Initial experience with taTME in patients undergoing laparoscopic restorative proctocolectomy for familial adenomatous polyposis.

BACKGROUND: Transanal total mesorectal excision (taTME) is a minimally invasive technique which was developed to overcome the difficulties associated with the "top-down" pelvic dissection by enabling a "bottom-up" dissection in patients with mid- and low rectal cancer. While this technique was primarily designed to manage tumors in the mid- and lower rectum, its spectrum of indications has been broadened to include benign colorectal pathologies. The aim of the present study was to assess our initial experience with taTME in patients undergoing restorative proctocolectomy for familial adenomatous polyposis (FAP). METHODS: All consecutive patients (undergoing prophylactic restorative proctocolectomy with IPAA for FAP using taTME between April and October 2016 at our institution) were included in the study. RESULTS: There were 8 patients (6 females and 2 males). The median age was 19.5 years (range 16-31 years). In all cases, surgery was successfully completed using with taTME. No perioperative complications were recorded. A median of 5 bowel movements (range 4-6 bowel movements) with intermittent anti-diarrheal medication was recorded in all cases. CONCLUSIONS: Our initial experience with 8 consecutive cases suggests taTME is safe and effective in patients undergoing prophylactic restorative proctocolectomy with IPAA for FAP.

[Young Women - Problematic Patients in Vascular Surgery]. / Junge Frauen - Problempatientinnen in der Gefäßchirurgie.

The treatment of peripheral arterial disease (PAD) in young women between 40 and 60 years of age represents a difficult challenge for the vascular surgeon. Excessive smoking, an early menopause and the unfavourable anatomic proportions of thinner arterial vessels or vein grafts during peripheral bypass-surgery lead to a higher rate of complications or re-occlusion following invasive therapy in comparison to male patients. A special anatomic manifestation appearing nearly only in women around the 6th decade is the so-called aortoiliac hypoplastic syndrome with a high rate of re-occlusion after balloon-dilatation or local thrombendarteriectomy and bypass grafting, respectively. Variabilities in coagulation and the undertreatment of classical risk factors of PAD by medical drugs lead to poorer results in the treatment of PAD in young women. Therefore a conservative therapy - whenever feasible - should be the first choice for treating PAD in young women.

Long-term antithrombotic protection by in vivo depletion of platelet glycoprotein VI in mice.

Coronary artery thrombosis is often initiated by abrupt disruption of the atherosclerotic plaque and activation of platelets on the subendothelial layers in the disrupted plaque. The extracellular matrix protein collagen is the most thrombogenic constituent of the subendothelial layer; therefore, a selective inhibition of the collagen activation pathway in platelets may provide strong antithrombotic protection while preserving other platelet functions. Here we demonstrate that treatment of mice with a monoclonal antibody against the activating platelet collagen receptor glycoprotein VI (GPVI; JAQ1) results in specific depletion of the receptor from circulating platelets and abolished responses of these cells to collagen and collagen-related peptides (CRPs). JAQ1-treated mice were completely protected for at least 2 wk against lethal thromboembolism induced by infusion of a mixture of collagen (0.8 mg/kg) and epinephrine (60 microg/ml). The tail bleeding times in JAQ1-treated mice were only moderately increased compared with control mice probably because the treatment did not affect platelet activation by other agonists such as adenosine diphosphate or phorbol myristate acetate. These results suggest that GPVI might become a target for long-term prophylaxis of ischemic cardiovascular diseases and provide the first evidence that it is possible to specifically deplete an activating glycoprotein receptor from circulating platelets in vivo.

Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients.

