy and portosystemic shunt 42%, Hassab's devascularisation 50%, and liver transplantation 80%. CONCLUSION--Despite the small number of patients who underwent liver transplantation and their poor initial prognosis (Child's class C, n = 4; class B, n = 1) our results suggest that liver transplantation should be considered for the treatment of patients with end stage cirrhosis and bleeding varices.     

Anti-endotoxin therapy in primate bacteremia with HA-1A and BPI.

OBJECTIVE: The in vivo neutralizing activities of an anti-lipopolysaccharide (LPS) antibody HA-1A (Centoxin [Centocor, Malvern, PA]), a human immunoglobulin M monoclonal antibody, and of bactericidal/permeability-increasing protein (BPI), an endogenously produced human LPS-neutralizing protein, were studied in a primate model of lethal Escherichia coli bacteremia. SUMMARY BACKGROUND DATA: HA-1A has been used with variable success against LPS activity in some animal models and in a recently reported clinical trial. However, no data assessing the efficacy of this agent in subhuman primates is available. Bactericidal/permeability-increasing protein is a product of polymorphomononuclear cells (PMNs) that is stored in azurophilic granules and exhibits LPS-neutralizing activity in vitro and in some in vivo models. METHODS: Immediately after E. coli infusion and in a blinded fashion, three baboons were treated with BPI (5 mg/kg bolus infusion and 95 micrograms/kg/min infusion over 4 hr). Three animals received 3 mg/kg BW of HA-1A, whereas another three baboons received a placebo treatment. RESULTS: The BPI-treated animals demonstrated significantly (p < 0.03) lower circulating LPS-limulus amoebocyte lysate (LAL) activity compared with the control animals, but this reduction in LPS-LAL activity was not associated with improved survival. HA-1A treatment did not reduce LPS-LAL activity. However, both BPI and HA-1A treatment did attenuate the pro-inflammatory cytokine response. CONCLUSION: The current data suggests that incomplete neutralization of endotoxin activity does not alter mortality from severe bacteremia. Given the diversity of mediator production under such circumstances, a strategy of combination therapy in the form of anti-lipopolysaccharide and anticytokine treatment may be necessary to achieve optimal survival.     

Reoperation after cholecystectomy. The role of the cystic duct stump

The so-called "Postcholecystectomy Syndrome" may be due to various pathological biliary causes. The aim of this study was to evaluate the significance of the cystic duct stump syndrome and if so, how often a long (greater than 1.5 cm) cystic duct stump was an indication for reoperation on the bile ducts after cholecystectomy in our patients. Three hundred and twenty two patients underwent a second operation on the bile ducts after cholecystectomy in the last ten years. In 35 patients (10.8%) a striking findings was a long cystic duct stump (greater than 1.5 cm). In 24 of these patients, a pathological finding, in addition to the long cystic duct stump, was found on exploration. Out of these 24 patients there were 14 with common bile duct stones; 6 with stenosis of the sphincter of Oddi; 3 with chronic pancreatitis and in one patient hepatitis was the cause of the symptoms. From the remaining 11 patients 8 had a stone in a partial gall bladder or cystic duct stump. One patient had a fistula between the cystic duct stump and duodenum and one a suture granuloma. There was only one patient where a 1.5 cm long cystic duct stump remnant was the only pathological finding. Four years after reoperation this patient is still suffering from the same intermittent gastrointestinal symptoms. We conclude that the cystic duct stump is hardly ever a cause for recurrent symptoms in itself. Total excision of the cystic duct does not eliminate the existence of postcholecystectomy symptoms.     

