Langenbecks Archiv fur Chirurgie最新文献

The full significance of laparoscopic technique in elective surgery of sigmoid diverticulitis has yet to be determined. However, it seems worthwhile to evaluate how minimally invasive surgery could be integrated into the surgical treatment of diverticulitis disease. Between January 1995 and August 1996, 26 patients with sigmoid diverticulitis underwent elective surgery. Following diagnostic laparoscopy, seven patients were treated with primary conventional resection, 15 patients with laparoscopic resection and four patients with laparoscopic-assisted surgery. One laparoscopic resection had to be converted to a median laparotomy. Postoperative complications (n = 2) only appeared in the group of conventional resections. Conventional resections required less time than laparoscopic or laparoscopic-assisted resections, but postoperatively, patients with laparoscopic resection were able to defecate sooner and required a shorter hospital stay. For 60% of the patients with diverticulitis disease of the colon, elective laparoscopic resection may prove to be the best alternative of surgical treatment. In selected patients it is a sound technique with a low complication rate. We recommend that all patients with diverticulitis disease requiring elective surgery undergo diagnostic laparoscopy to determine whether or not laparoscopic resection is a viable option.

From 1986 to 1995, 97 patients older than 65 years of age underwent hepatic resection at the Department of General Surgery, Hospital Lainz, Vienna. The population consisted of 39 men and 58 women with a mean age of 74 +/- 5.5 years. Primary neoplasia was the cause of resection in 35 patients, gallbladder cancer in 16 patients, and metastatic disease to the liver in 40 patients. Six patients underwent hepatic resection because of benign disease. The overall rate of major resections (> or = 3 liver segments) was 73% and the overall mortality was 13.5%. Sixty-five postoperative complications were recorded in 42 patients, and infection was the leading problem in nearly all of these patients (95%). The histologic type of tumor rather than the magnitude of resection had an influence on clinical mortality and morbidity. All complications occurred in patients with malignant disease (P = 0.03). Adverse effects on postoperative morbidity were observed in adenocarcinoma of the hepatic ducts, gallbladder carcinoma, and cholangiocellular carcinoma (P = 0.003). Intraabdominal infections were found in 25% of our patients and were due to biliary leakage in 58%, but had no significant impact on survival. Pneumonia was the leading complication in association with patient survival. All patients who developed pneumonia as a late complication during a complicated course died postoperatively (P = 0.0001). All of these patients had a reduced grade of mobilization. Severe preoperative liver dysfunction carried a significantly higher risk for postoperative morbidity and mortality (P = 0.003 and 0.01), which showed an incremental risk with age > 80 (P = 0.002 and 0.0004). Right lobectomies and extended right lobectomies carried a significantly increased risk for postoperative morbidity (P = 0.004). Infection is associated with nearly every complication recorded after hepatic resection in the elderly. Pneumonia as a late complication poses a worse prognosis in elderly patients who underwent hepatic resection. Patients older than 65 years of age and especially those older than 80 years of age are more liable to succumb to complications that are predominantly infectious. Better local drainage procedures may reduce intra-abdominal infectious complications and early mobilization of the patients may improve the rate of systemic infectious complications and final outcome.

After laparotomy and inoculation of a Bacteroides fragilis suspension (2 ml with 10(8) CFU/ml), we induced chronic abscess-forming peritonitis in rats (n = 19, untreated). Fifteen animals were treated with heparin 30 IU, administered s.c. from day 1 after inoculation of the bacteria onwards. The main groups were divided into three subgroups (n = 8/5/6 and n = 5/5/5), which were observed for 3/7/14 days, respectively. On days 3 and 7, abdominal swabs were not only B. fragilis positive, but also showed severe polyvalent mixed infection after translocation of intestinal bacteria into the abdominal cavity. In the heparin group, B. fragilis positive swabs were reduced and translocation was inhibited (P < 0.05 for days 3 and 7). In the untreated group, blood cultures were B. fragilis positive on days 3/7/14 in 3/2/1 animals versus 0/1/1 in the heparin group. Adhesions were found in the untreated group in 1/4/5 animals, whereas in the heparin group there were no adhesions (P < 0.05 for days 7 and 14). However, intra-abdominal abscesses were also diminished in the heparin group (0/2/1) compared with the untreated animals (2/4/6, P < 0.05 for day 14). Therefore, heparin was shown to have a favourable influence on chronic abscess-forming peritonitis in an animal model.