BACKGROUND: Groin hernia repair constitutes a very common procedure in general surgery. Minimal invasive closure of groin hernia has evolved to become the standard means of closure. However, there seems to be a gender-associated discrimination with regard to endoscopic groin hernia repair. We investigated the rate of endoscopic closure in female patients undergoing groin hernia closure. MATERIALS AND METHODS: A retrospective analysis of the data of patients undergoing elective groin hernia repair within a four-year period from 2013 to 2016 was performed. The rate of endoscopic hernia repair was calculated for both genders. RESULTS: Eight hundred and forty-six patients including 94 females and 752 males were included for analysis. The female group was significantly older compared to the male group (68.0 vs. 61.0 yrs, P=0.02). The rate of endoscopic groin hernia repair was significantly lower in the female group compared to in the male cohort (30% vs. 60%, P=0.001). The overall duration of surgery was 74.0min in the female cohort and 93.0min in the male group, P=0.001. However, there was no statistically significant difference amongst both groups with regard to the duration of surgery for endoscopic repair: 78.0min in the female group and 89.0min in the male group, P=0.67. CONCLUSION: Findings from this retrospective collective suggests that, there might be some degree of sex discrimination with regard to endoscopic groin hernia repair in favor of the male population.

Comparison of biomaterials: three meshes and TAPP for inguinal hernia.

BACKGROUND: In laparoscopic hernia repair the use of biocompatible materials is necessary. A prospective, double-blind study was projected to compare three different meshes. METHODS: Ninety male patients with primary inguinal hernia undergoing transabdominal preperitoneal (TAPP) implant procedures were included. Three different types of mesh were tested: a monofile, heavy-weight, rigid mesh (group A), a smooth, heavy-weight variant of polypropylene (group B), and a polyglactin/polypropylene compound mesh (group C). Complications, pain development, inability to work, physical conditions, testicular volume, and blood circulation were documented. RESULTS: Convalescence in group A was slower than in groups B and C: Postoperative values of visual scales for pain development were higher, inability to work was 7.3 days longer, urologic effects were more severe, activities of everyday life were more reduced, and data of the German SF-36 Health Survey Test showed a significant reduction of physical condition (p < 0.05). CONCLUSION: The compound mesh did not create more comfort for the patients than the smooth variant of the heavy-weight polypropylene mesh.

Comparison of a beta-blocker and an If current inhibitor in rabbits with myocardial infarction.

AIM: We compared protective effects of a ss-adrenoceptor blocker (metoprolol; Met) and a If current (Ivabradine; Iva) in a rabbit model of myocardial infarction. METHODS: Experiments were performed on 44 adult New-Zealand-White (NZW) rabbits. The effects of either metoprolol or ivabradine were assessed 15 min after experimental occlusion of a coronary artery (CAO), 28 days after CAO (drug gavage), and in vitro hearts (Langendorff apparatus). The results were compared with sham and placebo hearts. RESULTS: Metoprolol (0.25 mg/kg) slightly reduced heart rate and left ventricular systolic function. Ivabradine (0.25 mg/kg) reduced heart rate significantly (P<0.05) (18% vs control). Both drugs provided advantages over placebo: mortality was significantly (P<0.01)smaller (6/13 Pla animals died, 2/10 Met animals, and 3/11 Iva animals), left ventricular function was better preserved after 28 days (external power; Pla; Met; Iva=56%; 76%; 74%), and dilatation (BNP) was reduced (P<0.05). In the Pla group, the ST segment was significantly (P<0.05) elevated by 0.35 mV after CAO and exhibited in 50% of the animals Q waves after 28 days, while after ivabradine or metoprolol, ST displacement and Q waves had disappeared. The uneconomic myosin isoenzyme V3 predominated in Met hearts and Iva hearts (V3/V1: 63/37% and 62/38%), while it was further increased in Pla hearts (78/21%). External efficiency was lowest in Pla hearts (1.00+/-0.50 a.u.; P<0.05) and was significantly higher both in Met hearts (4.0+/-1.8 a.u.) and in Iva hearts (3.3+/-1.6 a.u.). CONCLUSIONS: Met and Iva seem suited for the treatment of chronic myocardial infarction.

Melanoma-inhibiting activity, a novel serum marker for progression of malignant melanoma.

