Langenbecks Archiv fur Chirurgie最新文献

The proximal third of the humerus is fed by the anterior and posterior circumflex arteries of the axillary artery. They construct a fine anastomoses network at the humeral head as well as longitudinal anastomoses to the diaphysis. The middle third of the humerus is maintained by the rami musculoperiostales originating in both the brachial artery and the deep brachial artery. These periosteal vessels are formed both horizontally and vertically. The distal third of the humerus is mainly supplied by the horizontal anastomoses of the collateral arteries. The inner part of the bone is normally penetrated by just one nutrient artery entering the nutrient canal below the middle of the humerus.

A 58-year-old woman presented with multiple gastroduodenal ulcera caused by a pancreatic polypeptidoma (PPoma) without hypergastrinemia or gastrin-producing tumor cells. After curative resection of the neoplasm, the clinical symptoms disappeared and the patient has now been disease-free for 6 years. We conclude that patients with non-gastrin-producing endocrine pancreatic tumors may demonstrate the clinical features of Zollinger-Ellison syndrome and should be included in the differential diagnosis of this syndrome.

Unlabelled: To assess the behavior of the LC-DCP with prebending and pretensioning we tested: gap angle vs. tensioning force without prebending; Bending moment for different prebending angles; In a model using a fiber tube to simulate the bone for different prebending angles and pretensioning forces of the LC-DCP the deformation in 4 point bending open was tested. Maximum prebending angle was 24 degrees, maximum pretensioning force was 2400 N; in human cadaver tibiae angles of 3 degrees, 9 degrees, 24 degrees and forces of 300 N, 1000 N and 1500 N, were tested to look for the difference in a less idealized model.

Results: 1. A near linear curve for gap angle vs. force with an angle of 0.45 degree/100 N was found between 100 N and 1500 N; 2. We did not find a near linear bending moment/bending angle curve up to 8 degrees like in the DCP but an exponential curve development as it had to be expected by the lower modulus of elasticity of titanium; 3. the maximum mechanical stability was found for a angle of 24 degrees and a force of 1500 N. The titanium LC-DCP shows a different mechanical reaction to prebending and pretensioning in the bone implant complex compared to stul DCP. Optimum prebending and pretensioning for axial compression and mechanical stability in the LC-DCP are by far greater than clinically possible. From our mechanical testing a prebending angle of 24 degrees and a pretensioning force of 1500 N would allow the largest axial compression and show the most resistance against deformation in bending open. In the clinical setting this would result in difficult reduction and therefore, we recommend a prebending angle of 9 degrees and a pretensioning force of 1000 N.

An important aim of proctocolectomy with ileal pouch-anal anastomosis (IPAA) is to maintain anal continence. Anal sphincter disruption during IPAA is felt to play an important role in loss of continence, which is described in up to 30% of the treated patients in the early postoperative period. Although sphincter function recovers gradually after surgery, some patients stay incontinent. In our investigation of possible parameters involved in preservation of continence after this operative procedure, we focused on changes in anal manometry. We compared these findings with the functional results obtained by questioning the patients and physical examination. Anal manometry was performed with a low-compliance hydraulic perfusion system. All patients underwent a J-pouch procedure with a short rectal cuff for ileoanal reconstruction. We examined 25 patients, 13 underwent operation for the treatment of ulcerative colitis, 12 because of adenomatous polyposis. In the colitis and polyposis group, 28% of the patients reported events of soiling. Three patients (12%) were incontinent. The remaining 15 patients were completely continent. The median time after operation was 58 months, ranging from 12 to 96 months. Comparing the results of anal manometry with standard values of ten age- and gender-matched healthy volunteers, it was found that there was a significant increase in the threshold of balloon awareness and urge to defecate. These sensations were sometimes elicited by pouch contractions. Median pouch-compliance was also clearly elevated in comparison to rectal compliance (P < 0.005). Inhibitory reflexes during balloon inflation could not be evoked in any of the patients. Comparing continent with incontinent patients there were significant differences in balloon awareness, urge to defecate, and stool frequency (P < 0.01, P < 0.01 and P < 0.001, respectively). But in contrast to other publications, we could not find significant differences in anal sphincter length, resting and squeezing, anal canal pressure. Pouch compliance was lowered in incontinent patients and negatively correlated with stool frequency (P < 0.001, r = -0.82). In conclusion, our study indicates that anal sphincter resting pressure alone is not a crucial factor in continence preservation in the long-term after total proctocolectomy and IPAA. Poor pouch-compliance and concomitant higher stool frequencies seem to be related to incontinence in this patient group.

