Ch. Herfarth

Risks of intestinal anastomoses in Crohn's disease.

Six hundred fifty-eight intestinal anastomoses in 429 operations for Crohns disease were studied prospectively during an 8-year period to detect variables connected with perioperative morbidity. Postoperative complications occurred in 9.7% of the patients, 4% had to be reoperated on, and the overall mortality rate was 0.5%. In multivariate analysis by stepwise logistic regression, the only variable significantly (p = 0.03) associated with overall rate of complications was long-term corticosteroid therapy. Serious complications were more common in cases of intra-abdominal abscesses (p = 0.01) and preoperative steroid medication (p = 0.03). The combination of both of these risk factors increased the rate of reoperations from 0.6% (no steroids, no abscess) to 16% (steroids and abscess). No significant association with postoperative complications could be found for age, sex, duration of disease, previous operations, nutritional status, emergency surgery, extent of disease, type, number, and localization of anastomoses, presence of proximal ileo-/colostomy, or histologically inflamed margins of resection.

Postoperative Recurrence of Crohn’s Disease in Relation to Radicality of Operation and Sulfasalazine Prophylaxis: A Multicenter Trial

Recurrence rate is high after operation for Crohns disease. A multicenter trial was performed to study the effect of radical or nonradical operation and of sulfasalazine prophylaxis versus placebo on postoperative recurrence rate in 232 patients with Crohns disease. Sixteen medical and surgical centers participated in the study, 7 operating radically and 9 nonradically. The follow-up period lasted 3 years, the allocation to drug treatment was randomized and double blind. Recurrence was significantly less frequent and occurred later in patients who were operated nonradically. Patients on sulfasalazine prophylaxis had a better prognosis than on placebo. This effect was statistically significant in the first 2 years of treatment. Both strategies were additive: nonradical operation and sulfasalazine had the best prognosis, radical operation and placebo was worst. It is concluded that postoperative recurrence is best prevented by resecting nonradically and prescribing 3 g of sulfasalazine daily at least over 2 years.

Long-term follow-up after ileoanal pouch procedure

PURPOSE: Inflammation of the ileoanal pouch (pouchitis) is one of the main complications after restorative proctocolectomy, yet its cause remains poorly understood. A standardized definition and diagnostic procedures in pouchitis are lacking. METHOD: We analyzed all cases of pouchitis occurring in a group of 308 patients (210 with ulcerative colitis, 98 with familial adenomatous polyposis) who took part in a prospective long-term follow-up program. The severity of pouchitis was measured using a pouchitis activity score (Heidelberg Pouchitis Activity Score). An algorithm for the classification and management of pouchitis was established which enables the clinician: 1) to determine theseverity of pouchitis, 2) to differentiate betweenprimary pouchitis and pouchitis caused by surgical complications (secondary pouchitis), and 3) to evaluate the course (acute vs. chronic (>3 months)). RESULTS: The median duration of follow-up was 48 (range, 13–119) months. At least one episode of pouchitis was diagnosed in 29 percent of patients with ulcerative colitis and in 2 percent of familial adenomatous polyposis patients. Secondary pouchitis occurred in 6 percent of ulcerative colitis patients and was cured by surgical treatment in 13 (87 percent) of 15 cases. Primary pouchitis was diagnosed in 23 percent of ulcerative colitis patients, including 6 percent of all ulcerative colitis patients with chronic primary pouchitis. The latter showed poor response to medical treatment. In one case multifocal high-grade dysplasia occurred. Histologic examination of the excised pouch identified a carcinoma originating from the ileal mucosa. CONCLUSIONS: Ulcerative colitis patients after restorative proctocolectomy face a high risk of developing pouchitis. The algorithm used in this study was highly efficient in identifying patients with a secondary pouchitis who require surgical treatment and patients with chronic primary pouchitis. For the latter, long-term surveillance seems mandatory because of the risk of malignant transformation of the pouch mucosa.