Melanoma-inhibiting activity (MIA) was isolated previously as a small soluble protein secreted from malignant melanoma cell lines in vitro. In vivo, highly restricted expression patterns in melanocytic tumors were identified. We therefore quantitated serum levels of MIA protein by means of a nonradioactive ELISA and investigated whether MIA provides a clinically useful parameter in patients with malignant melanomas. Here, we report enhanced MIA serum levels in 13 and 23% of patients with stage I and II disease, respectively, and in 100% with stage III or IV disease. Compared with S-100 and soluble intercellular adhesion molecule 1 serum levels in these patients, MIA was the most sensitive marker. Response to therapy in stage IV disease correlated with changes in MIA serum levels. Measuring repeatedly sera of 350 patients with a history of stage I or II melanoma during follow-up, we detected 32 patients developing positive MIA values. At the time of serum analysis, 15 of them had developed metastases, and one presented with metastatic disease 6 months later. In contrast, none of the patients with normal MIA serum levels developed metastases during the follow-up period of 6-12 months. In conclusion, MIA represents a novel serum marker for systemic malignant melanoma revealing the highest sensitivity and specificity among currently available markers. Useful clinical applications include staging of primary melanomas, detection of progression from localized to metastatic disease during follow-up, and monitoring therapy of advanced melanomas.

Comparative genomic in situ hybridization of colon carcinomas with replication error.

The aim of the present study was to detect complex genetic alterations in colorectal carcinomas with and without microsatellite instability (MIN) by comparative genomic in situ hybridization. MIN due to replication errors is the hallmark of hereditary nonpolyposis colon cancer. None of 6 MIN-positive tumors showed amplifications, and only 2 tumors displayed deletions of one chromosomal segment each. In contrast, different gains and losses were observed in 11 of 12 MIN-negative carcinomas. The most frequent gains affected chromosomes 7, 13, and 20q, whereas deletions were observed on chromosomes 17, 18, and 9p. These results demonstrate different mechanisms of genetic instability in subgroups of colorectal carcinomas and may, therefore, support the hypothesis of different etiologies in tumors with and without MIN.

Primary peritoneal adenocarcinoma as content of an incarcerated umbilical hernia: A case-report and review of the literature.

INTRODUCTION: Umbilical hernia is a common finding in many cases, posing potentially life-threatening complications, such as incarceration or strangulation. The presence of malignancy in hernia sacs is, however, rather rare. PRESENTATION OF CASE: Here we report on a case of primary peritoneal adenocarcinoma found through histological examination of omental tissue, resected due to an incarcerated umbilical hernia of an 84-years-old woman. There was no macroscopic sign of malignancy during operation; only after routine examination of histological sections the diagnosis was found. DISCUSSION: To our knowledge this is the first report of primary peritoneal cancer as content of an umbilical hernia. This is a rare neoplasm and histologically identical to epithelial ovarian carcinoma. For this reason, the diagnosis is usually based on the histological finding and exclusion of a primary ovarian tumor. Primary peritoneal cancer has a poor outcome in general. Early diagnosis is, therefore, essential for effective treatment. CONCLUSION: Histological analysis of resected hernia sac or content should be performed routinely to discover malignant diseases in the background of a hernia.

[Wrong site surgery : Incidence, risk factors and prevention]. / Verwechselungseingriffe in der Chirurgie : Inzidenz, Risikofaktoren und Prävention.

BACKGROUND: Wrong site surgery defines a category of rare but totally preventable complications in surgery and other invasive disciplines. Such complications could be associated with severe morbidity or even death. As such complications are entirely preventable, wrong site surgery has been declared by the World Health Organization to be a "never event". MATERIAL AND METHODS: A selective search of the PubMed database using the MeSH terms "wrong site surgery", "wrong site procedure", "wrong side surgery" and "wrong side procedure" was performed. RESULTS: The incidence of wrong site surgery has been estimated at 1 out of 112,994 procedures; however, the number of unreported cases is estimated to be higher. Although wrong site surgery occurs in all surgical specialities, the majority of cases have been recorded in orthopedic surgery. Breakdown in communication has been identified as the primary cause of wrong site surgery. Risk factors for wrong site surgery include time pressure, emergency procedures, multiple procedures on the same patient by different surgeons and obesity. Check lists have the potential to reduce or prevent the occurrence of wrong site surgery. CONCLUSION: The awareness that to err is human and the individual willingness to recognize and prevent errors are the prerequisites for reducing and preventing wrong site surgery.