Merkel cell carcinoma (MCC) is a rare neoplasm of the skin predominantly found on the head and extremities. Clinically MCC presents as a rapidly growing red or violaceous, dome-shaped, solitary tumor. The clinical and histological diagnosis of MCC remains difficult. Distinction from poorly differentiated small cell primary tumors or metastasis requires immunohistochemical analysis and-if available-electron-microscopic studies. We report on the follow-up of 10 patients with MCC treated in the past 6 years at our department. In nine patients the tumors were completely removable; in one patient with a large primary tumor of the upper lip no histologically proven complete excision could be performed. After a median follow-up of 42 months, local recurrence or lymph node involvement was observed in three patients. Two patients died following disseminated metastases, one elderly patient due to cardiac insufficiency. Our observations demonstrate that MCC is a potentially aggressive cutaneous tumor. Adequate primary surgical and adjuvant therapy as well as careful follow-up are mandatory.

During isolated limb perfusion (ILP) severe metabolic impairment with a subsequent alteration in oxygen consumption can be observed. The mechanisms responsible for this may be extracorporeal circulation, hyperthermia, and application of cytostatic drugs and cytokines. Thirty-three patients underwent ILP with rhTNF alpha and melphalan for melanoma or soft-tissue sarcoma. Cardiopulmonary monitoring consisted of arterial and mixed venous blood-gas analysis and a Swan-Ganz catheter was inserted after induction of general anesthesia prior to any surgical intervention. Arterial (SaO2) and mixed venous (SvO2) oxygen saturation, serum lactate and end-expiratory CO2 concentration were determined peri- and postoperatively for 72 h. Oxygen supply and consumption rates were measured systemically (DO2I, VO2I) and in the extracorporeal circuit ('DO2I, 'VO2I). For statistical analysis we used the t-test. During extracorporal circulation an increase of DO2I and VO2I was observed. A slight increase of lactate values began during the wash-out phase. Immediately after reperfusion. DO2I, VO2I and lactate increased significantly with normalization until the 2nd postoperative day. SaO2 and SvO2 remained unchanged. A significant correlation between regional toxicity and the postoperative maximum of serum lactate values was found. The increase of DO2I and VO2I in the tissues during ILP and after reperfusion was achieved by a significant increase in cardiac output while the oxygen extraction rate was not altered. Elevation of lactate values after reperfusion and the increase in oxygen utilization might be due to oxygen depletion in the perfused limb. This could contribute to the development of lactacidosis or rhabdomyolysis. Therefore, to minimize toxicity it seems to be mandatory to measure adequate tissue oxygen supply during ILP.

Primary anastomosis is increasingly favored even in emergency colorectal surgery. Two-stage procedures are frequently considered obsolete. The aim of this study is to define conditions when a two-staged operative strategy with a temporary colostomy is still appropriate. We analyzed a series of 126 patients who were treated by a colostomy following resection and subsequent closure of the colostomy. In 44 cases the primary operation was a Hartmann resection, in 39 cases a resection with colostomy and mucous fistula and in 43 cases a resection with primary anastomosis and proximal loop colostomy. Complications of diverticular or neoplastic disease were generally managed by resection without primary anastomosis. Protective loop colostomy was done after low anterior resection of the rectum or in cases of anastomotic leakage. Patients were hospitalized again after an average of 6 months for closure of the colostomy. Restoration of intestinal continuity carried no significant risk of severe intra- or post-operative complications. Disturbances of wound healing occurred in 4.5% (Hartmann resection), 17.9% (colostomy and mucous fistula) and 20.9% (loop colostomy) of patients. We found an anastomotic dehiscence rate of 2.4% after discontinuity resections and of 4.7% after closure of loop colostomies. Only one patient with anastomotic leakage required surgical reintervention. The mortality after closure of a colostomy was zero. The rate of anastomotic leakage of 2.4% was lower than in published series with more than 7.2% after primary anastomosis, thus emphasizing the beneficial effect of a two-stage operative strategy. In emergency situations of sigmoidal and rectal surgery or in cases of low anastomosis of the distal rectum, unnecessary surgical complications can be avoided by resection without primary anastomosis or by performing protective loop colostomies.

Background: Although port-site metastases occur after laparoscopic surgery, there is no generally accepted approach to prevent tumor implantation so far.

Methods: In order to prevent tumor metastases, the effect of taurolidine and heparin on the growth of colon adenocarcinoma DHD/K12/TRb was measured in vitro and in a rat model. After incubation of the cells with heparin, taurolidine or both substances, the cell kinetics were determined. In a second experiment, tumor cells were administered intraperitoneally in rats (n = 60) and pneumoperitoneum was established over 30 min. Rats were randomized into four groups (I: tumor cells; II: cells + heparin; III: cells + taurolidine; IV: cells + taurolidine + heparin).

