Langenbecks Archiv fur Chirurgie最新文献

Despite aggressive surgical treatment, prompt antibiotic therapy, and modern intensive care, up to one half of patients still die of diffuse peritonitis. There must be a distinction between infection as a microbiological phenomenon and sepsis as a complex, deleterious, inflammatory host response. Physiologic and metabolic changes during the latter process by taxonomically different organisms or different sources of infection are often clinically indistinguishable. Taurolidine, an amino acid derivate, seems to cover a variety of effects in peritonitis. As secondary peritonitis is associated with a significant cytokine release that is compartementalized in the peritoneal cavity, taurolidine is bactericidal, antiendotoxic, and antiadherent locally and, on the other hand, may modulate the systemic cytokine-mediated inflammatory response after being adsorbed systemically by the peritoneum. Current management of peritonitis can clear the peritoneal cavity of microorganisms and their products but patients continue to die of uncontrolled cytokine-induced systemic inflammation. In patients that undergo daily staged, planned relaparotomies they should not only be treated locally by taurolidine but also systemically by intravenous administration. The latter should, as a sort of sequential therapy, be continued, especially when the peritoneal cavity has been closed after a series of relaparotomies.

In a prospective study, the systemic inflammatory consequences of surgery-induced lung tissue injury were evaluated using biochemical markers. The aim was to examine whether this type of injury produces a specific pattern of prostanoid plasma levels (prostacyclin, thromboxane, PGE2, PGF2 alpha, and PGM). We, therefore, compared 18 patients (group 1) who underwent thoracotomy without injury to the lung with 26 patients (group 2) that had a resection of pulmonary tissue due to benign diseases. Group 2 patients clearly revealed increased plasma levels of C-reactive protein as well as of the granulocyte-specific PMN-elastase. In particular, there was a pronounced release of prostacyclin and its antagonist thromboxane A2 following lung tissue resection. In contrast to group 1 patients, lung tissue damage resulted in immediately elevated plasma levels of PGF2 alpha and PGE2. When, however, taking into account the time course of PGM, the stable cleavage product of PGF2 alpha, there was no hint of an altered pulmonary metabolic capacity. Presumably, this pattern of elevated prostanoid levels in group 2 is the result of the surgical damage to the lung tissue. Therefore, it can be suggested to be specific for that type of injury. Thus, the release of prostanoids following surgery-induced lung tissue damage may indicate the importance of these mediators, particularly in thoracic injuries associated with lung damage since those may lead to post-traumatic pulmonary dysfunction. These substances may also be useful in evaluating both the severity and the extent of lung tissue damage following major trauma.

Aim of the study: Experience in daily routine reveals that most of ICU patients usually go through "crisis" within 14 days of admission. Only few patients need remarkable more time to get to this point and it seems there is hardly anything to be done therapeutically to change the course of it. We therefore examined a large group of ICU patients in order to find reasons for this course or to spot them as an "entity of their own".

Methods: 1,861 ICU patients all being on IPPV for more than three days were included in the study. Every day 18 variables were taken down in a standardised way until the day IPPV was finished. We extracted 170 patients who were artificially ventilated for more than 40 days. For these patients we established mean values for each of the 18 variables during the first and the last 40 days of ventilation. In both groups we compared survivors to non-survivors.

Results: Mortality was almost the same in both groups (IPPV < 40 days vs. IPPV > 40 days). Survivors and non-survivors showed remarkable differences regarding extrapulmonary factors-in terms of total fluid amount and transfusion, state of abdomen, brain, liver and kidney function and circulation problems. Pulmonary factors revealed major differences only towards the end of the observation period.

Conclusions: There seems to be an "entity of ist own", a small population of patients who arrive at the crucial turning point later. Pulmonary complications (pneumonia, ARDS) is not the reason but the expression of cause for prolonged ventilation. The key to the extrapulmonary origin of the crisis remains unknown, the only thing we can do is alleviate its manifestations.

We examined the influence of lymph node dissection on morbidity and mortality of 13 patients after resection of the head of pancreas due to a ductal or periampullary carcinoma. In both groups the radicality of the operation was the main prognostic factor. In ductal pancreatic carcinoma the R-status was able to be determined better by normalisation of the postoperative Ca 19-9 serum level than by the evaluation of the surgeon or pathologist. For prognosis, the quotient of metastatic lymph nodes to resected lymph nodes indicates that an extensive lymph node dissection may increase the long term survival. A lymph node dissection is therefore to be recommended, especially since it does not increase the rate of postoperative complications.

A rare case of spurious aneurysm of an aberrant right hepatic artery is reported. Endoscopic retrograde cholangio-pancreaticography, computed tomography and selective angiography of the coeliac trunc are diagnostic. Resection of the aneurysm and interposition of saphenous vein is the preferred procedure. In selected cases ligation of the common hepatic artery is possible. Intrahepatic aneurysms are preferably treated interventionally.

Angiosarcoma of the spleen is a very rare but highly malignant vascular neoplasm. So far only 140 cases have been reported. A 42-year-old patient is presented in which the radiologic imaging misled to the diagnosis of infiltrating echinococcosis. After splenectomy histological and immunohistochemical staining gave proof of metastatic angiosarcoma. The patient died three months later as a consequence of multiple organ dysfunction syndrome. The literature is reviewed in regard to clinical features, diagnosis and therapy.

Benign symmetric lipomatosis (BSL), also known as Madelung's disease, is a rare condition and characterized by diffuse but painless growth of unencapsulated lipomas. A close correlation to alcohol and nicotine abuse, metabolic disturbances and malignant tumours have been observed. Surgical treatment is frequently followed by recurrence, nevertheless, it can yield satisfactory functional and cosmetic results. A case of BSL with uncommonly distributed tumors is reported.

In 24 human cadaver femora standardized instable pertrochanteric osteotomies were created. The right and left femur of each pair were alternately selected for osteosyntheses with the gamma nail and the dynamic hip screw. Afterwards an examination of stability was performed. Cyclical loads were increased in 500 N increments to the maximum loading capacity, while the deformation rate was continuously measured. Radiographs were taken to prove the results of loading. The mean deformation was much greater in the DHS group than for the gamma nail, the maximum load to failure was significantly lower. Femoral shaft fractures caused by the loading occurred five times as often in the gamma nail osteosyntheses than in the DHS.