Effect of pressure and gas type on intraabdominal, subcutaneous, and blood pH in laparoscopy

AbstractBackground: According to the literature, the number of port-site metastases in laparoscopic surgery varies considerably depending on the type of gas used for the pneumoperitoneum. In order to investigate this observation we studied the changes in blood, subcutaneous, and intra-abdominal pH during laparoscopy with helium, CO2 and room air in a rat model. In addition, we looked at the influence of intra-abdominal pressure and duration of pneumoperitoneum on the pH during the laparoscopy. Methods: pH was measured by tonometry, intra-abdominally and subcutaneously. A pH electrode was additionally placed into the subcutaneous tissue and the results compared to those measured by tonometry. Blood samples were taken from a catheter in the carotid artery. The intra-abdominal pressure was 0, 3, 6, 9 mmHg for 30 min in each case. We investigated the effect of pneumoperitoneum with CO2, helium and air in randomized groups of 5 rats. In an additional series the pressure was held constant at 3 mmHg and the pH was measured every 30 min. Results: Due to the different absorption capacity of the peritoneum, laparoscopy with CO2 decreases the subcutaneous pH from 7.35 to 6.81. Blood pH is reduced from 7.37 to 7.17 and the intra-abdominal pH from 7.35 to 6.24. Other, less absorbable gases induce smaller changes of blood and subcutaneous pH (only 10% of CO2). In a variance analysis the p value is less than 0.001. The influence of duration of laparoscopy (30 min vs 90 min) on the subcutaneous pH is less compared to the influence of intra-abdominal pressure (0, 3, 6, 9 mmHg). Conclusions: Depending on the type of gas (CO2, air, helium) used for laparoscopy blood, subcutaneous and intra-abdominal pH are influenced differently. Because lower pH is known to impair local defense mechanisms, these results may be one explanation for the higher incidence of port-site metastasis in laparoscopy with CO2 than with other gases, as reported in the literature.

Prospective randomized study of stress and immune response after laparoscopic vs conventional colonic resection

AbstractMethods: In order to evaluate the stress and immunological response to laparoscopic and conventional colon resection we operated on male Wistar rats (350–380 g), performing either laparoscopic (n= 15) or open colon resection (n= 15). A third group (n= 10) underwent anesthesia only. Immediately before and after surgery as well as 1 and 7 days postoperatively a 1 ml sample of blood was taken from the retrobulbar veinous plexus. Stress (corticosterone) and immune parameters (neopterin and interleukin [IL] 1-β) were measured. Furthermore, the body weight as a parameter of postoperative recovery was monitored. Results: The analysis of variance showed significant differences between the three groups over a period of 1 week (p < 0.0001 for corticosterone, p= 0.0854 for IL 1-β, p= 0.0045 for neopterin). Additionally in a t-test significant differences were found between the laparoscopic and conventional group with regard to corticosterone (p= 0.08), to neopterin (p= 0.045), and to IL 1-β (p= 0.0043) at the end of the operation.One week after the operation the stress and immune parameters were back to normal levels in each group except IL 1-β, but the recovery indicated by body weight was different according to the kind of the applied operative procedure: 7 days postoperatively the rats lost 5.99% of their body weight after open surgery and only 2.4% after laparoscopic surgery. After anesthesia only the body weight increased by about 4.8%. Conclusion: Laparoscopic colon resection alters the stress and immune system of healthy rats less than open colon resection. This observation is confirmed by the quicker recovery in laparoscopically operated rats.

A new way for surgical education — development and evaluation of a computer-based training module

Computer-based training (CBT) programs teach the material of a specific field and at the same time offer various ways of objectively assessing the knowledge gained. The interactive use of multi-media components such as text, graphics, animation, sound, digital slide shows, and videos as well as quizzes can theoretically facilitate the learning process. The aim of this study was the development and evaluation of a CBT-program by surgeons for student training. Using SuperCard, a teaching module for Distal Radius Fracture (DRF) was developed, which contains detailed clinical information. Video clips and vivid animations combine theoretical knowledge with practical experience. Fourth-year medical students (n = 103) were tested after using the module for 90 min. Other students (n = 47) served as the control group. In a 90 min lecture, DRF was discussed. CBT gained in all evaluated criteria (distinctiveness, detailed description, presentation of materials, structure, motivation for learning, time saved learning and memory retention) 15-20% better scores than the lecture. Although 82% of the students stated that their experience with computers was limited or insufficient, 100% found the use of CBT systems useful in student teaching. Most of them suggested the use of such programs as a method of exam preparation/self study (90%) or as a supplement to a lecture (40%). Based on these evaluations, CBT modules are an appropriate future teaching and learning system that is well accepted. In conclusion, the results of this study show that CBT-programs could be a valuable supplement to medical education. In addition, further development of CBT-programs and their use as information systems for surgical residency programs at universities can be suggested.

