Langenbecks Archiv fur Chirurgie最新文献

Background: Only a few indications exist for diaphragm replacement: aplasias, tumours and accidents. The defect may be so extensive that it is impossible to close the gap. Allogenic and autologous materials are proposed for replacement of the diaphragm. The disadvantages of allogenic materials are recurrence rates of up to 20% and a high rate of malalignment of thoracic muscles and bones; the implication of autologous materials requires a longer operation time and no long-term results exist. To avoid these disadvantages, we have tested a material from bovine serosa, which is absorbable for a short time, for diaphragm replacement.

Methods: The merits of four methods of diaphragmatic hernia repair were evaluated in animals. One hundred Sprague-Dawley rats underwent laparotomy. The control group had an incision in the diaphragm with primary repair. The other four groups underwent partial resection of the left hemidiaphragm. The defects were repaired in 20 rats with lyophilized dura, in 20 with polytetrafluoroethylene (PTFE), in 20 with autologous transversus muscle and in another 20 with absorbable serosa from a cow. The animals were followed up by electromyography (EMG) and post-mortem physical and histological examinations after 3 and 6 months.

Results: Eighty-nine animals survived the operations. The EMG showed normal function for the absorbable material and the transversus muscle. Only scanty physiological waves were recorded in the PTFE group. The examination for stretching and stress showed good results for all materials tested. The histological examinations showed strong foreign body reactions in the dura and PTFE groups. The absorbable bovine serosa had vanished after 3 months postoperatively.

Conclusion: We conclude that bovine serosa can be recommended for the treatment of diaphragmatic defects.

The aim of the present experimental investigation was to assess the circulatory, biochemical and histopathological consequences of complete portal vein arterialization of the transplanted liver in 'Göttinger' miniature pigs. Orthotopic liver transplantations using a passive portojugular shunt were performed in six male 'Göttinger' miniature pigs. Using an iliac artery segment interposition of the animal donor, the hepatic artery (HA) of the transplant liver was anastomized end-to-end and the portal vein (PA) also united with the internal iliac artery stump end-to-end. The central anastomosis was performed onto the suprarenal aorta. Portal vein blood was drained into the infrahepatic caval vein via an end-to-side shunt (PCS). During the course, the following parameters were determined: arterial blood pressure, venous pressure, cardiac output, electromagnetic blood flow measurements across the HA, PA, and PCS, PA mean pressure, transaminases, partial thromboplastin time and fibrinogen. Liver biopsies and autopsy specimens were investigated. One of six animals died a few hours postoperatively, two of six died after 48 and 72 h, respectively, whereas three pigs survived the scheduled 7 days. The cardiac output fell intraoperatively initially by an average of 20% but had approximately the starting volume of 2.2 l/min at the end of the operation. Although the diameter of the anastomosis was reduced to 4 mm, the flow in the arterialized PA on average was 340 ml/min when the vessel clamp was opened. At the end of operation the mean was 380 ml/min, the interval of measurement being 75 min. The flow across the PCS and the HA were constant during the course. As mechanism for this phenomenon, autoregulation of the liver blood flow on a sinusidal level has been suggested. The biochemical results and the histopathological findings showed no change compared to previous findings in a control group of animals in which liver transplantation was performed by our team. Complete arterialization of the PA is well tolerated in liver transplantation in 'Göttinger' miniature pigs with regard to circulation and liver function in a short-term trial of a maximum of 7 days. Long-term results are still to come.

Abscess is customarily thought of as a collection of a large number of microorganisms, inflammatory cells and necrotic debris separated from the surrounding tissue by a fibrous capsule. Modern work focussed attention on more physico-chemical parameters in abscess pathogenesis. Recent experiences from animal models underline the impact of abscess pressure and bio-physicochemical parameters in the "abscess compartment" for systemic spreading. Artificial raising of abscess-pressure in pigs up to 80 mmHg was followed by increase of temperature and heartbeat rate and decrease of median arterial pressure. Elevated levels of TNF alpha, IL-1 and positive blood cultures support the theory of abscess pressure as a most important variable in abscess formation. We conclude that abscess pressure may play a pivotal role in systemic spreading of the primarily localized process.

Hepatocellular carcinomas (HCC) frequently recur after partial liver resection or orthotopic liver transplantation, possibly because of the presence of a small number of hepatoma cells in the peripheral blood. Detection of circulating HCC cells might improve therapeutic options and could predict disease recurrence resulting from a metastasizing disease. In the present study, human albumin-mRNA was detected by RT-PCR in the peripheral blood of patients with hepatocellular carcinoma. Circulating albumin-specific PCR products were detected in each patient with HCC, but also in healthy volunteers. It is concluded that albumin-mRNA is not specific to circulating hepatoma cells and therefore does not indicate metastasizing disease.

