C. Hasse

Influence of ultrasound on clinical decision making in acute appendicitis : A prospective study

OBJECTIVE To assess the efficacy of ultrasound (US) as part of an algorithm to establish the indication for laparotomy in patients with suspected acute appendicitis. DESIGN Prospective investigation. SETTING University department of surgery, Germany. SUBJECTS 669 unselected patients admitted with suspected acute appendicitis. INTERVENTIONS Clinicopathological and procedural diagnoses of the algorithm were evaluated by correlating clinical and US findings with the results of laparotomy in 171 patients of whom 143 had acute appendicitis (prevalence 21%), and clinical as well as follow up data in the remainder. MAIN OUTCOME MEASURES The major clinicopathological variables were accuracy and positive predictive value; the rate of negative laparotomies and that of bad diagnostic errors served as the main procedural variables. RESULTS The overall sensitivity, specificity, and accuracy of the clinical diagnosis were 0.503, 0.950, and 0.855, respectively (positive predictive value: PPV 0.734, negative predictive value: NPV 0.875), those of ultrasound: 0.797, 0.967, and 0.931 (PPV 0.870, NPV 0.946); and 0.853, 0.927, and 0.940 at the end of the algorithm (PPV 0.762, NPV 0.958). However, the algorithm would have resulted in a significant increase in the rate of unnecessary laparotomies (from 13% to 16%). A revised clinical algorithm gave an overall diagnostic accuracy of 0.940 (p < 0.001) together with a low rate of negative laparotomies (11%, p < 0.01) and a significantly reduced number of diagnostic errors (from 71 to 21, p < 0.001). CONCLUSION Ultrasonography enabled us to diagnose acute appendicitis in more patients more often and more quickly than clinical evaluation alone, suggesting that US may produce a better outcome. The revised clinical algorithm may be helpful in the study of US in patients with suspected acute appendicitis in prospective randomised controlled clinical trials.

Hepatic-portal venous gas in acute colonic diverticulitis

The diagnosis and assessment of severity of acute colonic diverticulitis may be difficult. A case is presented, in which the delayed diagnosis of diverticulitis resulted in the development of a diverticular mesocolic abscess complicated by hepatic-portal venous gas (HPVG). The utility of ultrasound as a rapid, noninvasive tool to diagnose this distinctly rare condition is outlined. The literature on HPVG associated with acute colonic diverticulitis is reviewed, and the therapeutic options are discussed.

Influence of Ceruletid on Gallbladder Contraction: A Possible Prophylaxis of Acute Acalculous Cholecystitis in Intensive Care Patients?

The purpose of this study was to investigate the utility of repeated applications of ceruletid to reduce gallbladder volume and its feasibility as a means of prophylaxis of acute acalculous cholecystitis in intensive care patients. First, a dose-response curve of ceruletid was obtained in 20 mechanically ventilated patients of a surgical intensive care unit (SICU) not receiving enteral nutrition. An effective dose of ceruletid, defined by a 50% reduction of gallbladder volume was established and subsequently studied in 40 mechanically ventilated SICU patients on total parenteral nutrition in a prospective, randomized, controlled, triple-blind trial. Gallbladder volume, sludge formation and side effects were evaluated. A dose of 1.5 micrograms/kg body weight ceruletid was established as the effective dose, causing 50% reduction of gallbladder volume in all patients studied and reduction of gallbladder sludge in 95%. In 67.5% of patients side effects were observed, requiring therapeutic intervention in 68%. It is concluded that ceruletid is effective in stimulating gallbladder contraction and reducing sludge formation in severely ill patients on intensive care units. Its routine use as prophylaxis of acute acalculous cholecystitis, however, may be limited by the nature, severity and frequency of side effects.

Amitogenes Alginat — Schlüssel zum ersten klinischen Einsatz der Microencapsulierungstechnologie

Aufgrund der vielfaltigen Stoffwechselfunktionen des Parathormons ist die medikamentose Therapie des permanenten Hypoparathyreoidismus von allen endokrinen Unterfunktionstorungen am schwierigsten. Ziel ist deshalb die kausale Therapie dieses Mangelsyndroms, die Allo- oder Xenotransplantation der Parathyreoidea. Der Bedarf, allein fur die BR Deutschland, wird auf mindestens 1500 Transplantationen pro Jahr geschatzt.