Studies on tumor-cell-induced platelet aggregation in human lung cancer cell lines.

We investigated the ability of human lung cancer cells of different histological subtypes to cause platelet aggregation. Tumor-cell-induced platelet aggregation (TCIPA) was studied in vitro in 13 human lung cancer cell lines [small-cell lung cancer (SCLC), squamous-cell lung cancer, large-cell lung cancer, adenocarcinoma and alveolar-cell lung cancer]. Three tumor cell lines failed to aggregate platelets in platelet-rich plasma, whereas platelet aggregation was induced by 12 cell lines when added to washed platelets and minimal amounts of platelet-poor plasma (0.5% v/v). The thrombin antagonist hirudin inhibited TCIPA in non-small-cell lung cancer cell lines (NSCLC). In SCLC, TCIPA was fully abolished only when the ADP scavenger apyrase was added to hirudin. Thus ADP and thrombin generation by these tumor cell lines are responsible for platelet aggregation. The ability to activate platelets independently of coagulation factors VII and X was demonstrated for 8 cell lines. Electron-microscopically, direct tumor-cell/platelet contact was found to be the initiating mechanism of TCIPA in SCLC, whereas tumor-cell/platelet contacts in NSCLC could only be observed at the peak of the aggregation curve. Lung cancer cells activate platelets in vitro by generation of thrombin and/or ADP.

Detection of microsatellite instability in human colorectal carcinomas using a non-radioactive PCR-based screening technique.

The aim of the present study was to establish a rapid, non-radioactive screening method for the detection of microsatellite instability (MIN). MIN is the primary characteristic of the mutator phenotype in tumours constituting hereditary non-polyposis colon cancers (HNPCC). We investigated 30 patients suffering from colorectal cancer using a non-radioactive PCR-based technique. MIN was present in 7 of 30 (23%) of the cases. There was a statistically significant correlation between MIN and localization of the tumour. Five of 7 (72%) tumours with MIN but only 4 of 23 (17%) tumours without MIN were localized in the proximal colon (P < 0.01). There was a tendency to higher MIN frequency in tumours of patients with familial clustering of cancers. However, this was statistically not significant (P > 0.05). In addition, no correlation between MIN and tumour grade and stage was found. For the investigations in the present study we used a non-radioactive PCR-based method followed by denaturating polyacrylamide gel electrophoresis and silver staining. This method is highly sensitive and reproducible. Thus, PCR-based analysis using a non-radioactive staining technique represents a comprehensive tool for MIN screening in diagnostic pathology.

Plasmapheresis combined with continuous venovenous hemofiltration in surgical patients with sepsis.

OBJECTIVE: To examine the effect of continuous venovenous hemofiltration (CVVHF) combined with plasmapheresis (TPE) in critically ill surgical patients after treatment of the septic focus. DESIGN: Observational pilot study. SETTING: University teaching hospital intensive care unit. INTERVENTIONS: TPE and CVVHF were administered 24 h after surgical and/or interventional treatment of septic focus. Arterial blood pressure, cardiac output, and systemic vascular resistance values were monitored. We examined the effect of the combined extracorporeal detoxification on outcome related to age, morbidity, organic failure rate, and initial APACHE II score. MEASUREMENTS AND RESULTS: Forty-three patients with sepsis were treated; 19 received TPE in combination with CVVHF, and 24 did not receive extracorporeal therapy. Overall mortality was 44.2%. In the therapy group mortality was lower (42.1 vs. 45.8%), but the primary organic failure rate was higher. The relationship between mortality and age was similar in the two groups. There was also no difference between the groups in the course of scores on APACHE II, multiple-organ failure, and sepsis severity. Only patients with an initial APACHE II score of 21-25 had a significant reduction in mortality after combined extracorporeal detoxification. Mortality of 17% in TPE/CVVHF patients with single- (pulmonary) and double-organ failure (renal/pulmonary) was significantly lower (P < 0.0001) than in untreated patients. CONCLUSIONS: Reduction in mortality in single- and double-organ failure was as high as 28% in septic patients with combined extracorporeal detoxification. A prospective randomized trial in sepsis and double-organ failure should be projected.

