Karl H. Treutner

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.

VECTORMANOMETRY FOR DIFFERENTIAL DIAGNOSIS OF FECAL INCONTINENCE

PURPOSE: This study was designed to investigate the reliability of three-dimensional vectormanometry for differential diagnosis of fecal incontinence. METHODS: Eight-channel, continuous pull-out perfusion manometry was performed on 23 female patients with traumatic (n=11) or idiopathic (n=12) incontinence, respectively. RESULTS: At rest, the minimum sector pressure of patients with traumatic incontinence (32±14 mmHg) was significantly lower than it was in the controls (76±16 mmHg) and in those with idiopathic incontinence (64±28 mmHg) (P<0.001). At maximum squeezing, the minimum sector pressure was 57±22 mmHg in patients with traumatic incontinence and 79±33 mmHg in those with idiopathic incontinence, both being significantly lower than in the control group with 152±27 mmHg (P<0.001). The asymmetry index of the patients with a sphincter defect was significantly higher, both at rest (23±13 percent) and squeeze (26±12 percent), in comparison with the control group (7 ±2 percent at rest and 6.2±1.6 percent at squeeze) and the patients with idiopathic incontinence (10±5 percent at rest and 8.4±4 percent at squeeze). CONCLUSION: Three-dimensional vectormanometry identifies localized pressure deficits in the anal canal, thereby differentiating between sectorial and global sphincter insufficiency.

Phospholipids reduce adhesion formation in the rabbit uterine horn model

OBJECTIVE To access the ability of intraperitoneal phospholipids to reduce adhesions in a standardized model for gynecologic operations. DESIGN A randomized, experimental, blinded study using the double uterine horn model. SETTING Academic animal research laboratory. ANIMAL(S) Thirty-three Chinchilla rabbits. INTERVENTION(S) Phospholipids or Ringers lactate were intraperitoneally administered after bilateral uterine horn injury. MAIN OUTCOME MEASURE(S) After 10 days, adhesions were evaluated concerning area and strength as well as scores describing tenacity and degree. RESULT(S) Phospholipids (median 102.1 mm2) significantly reduce adhesion areas in comparison to surgical controls (median 392.2 mm2) and Ringer group (median 323.8 mm2). Scores reflecting severity and degree of adhesions support this finding. CONCLUSION(S) These results prove the efficacy of phospholipids in the double uterine horn model. Future clinical studies are recommended.

Diaphragm replacement: An experimental animal study

SummaryWe performed an open experimental study for evaluation of rapidly absorbable material of bovine serosa for diaphragm replacement. A total of 100 Sprague-Dawley rats were randomly assigned to five groups of equal size. In the control group (n=20) incision of the diaphragm was followed by primary suture. The animals of the four other groups underwent partial resection of the left hemidiaphragm. The defects were repaired by lyophilized dura, polytetrafluorethylene (PTFE), autologous transversus muscle or rapidly absorbable bovine serosa. We performed electromyography (EMG) and postmortem physical examinations of elasticity and load capacity of the different materials as well as histologic examinations after three and six months. A total of 89 animals survived and were subject to the analysis. There were no differences between the groups concerning growth and weight gain. The EMG showed normal function for the absorbable material and the transversus muscle. Only scanty physiologic waves were registered in the PTFE group. Load capacity measurements showed the lowest value of 4.71 N for the native diaphragm; all other materials had much higher values (17.66 N – 51.99 N) with a peak load capacity in the PTFE group. Measurements of elasticity displayed similar results. The native diaphragm had the lowest value (1516 N/m); much higher values were found in all the other materials tested (3905 N/m – 7654 N/m) with again peak values for PTFE. The differences of all materials compared to native diaphragm were statistically significant (p<0.05). The histologic examinations revealed strong foreign body reactions in the dura and PTFE groups. The absorbable bovine serosa had vanished three months postoperatively. Short-term absorbable bovine serosa tested successfully as a partial replacement of the diaphragm in this experimental study on rats. There may be additional indications for this material if a temperary replacement is intended.

