G. Winkeltau

Results of intersphincteric resection of the rectum with direct coloanal anastomosis for rectal carcinoma.

Between 1977 and 1987, 519 patients underwent operation for rectal carcinoma. Sixty-three patients underwent intersphincteric resection with direct coloanal anastomosis (CAA), and 77 had an abdominoperineal resection (APR). Curative surgery was achieved in 57 and 65 patients, respectively. Both groups were comparable regarding age, stage of tumors, and localization of tumors. During the mean period of 6.7 years (range: 3 to 13.6 years), all patients were examined according to a predefined follow-up plan. From those patients with curative surgery, 11% presented with pelvic recurrence and 33% with distant metastases after coloanal anastomosis; the rates of recurrence and distant metastases after APR were 17% and 35%, respectively. The corrected 5-year survival rates were 62% following CAA and 53% following APR. Eighty-five percent of the patients with CAA reported good functional results regarding anal continence. Our study demonstrates that the intersphincteric resection with CAA is a valuable surgical technique for rectal carcinoma with the benefit of preservation of continence. It is suitable for neoplasms with high- and medium-grade differentiation (G1 to G2) and a localization that allows a minimum distal clearence of 3 cm.

Induction of heat shock protein 70 by zinc-bis-(DL-hydrogenaspartate) reduces cytokine liberation, apoptosis, and mortality rate in a rat model of LD100 endotoxemia.

A prospective, randomized model of LD100/24 h endotoxemia was performed in male Wistar rats (n = 26; 250–300 g). The animals were divided into four groups: Group I (n = 5; saline treatment only), Group II (n = 5; Zn2+ treatment only), Group III (n = 8; saline pretreatment, lipdpolysaccharide (LPS) treatment), and Group IV (n = 8; Zn2+ pretreatment, LPS treatment). Zn2+ pretreatment was carried out by intraperitoneal injection of 50 mg/kg zinc-bis-(DL-hydrogenaspartate) (10 mg/kg Zn2+). LD100/24 h endotoxemia was induced by intraperitoneal administration of 20 mg/kg LPS of the Escherichia coli strain WO111:B4. Tumor necrosis factor α, interleukin-1β, and interleukin-6 were detected by enzyme-linked immunosorbent assay (ELISA). HSP70 expression in the lungs, the liver, and the kidneys was determined by immunohistochemistry, Western blotting, and an HSP70 ELISA. Apoptosis was also detected by an in situ apoptosis detection kit (TUNEL) and a cell death detection ELISA, respectively. This rat model of endotoxemia proves the close relationship between HSP70 expression, cytokine liberation, and development of apoptosis. The data demonstrate that: 1) Zn2+ is a potent inducer of HSP70 expression; 2) the application of Zn2+ leads to slightly increased cytokine plasma levels; and 3) the manipulation of the heat shock response by Zn2+ significantly increases the survival rate after LD100 endotoxemia. Enhanced survival rate in animals pretreated with Zn2+ may be explained by increased tissue levels of HSP70, a subsequent significantly decreased liberation of the proinflammatory cytokines after LPS challenge, and a significantly decreased rate of apoptosis.

The Influence Of Heat Shock Protein 70 Induction On Hemodynamic Variables In A Porcine Model Of Recurrent Endotoxemia

The manipulation of stress gene expression by heavy metals provides protection against the lethal effects of endotoxemia in murine models of septic shock. These findings suggest that the increased resistance to endotoxin in vivo after stress protein induction could be explained by an attenuation of hemodynamic alterations and an altered pattern of inflammatory mediator release. Therefore, we measured main hemodynamic variables such as systemic and pulmonary artery pressure, cardiac output, heart rate, central venous pressure, and pulmonary artery wedge pressure, as well as the time-course of thromboxane-B2, 6-keto-PGF1α, and interleukin 6 formation with and without induction of the stress response in an established porcine model of recurrent endotoxemia (Circ Shock 35:237–244, 1991). Induction of the stress response was carried out by a pretreatment with Zn2+ (25 mg/kg zinc-bis-(DL-hydrogenaspartate) = 5 mg/kg Zn2+). Pretreatment with Zn2+ prior to lipopolysaccharide (LPS) infusion induced an increased heat shock protein 70 (HSP70) expression in the lungs, liver, and kidneys and significantly increased plasma levels of interleukin 6, 6-keto-PGF1α, and thromboxane-B2, compared with untreated controls. After LPS infusion, however, pretreated animals showed significantly decreased peak plasma levels of all mediators compared with the untreated group. Hemodynamic data presented significantly decreased peak pulmonary artery pressure and pulmonary vascular resistance index values, significantly increased systemic artery pressure and systemic vascular resistance index values, and significantly altered hypodynamic/hyperdynamic cardiac output levels in the pretreated group. In conclusion, the data show that the induction of HSP70 by Zn2+ attenuates the liberation of inflammatory mediators, as well as the course of hemodynamic variables due to LPS.

