Kininase II in bronchoalveolar lavage fluid and serum of patients with pulmonary disorders.

In 68 patients with pulmonary diseases such as lung cancer (n = 32), sarcoidosis (n = 21) and chronic bronchitis (n = 15), kininase II (EC 3.4.15.1) (KII) was fluorimetrically (F-LKII) and the albumin concentration (LALB) spectrophotometrically measured in native unconcentrated bronchoalveolar lavage fluid. For comparison in serum, the KII was also spectrophotometrically (SP-SKII) and fluorimetrically (F-SKII) determined. In all patients, the mean (means) +/- SD F-LKII activity was 0.2 +/- 0.4 U/L, the LALB concentrations 0.17 +/- 0.44 g/L, and the resulting specific F-LKII activity was 3 +/- 3 U/g LALB. The highest elevations of LALB concentrations were determined in lung cancer. The highest activities of F-LKII, F-SKII, and SP-SKII were observed in sarcoidosis. A significant linear relation was found between F-LKII and LALB (R = 0.60, P less than 0.0002) and also between F-SKII and SP-SKII (R = 0.88, P less than 0.0001), but no relation could be established between F-SKII and F-LKII, indicating that the KII measured in lavage was not identical with the KII found in serum.

Value of determination of kininase II in bronchoalveolar lavage fluid.

Kininase II (KII), identical with angiotensin-I-converting enzyme (E.C. 3.4.15.1) was characterized biochemically and assayed fluorimetrically in bronchoalveolar lavage fluid and serum of 153 patients with several pulmonary disorders. The albumin concentrations of serum and bronchoalveolar lavage fluid (BLF) have also been measured. The pH optimum of KII derived from BLF (LKII) was 8.0. The Michaelis Menten constant was 38.5 mumol/l using benzyloxycarbonyl-phenylalanyl-histidyl-leucine as synthetic substrate. LKII could be inhibited between 80 and 100% by EDTA, phenanthroline, dimercapto-1-propane-sulfonic acid (DMPS), hydroxyquinoline and captopril. The LKII activity (mU/ml BLF) showed no differences in all lung diseases, but the specific LKII (mU/mg albumin) was significantly elevated in sarcoidosis compared to pneumonia (p less than 0.05), fibrosis (p less than 0.05), chronic obstructive bronchitis (p less than 0.005) and lung cancer (p less than 0.01), but not in tuberculosis. This study shows that LKII is measurable in native, unconcentrated BLF and the results indicate that LKII could be useful for diagnosis of pulmonary disorders.

[Endorectal ultrasound for evaluating perirectal processes]. / Die endorectale Sonographie zur Beurteilung perirectaler Prozesse.

Between July 1992 and December 1993 we examined 258 patients by endorectal ultrasound at the Surgical Department of the University of Würzburg. In 24 (9.3%) patients we found 27 perirectal lesions. These comprised abscesses, cysts, primary and secondary malignancies, as well as various benign tumours. All lesions but one underwent histological and/or microbiological examination. Endosonographic assessment with regard to size, location and anatomical structure was correct in 24 (89%) cases. We performed ultrasound-guided, transrectal aspiration in six patients. Endorectal ultrasound is a useful complementary imaging device in the assessment of pararectal disease. Owing to its high resolution it may be superior to other methods (e.g. CT or MRI). Another advantage is the possibility of ultrasound-guided aspiration biopsy. Precise knowledge of the topographic anatomy and its endosonographic appearance is of great importance.

[Country-wide survey of therapeutic procedures in hemorrhoids and anal fissure]. / Bundesweite Umfrage zum therapeutischen Vorgehen bei Hämorrhoidalleiden und Analfissur.

A survey among coloproctologists was performed to assess current therapeutic concepts for the treatment of hemorrhoidal disease and anal fissure. A total of 261 clinical and non-clinical proctologists participated, representing the entire range of therapies in hospital and practise. A wealth of widely differing, in some aspects contradictory concepts were recorded, leaving almost no subject entirely undisputed. There are controversies regarding the different therapeutic alternatives as well as indications for surgery and choice of operative procedure. Future research has to address the existing controversies in order to reach a higher degree of standardization in the therapy of these common proctological disorders.

[Open surgical therapy of functional disorders of the rectum and pelvic floor]. / Offene chirurgische Therapie von funktionellen Störungen des Enddarms und Beckenbodens.

An overview is given of common transabdominal procedures for functional disorders of the rectum and pelvic floor which are caused by degenerative morphological changes, and termed pelvic floor insufficiency. Only the transabdominal approach permits a comprehensive and pathophysiological repair of changes associated with the disorder. Own results and a review of the literature confirm a superior functional outcome and low recurrence rates with a combined procedure consisting of rectopexy, colonic resection and pelvic floor repair.

[Anorectal endosonography in tumor after-care]. / Die anorektale Endosonographie in der Tumornachsorge.

Due to its high resolution and the possibility to compare the images with previous examinations the transrectal ultrasound (TRUS) can lead to an earlier diagnosis of locally recurrent rectal cancers. Using TRUS we were able to correctly identify ten of 12 local recurrences. In four cases TRUS was the only diagnostic tool as neither the alternative imaging technique nor endoscopy were able to show the recurrence.