In a rat model, the effect of the intraperitoneal application of fibrinolytic agents on the development of adhesions was examined. Streptokinase and TPA reduced sero-serosal adhesions significantly, whereas urokinase did not reduce them. Intravascular coagulation was not affected.

The aim of the study was to determine whether the induction of HSP70 by Zn2+ is able to protect the small bowel of rats against ischemia. Twenty-four male Wistar rats (weight 200-300 g) were divided into four groups: (1) saline treatment for 24 h (n = 4); (2) Zn2+ treatment for 24 h (n = 4); (3) Saline pretreatment for 24 h and ischemia (n = 8); (4) Zn2+ pretreatment for 24 h and ischemia (n = 8). Pretreatment with Zn2+ was carried out by intraperitoneal administration of 50 mg/kg zinc bis (DL-hydrogen aspartate) = 10 mg/kg Zn2+. Ischemia in a defined segment of the small bowel was produced by ligation of the mesenteric vein and artery and ligation of both ends of the segment. Tissue samples were collected before and 2, 4 and 6 h after ligation and investigated by histology, immunohistochemistry and Western blotting. Twenty-four h after i.p. Zn2+ injection, the small bowel expressed increased HSP70 tissue levels. Histology with subsequent grading of ischemic tissue injury showed significantly decreased tissue necrosis after Zn2+ pretreatment and HSP70 induction compared with saline pretreated controls. In conclusion, this study proves that Zn2+ is inducing HSP70 in the small bowel in vivo and hereby able to protect the small bowel against ischemia.

In both jurisdiction and medical science, given conditions require appropriate intervention, which may in turn result in norms being created. Norms, however, counteract individuality. An essential prerequisite for free decision--making is an absolute awareness of all possibilities available. Therefore the physician/surgeon too, is obliged to impart all relevant information to the patient prior to an operation to enable the patient to reach a decision, either to agree to or refuse the operation. This process of information transfer may sometimes fail on one or both sides. Treatment errors are usually classified according to scientific medical practice. In the case of "breach to duty in information patient" the final decision is the judges. As judicial decisions are not foreseeable, the communication between patient and surgeon thus becomes standardized and doctors tend to become defensive, resulting in the information becoming even more extensive covering all possible situations. There is no guarantee of success in surgery. Selective perception on the part of the patient is unavoidable and confidence in the relationship between patient and surgeon is beneficial to the patient's rehabilitation. Therefore, we should strive to decriminalize the preoperative talk held between surgeon and patient.

In a retrospective study including 163 patients we investigated the necessity of i.v. cholangiography in preoperative routine diagnostic workup prior to laparoscopic cholecystectomy. We evaluated the evidence of i.v. cholangiography concerning the anatomy of the biliary system, the evidence of common bile duct or cystic duct stones and the influence on the further therapeutic procedure. While the common bile duct could be demonstrated in 96.3%, the cystic duct could be visualized in only 54.6%. One out of two patients with a short cystic duct was identified. Stones in the gallbladder were recognized in 72.4% of cases, while only two out of three patients with common bile duct stones were diagnosed. In nine cases a deep junction of the cystic duct was found, but there was no influence on further operative procedure. Thus we found no improvement after routine use of i.v. cholangiography concerning the evidence of common bile duct stones or avoidance of intraoperative lesions of the common bile duct. The routine use of i.v. cholangiography prior to laparoscopic cholecystectomy is therefore not justified.

Using the pig as a model, it was shown that stimulation of the distal nerve ending of the pudendal nerve leads to the isolated stimulation of the external anal sphincter muscle. No difference in pressure response was noted after application of between 0.5 and 1.5 mA unilateral or bilateral stimulation. Major advantages observed using between 1.5 and 2.5 mA bilateral stimulation; with a stimulation between 2.0 and 2.5 mA the pressure response was twice as high compared to unilateral stimulation. Continuous stimulation of the striated anal sphincter muscle leads to fatigue, reaching 50% fatigue after a median time between 40-90 s. In cyclic stimulation (alternation every 15 s, duration 20 min) a fatigue reaction was also seen. The peak pressure decreased after 20 min for a median of 11%, the final pressure was lowered in 15% following a logarithmic curve pattern. The experimental application of variable impulse ranges also caused pressure differences. Increasing the impulse range from 200 to 450 microseconds (peak pressure) vs. 400 microseconds (final pressure) resulted in a statistically significant pressure increase. Therefore, it was proven that selective stimulation of the external anal sphincter muscle can lead to a transient pressure increase, which possibly improves fecal continence.