Bedside ultrasound in decision making for emergency surgery: Its role in medical intensive care patients

During an 18-month period the authors followed 1,024 patients referred to a general medical intensive care unit. A total of 7% of these patients underwent emergency surgery at some point during their admission. The role of abdominal ultrasound in the decision-making process for these emergency surgical interventions was evaluated and the patients were identified for whom the pathologic result of sonography was regarded sufficient to operate without any additional imaging procedures. Of 71 patients with unexpected surgical emergencies, abdominal ultrasound provided a definite diagnosis for 18 patients (25%), and the decision to operate could be made without delaying for further or more invasive diagnostic techniques. In all cases the sonographic diagnosis was confirmed during the operation. The critical care patients most likely to benefit from bedside ultrasound in a surgical emergency were those with hemorrhage of unknown origin (44%) or septicemia from an undetected focus (39%). The most frequent site of operation where ultrasound was considered diagnostic was the urinary tract (56%), particularly in emergencies following renal transplantation.

Postoperative, intraabdominelle Adhäsionen —Ein neues standardisiertes und objektiviertes Tiermodell und Testung von Substanzen zur Adhasionsprophylaxe

Summary80 male Sprague Dawley rats were divided in 8 groups of equal size. After median laparotomy defined abrasions of the serosa of abdominal wall, cecum and ileum were performed (400p, abrasive paper 280 grains/cm2, 8 cm2). The control group (I) received no medication. In the treatment groups 5 ml of the following agents were instilled before closure of the abdominal wall: normal saline (II), 16 250 IE Neomycin with 1250 IE Bacitracin (III), 30% dextrose (MW 70 000) (IV), 50 000 IE Streptokinase with 12 500 IE Streptodornase (V), or TCDO in concentrations of 10% (VI), 50% (VII), and 100% (VIII). All animals were relaparotomized on the 7th postoperative day, the adhesions were dissected and their extent was calculated by computer aid. Furthermore specimens were obtained for microscopic studies. Compared to the controls no reduction of adhesions could be achieved by dextrose. Significantly more adhesions were observed after treatment with Neomycin/Bacitracin. A reduction of about 23% was registered with normal saline and TCDO 10%. The greatest reduction of adhesions was seen after application of Streptokinase/Streptodornase as well as TCDO in concentrations of 50% and 100% (63%). The results were significant after evaluation with the Mest. Histologically there was a correlation between the extent of adhesions and the fibrin film. The new animal model has proven to result in reproducible data if used to evaluate substances for prevention of adhesions. Clinical studies with the best of these agents could serve as an approach to solve the problem of adhesion ileus.Zusammenfassung80 männliche Sprague Dawley-Ratten wurden in 8 gleich große Gruppen eingeteilt. An Bauchwand, Coecum und Ileum wurden im Rahmen einer medianen Laparotomie definierte Serosaldsionen gesetzt (400p, 280er Schleifpapier, 8 cm2). Die Kontrollgruppe (I) erhielt keine Medikation. In den Behandlungsgruppen wurden vor Verschluß der Bauchdecken jeweils 5 ml der folgenden Substanzen instilliert: 0,9% NaCI-Lösung (II), 16 250 IE Neomycin mit 1250 IE Bacitracin (III), 30%iges Dextran (MW 70 000) (IV), 50 000 IE Streptokinase mit 12 500 IE Streptodornase (V) oder Chlor-IV-oxid-Sauerstoff-Komplex-(4:1)-Hydrat (TCDO) in den Konzentrationen 10% (VI), 50% (VII) und 100% (VIII). Am 7. postoperativen Tag wurden alle Tiere relaparotomiert, die Adhäsionen wurden präpariert und das Ausmaß der Verwachsungen rechnergestiitzt vermessen. Zudem wurden Prdparate zur histologischen Untersuchung gewonnen. Mit Dextran konnte keine Reduktion der Adhäsionsfldchen gegenüber der Kontrollgruppe erreicht wurden. Deutlich umfangreichere Verwachsungen wurden bei Anwendung von Neomycin/Bacitracin gesehen. Mit NaCl und 10%igem TCDO ließ sich der Adhäsionsumfang um etwa 23% senken. Die größte Reduktion der Adhäsionen wurde mit Streptokinase/Streptodornase sowie TCDO in den Konzentrationen 50% und 100% erzielt (63%). Die Ergebnisse waren imt-Test significant. Histologisch korrelierte der Verwachsungsumfang mit der Fibrinausschwitzung. Das neue Tiermodell konnte seine Eignung zur reproduzierbaren Substanztestung unter Beweis stellen. Klinische Überprüfungen der im Versuch besten Substanzen könnten einen Ansatz zur Lösung des Problems Adhäsionsileus darstellen.

