Langenbecks Archiv fur Chirurgie最新文献

Infected pelvic pressure sores of Campbell stages IV-VII require soft tissue reconstruction, which means stable, multi-layered filling cover of the defect and reliable prophylaxis of relapse. Myocutaneous flaps meet these conditions well. Depending on the extent and the area of the sore, with predilection for the sacrum, the ischial tuberosity and the femoral trochanter, the gluteus maximus, biceps femoris and tensor fasciae latae muscles are most often used for myocutaneous flaps. Primary sutures, split skin grafts or local fasciocutaneous flaps are often sufficient treatment for smaller, superficial defects. Between 1981 and 1996, 133 patients (average age 50 years) with 212 pelvic pressure sores of all stages were treated in our clinic. After radical decubitus excision with pseudotumor technique and resection of the osseous prominences, one-stage reconstruction of solitary as well as multiple defects was performed with myocutaneous flaps in 135 cases. The postoperative general complication rate for all treatments was about 10-30%. With regard to the muscle flaps, one third healed without any problems, partial flap necrosis occurred in 6% and there was total loss of flap in 2% of all myocutaneous flaps. According to present knowledge, myocutaneous flaps seem to be the most reliable method for definitive covering of deep pelvic pressure sores, independent of the cause of the ulcer.

Severe intra-abdominal infection is associated with a high mortality rate. In addition to risk factors in the patients, the causal pathogens and the selection of appropriate therapeutic procedures play an essential part in the course of these conditions. In the majority of intra-abdominal infections mixed aerobic/anaerobic infections, mostly with some involvement of enterobacteria and also of enterococci and staphylococci can be demonstrated. In addition to surgical intervention a calculated antimicrobial initial treatment of intra-abdominal infections with an antibiotic with an adequate effect to combat the pathogen concerned can contribute to improving the patient's prognosis. A calculated antibiotic treatment can only be effectively and reliably carried through if the frequency of the pathogen and the resistance situation are known. Retrospective evaluations of data on the sensitivity and frequency of pathogens from a defined group of subjects allow conclusions on the epidemiological situation in a particular catchment area or in a medical sector and thus make it possible to calculate the appropriate therapy for infections. In 1996 a total of 2,779 bacterial isolates from the intra-abdominal infection sector were examined: 935 Enterobacteriaceae, 83 nonfermenters, 177 Staphylococcus spp., 211 Enterococcus spp., 39 Streptococcus spp., and 1334 different anaerobic bacteria. Fresh clinical isolates were available for all pathogens tested. The most frequent gram-negative pathogen was E. coli (60%) and the most frequent gram-positive pathogen, E. faecalis (44%); the most frequent anaerobic pathogen was B. fragilis (39%). Taurolodine had the lowest resistance rate against gram-negative and anaerobic pathogens. Teicoplanin had the highest activity against gram-positive pathogens.

Inguinal hernia is a frequent surgical disease during infancy, occurring in 1 to 2% of all mature newborns and rise up to 30% of all premature babies. In 9.5% a contralateral hernia is found after unilateral operation. In our own patients this rate was 5.6%. The development of a contralateral hernia was significantly more often found in boys than in girls. If the hernia occurred during the first two months of life, a contralateral hernia developed later highly significant (p > 0.0001). Within the first two postoperative years the second hernia arose in 84.9%. We recommended to routinely operation for a contralateral hernia in all children younger than two months.

The application of open intraoperative intraperitoneal chemotherapy following cytoreductive surgery for the treatment of pseudomyxoma peritonei or peritoneal carcinomatosis requires safety precautions for the medical and non-medical personnel. In agreement with already existing rules, precautions were established which result in an optimum of safety. These concern the preparation of the cytostatic drugs, the application in the operating room as well as personal precautions intra- and postoperatively. After the establishment of theses recommendations, 22 patients were treated with open intraperitoneal chemotherapy in 1.5 years without any severe accidents. Therefore, a safe intraoperative use of cytotoxic drugs is possible. At the moment, the indication for such an approach may be given in peritoneal carcinomatosis from appendix, colon or ovarian cancer. In the future, an adjuvant application in other gastrointestinal malignancies (e.g. T3/T4 gastric carcinoma) may be considered.