Acute necrotizing pancreatitis and fylecal or diffuse purulent peritonitis are the diseases primarily responsible for mortality due to surgical infections of the abdomen. The most recent figures indicate that a mortality rate of 50%-80% in this specialized treatment group is still a reality. Without doubt, surgical sanitation of the focus is the most important therapeutic measure. A generalized inflammation reaction has been regularly observed in nearly all patients within this disease category. Local surgical therapy has the greatest effect on prognosis. If the therapeutic goal is not reached with the first intervention, adjuvant surgical therapy is necessary. The different forms are continuous peritoneal lavage (CPL), open dorsoventral lavage, and relaparotomy or scheduled reoperation ("Etappenlavage"). Adjuvant medical treatments include TNF alpha and interleukin-1 synthesis inhibitors or antibodies. Unfortunately, clinical studies with these mediators have only been partly successful in the subgroups, so that a general clinical adjuvant treatment is not considered viable. The bacterial properties of taurolidine destroy the bacterial membrane and, at the same time, lead to cross-linking of the membrane components and functional proteins (LPS), so that a bactericidal effect and endotoxin reduction take place simultaneously. Both local and intravenous routes of administration can be used.

Despite diagnostic and therapeutic advances, mesenteric vascular occlusion with intestinal infarction is often fatal. Parameters determining the high mortality are seldom discussed in the literature. By univariate statistical analysis we correlated the therapeutic outcome of our patients to 20 parameters. Between 1 January 1984 and 30 April 1996 we treated 22 men and 18 women with acute bowel ischemia of vascular origin. All patients underwent laparotomy, 40% (n = 16) due to the diagnosis of mesenteric infarction. In 15% (n = 6) the laparotomy was only exploratory; in 34 cases (85%) bowel resection was carried out. Mortality for all patients was 55% (n = 22). Univariate analysis of the 20 parameters showed that the therapeutic outcome was significantly correlated to a pre-existing diabetes, the course of hospitalization, and the high ASA class. There was no correlation to the length of resected bowel. Most parameters that determine the mortality of bowel infarction are pre-existing and cannot be influenced, but survival can be achieved in some patients if radical and aggressive resection is carried out at the side of almost complete small bowel infarction and followed by an elective second-look operation. Even short-bowel syndrome can be treated. Patients can return to a near normal lifestyle with an acceptable quality of life with the aid of parenteral nutrition at home.

Merkel cell carcinoma is a rare malignant tumor of the skin with predominance in older patients; 78.6% of patients are older than 59 years. Female and male patients are equally involved in the age group below 60 years. After 60 years, Merkel cell carcinomas are more often observed in female patients. The tumor is most often located in the head and neck region (50.8%) or the extremities (33.7%). The average size is 29 mm at presentation. Clinically, only a presumptive diagnosis of Merkel cell carcinoma can be established. The definite diagnosis is made by histological, especially immunohistological methods (detection of intermediate filaments and neuroendocrine markers). The therapy of choice is local excision. Secondary therapy may be a combination of operation and radiation or chemotherapy. Since this combination may reduce the risk of recurrences it should be applied for patients with poor prognostic features. Especially in young patients, additional lymphadenectomy should be discussed. Clinical control is necessary. Distant metastases should be treated by chemotherapy. Bad prognostic features are: lymph node metastasis, size larger than 2 cm, male sex.