Gene therapy in surgery

Summary Background With the increasing body of knowledge in molecular biology, gene transfer respectively gene therapy becomes more and more a valid therapeutic option. Methods This is a critical review of gene therapy protocols for treatment of different types of cancer. Furthermore, the pathophysiological mechanism, therapeutically strategies as well as experimental approaches toward gene transfer in septic shock and organ transplantation are critically elucidated. Results Gene transfer as a therapeutic option was first successfully applied in children with severe combined immunodeficiency (SCID) in 1990. The majority of gene marking or gene therapy protocols approved for human clinical trials to date are related to the treatment of cancer. Besides viral vectors for brain tumors, non-viral vectors, liposomes particularly, with almost no side effects are increasingly used. Conclusions Different approaches of gene transfer in cancer patients are under investigation. Experimental data of septic shock treatment and rejection therapy of the allograft in organ recipients with gene transfer are encouraging for future applications in clinical trials. Part II: “Application to septic shock and to organ transplantation” will be published in Acta Chir Austriaca 1997; 29: Issue 1. References are listed at the end of part. II.     

Pharmacokinetics of lidocaine with epinephrine following local anesthesia reversal with phentolamine mesylate

Phentolamine mesylate accelerates recovery from oral soft tissue anesthesia in patients who have received local anesthetic injections containing a vasoconstrictor. The proposed mechanism is that phentolamine, an alpha-adrenergic antagonist, blocks the vasoconstriction associated with the epinephrine used in dental anesthetic formulations, thus enhancing the systemic absorption of the local anesthetic from the injection site. Assessments of the pharmacokinetics of lidocaine and phentolamine, and the impact of phentolamine on the pharmacokinetics of lidocaine with epinephrine were performed to characterize this potentially valuable strategy. The blood levels of phentolamine were determined following its administration intraorally and intravenously. Additionally, the effects of phentolamine mesylate on the pharmacokinetics of intraoral injections of lidocaine with epinephrine were evaluated. Sixteen subjects were enrolled in this phase 1 trial, each receiving 4 drug treatments: 1 cartridge lidocaine/epinephrine followed after 30 minutes by 1 cartridge phentolamine (1L1P), 1 cartridge phentolamine administered intravenously (1Piv), 4 cartridges lidocaine/epinephrine followed after 30 minutes by 2 cartridges phentolamine (4L2P), and 4 cartridges lidocaine/epinephrine followed by no phentolamine (4L). Pharmacokinetic parameters estimated for phentolamine, lidocaine, and epinephrine included peak plasma concentration (Cmax), time to peak plasma concentration (Tmax), area under the plasma concentration-time curve from 0 to the last time point (AUClast) or from time 0 to infinity (AUCinf), elimination half-life (t1/2), clearance (CL), and volume of distribution (Vd). The phentolamine Tmax occurred earlier following the intravenous administration of 1Piv (7 minutes than following its submucosal administration in treatment 1L1P (15 minutes) or 4L2P (11 minutes). The phentolamine t1/2, CL, and Vd values were similar for 1L1P, 1Piv, and 4L2P. The Tmax for lidocaine occurred later and the Cmax for lidocaine was slightly higher when comparing the 4L2P treatment and the 4L treatment. The phentolamine-induced delay of the lidocaine Tmax likely represents phentolamine's ability to accelerate the systemic absorption of lidocaine from oral tissues into the systemic circulation.     

Open approach in pancreatic and infected pancreatic necrosis: Laparostomies and preplanned revisions

One hundred and two patients with acute necrotizing pancreatitis were treated in accordance with a combined regimen of necrosectomy, open drainage by laparostomies, and repeated re-explorations. The severity of pancreatitis was assessed by the APACHE II score (median 15 on admission). Eighty-seven (85%) patients were classified as having infected pancreatic necrosis and only 15 (15%) as having pancreatic necrosis. Overall, 36 (35%) patients died, most of multiple organ failure. Survival was significantly impaired by bacterial contamination of pancreatic necrosis (p=0.008),bacteremia (p=0.0001)and infected bronchial secretions (p=0.05).The mortality rate was reduced from 53% to 28% by changing the regimen of re-explorations from on demand to regular 48 hour intervals. Despite the fact that open packing was associated with a high frequency of gastrointestinal fistulas (30%), this concept seems to be a successful and recommendable approach in the therapy of pancreatic and infected pancreatic necrosis.