Experimental Prevention of Peritoneal Adhesions in General Surgery

Postoperative peritoneal adhesions account for a wide range of clinical symptoms from unspecific abdominal complaints to intestinal obstruction. They make repeated surgery time-consuming and hazardous. This problem increases with longevity, the growing numbers of laparotomies worldwide, and the feasibility of operations on elderly patients. Adjuvant means are needed to reduce the formation of these adhesions.

Material and structure of drainages

ZusammenfassungDie lange Geschichte chirurgischer Drainagen steht im Gegensatz zu den verfügbaren, gesicherten Daten. Geschlossene Systeme aus Silikon sind aus heutiger Sicht zu bevorzugen. Berücksichtigt man die möglichen Komplikationen und die guten Resultate von Routineeingriffen ohne Drainagen, so sollte die Indikation zum Einsatz kritisch gestellt werden.Die interdisziplinäre Forschung bietet im Hinblick auf Material- und Oberflächeneigenschaften, Biostabilität,Biokompatibilität und Flussraten jedoch Möglichkeiten zur weiteren Optimierung.Neue Drainagen mit höherer Effektivität und geringeren Nebenwirkungen könnten der aktuellen Tendenz zum Verzicht entgegenwirken.AbstractThe long history of surgical drainages stands in contradiction to available and reliable data. As of today, closed systems made of silicone are preferable.Taking possible complications into consideration and the good results of routine operations without drainages, indication for use should be critically evaluated. Interdisciplinary research,however, offers the chance of optimizing material and surface characteristics, biostability, biocompatibility, and flow rates.New drainages with improved performance and reduced side effects may counteract the current tendency to do without.

PERIOPERATIVE ORGANISATIONSABLAUFE AUS DER SICHT DES CHIRURGEN

Summary. Perioperative management requires close cooperation between the referring practitioner, anesthesiologist, surgeon, and nursing staff. Standards in diagnostics, risk assessment, and choice of procedure, as well as integration of the anesthesiologist into the surgical outpatient department, are all important prerequisites for the optimum preparation of patients. Elective operations are to be planned in advance, taking into account the surgical resources available. Additional operating rooms with interdisciplinary access should be available for emergency procedures. Turnaraound times between operations can be reduced by separate rooms for pre- and postsurgical preparation and recovery. Small functional units allow for a flexible response to necessary changes in the schedule. These measures increase the quality of treatment and economic efficiency, as well as the satisfaction of patients and staff.Zusammenfassung. Die Organisation der perioperativen Abläufe verlangt eine enge Kooperation zwischen zuweisendem Arzt, Anaesthesist, Chirurg und Pflegepersonal. Standards bei Diagnostik, Risikoeinstufung und Verfahrenswahl sowie die Integration des Anaesthesisten in die chirurgische Poliklinik sind wichtige Voraussetzungen für die optimale Vorbereitung des Patienten. Elektiveingriffe sollten unter Berücksichtigung der verfügbaren Operationskapazitäten im voraus geplant werden. Für Notfalleingriffe sollten interdisziplinär verfügbare Operationssäle zur Verfügung stehen. Die Wechselzeiten zwischen den Eingriffen können durch Bereitstellung von Räumen und Personal für die prä- und postoperative Phase verkürzt werden. Kleine Funktionseinheiten ermöglichen eine flexible Reaktion auf notwendige Änderungen des geplanten Ablaufes. Durch diese Maßnahmen lassen sich die Qualität der Behandlung und die wirtschaftliche Effizienz sowie die Zufriedenheit von Patienten und Mitarbeitern steigern.

Einfluss von Phospholipiden und Icodextrin auf Infektion und Adhäsionen bei Peritonitis

Background Bacterial peritonitis is a strong promoter of adhesion formation besides mechanical, chemical, thermic, and ischemic trauma. In the present study the usefulness of fluid devices, that worked efficaciously in other, non infectious models, was evaluated in a standardized rat peritonitis model.