Whipple's procedure plus intraoperative pancreatic duct occlusion for severe chronic pancreatitis: clinical, exocrine, and endocrine consequences during a 3-year follow-up.

The present investigation provides follow-up data (up to 36 months) of exocrine and endocrine pancreatic function, inflammatory activity, pain, and body weight in 23 chronic pancreatitis patients submitted to Whipple's procedure plus intraoperative Ethibloc occlusion of the remaining pancreatic duct system between January 1983 and February 1984. Clinically, Whipple's procedure plus intraoperative pancreatic duct occlusion resulted in almost complete and continuous cessation of pain as well as significant (p less than 0.05) increase in body weight. With regard to exocrine pancreatic function (Secretin-Pancreozymin test, plasma amino acid consumption test, Pankreolauryl test, fecal chymotrypsin determination), intraoperative pancreatic duct occlusion was shown to induce high-grade insufficiency and thus exocrine parenchymal atrophy in all patients. Simultaneously, the inflammatory process (represented by serum levels of trypsin, lipase, and pancreatic isoamylase) was terminated in all 23 patients. Endocrine pancreatic function, evaluated by serum levels of insulin and C-peptide measured under fasting conditions and subsequent maximal combined beta-cell stimulation as well as corresponding integrated hormone releases, was reduced by partial pancreas resection by about 50%, while there was no further impairment during the 36-month follow-up period in consequence of additional intraoperative pancreatic duct occlusion. Altogether, Whipple's procedure plus intraoperative Ethibloc occlusion of the residual pancreatic duct system seems suitable for termination of the inflammatory process and thus preservation of residual endocrine pancreatic function in chronic pancreatitis.

Immunocytology improves prognostic impact of peritoneal tumour cell detection compared to conventional cytology in gastric cancer.

AIMS: Studies on the value of peritoneal tumour cell dissemination for prognosis in gastric cancer using various methods to detect tumour cells have produced conflicting conclusions. We studied the incidence and prognostic relevance of microscopic intraperitoneal tumour cell dissemination in gastric cancer, comparing conventional and immunocytological detection. METHODS: Peritoneal wash-outs of 111 consecutive gastric patients without overt peritoneal carcinomatosis, including 75 curatively resected patients, were studied. Sixty patients with benign disorders served as controls. 100 ml of warm NaCl 0.9% was instilled intraoperatively and 20 ml was reaspirated. The specimens were stained peri-operatively with H&E. In the last 47 patients (30 of whom were curatively resected) additional immunostaining with the HEA-125 antibody was performed. The results of cytology were correlated with the TNM categories and with post-operative follow-up. RESULTS: Of the patients, 42.3% and 48.9% were positive when conventional and immunocytological staining were employed, respectively. Conventional cytology was significantly associated with the pT and M categories. Immunocytology was significantly associated with the pT, pN and M caterogies. In four of 30 curatively resected patients (13.3%), the results of conventional and immunocytology were different. Three patients with positive immunocytology but negative conventional cytology died during follow-up (median follow-up 45.3 months), whereas one patient with positive conventional but negative immunocytology is still alive. In an univariate analysis 4 years post-surgery, positive immunocytology was significantly associated with an unfavourable prognosis in patients with curatively resected gastric cancer. While only 28.6% (six of 21) of the patients with negative immunocytology had died, this proportion increased to 77.8% (seven of nine) with positive immunocytology (P=0.018). The mean survival of negative vs positive patients amounted to 1205+/-91 vs 772+/-147 days (P=0.007). In contrast, in conventional cytology we found no significantly different survival time between negative and positive patients. CONCLUSIONS: Immunocytology seems to be superior to conventional cytology and should be preferred.