Erstes kontinuierliches Nerven-Monitoring in der Schilddrüsenchirurgie

Abstract. A new „all in one“ sensing device was developed for continuous transtracheal intraoperative monitoring and in situ detection of the recurrent laryngeal nerve (RLN) during thyroid surgery. Patients and methods: The new system is based on a double-balloon endotracheal tube with integrated atraumatic stimulating and tracing electrodes. The recurrent laryngeal nerve is stimulated transtracheally and compound action potentials are recorded from the laryngeal muscles. Fifty-five patients were introduced into a phase-one clinical trial. Thirty-five patients with primary thyroid operations, 20 patients with reoperations, 10 of whom had neck dissections. All patients were evaluated laryngoscopically and phoniatrically by an ENT specialist before and after surgery. Results: Compound muscle action potentials were recorded continuously during the whole operation and responded sensitively to tension and pressure to the nerve. There were no accidental permanent RLN palsies. Conclusion: The new system offers five advantages: (1) it is atraumatic; (2) it is easy to use; (3) it can monitor continuously with an audio feedback to the surgeon; (4) it works outside the operation field; and (5) it is highly sensitive, even indicating reversible irritation to the nerve.Zusammenfassung. Ein neuartiges „all in one“ Monitoringsystem für den N. laryngeus recurrens (NLR) erlaubt sowohl eine kontinuierliche, atraumatische Überwachung des NLR als auch eine in situ Detektion des Nerven. Patienten und Methode: Das System basiert auf einem Doppelballontubus mit integrierten Oberflächenelektroden zur transtrachealen Stimulation und Ableitung des Erfolgsorgans. Fakultativ kann über eine elektrische Stimulationsnadel der NLR im OP-Feld identifiziert werden. Die Signalverarbeitungs-Software stellt eine Neuentwicklung unserer Arbeitsgruppe dar und führt eine Echtzeit-Signalanalyse mit akustischer Rückkoppelung durch. 55 Patienten wurden in die klinische Zulassungsstudie eingebracht, 35 Primäreingriffe, 20 Sekundäreingriffe, davon 10 Halsausräumungen. Ergebnisse: Die Plazierung des EMG-Tubus ist mit der Routineintubation abgeschlossen und erfordert keinen zusätzlichen Zeitbedarf. Das System ist außerhalb des OP Feldes lokalisiert und beeinträchtigt daher nicht den OP Ablauf. Die akustische Rückkoppelung wurde von allen 8 Operateuren als hilfreich und nicht störend beurteilt. Die phoniatrische und HNO-ärztliche Analyse erbrachte keine permanenten Beeinträchtigungen. Schlußfolgerung: Das neue kontinuierliche Monitoringsystem ermöglicht erstmals eine atraumatische nebenwirkungsfreie Dauerüberwachung des NLR. Es ist einfach anzuwenden, arbeitet außerhalb des OP-Gebiets und ist so sensitiv, daß auch reversible Irritationen erkannt werden können.

