Influence of heat shock protein 70 and metallothionein induction by zinc-bis-(DL-hydrogenaspartate) on the release of inflammatory mediators in a porcine model of recurrent endotoxemia.

The manipulation of stress gene expression by heavy metals provides protection against the lethal effects of endotoxemia in murine models of septic shock. Recent in vitro studies with alveolar macrophages or monocytes show that induction of the stress response in these cells is followed by a decreased liberation of major cytokines [tumor necrosis factor-alpha (TNF alpha) and interleukin-1 (IL-1)] after endotoxin challenge. These findings suggest that the increased resistance to endotoxin in vivo after stress protein induction could be explained by an altered pattern of inflammatory mediator release. Therefore, we measured the time course of thromboxane-B2 (TxB2), 6-keto-PGF1 alpha, platelet activating factor (PAF), TNF alpha, interleukin-1 beta (IL-1 beta), and interleukin-6 (IL-6) formation with and without induction of the stress response in an established porcine model of recurrent endotoxemia (Klosterhalfen et al., Biochem Pharmacol 43: 2103-2109, 1992). Induction of the stress response was done by a pretreatment with Zn2+ (25 mg/kg zinc-bis-(DL-hydrogenasparate = 5 mg/kg Zn2+). Pretreatment with Zn2+ prior to lipopolysaccharide (LPS) infusion induced an increased heat shock protein 70 and metallothionein expression in the lungs, liver, and kidneys and increased plasma levels of TNF alpha, IL-1 beta, IL-6, and TxB2 as opposed to untreated controls. After LPS infusion, however, pretreated animals showed significantly decreased peak plasma levels of all mediators as opposed to the untreated group. The time course of mediator release was identical with the decreasing and increasing three peak profiles described previously. Hemodynamic data presented significantly decreased peak pulmonary artery pressures and significantly altered hypodynamic/hyperdynamic cardiac output levels in the pretreated group. In conclusion, the data show that the induction of stress proteins by Zn2+ could be a practicable strategy to prevent sepsis.

The influence of heat shock protein 70 induction on hemodynamic variables in a porcine model of recurrent endotoxemia.

The manipulation of stress gene expression by heavy metals provides protection against the lethal effects of endotoxemia in murine models of septic shock. These findings suggest that the increased resistance to endotoxin in vivo after stress protein induction could be explained by an attenuation of hemodynamic alterations and an altered pattern of inflammatory mediator release. Therefore, we measured main hemodynamic variables such as systemic and pulmonary artery pressure, cardiac output, heart rate, central venous pressure, and pulmonary artery wedge pressure, as well as the time-course of thromboxane-B2, 6-keto-PGF1 alpha, and interleukin 6 formation with and without induction of the stress response in an established porcine model of recurrent endotoxemia (Circ Shock 35:237-244, 1991). Induction of the stress response was carried out by a pretreatment with Zn2+ (25 mg/kg zinc-bis-(DL-hydrogenaspartate) = 5 mg/kg Zn2+). Pretreatment with Zn2+ prior to lipopolysaccharide (LPS) infusion induced an increased heat shock protein 70 (HSP70) expression in the lungs, liver, and kidneys and significantly increased plasma levels of interleukin 6, 6-keto-PGF1 alpha, and thromboxane-B2, compared with untreated controls. After LPS infusion, however, pretreated animals showed significantly decreased peak plasma levels of all mediators compared with the untreated group. Hemodynamic data presented significantly decreased peak pulmonary artery pressure and pulmonary vascular resistance index values, significantly increased systemic artery pressure and systemic vascular resistance index values, and significantly altered hypodynamic/hyperdynamic cardiac output levels in the pretreated group. In conclusion, the data show that the induction of HSP70 by Zn2+ attenuates the liberation of inflammatory mediators, as well as the course of hemodynamic variables due to LPS.

Induction of heat shock protein 70 by zinc-bis-(DL-hydrogenaspartate) reduces cytokine liberation, apoptosis, and mortality rate in a rat model of LD100 endotoxemia.

A prospective, randomized model of LD100/24 h endotoxemia was performed in male Wistar rats (n = 26; 250-300 g). The animals were divided into four groups: Group I (n = 5; saline treatment only), Group II (n = 5; Zn2+ treatment only), Group III (n = 8; saline pretreatment, lipopolysaccharide (LPS) treatment), and Group IV (n = 8; Zn2+ pretreatment, LPS treatment). Zn2+ pretreatment was carried out by intraperitoneal injection of 50 mg/kg zinc-bis-(DL-hydrogenaspartate) (10 mg/kg Zn2+). LD100/24 h endotoxemia was induced by intraperitoneal administration of 20 mg/kg LPS of the Escherichia coli strain WO111:B4. Tumor necrosis factor alpha, interleukin-1 beta, and interleukin-6 were detected by enzyme-linked immunosorbent assay (ELISA). HSP70 expression in the lungs, the liver, and the kidneys was determined by immunohistochemistry, Western blotting, and an HSP70 ELISA. Apoptosis was also detected by an in situ apoptosis detection kit (TUNEL) and a cell death detection ELISA, respectively. This rat model of endotoxemia proves the close relationship between HSP70 expression, cytokine liberation, and development of apoptosis. The data demonstrate that: 1) Zn2+ is a potent inducer of HSP70 expression; 2) the application of Zn2+ leads to slightly increased cytokine plasma levels; and 3) the manipulation of the heat shock response by Zn2+ significantly increases the survival rate after LD100 endotoxemia. Enhanced survival rate in animals pretreated with Zn2+ may be explained by increased tissue levels of HSP70, a subsequent significantly decreased liberation of the proinflammatory cytokines after LPS challenge, and a significantly decreased rate of apoptosis.