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Resumen Ciento dos pacientes con pancreatitis aguda necrotizante fueron tratados con un método combinado de necrosectomía, drenaje abierto por laparostomía y exploraciones repetidas. La gravedad de la pancreatitis fue determinada mediante el indice APACHE II (promedio de 15 en el momento de la admisión). 87 (85%) pacientes fueron clasificados como necrosis pancreática infectada y sólo 15 (15%) como necrosis pancreática. Globalmente murieron 36 (35%) pacientes, la mayoría por falla orgánica multisistémica. La sobrevida fue significativamente afectada por la contaminatión bacteriana de la necrosis pancreática (p=0.008), la bacteremia (p=0.0001) y la infección bronquial (0.05). La mortalidad pudo ser significativamente reducida, de 53% a 28%, mediante el cambio de reexplorar según demanda a reexplorar regularmente cada 48 horas. A pesar de que el empaquetamiento abierto (open packing) apareció asociado con una alla incidencia de fistulas gastrointestinales (30%), este método parece ser un aproche razonable y exitoso en el tratamiento de la necrosis pancreática infectada.

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Résumé Cent deux patients ayant une pancréatite nécrosante ont été traités par nécrosectomie, suivie de drainage ouvert par laparotomie avec réexploration répétée. La sévérité de la pancréatite a été évaluée par système APACHE II (médiane=15 à l'admission). Quatre vingt patients (85%) ont été classés comme ayant une nécrose pancréatique infectée et 15 seulement (15%) comme ayant une nécrose pancréatique. Trente six patients (35%) sont morts, la plupart de défaillance polyviscérale. La survie a été influencée de façon significative lorsque la nécrose était contaminée (p=0.008), lorsqu'il existait une bactériémie (p=0.0001) et lorsqu'il y avait un examen bactériologique des sécrétions bronchiques positif (p=0.05). Le taux de mortalité a été réduit de 53% à 28% lorsque la réexploration chirurgicale a été effectuée régulièrement toutes les 48 heures plutôt qu'à la demande. Malgré un taux élevé de fistules gastrointestinales associées avec la méthode de drainage ouvert (30%), cette approche paraît un succès et nous la recommandons dans le traitement de la pancréatite nécrotique, infectée ou pas.

     

Ätiologie und Konsequenz der postoperativen Wundinfektion

Zusammenfassung Die Inzidenz postoperativer Wundinfektionen liegt zwischen 4,6% and über 36% nach Eingriffen am Gastrointestinaltrakt. In einer prospektiv angelegten Studie zwischen 1/89 und 1/90 versuchten wir mögliche ursächliche Faktoren für die postoperative Wundinfektion zu erfassen. In die Studie wurden 444 Patienten von 3 allgemeinchirurgischen Stationen unserer Klinik eingebracht. Die gesamte Wundinfektionsrate betrug 6,3%. Die Patienten wurden nach 3 operativen Gruppen klassifiziert: Gruppe I: subkutane Operationen; Gruppe II: intraabdominelle Operationen ohne Eröffnung des GI-Trakts; Gruppe III: gastrointestinale Operationen. Die Wundinfektionsrate in Gruppe I betrug 1,8%, in Gruppe II 7,3% and in Gruppe III 13,7%. Die erhobenen Werte waren statistisch significant. Die statistische Analyse wurde mittels univariater Berechnung (²-Test) and logistischer Diskriminanzanalyse (Cox-Modell) durchgeführt. Es zeigte sich, daß die Klassifizierung in 3 Gruppen (p = 0,000), Operationszeit (p = 0,009), Operationssaal (p = 0,000), Intensivstation (p =0,026), Langzeitantibiotikaprophylaxe (p = 0,001), subkutanes Hämatom (p = 0,000) and Drainagedauer. (p = 0,001) von signifikanter Bedeutung sind. In der multivariaten Analyse stellte sich die Klassifizierung in 3 Operationsgruppen als der gewichtigste Faktor dar. Der postoperative Krankenhausaufenthalt verlängerte sich significant bei Patienten mit Wundinfektionen (p = 0,0024).