Beitrag zur Morphologie der Niere beim akuten Nierenversagen

ZusammenfassungAn Nieren von insgesamt 38 ausgewählten Patienten, die an den Folgen eines akuten Nierenversagens gestorben waren bzw. bei denen in den letzten Lebenstagen die Zeichen einer akuten Niereninsuffizienz bestanden hatten, wurden bei 750facher Vergrößerung jeweils 10–20 quergetroffene Tubuli contorti I und II sowie absteigende Henleschen Schleifen planimetriert und die Ergebnisse statistisch ausgewertet. Als Kontrolle dienten die Nieren von 10 Patienten, deren Nierenfunktion bis zum Tode normal gewesen war. Dabei zeigte sich in erster Linie, daß es nach Schockzuständen unabhängig vom Grundleiden relativ oft zu einer mehr oder weniger hochgradigen Dilatation der Lichtungen der Tubuli contorti I kommt. Diese Erweiterung geht zum Teil mit einer Zunahme der mittleren Gesamtfläche der Hauptstücke einher. Die Lumenweite der absteigenden Henleschen Schleifen entspricht annähernd der der Kontrollnieren. Die mittlere Gesamtfläche der Tubuli contorti II stimmt mit der der normalen Nieren überein oder liegt etwas unter dem Kontrollwert, das zugehörige Lumen ist nur bei einem Teil der Fälle weiter als bei den Kontrollnieren, die Epithelfläche jedoch stets mehr oder weniger vermindert. Die im Vordergrund unserer Befunde stehendediffuse Dilatation der Hauptstücklichtungen, die sich vor allem bei jenen Fällen findet, bei denen keine Nekrosen der Tubulusepithelien bestehen, läßt sich nicht mit einer Verstopfung der Lumina der distalen Abschnitte des Nephrons durch Zylinder erklären. Diese Dilatation muß vielmehr auf eine intratubuläre Drucksteigerung zurückgeführt werden, deren mögliche Pathogenese im einzelnen diskutiert wird. Es wird schließlich im Sinne einer Arbeitshypothese die Ansicht vertreten, daß diese intratubuläre Drucksteigerung unter anderem eine Kompression der Tubuli contorti II mit so hochgradigem konsekutivem intratubulärem Druckanstieg zur Folge hat, daß zwischen den Henleschen Schleifen und den Tubuli contorti 2. Ordnung kein Druckgefälle mehr besteht. Dieses Fehlen eines intratubulären Druckgefälles ist vermutlich bei der Mehrzahl unserer Fälle von akutem Nierenversagen die Ursache der hier festgestellten Anurie bzw. Oligurie.

Diagnosis and treatment of retroperitoneal hematoma in multiple trauma patients.

SummaryFrom 1984 to 1991 20 multiple trauma patients with pelvic fractures and retroperitoneal bleeding from pelvic vessels underwent angiographic localization and embolization of massively bleeding arterial vessels. Nine patients survived (multiple trauma index grade III, Hanover polytrauma index), three patients with very severe injuries died immediately (multiple trauma index grade IV). After successful control of bleeding by embolization, three other patients died from severe brain injuries and five patients from septic multiorgan failure. The interval to definite localization and treatment of the bleeding source was three times shorter in the group of survivors, and the amount of transfusions needed was less by a factor of three. This underlines the importance of early angiography in multiple trauma patients with pelvic fractures and persisting hemorrhage. Embolization has proven to be effective in the treatment of such injuries.

Soluble lnterleukin-2 Receptor, lnterleukin-6 and Interleukin-1 β in Patients with Crohn’s Disease and Ulcerative Colitis: Preoperative Levels and Postoperative Changes of Serum Concentrations

Crohns disease (CD) and ulcerative colitis (UC) show an intestinal activation of T cells and macrophages within the inflamed lesions. The aim of the present prospective study was to determine whether circulating interleukins (IL) represent useful markers of immune activation in vivo and to characterize their respective roles in monitoring disease activity. Serum concentrations of the soluble IL-2 receptor (sIL-2R), IL-6 and IL-1 beta were measured in 10 patients with CD and 10 patients with UC before, at day 10 and 2 years after resection of inflamed bowel segments. The data were correlated with neopterin, C-reactive protein and other standard parameters of disease activity. Preoperatively, mean sIL-2R concentration was 495 +/- 62 U/ml (mean +/- SEM; healthy controls; 210 +/- 25 U/ml; p less than 0.02) in CD and 705 +/- 120 U/ml (p less than 0.00002) in UC. The corresponding IL-6 serum concentrations were 37 +/- 6 U/ml in CD (controls: 11 +/- 0.6 U/ml; p less than 0.0036) and 33 +/- 6 U/ml (p less than 0.04) in UC. Two years postoperatively, sIL-2R was still elevated in 6 out of 9 patients in both disease groups. These patients did not differ from the remaining group with respect to disease activity. Serum IL-6, elevated in 7 patients with CD and in 6 patients with UC at day 10 postoperatively, had returned to normal in all patients by this time.(ABSTRACT TRUNCATED AT 250 WORDS)