Chirurgische therapie von lebermetastasen therapieverfahren, ergebnisse und prognosefaktoren

In a period of 7 years, 151 patients were treated by resection and/or regional chemotherapy after liver metastases from various primary tumours. The subgroup of patients with colorectal liver metastases was evaluated separately from the heterogeneous group with any other primaries. Radical resection of colorectal liver metastases was followed by a 5-year survival of 17%. The time from resection of the primary to development of the metastatic lesions was shown by univariate and multivariate analysis to be the most important prognostic factor. Adjuvant regional chemotherapy failed to improve outcome after curative resection of liver metastases. Neither palliative regional chemotherapy in cases of diffuse hepatic metastases nor the combination of palliative resection with regional or systemic chemotherapy significantly prolonged survival.ZusammenfassungIn einem Zeitraum von 7 Jahren wurden 151 Patienten mit Lebermetastasen verschiedener Primartumoren durch Leberresektion and/oder regionale Chemotherapie behandelt. Aufgrund der Heterogenität and geringen Zahl der übrigen Primartumoren wurden Patienten mit kolorektalem Karzinom gesondert betrachtet. Die beste Prognose wurde durch eine potentiell kurative Resektion mit einer 5-Jahres-Überlebensrate von 17% erzielt. Einziger signifikanter and unabhängiger Prognoseparameter war neben der Radikalität das Intervall zwischen Primärtumoroperation and Auftreten der Metastasierung. Durch eine adjuvante regionale Chemotherapie konme kein zusätzlicher Prognosegewinn nach kurativer Resektion erzielt werden. Die alleinige regionale Chemotherapie bei diffuser hepatischer Metastasierung führte ebenso wie die additive regionale oder systemdsche Chemotherapie nach palliativer Leberresektion zu keiner signifikanten Verlängerung der Überlebenszeiten.

Protection of intestinal anastomoses by biodegradable intraluminal bypass tubes under the condition of general peritonitis: An experimental study on the CLP model in rats

The purpose of this experimental study was to affirm the protective effect of biodegradable tubes for the intraluminal bypass procedure under the adverse condition of general peritonitis. General peritonitis was induced by means of the cecal ligation and puncture (CLP) model in the rat. The leakage rate in the control group (n=20) without anastomotic protection was 70 percent (14/20). In three therapeutic groups, each consisting of 20 animals, the intestinal anastomoses were protected by an intraluminal bypass tube of different biodegradable biomaterials (collagen-II, BCL-002, and BCL-004). The best results were noted in the collagen-II and BCL-002 groups, where the leakage rates could be reduced to 10 percent. These highly significant results (P=0.0001) prove the feasibility of biodegradable biomaterials for the intraluminal bypass procedure in the rat, even in cases with underlying peritonitis.

Die intraluminäre Schienung problematischer intestinaler Anastomosen mit Biomaterialrohren

