Michael Ardelt

Microbiology of the infected recurrent sacrococcygeal pilonidal sinus

The aim of the present retrospective single centre study was to define the changes in the microbiological flora of the recurring sacrococcygeal pilonidal sinus (PS). Microbiological findings of swab samples of abscess‐forming PS from 2000 to 2010 were evaluated. Within this time span, 73 swab samples were taken from primary sacrococcygeal pilonidal sinus (pPS) and 23 swab samples of patients with recurring sacrococcygeal pilonidal sinus (rPS). Our results show a statistically significant shift of the bacterial flora towards the gram‐positive range (P = 0·029) and a shift with tendency towards the aerobic range (P = 0·090). Pathogens of pPS are not always solely anaerobic or gram‐negative, and those of rPS not always aerobic or gram‐positive. Therefore, antibiosis preceding microbiological examination should cover both the aerobic and anaerobic bacteria as well as the gram‐positive and the gram‐negative spectrum.

Role of NK, NKT cells and macrophages in liver transplantation.

Liver transplantation has become the treatment of choice for acute or chronic liver disease. Because the liver acts as an innate immunity-dominant organ, there are immunological differences between the liver and other organs. The specific features of hepatic natural killer (NK), NKT and Kupffer cells and their role in the mechanism of liver transplant rejection, tolerance and hepatic ischemia-reperfusion injury are discussed in this review.

Post-operative internal hernia through an orifice underneath the right common iliac artery after Dargent's operation.

We report the case of a 39-year-old woman with ileus resulting from a small bowel incarceration underneath the right common iliac artery. The patient had a history of a radical trachelectomy with laparoscopic pelvic lymphadenectomy (“Dargent’s operation”) for cervical carcinoma. After dissection of the iliac vessels, a small bowel loop could slide underneath the common iliac artery. The hernia was closed by gluing a collagen patch over the right common iliac artery onto the retroperitoneal cavity. To our knowledge, such a case has not previously been reported in the medical literature.

Liver transplantation for hepatocellular carcinoma - factors influencing outcome and disease-free survival.

Hepatocellular carcinoma is one of the leading causes of cancer-related death worldwide. Liver transplantation can be a curative treatment in selected patients. However, there are several factors that influence disease-free survival after transplantation. This review addresses the pre-, intra- and postoperative factors that influence the risk of tumor recurrence after liver transplantation.

Suture granuloma mimicking a recurrent sacro-coccygeal pilonidal sinus after Limberg flap

Sacro‐coccygeal pilonidal sinus disease is classified as an asymptomatic, acutely abscess‐forming or chronic subcutaneous inflammation in the sacro‐coccygeal region featuring characteristic pits in the bottom cleft. Due to high rates of recurrence, two flap techniques have been established in the course of the past three decades. One of them is the Karydakis operation, the other option is a rotation flap named Limberg procedure. We report about a case of suture granuloma in the area of a Limberg flap after recurrent pilonidal sinus with extrusion of the suture material, thus mimicking recurrence. In case of recurrent pilonidal sinus following plastic coverage or primary closure, respectively, the differential diagnosis of suture granuloma should be considered.

Rapid progressive colon cancer metastasized to the right epididymis and liver: report of a case and review of the literature

Dear Editor: Colorectal cancer is the third most common malignancy with 1.2 million new patients per year [1]. Overall survival rates improved significantly over the last decades, and 5-year survival rate is actually about 65 % for all patients and tumor stages [1]. Depending on the tumor spread, survival rates decrease from 90 % in localized to about 70 % with regional metastases and to about 12 % with distant metastatic spread [2]. Apart from regional lymph nodes, the liver represents the most common site of distant metastases (with 15–25 % of all colorectal cancer patients) [3]. Metastases of colorectal cancer to the testes are uncommon and only 35 patients have been reported so far [4]. To shed light on this infrequent presentation of a colon cancer metastasis, we present this unusual case of a young patient with occlusive colorectal cancer undergoing emergency resection due to ileus with rapid progressive metastases to the right epididymis and liver.