Procalcitonin is a protein which is found in elevated concentrations in the blood circulation during systemic bacterial, fungal or protozoal infection. In contrast to classical acute-phase proteins like C-reactive protein or interleukin-6, it is not elevated after operative trauma. In this paper we present current opinions on the assumed induction mechanisms of the protein by cytokines and endotoxin. Furthermore, the clinical value for early detection of systemic infections in abdominal and transplantation surgery is demonstrated by examples from the literature. Our investigation shows that eight patients with necrotizing pancreatitis had a PCT mean value of 6.9 ng/ml on the day of admission. Seven patients with edematous pancreatitis had only a PCT mean value of 0.69 ng/ml. Despite these differences in the mean values, a significant difference between the normal value and the mean value of the group with necrotizing pancreatitis or edematous pancreatitis was not observed due to the wide range of PCT levels in the group of patients with necrotizing pancreatitis. The fact that only a few of the patients had a superinfected necrosis with systemic evasion of bacterias or their toxins may be the reason for this wide range. We suggest that a discrimination between superinfected necrotizing or sterile pancreatitis and edematous pancreatitis by PCT could be possible but more extensive studies with microbiological examination of the necrotic material are required to recognize the subgroups and to establish the real diagnostic efficiency of PCT in clinical practice, especially in the prediction of the outcome of acute pancreatitis.

In a prospective randomised study 30 mongrel rabbits received two standard colon-resections. Three types of drains were tested: (latex-rubber-) Penrose-drains, rubbertube- and silicontube-drains, which were placed in the lower abdomen. As a closed drainage-system the extraperitoneal tip of the drain was placed in a closed subcutis-pocket. One of the two colon-anastomoses also was drained. The findings were recorded on the 7th postoperative day. A single mechanic alteration was found, an ulcer caused by a silicon-drain, that pushed against the abdominal wall. The other signs of mechanic irritation were microscopically unspecified inflammatory reactions to the foreign body drain. There was no ascending infection caused by the drain. All infections came from complications of the colon resections. In contrast to common opinions the drains in the lower abdomen showed no adhesions to the abdominal wall or organs. Only the entrance of the drain into the peritoneum and the cotton-gaze of Penrose-drains showed in nearly all cases adhesions. The large amount of adhesions to the anastomosis-drains came from complications of the colon-anastomoses. As a cause of material, rubber- and latex-rubber-drains showed large fibrin-clots on their surfaces. 7 days after the operation only about 20% of the drains had sufficient function. The rest was occluded by fibrin-clots in the lumen of the drain or the cotton-gaze. Over all there is no difference in changes and effects of the three different types of drains, but silicon as material showed advantages.

The popliteal entrapment syndrome arises due to a compression of the popliteal artery by tendomuscular structures often combined with an anomal position of the artery. Mostly young men are complaining of this disease. We report about an eleven-year old boy, who had an interview with us because of acute ischaemic symptoms in the left shank. We ensured a popliteal entrapment syndrome type I by Kogel. By a dorsal approach to the fossa poplitea we performed the myotomy and the restoration of the artery into the normal position. Eight month postoperative the boy is without any complaint. In doppler-scan we record an normal arterial flow.

Laparoscopic transperitoneal and endoscopic extraperitoneal adrenalectomy are two safe options in minimally invasive surgery associated with a very low morbidity. Comparative studies with the conventional access to the adrenal gland demonstrated the advantages of the endoscopic technique. The anterior transperitoneal approach yields a better exposure of the anatomic structures and allows the surgeon to orient himself more easily, while at the same time he may perform additional laparoscopic maneuvers. In two cases of bilateral pheochromocytoma a bilateral laparoscopic adrenalectomy was performed simultaneously by employing the transperitoneal approach. The duration of surgery was approximately 210 and 270 min, respectively, with an intraoperative blood loss of about 350 and 400 ml. There were no complications following this procedure. Already on the 1st postoperative day, the patients could be fully mobilized. Furthermore, immunological data obtained perioperatively support the minimal invasiveness of this technique.