Interleukins and their antagonists but not TNF and its receptors are released in post-ERP pancreatitis.

OBJECTIVE: Usually it is not possible to study the initial systemic response in patients with acute pancreatitis in the first hours after onset of the disease. We used postendoscopic retrograde pancreatography (ERP) pancreatitis as a model to study cytokine and anticytokine release in the early phase of human acute pancreatitis. METHODS: Post-ERP pancreatitis was defined as a threefold increase in serum amylase and at least two of the following clinical symptoms: abdominal pain, nausea, vomiting or peritonism 24 h after ERP. Serum levels of pro-inflammatory cytokines interleukin-1beta (IL-1beta), interleukin-6 (IL-6), interleukin-8 (IL-8), tumour necrosis factor alpha (TNF), as well as endogenous antagonistic mediators of the systemic inflammatory response such as soluble tumour necrosis factor alpha receptors p55 (TNFR p55) and p75 (TNFR p75), and IL-1-receptor antagonist (IL-1-RA) and interleukin-2-receptor (IL-2R) as indicators of lymphocyte activation were measured before and 0, 1, 4, 12, 24 and 48 h after ERP. In nine patients with acute post-ERP pancreatitis, these parameters were monitored daily until C-reactive protein (CRP) was within normal ranges and were compared to patients without pancreatitis after ERP. RESULTS: IL-1beta was not detectable in five patients with and four patients without post-ERP pancreatitis. The values of the remaining patients in both groups were lower than 3.9 pg/ml. IL-8 and IL-1-RA serum concentrations peaked 12 h after ERP (132.9 and 3245.0 pg/ml respectively) compared to patients without post-ERP pancreatitis (25.8 and 389.9 pg/ml respectively). The IL-6 concentration increased to 81.6 pg/ml (8.0 pg/ml in control patients) 24 h after ERP, while the peak values for CRP were measured 72 h after ERP (164.0 versus 7.7 mg/l). IL-2R content was maximally elevated 144 h after ERP (688.8 versus 255.9 U/ml), while concentrations of TNF and its receptors showed no significant change over time. CONCLUSION: The initial response of the cytokine network to damage of the human pancreas leading to acute pancreatitis includes the release of IL-8 and the IL-1 antagonist IL-1-RA, while IL-1beta is not found in the systemic circulation. The TNF system does not seem to be involved as indicated by the lack of detectable changes in TNF and the soluble TNFR p55 and p75 serum concentrations. Lymphocyte activation as indicated by elevated IL-2R levels occurred days after the initial trauma. Even mild post-ERP pancreatitis leads to significant systemic release of cytokines and their biological counterparts.

Extracellular matrix proteins in human bile and gallstones.

OBJECTIVE: To investigate the presence of extracellular matrix (ECM) proteins in human bile and gallstones and to determine whether they play a role in gallstone formation. METHODS: ECM components [procollagen-III-peptide (P-III-P), laminin, and hyaluronic acid] in bile from patients with (n = 22) and without (n = 6) gallstone disease were investigated by immunoassay. Bile, gallstones, and serum were assayed for extracellular matrix components in an additional 19 patients with gallstone disease and gallstones were analysed in a third set of 26 patients. The expression of hyaluronic acid synthetase in bile duct and gall bladder epithelia was investigated by immunocytochemistry. RESULTS: Hyaluronic acid levels were significantly elevated in hepatic and gall bladder bile, but not in the serum of patients with compared with those without gallstone disease (137 versus 81 micrograms/l, respectively; P < 0.05). No differences were found between hepatic and gall bladder bile. Procollagen-III-peptide and laminin were detected in the hepatic bile of patients in both groups. Laminin levels were higher in gall bladder bile than in serum in all patients and measurable amounts of hyaluronic acid were found in gallstones. The amount of hyaluronic acid was inversely correlated to the volume of the gallstone, i.e., the smallest gallstones contained the highest levels of hyaluronic acid. No procollagen-III-peptide or laminin was found in the gallstones. Immunocytochemistry of the epithelial cells of bile duct and gall bladder mucosa stained strongly for hyaluronic acid synthetase. CONCLUSIONS: Hyaluronic acid as a progenitor of ECM can be detected in bile and is significantly elevated in patients with gallstone disease. Small gallstones contain more hyaluronic acid than large stones, suggesting that hyaluronic acid may play a role in gallstone formation, particularly since it is produced by the epithelial lining of bile ducts and is found in gall bladder mucosa.