Phospholipide reduzieren Adhäsionen im Uterus-Horn-Modell beim Kaninchen

Background. Adhesion formation following gynecologic or visceral surgery is a major cause of female infertility. Further sequelae are recurrent and chronic abdominal complaints and pain. Adjuvant therapy is needed to prevent adhesion formation as an important reason for postoperative morbidity and mortality. Previously published data proved the efficacy of phospholipids (PL) for this indication. This study was designed to access the ability of intraperitoneal phospholipids to reduce adhesions in a standardized model for gynecologic operations. Materials and Methods: A total of 33 female Chinchilla rabbits were included in this study. After lower midline incision a 5 cm segment the uterine horns were abraded circularly and ischemia was induced by removal of the collateral blood supply. The operation was completed by intraperitoneal administration of 5.0 ml per kg body weight of phospholipids (75 mg per kg body weight) or the same volume of Ringer‘s lactate solution. In animals assigned to the surgical control group, the abdomen was closed without additional treatment. After 10 days the animals were sacrificed and adhesions were examined and scored concerning severity and tenacity. The force of adhesions measuring larger than 25 mm2 were assessed using a spring scale (values in Newton). After subtle dissection the areas of adhesions (mm2) were measured using a digitizer board and a custom-made software on a personal computer. Results: The mean area of adhesions in the surgical control group amounted to 394.0 mm2 ±41.9 mm2 (median 392.2 mm2) in comparison to 384.2 ± 67.0 mm2 (median 323.8 mm2) in the Ringer group and 110.3 mm2 ±25.1 mm2 (median 102.1mm2) in the phospholipid (PL) group. The comparison of the control group and the Ringer group versus the PL group were significant (p < 0.05). The differences in the severity score and the degree score according to Leach between surgical controls and PL as well as Ringer and PL were significant (p < 0.05). The differences of the force to tear apart the adhesions were significant (p < 0.05). Statistical analysis of the force correlated with the area of the measured adhesions revealed no significant difference. Conclusions: These results prove the efficacy of phospholipids in the double uterine horn model. Further clinical studies are recommended.

Auswirkungen der intraabdominellen Applikation von Phospholipiden auf Wundheilung und Adhäsionsbildung

Background: Adjuvant therapy is needed to prevent adhesion formation as a major cause of postoperative morbidity and mortality. Previously published data proved the efficacy of phospholipids (PL) for this indication; however, additional information on drug safety was still outstanding. This study was designed to investigate the influence of phospholipids on three different types of healing tissue. Materials and Methods: A total of 48 Chinchilla rabbits underwent median laparotomy, standardized abrasion of the visceral and parietal peritoneum, jejunal anastomosis, and an electrocautery incision of the liver. The operation was completed by intraperitoneal administration of 10 ml/kg of either normal saline (NaCl, 0.9%) or phospholipids (PL, 12%). After intervals of 5 and 10 days, respectively, 50% of the surviving animals were sacrificed and adhesions were measured using a digitizer board. The fresh 10-cm long segment of the jejunum carrying the anastomosis was examined using a bursting experiment. Tensile strength of the midline laparotomy wound was assessed. Specimens of the scar tissue of liver, anastomosis, and abdominal wall were stained with Sirius red and Fast green to determine the collagen protein ratio. Results: After 5 (NaCl 691 mm2 vs. PL 192 mm2 ) and after 10 days (NaCl 625 mm2 vs. PL 88 mm2) the control group presented with significantly larger adhesion areas (p < 0.05). The bursting pressure of the anastomosis on the fifth (NaCl 16.1 kPa vs. PL 18.2 kPa) and tenth (NaCl 19.7 kPa vs. PL 18.6 kPa) postoperative day showed no statistically significant difference. The tensile strength of the laparotomy wound measured after intervals of 5 (NaCl 8.5 N cm-1 vs. PL 6.8 N cm-1) and 10 days (NaCl 23.0 N cm-1 vs. PL 20.2 N cm-1) was not statistically different either. The collagen protein ratio of anastomoses, laparotomy wounds, and liver incisions, as well as the inflammatory reparative response of the different tissues, were not affected by PL. Conclusions: These results prove the efficacy of phospholipids in adhesion prevention. The findings of uncompromised healing of anastomoses, laparotomy wounds, and liver incisions reveal the safety of this agent. Further data may qualify phospholipids for a clinical trial.