Zystische nebenschilddrüsenadenome : pathologisch-anatomische variante von epithelkörperchenadenomen oder krankheitsbild mit eigener bedeutung?

SummaryBetween 01. 01.1987 and 31.12.1990 a primary operation was performed on 126 patients in the Dept. of General Surgery, University of Marburg Hospital for primary hyperparathyroidism due to a parathyroid adenoma. Their clinically relevant data were prospectively documented. In 6 patients (4.8%) a total of 7 cystic parathyroid adenomas was found. While there was no difference in age- and sex-distribution, patients with cystic adenomas were found to have markedly higher serum parathormone and alkaline phosphatase levels than patients with solid adenomas. Calcium levels were similar in both groups. Cystic adenomas were much heavier than solid adenomas. A significant number of cystic adenomas was found to be displaced into the posterior mediastinum. The property of cystic parathyroid adenomas to be frequently located away from their usual anatomical position can make the intraoperative search for them difficult.ZusammenfassungDie klinisch relevanten Daten von 126 Patienten, die sich zwischen dem 1.1.1987 und dem 31.12.1990 wegen eines Nebenschilddrüsenadenoms an der Klinik für Allgemeinchirurgie der Philipps-Universität Marburg einer Erstoperation unterzogen, wurden prospektiv dokumentiert. Bei 6 Patienten (4,8 %) wurden insgesamt 7 zystische Adenome gefunden. Bei gleicher Alters- and Geschlechtsverteilung wiesen Patienten mit zystischen Adenomen deutlich höhere Serumspiegel für Parathormon and alkalische Phosphatase auf als die mit soliden Adenomen. Der Serumkalziumspiegel in den beiden Gruppen war nicht unterschiedlich. Zystische Adenome waren deutlich schwerer als solide Adenome. Ein erheblicher Anteil der zystischen Adenome war in das hintere Mediastinum verlagert. Die Eigenschaft zystischer Nebenschilddrüsenadenome, häufig nicht an den normalen anatomischen Positionen zu liegen, kann bei ihrer intraoperativen Suche zu Schwierigkeiten führen.

Optimierung der Sauerstoffversorgung von Mikrokapseln zur transgenen Transplantation der Parathyreoidea durch Perfluorokarbon (FC 43)

Background: At least 1000 new patients per annum suffer from permanent hypoparathyroidism in Germany alone, generally caused by thyroid surgery. The need for transgenic transplantation of parathyroid tissue (PT) is undisputed. In this study it was tested whether perfluorocarbone (FC 43) increases as additive the oxygen supply and stability of microcapsules containing PT, as the first results in islet cell transplantation have indicated before. Methods: Hyperplastic PT was cut into 144, ca. 2-mm3 large particles and underwent a tissue culture passage. After 3 days, 48 of these particles were microencapsulated without and with FC 43, respectively, in highly purified alginate microspheres. A total of 48 native PT particles formed the control group. Every 4 days the stability of the capsules was controlled by a standardized test. The function of the encapsulated PT was evaluated by the measurement of the PTH release every 4 days and the vitality of PT was determined by histological evaluation (H&E staining). The duration of the study was 32 days for all measurements. Results: The diameters of microcapsules without and with FC 43 remained nearly constant with 2.26±0.09 and 2.21±0.12 mm. PTH release was in the median 2068.14 pg/ml (initially: 3249.52 pg/ml) for microcapsules without FC 43 and 3051.17 pg/ml (initially: 2814.54 pg/ml) for microcapsules containing FC 43 and 67.1 pg/ml (initially: 2698.53 pg/ml) for native PT particles after 32 days. Histologically, PT of microcapsules without FC 43 showed a vitality of 45% after 32 days, whereas PT encapsulated with FC 43 had a vitality of 55%. Native PT particles already developed total necrosis after 8 days. Conclusions: These results clearly indicate the importance of the biophysical properties of alginate material for the microencapsulated transplants. FC 43 significantly improves in vitro the nutritive supply of encapsulated PT followed by increased function while maintaining constant stability of the microspheres.

