Reduced neorectal capacitance is a more important factor for impaired defecatory function after rectal resection than the anal sphincter pressure.

OBJECTIVE: The role of the diverse anorectal diagnostic tools like manometry and determination of the preception threshold and the maximal tolerable volume is still a matter of debate. Currently, there is a scarcity of physiological data in the long-term follow-up of patients who underwent sphincter-preserving rectal resection. The aim of this study was therefore to perform these anorectal physiological measurements and to correlate the determined parameters with a faecal incontinence score. METHOD: In 45 patients, anorectal manometry, electromyography (EMG) and neorectal volume measurements were performed 21.6 +/- 1.4 months after rectal resection. Additionally, patients answered questions to help in the determination of a modified faecal incontinence score. RESULTS: More than half of the patients had more than four bowel movements per day and suffered from defecatory urgency, evacuation and discrimination problems. Manometric data were not related to any functional deficits. In contrast, perception threshold and maximal tolerable volume were correlated with the faecal incontinence score. CONCLUSION: Defecatory problems especially after radiochemotherapy are still common after rectal resection and the satisfactory functionality post resection should not be oversimplified to just the number of bowel movements. A precondition of an adequate defecation is not only the integrity of the sphincter muscles, but also the recovery of the rectal reservoir function.

[Anatomic and atypical resections of the gallbladder bed in patients with gallbladder carcinoma]. / Anatomische und atypische Resektionen des Gallenblasenbetts beim Gallenblasenkarzinom.

BACKGROUND: At present, atypical as well as anatomic liver resections are recommended as the surgical therapy for gallbladder cancer (GC) at stages > or = T 2. The aim of this study was to compare atypical with anatomic resections (mostly resections of segments IV b / V with selective vascular occlusion using the round ligament approach). PATIENTS AND METHODS: Between November 1994 and January 2007, n = 56 patients were treated for GC. The staging, operative and histological results and the postoperative course were recorded. In addition, the survivals at a mean follow-up of 13 (range: 3-54) months were estimated and compared between the two study groups. RESULTS: We performed 28 liver resections for GC (n = 14 atypical and n = 14 anatomic resections). In the anatomic resection group, there was one extended right hepatectomy as well as thirteen segment IV b / V resections. The volume of the resected liver specimen, the frequency of the Pringle manoeuvre, the transfusion requirements, and the duration of the operation did not differ between the two study groups. However, in only 64 % of the atypical resections, the recommended resection margin of at least 3 cm could be achieved. One patient died after extended hepatectomy. There were no other major complications. The mean follow-up was 16 +/- 5 months in the anatomic and 22 +/- 7 months in the atypical resection group. Survival was not statistically different between the two study groups. CONCLUSION: Segment IV b / V resections are attractive procedures to treat GC due to their lower invasiveness in spite oncological adequacy. However, we could not demonstrate any superiority in terms of survival for the segment IV b / V liver resections. Nevertheless, extended liver resections are rarely necessary in the operative treatment of GC.

Inhibition of hemoxygenase-1 improves survival after liver resection in jaundiced rats.

BACKGROUND: The role of hemoxygenase (HO)-1 after partial liver resection (PLR) in jaundiced animals has yet to be defined. We therefore investigated: (1) the acute effects of bile duct ligation (BDL) on bilirubin accumulation and hepatocellular integrity after PLR; (2) how BDL and PLR affect HO-1 protein expression; (3) how functional HO-1 blockade affects survival and liver regeneration after BDL and PLR. METHODS: Male Sprague-Dawley rats were subjected to BDL or a sham operation. After 3 days, a 70% hepatectomy was performed. In a second set of experiments, BDL animals received either Sn(IV) mesoporphyrin IX dichloride (SnMP) for HO-1 blockade or a vehicle. Three days later, PLR was performed and survival of the animals was observed for 7 days. RESULTS: PLR, BDL and both together cause a hepatocellular injury and HO-1 expression. Inhibition of HO-1 with SnMP in jaundiced rats that underwent PLR was associated with improved survival, attenuated postoperative weight loss and better liver synthesis. CONCLUSION: The present findings add further evidence that the protective properties of increased HO-1 expression largely depend on the model used, and that HO-1 overexpression in the model of liver resection during acute cholestasis may also be detrimental.