[Endo-anal sonography in diagnosis of fecal incontinence]. / Die endoanale Sonographie in der Diagnostik der Stuhlinkontinenz.

Endoanal ultrasound is a new imaging technique in the diagnostic work-up of patients suffering from anal incontinence. A standardised examination as well as hardware specific reference values for the sphincter muscles are of paramount importance to allow correct interpretation of the continence organ. At the University Hospital of Würzburg from 1.2.1993 to 31.7.1994 90 patients (50 male, 40 female; age: 16-81 y.) with normal continence underwent endosonographic assessment of their sphincter complex. We measured the internal anal sphincter (IAS), puborectalis muscle as well as the three separate parts of the external anal muscle (EAS). Apart from establishing reference values we found a significant increase in thickness of both EAS and IAS with increasing age. However, no correlation was seen between muscle thickness, sex, height or weight. We also examined 29 patients with a history of incontinence. 13 (45%) had a morphological sphincter defect, most of which were due to obstetric trauma or previous proctological operations. 10 (35%) patients suffered from so called idiopathic incontinence. Anal ultrasound in these patients revealed muscle hypotrophy of the structurally intact sphincters.

[Surgical therapy of rectal prolapse]. / Chirurgische Therapie des Rektumprolapses.

A review of literature and own clinical studies confirm that best postoperative functional results in complete rectal prolapse may be reached with rectopexy in combination with partial resection of the colon. Incontinence may be improved in 38% to 93%, depending on the author. Constipation may be reduced in 41% to 83% of the cases. In comparison, rectopexy without resection resulted in a reduction of constipation of only 11% to 28%, with even a change to the worse in 60% of the patients. Improved operative and anesthesiological conditions cause an acceptable perioperative morbidity (7-13%) and mortality (0-2%) after rectopexy with partial resection of the colon.

Macroscopic assessment of the appendix at diagnostic laparoscopy is reliable.

BACKGROUND: Healthy-looking appendixes are often removed at laparoscopy for suspected appendicitis. This practice may have adverse secondary effects. METHODS: We reviewed the literature for the years 1978 to 1998 to analyze the negative appendectomy rates, complication rates, the accuracy of laparoscopic appendix assessment, and the incidence of false negative diagnosis of appendicitis at surgical and gynecological laparoscopy. RESULTS: The respective negative appendectomy rates were 22% and 15% in studies that compared laparoscopic with open appendectomy. The appendix was left in situ in 37% of 4,281 surgical diagnostic laparoscopies. There were instances of missed appendicitis among the 3,367 gynecological diagnostic laparoscopies performed on women for lower abdominal pain, and there were 188 appendectomies in this group. Studies comparing the macroscopic appearance of the appendix at operation with microscopic findings from the excised specimen had a false negative error rate of 3%. CONCLUSIONS: Contrary to general opinion, there is no substantial evidence to support the assumption that the macroscopic diagnosis of appendicitis is unreliable. High rates of conflicting diagnoses of excision specimens suggest that endoappendicitis has little clinical significance. At present, negative appendectomy rates are considerably higher for laparoscopic appendectomy than for the open approach. The role of diagnostic laparoscopy in suspected appendicitis should be reconsidered. It may be useful in particular subgroups of patients, but it is no substitute for good clinical judgment. Furthermore, it is not always necessary to perform an incidental appendectomy.

[Techniques of follow-up examination of the ileoanal and colo-anal pouch]. / Nachuntersuchungstechniken des ileoanalen und koloanalen Pouches.

For the assessment of ileoanal and coloanal pouches different diagnostic tests should be applied. Apart from case history and rectal digital examination the most important methods comprise a radiologic evaluation of the pouch and its afferent loop as well as anorectal manometry for the assessment of pouch motility and sphincter function. Increasingly transanal endosonography is being used for the precise examination of size, volume, and shape of ileoanal and coloanal pouches. The afferent loop is also easily accessible to endosonography, e.g. for evaluation of bowel wall morphology and function. Furthermore, in cases of coloanal pouches following an oncologic lower anterior resection, endosonography is used in follow-up examinations for the detection of local tumor recurrence.

The value of endorectal ultrasound in the assessment of adenomas, T1- and T2-carcinomas.

In a prospective study we examined the value of endorectal ultrasound (ERUS) in the preoperative staging of potentially locally excisable tumours. During the study period from 1.1.1991 to 1.3.1996 a total of 160 rectal tumours in 152 patients were staged endosonographically (uT/uN) and compared postoperatively with the histologic result (pT/pN) at the University Hospital of Würzburg. Thirty-eight (24%) patients had an adenoma and 15 (9%) a T1-carcinoma. In 29 (18%) cases a T2-cancer was diagnosed, further 67 (42%) and 11 (7%) patients presented with a T3 and T4 tumour, respectively. The sensitivity for adenomas and T1-Ca (uT0/1) was 81%, the specificity 98%. For T2 tumours, the sensitivity was only 41% and the specificity 92% as the majority (17 of 29) of pT2 neoplasias were overstaged (uT3). The overall staging accuracy (T1-4) was 77.5%. Two patients with a pT1-Ca and seven with a pT2-Ca had lymph node metastases which were detected preoperatively in five. The accuracy for lymph node staging was 83%. We conclude that adenomas and T1 tumours can be assessed with a high grade of accuracy using ERUS. In these tumours ERUS can be used to assist clinical decision-making (transanal vs. abdominal operation). Owing to the lack of sensitivity ERUS is of no help in the assessment of T2 carcinomas.