Functional parameters before and after parathyroidectomy: a prospective, randomized long-term trial on different rat strains.

For clinical controls before and after parathyroidectomy and for evaluation of the function of transplants of parathyroid tissue, it is necessary to establish standard values of relevant laboratory parameters for donor and recipient animals as well as for different types of nutrition. Since no such data are yet available, it was the purpose to define such standards. In a prospective randomized trial on 400 rats of the Dark Agouti (DA) and Lewis strain, different functional laboratory parameters such as total calcium, intact parathyroid hormone, phosphate, 1.25-dihydroxyvitamin D, and alkaline phosphatase were measured under a standard and low calcium diet over a period of 40 weeks. Two hundred of these animals underwent a parathyroidectomy four weeks after the beginning of the study and specimens were evaluated histologically. For all eight different study groups normal values could be defined within tight limits for parameters which describe the function of the parathyroid gland or elements of calcium metabolism under different conditions. The optimal conditions for a transplantation model of parathyroid glands were established. Lewis-rats were identified as the ideal donor and DA rats as the better recipient animals. These data can serve as reference values for future studies on transplantation of the parathyroid without immunosuppression.

Heterologe Transplantation der humanen Parathyreoidea nach Mikroenkapsulierung mit klinisch einsetzbarem Alginat: Langzeitfunktion ohne Immunsuppression im Tierversuch

Wenn uber einen Zeitraum von 6 Monaten hinaus, an mehreren Tagen gemessen, Calcium- und Parathormonkonzentrationen im Serum unterhalb des Normbereiches liegen, sprechen wir von permanentem Hypoparathyreoidismus. Er ist symptomatisch, wenn Beschwerden und/oder Folgeerkrankungen auftreten, die mit diesem Mangelsyndrom verbunden sind bzw. mit ihm assoziiert werden.

Ist die Prophylaxe der Streßgallenblase mit Ceruletid möglich

Ziel unserer Untersuchungen war es zu prufen, ob und in welcher Dosis das Medikament Ceruletid die Gallenblase von Intensivpatienten zur 50%igen Volumenverminderung als Prophylaxe der alkalkulosen Cholezystitis bringen kann und mit welchen Nebenwirkungen dies verbunden ist. Fur die Tonisierung der Gallenblase bedarf es 1,2 μg/kg Korpergewicht Ceruletid. Darunter kommt es bei 92 % der Patienten (37/40) zu einer Gallenblasenkontraktion, die zu einer Verringerung des Ausgangsvolumens um mehr als die Halfte fuhrt. Bei 32,5% der Patienten (n = 13) traten Nebenwirkungen in Form von Hypotonie und Storungen des Elektrolyt- und Saure-Basen-Haushaltes auf, in 5 Fallen (12,5%) mit therapeutischen Konsequenzen. Ceruletid ist in der Lage, das Gallenblasenvolumen von Intensivpatienten deutlich zu vermindern und kann so mit der Prophylaxe der alkalulosen Cholezystitis dienen. Dessen Nebenwirkungen mussen jedoch auf die Entscheidung uber einen solchen Einsatz des Medikamentes einfliesen.

Experimentelle Allotransplantation von Rattennebenschilddrüsen: Nachweis der Langzeitfunktion ohne Immunsuppression

Aufgrand der vielfaltigen Stoffwechselfunktionen des Parathormons ist die medikamentose Therapie des permanenten Hypoparathyreoidismus von allen endokrinen Unterfunktionsstorungen am schwierigsten. Wahrend die Autotransplantation von Epithelkorperchengewebe inzwischen klinisch erprobt ist (Brennan et al 1979; Saxe et al 1982), befindet sich die Allotransplantation ohne postoperative Immunsuppression noch im tierexperimentellen Stadium. Problematisch ist die Manipulation der Immunogenitat, die einen langfristigen Transplantationserfolg bisher verhinderte (Roka et al 1982; Sollinger et al 1983). Von zentraler Bedeutung sollen die mittransplantierten immunkompetenten Zellen (Passenger-Leukocyten) sowie die Expression der Klasse-I-Antigene sein (Sollinger et al 1983).