[Public service strike. Effects on operating room management and training at a surgical university clinic]. / Streik im öffentlichen Dienst. Folgen für OP-Management und fachärztliche Weiterbildung an einer chirurgischen Universitätsklinik.

BACKGROUND: In 2006 the longest strike so far in the German health service occurred. Contrary to most hospitals in public authorities, the medical doctors of the University Hospital of Homburg/Saar did not participate in the strike, leading to pronounced tensions between patients, strikers and medical staff. MATERIAL AND METHODS: The effect of the strike on operating room (OR) management, medical personnel resource planning, and surgical training were compared with the remaining period of the year 2006. RESULTS: Elective surgical procedures were accomplished significantly more frequently by more qualified surgeons, leading to shorter OR time; surgical training was performed significantly less. The rate of emergency operations and the care of tumor patients increased significantly during the strike. CONCLUSION: Surgical training was neglected during the strike. Transferring non-job-related tasks to medical doctors and expanding their working time allowed optimal utilization of the limited resources.

Monitoring of acid-base and regulating variables during abdominal lavage.

This prospective clinical study was performed to determine acid-base regulating variables during abdominal lavage treatment for patients with severe peritonitis or after abdominal surgery. Arterial blood was sampled from twelve patients with secondary peritonitis and nine patients after abdominal surgery without peritonitis at three time points: immediately before, immediately after and 15 minutes after abdominal lavage with normal saline solution. The total amount of irrigant fluid, the strong ion difference [(Na+ + K+)-(Cl- + lactate-)], and total protein concentrations were determined and standard bicarbonate, standard base excess were calculated from pH and PaCO2. Peritonitis patients developed a moderate alkalaemia (pH 7.440-7.485). The alkalaemia was unmasked after optimization of mild hypoventilation, but was supported by a decrease in protein concentration of about 3.4 mEql/l in the first 15 minutes after the lavage. There was no marked increase in chloride concentration in either the peritonitis or the control group. The data indirectly exclude major fluid absorption during abdominal lavage with 3000 to 6000 ml normal saline, given that we found no clinically relevant electrolyte and acid-base changes that might be expected after rapid fluid absorption. The factors of major influence in acid-base regulation were ventilation and protein loss in the course of abdominal lavage. Monitoring of the Stewart variables is an easily applicable method of monitoring acid-base regulating variables in the perioperative course of patients undergoing abdominal lavage therapy.

Limits of peritoneal cytokine measurements during abdominal lavage treatment for intraabdominal sepsis.

BACKGROUND: Monitoring of peritoneal cytokine concentrations of tumor necrosis factor (TNF)-alpha was recommended for early detection of severe postoperative complications. In the present study the clinical application of cytokine monitoring was examined in the treatment course of severe peritonitis. METHODS: Nineteen patients with secondary peritonitis were followed up during 75 abdominal lavages. Serum and peritoneal interleukin (IL)-6, IL-8, and IL-10 and TNF-alpha were measured before the surgical intervention, after 1 hour, 3 hours, 6 hours, and 24 hours. Additionally, cardiorespiratory parameters, osmolarity, C-reactive protein, and total leucocyte count were recorded. RESULTS: Serum and peritoneal cytokine concentrations did not correlate to each other as well as to the observed cardiorespiratory parameters. Peritoneal cytokine concentrations were 10- to 1000-fold higher to serum concentrations and showed an intermittent wash out. There were no differences in determined cytokine concentrations between survivors and nonsurvivors. CONCLUSIONS: Once elevated, peritoneal cytokine measurements offer no new diagnostic or prognostic tool in abdominal lavage peritonitis treatment.

Acid-base changes caused by 5% albumin versus 6% hydroxyethyl starch solution in patients undergoing acute normovolemic hemodilution: a randomized prospective study.