Comparison of biomaterials in the early postoperative period.

BACKGROUND: Laparoscopic hernia repair necessitates the use of biocompatible materials. A prospective, double-blind study was conducted to compare two different polypropylene meshes. METHODS: The study included 40 men with primary inguinal hernia undergoing transabdominal preperitoneal polypropylene mesh repair. In 20 of these men, a monofile, heavy-weight, rigid mesh was implanted (group A), and in the remaining 20 men, a smooth, heavy-weight variant of polypropylene mesh was implanted (group B). Complications, pain development, inability to work, physical conditions, testicular volume, and blood circulation were documented. RESULTS: Reconvalescence in group A was slower than in group B. In group A, the postoperative values of the visual scales for pain development were higher; inability to work was 7.3 days longer; urologic disorders were worse; activities of everyday life were more reduced; and SF-36 data showed a significant reduction of physical problems ( p < 0.05). CONCLUSIONS: The polypropylene mesh variant seems to be more compatible with the human organism than conventional mesh. Not only the material, but also the structure seems to influence the comfort of the mesh.

Sympathetic nervous system activity during laparoscopic and needlescopic cholecystectomy.

BACKGROUND: It is difficult to quantify the impact of surgical trauma on patients with conventional measurement techniques. We report our preliminary experience with the determination of sympathetic nervous system activity during laparoscopic and needlescopic cholecystectomy. METHODS: The electroconductivity of representative dermatomes (24 measuring points) was recorded prior, during, and after performing laparoscopic and needlescopic cholecystectomy on 40 consecutive patients according to the method of Nakatani (Ryodoraku). Fifty-five healthy adults served as a control group. RESULTS: Median age in the two groups was 52.4 and 54.1 years, respectively. Prior to the operation and on the 1st postoperative day, sympathetic nervous activity was equal in both groups. In the needlescopic patients, sympathetic activity was lesser at 30 min after the start of the laparoscopic procedure (p <0.05). CONCLUSIONS: The measurement of electroconductivity is a useful noninvasive technique for the evaluation of sympathetic nervous activity. As far as activation of sympathetic nervous system is concerned, the needlescopic technique was found to be superior.

Depression of tumor necrosis factor-alpha, interleukin-6, and interleukin-10 production: a reaction to the initial systemic hyperactivation in septic shock.

Sepsis remains a major cause of mortality in surgical intensive care units. Patients who survive the initial shock phase but die weeks later from multiple organ dysfunction still are a challenge to basic and clinical research. We addressed whether fulminant sepsis results in rapid changes (24 h) in the cellular capacity to produce cytokines in whole blood of septic patients on further stimulation after the initial systemic inflammatory response. Interleukin (IL)-6 plasma concentrations from 279 pg/mL to 5979 pg/mL confirmed the presence of a systemic inflammatory response. Anti-inflammatory IL-10 concentrations up to 275 pg/mL were detected, but there was no biologically active tumor necrosis factor-alpha (TNFalpha) detectable (by bioassay) at the time of investigation. On stimulation with Escherichia coli ex vivo, pro-inflammatory TNFalpha (130 pg/mL), IL-6 (4061 pg/mL), and anti-inflammatory IL-10 (711 pg/mL) production were markedly depressed in all patients compared with controls (2339 pg/mL, 50,319 pg/mL, and 9654 pg/mL, respectively). Septic shock resulted in early depression of the capacity for pro- and anti-inflammatory cytokine production. Monitoring of this effect, including its relationship to outcome, may offer a target variable for therapeutic efforts to maintain or restore adequate immune reactions to improve survival.