SummaryWe performed small intestinal dissection in 80 laboratory rats. A critical anastomosis was achieved by two point adaption of small intestine with single sutures. 10 control animals receiving no intestinal splinting died within two days of operation. The remaining 70 animals underwent intestinal internal splinting with tubes of different absorbable (Polyglactine, Collagen, and B 111) and non-absorbable (Polyurethane) biomaterials. Significantly smaller leakage rates in the therapy groups proved the principle of internal splinting of complicated anastomoses in this animal model to be effective.ZusammenfassungIn einem tierexperimentellen Grundlagenversuch wurde an 80 Ratten das Prinzip der inneren Schienung problematischer intestinaler Anastomosen mit Biomaterialrohren überprüft. Eine problematische Anastomose entstand durch Zweipunktadaptation des oberen Dünndarmes. Alle Tiere der Kontrollgruppe (n =10) ohne innere Schienung verstarben bis zum zweiten postoperativen Tag. In den Behandlungsgruppen I-IV (n = 70) wurde die Dünndarmanastomose durch intraluminär plazierte, resorbierbare (Polyglactin, Kollagen, B 111) bzw. nicht resorbierbare (Polyurethan) Biomaterialrohre gesichert. Signifikant geringere Insuffizienzraten in den Behandlungs gruppen belegen die prinzipielle Effektivität dieses Verfahrens.We performed small intestinal dissection in 80 laboratory rats. A critical anastomosis was achieved by two point adaptation of small intestine with single sutures. 10 control animals receiving no intestinal splinting died within two days of operation. The remaining 70 animals underwent intestinal internal splinting with tubes of different absorbable (Polyglactine, Collagen, and B111) and non-absorbable (Polyurethane) biomaterials. Significantly smaller leakage rates in the therapy groups proved the principle of internal splinting of complicated anastomoses in this animal model to be effective.

Prophylaxe postoperativer, intraabdomineller Adhäsionen: Substanzprüfung mit einem neuen, standardisierten und objektivierten, tierexperimentellen Modell

In bis zu 75% der Falle sind Verwachsungen fur die Entstehung eines Ileus verantwortlich. Bei etwa 40% dieses Krankengutes geht diesem mit einer Appendektomie lediglich ein kleiner, chirurgischer Eingriff voraus. Dem gegenuber steht die hohe Mortalitat des Adhasionsileus von 8 – 17%. Trotz subtiler Operations technik und des Einsatzes von Antibiotica und Rheologica konnte die Komplikationsrate postoperativer Verwachsungen nicht entschei dend gesenkt werden. Deshalb ist der gezielte Einsatz von Pharmaka zur Pravention intraabdomineller Adhasionen zu erwagen (1, 3, 5).

[Significance of pancreatic and duodenal secretions for the protection of gastrointestinal anastomoses following stomach resection--an animal experiment study].

SummaryThe consequences of deviation of pancreatic juice and bile after gastric resection were studied in an experimental animal model in 66 rats. After hemigastrectomy and Billroth I resp. Billroth II anastomoses papilla vateri was transplanted into a deep jejunal limb in a B I and a B II group each. Absence of alkaline secretions of Papilla vateri was followed by a marked increase in acidity in the gastric remnant and connected intestine. Especially in the Billroth II operated stomach we found an increased ulcer risk under these circumstances. With additional histaminestimulation frequency of ulcer was 75% in Billroth II but only 33% in Billroth I animals. When alkaline reflux was preserved the ulcer rate ranged from 15 to 40% in all groups. These results confirmed the protective property of postresectional reflux for the integrity of anastomoses after gastric resection. The increased resistance of Billroth I anastomoses in spite of deficient luminal acid buffers could be explained by the mucus-bicarbonate-barrier of the duodenal mucosa.ZusammenfassungIn einer tierexperimentellen Studie an 66 Ratten wurde der Einfluß der isolierten Ableitung der alkalischen Papillensekrete auf Sekretion und Morphologie des Resektionsmagens untersucht. Nach distaler Hemigastrektomie und Billroth 1 bzw. Billroth 11 Anastomose erfolgte die autologe Transplantation der Papilla Vateri in eine tiefe Jejunumschlinge in je einer B 1 und B 11 Gruppe. Es zeigte sich, daß der Verlust von Pankreas- und Gallereflux die Acidität in Restmagen und anastomosiertem Dünndarm steigert. Im Spontanverlauf sowie bei submaximaler Histaminstimulation war unter diesen Bedingungen im Billroth 11 Magen eine verstärkte Disposition zum Anastomosenulcus zu beobachten. 75% aller Billroth II Tiere mit Ableitung der Papillensekrete entwickelten ein Ulcus. In der vergleichbaren Billroth 1 Gruppe waren es 33% der Tiere. Bei erhaltenem alkalischem Reflux lag die Ulcusfrequenz uniform zwischen 15 und 40%. Die vorliegenden Ergebnisse bestätigen das protektive Prinzip des postresektionellen Refluxes für die Integrität der gastroenteralen Anastomose nach Magenresektion. Die größere Säureresistenz der Billroth 1 Anastomose auch bei insuffizienter luminärer Säurepufferung ist durch die mucosaeigene Schleim-Bicarbonat-Barriere des Duodenums zu erklären.