For determination of the efficacy of intraluminal bowel decompression by an endoscopically placed Dennis tube, 174 patients with paralytic ileus or different kinds of partial small bowel obstruction were reviewed retrospectively. There were 66 cases (37.9%) of early postoperative ileus (A), 27 (15.5%) of late postoperative ileus (B), 38 (21.8%) of paralytic ileus (C), 31 (17.8%) with obstruction due to advanced intraabdominal tumors (D), and 12 (6.8%) of obstructive ileus caused by inflammatory stenosis of the small bowel in Crohn's disease (E). Successful endoscopic placement of the intestinal tube was achieved in 97.2% of patients. Placement of the tube was impossible in 5 cases. A total of 95 patients (54.6%) were successfully managed by long intestinal tube decompression. Success rates for the individual groups were 71.2% (A), 18.5% (B), 86.8% (C), 16.1% (D), and 41.7% (E). Some 75 patients (43.1%) had to be operated on because of insufficient conservative therapy. Four patients with advanced intraabdominal tumors died during the treatment with the intestinal tube; 13 patients died postoperatively. There was no tube-related mortality, but tube-related complications occurred in 6.9%. We conclude that intraluminal intestinal tube decompression after endoscopic placement provides a therapeutic tool with a concomitant low complication and high success rate in paralytic and early postoperative ileus.

Modern surgical hernia repair depends increasingly on synthetic meshes for reconstruction of the abdominal wall. Despite the undisputed advantages of the synthetic meshes currently available, reports of late complications after implantation are accumulating. It is essential that the synthetic meshes be improved, but this makes a standardized animal model necessary for evaluation of their biocompatibility on both functional and morphological levels. In the present study, commercially available polypropylene and polyester meshes were implanted in a rat model, and detailed morphological and morphometric analysis were carried out. Correlations between the morphological and morphometric data and the function of the artificial abdominal wall were then sought. In summary, the data show that the mesh construction currently available are oversized and definitely restrict the function of the artificial abdominal wall. The degree of inflammation and fibrosis, the pattern of fibrosis, and the composition of the extracellular matrix exert decisive influences on the function. Fibrosis and inflammation are caused less by the material itself, however, than by its density, the way it is processed, and its surface. Future, that is to say second-generated, mesh constructions should be designed with the aims of reducing the amount of material used and finding material-specific processing methods in mind, to improve the functionally and morphologically defined biocompatibility.

The somatostatin analogue octreotide is effective in the treatment of neuroendocrine and other tumours. 111-In-labelled DTPA-octreotide scintigraphy is successful in localizing primary neuroendocrine tumours and metastases and other tumours containing somatostatin receptors. An antiproliferative effect of octreotide was also demonstrated for colorectal carcinoma. Since only about 40% of colorectal carcinomas express somatostatin receptors, we tried to establish whether 111-In-labelled DTPA-octreotide scintigraphy is able to reveal the receptor status of liver metastases in patients with colorectal liver metastases. This would be useful in selecting patients for adjuvant therapy studies with octreotide. We performed 111-In-labelled DTPA-octreotide scintigraphy in ten patients with nonresectable liver metasoffes of colorectal origin and curatively resected primary. In nine of ten patients the liver metastases were somatostatin receptor negative, in one patient somatostatin receptor positive. In the patient with somatostatin receptor-positive liver metastases after resection of a rectal carcinoma, the histological examination of the biopsies from the liver metastases showed a solid tumour of neuroendocrinal differentiation. In the repeated histological examination of the specimen of the rectal primary, a small solid tumour with neuroendocrinal differentiation was found between formations of adenocarcinoma (adenoendocrine carcinoma). In our study 111-In-labelled DTPA-octreotide scintigraphy did not indicate the receptor status of liver metastases from colorectal carcinoma and was not useful in the planning of therapeutic regimens. For the diagnosis of the receptor status of colorectal liver metastases autoradiographic investigation on tissue biopsies are still necessary. In patients with adenoendocrine carcinomas 111-In-labelled DTPA-octreotide scintigraphy may help to histologically differentiate the metastases.