[Is perforating appendicitis a separate disease picture?]. / Ist die perforierende Form der Appendicitis ein eigenständiges Krankheitsbild?

Large epidemiological studies recently published suggest that perforating appendicitis may represent a separate disease entity. To find out whether perforating and nonperforating appendicitis may be distinguished by clinical features (history and examination, lab tests) data from 519 cases of acute appendicitis (17.7% perforations) were analysed, and significant differences were recorded in various aspects of history and clinical examination. It was concluded that perforating and nonperforating appendicitis may clinically be distinguished reliably in the majority of cases.

Perforating appendicitis: is it a separate disease? Acute Abdominal Pain Study Group.

OBJECTIVE: To find out whether perforated and unperforated appendicitis are separate diseases and can be distinguished clinically. DESIGN: Prospective multicentre study. SETTING: 11 departments of surgery in Germany and Austria. SUBJECTS: 519 patients over 6 years old who had histologically confirmed acute appendicitis between October 1994 and March 1996. MAIN OUTCOME MEASURES: Differences in history, clinical findings, lab results, clinical course and outcome. RESULTS: 92 of the 519 patients (18%) had perforated appendicitis. The following variables were shown by univariate analysis to be significantly more common in the group with perforated appendicitis: rigidity, reduced abdominal wall movement, abdominal distension, reduced bowel sounds (all p<0.001), pale skin (p<0.005), generalised abdominal tenderness, severe abdominal tenderness (both p<0.01), WCC > or =10(9)/L (p<0.05). By multivariate analysis the following variables were significantly more common in the group with perforated appendicitis: age over 50 years (p<0.0001); change in bowel habit and rigidity of the abdominal wall (both p = 0.001); generalised tenderness (p<0.01); male sex (p<0.01); and distended abdomen (p<0.05). Rectal examination failed to make the distinction. CONCLUSIONS: Perforated and unperforated appendicitis behave clinically like two different diseases. They can in most cases reliably be distinguished using clinical criteria alone. Although greater diagnostic accuracy may result in a higher rate of perforation, close observation and timely intervention will only marginally affect the outcome.

[Endosonographic imaging of anal fistulas in infants]. / Die endosonographische Darstellung von Analfisteln bei Säuglingen.

Anorectal endosonography is established as a diagnostic tool in anorectal fistulas, today. Yet, there is still little experience with the use of this method in small children. We could visualize three intershincteric fistulas in children at an age of 6, 7 and 14 months. The procedure is well tolerated and even children under the age of one year can be examined with a special probe.

Influence of tumor position on accuracy of endorectal ultrasound staging.

UNLABELLED: Endorectal ultrasound is a well-established method of preoperative staging of rectal neoplastic lesions. PURPOSE: This study was undertaken to evaluate whether tumor site (in terms of height) and position (with respect to the rectal circumference) have an influence on the reliability of endoluminal ultrasound staging. METHODS: From January 1991 to May 1996, 154 consecutive patients with a total of 162 rectal tumors were examined preoperatively using endorectal ultrasound. Apart from staging all tumors using the uT/uN classification, tumor level and tumor position were recorded prospectively. Neoplasms were subdivided into low rectal (0-6 cm from the anal verge), mid rectal (7-12 cm), and higher lesions (> 12 cm). Furthermore, the lumen was divided into an anterior, left lateral, posterior, and right lateral position, and all tumors, apart from circular lesions (n = 9), were subclassified accordingly. RESULTS: Overall, we found 40 (25 percent) adenomas, 15 (9 percent) T1, 29 (18 percent) T2, 67 (41 percent) T3, and 11 (7 percent) T4 lesions. Overall accuracy was 78 percent. Staging accuracy for low rectal tumors (n = 41) was 68 percent, whereas 76 and 88 percent of mid (n = 96) and high (n = 25) neoplasms were staged correctly, respectively. The difference was not statistically significant. With regard to position, 47 tumors were situated anteriorly (77 percent accuracy), 42 in the left lateral position (69 percent accuracy), 33 posteriorly (73 percent accuracy), and 31 in the right lateral position (81 percent accuracy). Differences did not reach statistical significance. CONCLUSION: Endorectal ultrasound is currently the best method for preoperative assessment of the depth of infiltration of rectal tumors. However, rectal anatomy seems to affect staging accuracy in the lower rectum because the structure of the ampulla recti renders endosonographic examination more difficult. In addition, endosonographic layers are less well defined at this level. Both factors contribute to a lower reliability and predictive value of endorectal ultrasound staging in the lower rectum, although statistical significance was not reached in this study. On the other hand, tumor position with respect to rectal circumference does not influence the predictive value of endorectal ultrasound.