Results: While tumor cell growth was not influenced by heparin in vitro, growth decreased significantly after incubation with taurolidine and taurolidine/heparin. In vivo, intraperitoneal tumor weight was lower in rats receiving heparin (298 +/- 155 mg) and taurolidine (149 +/- 247 mg) than in the control group (596 +/- 278 mg). When the two substance were combined, tumor growth was even less (21.5 +/- 36 mg). Trocar metastases were only lower in rats receiving taurolidine or the combination of taurolidine and heparin.

Conclusion: In vivo, heparin inhibits intraperitoneal tumor growth only slightly, while taurolidine causes a significant decrease in tumor cell growth in vitro as well as intraperitoneal tumor growth and trocar metastases in vivo.

The morphology of the inflammatory activity of the peritoneum has been measured qualitatively but quantitative assessments are not common. In a standardized rat model we induced chronic abscess-forming peritonitis after laparotomy and inoculation of 2 ml Bacteroides fragilis suspension at a concentration of 10(9)/ml colony-forming units. The morphological inflammatory activity was determined quantitatively by staining the specimen of the peritoneum with naphthol-AS-D-chloracetate-esterase (NASDCE); through this staining the cytoplasm of granulocytes and tissue mast cells were marked. The peritonitis group (n = 53) and controls (n = 15) were randomly divided into three subgroups (nPeritonitis = 17/18/18 vs. ncontrol = 5/5/5) and observed for 3/7/14 days, respectively. On days 3/7/14 we diagnosed intra-abdominal abscesses in 2 of 17, 13 of 18, and 12 of 18 animals in the peritonitis group. In controls there were no abscesses (P < 0.05). The total cellularity and NASDCE-positive rates on days 3/7/14 in the peritonitis group were 301/409/280 (vs. 155/240/273 in controls) and 1.8/2.9/3.6% (vs. 0.7/0.9/1.4%) in the non-abscess-forming regions and 392/661/625 and 14.4/12.9/11.5% in the abscess-surrounding regions in the infected animals, respectively (P < 0.05). We conclude that the qualitative histological evidence of the morphological inflammatory activity of the peritoneum in the form of an abscess can be supplemented by a quantitative method. Through NASDCE staining the granulocyte and tissue mast cell proportion of the total cellularity as main indicators of the local inflammatory activity can be estimated in peritonitis. This method can be helpful in deciding when to definitively close the abdomen in the course of a programmed lavage treatment in peritonitis.

Due to the superficial position of shunt vessels we do not use complicated equipment or diagnostic procedures in the morphological assessment of shunt insufficiency or shunt occlusion. Preoperatively, we merely conduct a clinical examination including inspection, pulse, palpation of the shunt veins and arteries with and without venous congestion, and shunt auscultation. Subsequently, we reoperate the shunt under local anesthesia, at which time the anastomosis is usually checked and repositioned. From January 1995 to May 1996, 539 shunt operations were performed in 371 patients, whereby 263 of these were reoperations. The reoperations were performed due to shunt occlusion (n = 144), shunt stenoses (n = 60), shunt aneurysms (n = 17), steal syndrome (n = 3), and rare complications such as hematoma, shunt infection, seroma, and other disturbances (n = 6) (32 patients were treated in other clinics after reoperation or the functional disturbance of the shunt was not recorded). Angiography was only conducted if the clinical examination did not provide enough information about the shunt problems, and so, preoperatively, only six angiographic examinations were conducted (stenosis, n = 3; aneurysm, n = 1; steal syndrome, n = 2). All reoperations, with only few exceptions (PTFE shunt), were conducted under local anesthesia. At reoperation, 184 new proximal shunts were made, 14 thrombectomies conducted, seven PTFE fistulas made, 13 shunts positioned on the opposite side, five shunts ligated, and eight various other operations performed (32 patients were given further treatment elsewhere or no treatment records were available). If during reoperation flow disturbances were suspected (arterial stenosis) or the blood was flowing towards center (proximal venous stenosis) angiography was performed intraoperatively to assess the condition of the vessels. The 4% rate of early occlusion using this procedure was very low. Only 21 patients had to have more than two reoperations. After 2 years 65% of the reoperated AV fistulas were still functional. Without further diagnostic procedures, we performed immediate, outpatient reoperation under local anesthesia, preferably positioning new proximal shunts so that dialysis could be conducted immediately using the existing dialysis shunt. Only if there were particularly complex functional shunt disturbances (steal syndrome, proximal venous flow disturbance, or arterial stenosis) did we employ other diagnostic procedures (angiography, DSA). With this approach the functional shunt disturbances could be eliminated quickly and effectively, which also minimized the cost and stress for the patient.