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Etiology and consequences of postoperative wound infection

Summary The incidence of postoperative wound infection ranges between 4.6% and 36% after gastrointestinal operations respectively. To evaluate the factors which influence the postoperative wound infection we prospectively analyzed our patients between 1/1989 and 1/1990. 444 patients from three general surgical units of our clinic entered this study. The overall wound infection rate was 6.3%. We classified the patients into 3 operative groups: Group I: subcutaneous operations; Group 11: intraabdominal operations without opening the GI-tract; Group III: gastrointestinal operations. Wound infection rate in group I was 1.8%, in group 11 7.3% and in group III 13.7%. The differences were highly significant. Both univariate (²-test) as well as a multivariate (Cox-Model) analysis were done. We figured out that classification of patients (p = 0.000), operation time (p = 0.009), operating room (p = 0.000), intensive care unit (p = 0.026), longterm antibiotic prophylaxis (p = 0.001), subcutaneous haematoma (p = 0.000) and length of closed drainage time (p = 0.001) are of significant value. In the Cox model the classification of patients into 3 groups surpassed all the other factors. Postoperative hospital stay was lengthened in patients with wound infection significantly (p = 0.0025).

     

Transfer of interleukin-4 and interleukin-10 in patients with severe inflammatory bowel disease of the rectum

Inflammatory bowel disease (IBD) comprises the two disorders ulcerative colitis (UC) and Crohn's disease (CD). Although the etiology is still unclear, initiation and aggravation of the inflammatory processes seem to be due to a massive local mucosal immune response. An increased number of greatly activated macrophages seems to contribute to the onset of IBD by expressing upregulated costimulatory molecules (e.g., CD80/CD86) and a cytokine profile favouring a type I proinflammatory response. The release of interleukin 2 (IL-2) and Interferon-gamma (IFN-gamma) by naive T lymphocytes predominantly stimulates cytotoxic T lymphocytes, macrophages, and natural killer (NK) cells and increases the antigen-presenting potential of all these cell types. Opposite this proinflammatory immune reaction a compensatory type II antiinflammatory response has been suggested in the inflamed mucosa, involving mainly interleukin 4 and interleukin 10. Both cytokines are able to down-regulate inflammatory mediators including tumor necrosis factor-alpha (TNF-alpha) and interleukin 1 and favor a humoral immune response. The main goal of this clinical trial is the local liposome-mediated gene transfer of these two antiinflammatory cytokines, interleukin 4 and interleukin 10, in patients with severe IBD of the rectum. This local administration of antiinflammatory cytokines will avoid toxic systemic side effects, prevents blocking of the beneficial effects of proinflammatory cytokines, e.g., TNF-alpha in other tissue compartments and increases the local concentration of interleukin 4 and interleukin 10 over a prolonged period of time. The combined effects of IL-4 and IL-10 have been shown to shift the Th1/Th2 cell activation in favor of a Th2 immune response which seems to be essential for fighting against the inflammation and ultimative healing.     

Submucous large-bowel lipomas--presentation and management. An 18-year study.

Gastrointestinal lipomas are rare, but commonest in the colon and rectum, characteristically submucosal and seldom subserosal. An 18-year analysis revealed 17 cases of large-bowel lipoma, 13 presenting with colicky pain, abdominal discomfort, blood-stained feces or rectal bleeding and altered bowel habits and four asymptomatic. The 17 patients had totally 21 lipomas, all submucosal. No patients with multiple lipoma had evidence of lipoma at other sites. The ileocecal valve and cecum were most commonly affected, followed by the rectum, sigmoid colon and descending colon. Tumor size (largest diameter) was 0.5-10 cm, averaging 3.1 cm (3.5 cm in symptomatic, and 1.8 cm in asymptomatic patients). The primary diagnosis (with barium enema, colonoscopy and CT) was lipoma in only five cases, but CT gave the correct diagnosis in all three cases in which it was used. Two lipomas were found in surgical specimens from colorectal malignancy, while nine were misinterpreted as polyps and one as angiodysplasia. In symptomatic patients unnecessary colotomy or colonic resection may be avoidable by colonscopic removal of lipoma.