Induction of chronic cholestasis without liver cirrhosis - Creation of an animal model

AIM To analyze time intervals of inflammation and regeneration in a cholestatic rat liver model. METHODS In 36 Lewis rats, divided into six groups of 6 animals (postoperative observation periods: 1, 2, 3, 4, 6, 8 wk), the main bile duct was ligated with two ligatures and observed for the periods mentioned above. For laboratory evaluation, cholestasis parameters (bilirubin, γ-GT), liver cell parameters (ASAT, ALAT) and liver synthesis parameters (quick, albumin) were determined. For histological analysis, HE, EvG, ASDCL and HMGB-1 stainings were performed. Furthermore, we used the mRNA of IL-33, GADD45a and p-21 for analyzing cellular stress and regeneration in cholestatic rats. RESULTS In chemical laboratory and histological evaluation, a distinction between acute and chronic cholestatic liver injury with identification of inflammation and regeneration could be demonstrated by an increase in cholestasis (bilirubin: 1-wk group, 156.83 ± 34.12 μmol/L, P = 0.004) and liver cell parameters (ASAT: 2-wk group, 2.1 ± 2.19 μmol/L.s, P = 0.03; ALAT: 2-wk group, 1.03 ± 0.38 μmol/L.s, P = 0.03) after bile duct ligation (BDL). Histological evaluation showed an increase of bile ducts per portal field (3-wk group, 48 ± 6.13, P = 0.004) during the first four weeks after bile duct ligation. In addition to inflammation, which is an expression of acute cholestasis, there was an increase of necrotic areas in the histological sections (2-wk group, 1.38% ± 2.28% per slide, P = 0.002). Furthermore, the inflammation could be verified by ASDCL (4-wk group, 22 ± 5.93 positive cells per portal field, P = 0.041) and HMGB-1 [2-wk group, 13 ± 8.18 positive cells per field of view (FoV), P = 0.065] staining. Therefore, in summary of the laboratory evaluation and histological studies, acute cholestasis could be found during the first four weeks after bile duct ligation. Subsequently, the described parameters declined so that chronic cholestasis could be assumed. For quantification of secondary biliary cirrhosis, eosin staining was performed, which did not reveal any signs of liver remodeling, thus precluding the development of a chronic cholestasis model. Additionally, to establish the chronic cholestasis model, we evaluated liver regeneration capacity through measurements of IL-33, p-21 and GADD45a mRNA. CONCLUSION We created a chronic cholestasis model. The point of inflammatory and regenerative balance was reached after four weeks. This finding should be used for experimental approaches dealing with chronic cholestatic liver damage.

Searching the ideal hepatocellular carcinoma patient for liver transplantation: are the Toronto criteria a step in the right direction?

Since the introduction of Milan criteria by Mazzaferro et al. in 1996 (1), many transplant programs and allocation systems use these criteria for the selection of suitable candidates for liver transplantation in hepatocellular carcinoma (HCC) patients.

Bowel Ischemia in ICU Patients: Diagnostic Value of I-FABP Depends on the Interval to the Triggering Event

Background Intestinal fatty acid-binding protein (I-FABP) has been shown to be of high diagnostic value in patients with acute mesenteric ischemia. Whether these results can be reproduced in critically ill patients on the ICU was to be investigated. Materials and Methods I-FABP was measured in serum and urine of 43 critically ill patients in ICU when mesenteric ischemia was suspected. Bowel ischemia was confirmed in 21 patients (group 1). 22 patients who survived at least seven days without confirmation of ischemia were assigned to group 2. I-FABP levels were compared between the groups, and interval from the event that has triggered ischemia to I-FABP measurement was recorded. Results For the identification of patients with mesenteric ischemia, sensitivity, specificity, and area under the curve (AUC) for serum and urine I-FABP were 33.3%, 95.5%, and 0.565 and 81.3%, 70.0%, and 0.694, respectively. I-FABP measurements performed within 12 to 48 h after the event that triggered ischemia showed a sensitivity, specificity, and AUC for serum and urine of 75%, 100%, and 0.853 and 100%, 73.3%, and 0.856, respectively. Conclusions In ICU patients, one single I-FABP measurement at the time of clinical suspicion failed to reliably detect or exclude mesenteric ischemia. A higher diagnostic value of I-FABP was only confirmed in the early stages of mesenteric ischemia. I-FABP may be used most appropriately in perioperative monitoring.

Anatomic effect of classical Limberg plastic surgery procedure in the sacro-coccygeal region for pilonidal sinus disease - a pilot study

Abstract Objective Sacro-coccygeal pilonidal sinus disease is a frequent surgical problem. Some authors assign the low recurrence rates of the Limberg flap to the flattening or elevation of the nat...