BACKGROUND: Preoperative acute normovolemic hemodilution (ANH) is an excellent model for evaluating the effects of different colloid solutions that are free of bicarbonate but have large chloride concentrations on acid-base equilibrium. METHODS: In 20 patients undergoing gynecologic surgery, ANH to a hematocrit of 22% was performed. Two groups of 10 patients each were randomly assigned to receive either 5% albumin or 6% hydroxyethyl starch solutions containing chloride concentrations of 150 and 154 mm, respectively, during ANH. Blood volume (double label measurement of plasma and red cell volumes), pH, Paco2, and serum concentrations of sodium, potassium, chloride, lactate, ionized calcium, phosphate, albumin, and total protein were measured before and 20 min after completion of ANH. Strong ion difference was calculated as serum sodium plus serum potassium minus serum chloride minus serum lactate. The amount of weak plasma acid was calculated using a computer program. RESULTS: After ANH, blood volume was well maintained in both groups. ANH caused slight metabolic acidosis with hyperchloremia and a concomitant decrease in strong ion difference. Plasma albumin concentration decreased after hemodilution with 6% hydroxyethyl starch solution and increased after hemodilution with 5% albumin solution. Despite a three-times larger decrease in strong ion difference after ANH with 6% hydroxyethyl starch solution, the decrease in pH was nearly the same in both groups. CONCLUSIONS: ANH with 5% albumin or 6% hydroxyethyl starch solutions led to metabolic acidosis. A dilution of extracellular bicarbonate or changes in strong ion difference and albumin concentration offer explanations for this type of acidosis.

Are there acid base changes during transurethral resection of the prostate (TURP)?

UNLABELLED: Acid base status during transurethral resection of the prostate (TURP) has been almost neglected. We therefore measured the acid base status and interpreted the observed changes according to the Stewart approach. The Stewart model focuses more on the influence of serum electrolyte concentrations on acid base changes than does the conventional Henderson-Hasselbalch approach. In 20 patients undergoing TURP, the following variables were determined: PaO(2), PaCO(2), pH(a), actual bicarbonate, standard base excess, serum concentration of sodium, potassium, chloride, lactate, and total protein. A study group (n = 11) and a control group (n = 9) were built, depending on the maximal amount of fluid absorption estimated with the aid of ethanol concentration monitoring in the expired gas. The study group developed a mild acidosis with a decrease in pH from 7.41 to 7.37 (P = 0.037), compared with a very discrete pH decrease from 7.44 to 7.42 in the control group. We found that moderate irrigant absorption during TURP leads to a specific metabolic acidosis. We speculate that larger amounts of irrigant absorption may cause a more severe metabolic acidosis. As the constellation of independently pH regulating variables appears to be typical for TURP, this acidosis could be named "TURP-acidosis." IMPLICATIONS: We measured acid base status in 20 patients undergoing transurethral resection of the prostate comparing a larger fluid absorption group with a minor or no fluid absorption group. We postulate the development of a typical metabolic transurethral resection of the prostate-acidosis caused by irrigant absorption.

Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery.

BACKGROUND: Changes in acid-base balance caused by infusion of a 0.9% saline solution during anesthesia and surgery are poorly characterized. Therefore, the authors evaluated these phenomena in a dose-response study. METHODS: Two groups of 12 patients each who were undergoing major intraabdominal gynecologic surgery were assigned randomly to receive 0.9% saline or lactated Ringer's solution in a dosage of 30 ml x kg(-1) x h(-1). The pH, arterial carbon dioxide tension, and serum concentrations of sodium, potassium, chloride, lactate, and total protein were measured in 30-min intervals. The serum bicarbonate concentration was calculated using the Henderson-Hasselbalch equation and also using the Stewart approach from the strong ion difference and the amount of weak plasma acid. The strong ion difference was calculated as serum sodium + serum potassium - serum chloride - serum lactate. The amount of weak plasma acid was calculated as the serum total protein concentration in g/dl x 2.43. RESULTS: Infusion of 0.9% saline, but not lactated Ringer's solution, caused a metabolic acidosis with hyperchloremia and a concomitant decrease in the strong ion difference. Calculating the serum bicarbonate concentration using the Henderson-Hasselbalch equation or the Stewart approach produced equivalent results. CONCLUSIONS: Infusion of approximately 30 ml x kg(-1) x h(-1) saline during anesthesia and surgery inevitably leads to metabolic acidosis, which is not observed after administration of lactated Ringer's solution. The acidosis is associated with hyperchloremia.