Quantitative evaluation of abdominal wall perfusion after different types of laparotomy closure using laser-fluorescence videography.

Laparotomy closure relies on the incisional edges as anchor for the suture material. The results of these techniques are not satisfying, with failure rates of up to 20%. To investigate the effect of different conventional closure techniques and a novel "bridging technique" on abdominal wall perfusion an animal study was performed in rabbits. Abdominal wall perfusion was measured using the method of dynamic laser-fluorescence videography in the first 72 h of incisional wound healing in 25 animals. Suture tension was controlled with a water-filled polyurethane balloon connected to a pressure detector. The effect of laparotomy closure on abdominal wall tissue perfusion depends significantly on the applied technique and suture tension. Avoiding direct sutures in the incisional edges during laparotomy closure leads to a better tissue perfusion of the incisional region than conventional suture techniques. Suture tension can be controlled and adjusted using a water-filled polyurethane balloon as a pressure sensor.

Intra-abdominal pressure: a reliable criterion for laparostomy closure?

BACKGROUND: Laparostomy is frequently performed in the surgical therapy of mechanical obstruction, peritonitis, or trauma to prevent abdominal compartment syndrome (ACS). Extended incisional hernia is inevitable when fascial closure is missed (up to 90% of cases). Intra-abdominal pressure (IAP) has not yet been evaluated as a criterion for the feasibility of fascial closure. PATIENTS AND METHODS: Over 12 months laparostomy was carried out in 40 patients. Definitive closure of the abdomen was performed after 4.4+/-3.7 days in 23 of these. Intravesical pressure was used to assess IAP before and after fascial closure. The resulting IAP was compared to the values of 90 patients undergoing elective abdominal surgery. Parameters of cardiocirculatory, renal, pulmonary, and liver function were also recorded. RESULTS: After closure of the laparostomy IAP increased significantly from 6.5+/-3.3 to 12.0+/-4.1 mmHg. Urine output decreased by 27% on the first postoperative day but regained normal levels thereafter. The central venous pressure increased by 31%. Other parameters of cardiocirculatory, renal, pulmonary, and liver function were unchanged. No case of ACS occurred. In the patients undergoing elective abdominal surgery IAP ranged from 6.5+/-2.1 to 10.0+/-4.0 mmHg. CONCLUSIONS: Fascial closure increased the IAP, which was accompanied by short-termed decrease in urine output. At these levels of IAP fascial closure appears to be harmless, but further prospective studies are needed to determine the critical level of IAP for allowing a safe repair of large fascial defects.

[The ramus genitalis syndrome following hernia repair. A clinical study concerning its preventability]. / Das Ramus-genitalis-Syndrom nach Hernienreparation. Eine klinische Studie zur Frage der Vermeidbarkeit.

Postoperative chronic inguinal pain was studied in 460 patients who underwent Shouldice repairs. A follow-up investigation (91.9%) found a reduced incidence of chronic inguinal pain by preparing the genital branch of the genito-femoral nerve and severing it if necessary. By proceeding in this fashion, the incidence of inguinal entrapment syndromes can be reduced below 2% without influencing the early postoperative complication rate (5.5% and 6.7%) or the recurrence rate (0.5% and 0.96%). Compared with the ilio-inguinalis syndrome the ramus genitalis syndrome is an important cause of chronic inguinodynia after hernia repair.

[Large flank tumor after covered gallbladder perforation]. / Grosser Flankentumor nach gedeckter Gallenblasenperforation.

We report on a 79-year-old woman patient with a tumor with a diameter of 18 cm in the right flank. The medical history of the patient was normal except for a single asymptomatic gallstone, which had been known since 12 years. Sonography and abdominal CT showed an enormous intra-abdominal mass filled with liquid with a permanent union with the gallbladder. We than performed an explorative laparotomy with a tumor resection and a cholecystectomy. The histological examination showed perforation of the gallbladder with a great pseudocyst filled with 1800 ml infected bile and with penetration through the abdominal wall.

[Perforated diverticulum of the vermiform appendix]. / Divertikelperforation der Appendix vermiformis.

Diverticulitis of the vermiform appendix is an often disregarded disease. Diagnosis follows after appendectomy due to inflammatory complications in the form of diverticulitis and appendicitis. Diverticula can also be found as a reason for complaints in histologically unaltered appendix or as an incidental finding. Diverticula of the vermiform appendix are classified as false (acquired) or true (congenital). We report on the case of a 57-year-old man with a perforated appendix diverticulum as reason for peritonitis and a paralytic ileus of the colon and small intestine.

[Surgery for inguinal hernia in Germany 1992: a survey of 1,656 German clinics]. / Leistenhernienchirurgie in Deutschland 1992: Eine Umfrage an 1656 deutschen Kliniken.

A questionnaire of 1656 German surgical departments shows the preferentially applied procedures: in hernia of childhood Rehbein/Grob (24.1%) and Gross/Ferguson (24.4%). In primary hernia of adults Shouldice repair (47.7%), in recurrent hernia Shouldice-repair as well. McVay, mesh or plug-techniques are applied only for problematic cases of recurrent hernia. Laparoscopic hernia-repair is accepted in less than 10% of clinics.

[Repair of recurrent inguinal hernia. Tactics, technic and results]. / Reparation der Rezidivleistenhernie. Taktik, Technik und Ergebnisse.

Based on 301 surgical repairs of recurrent groin hernias perioperative management and recommended techniques for preparation and repair of various kinds of recurrent hernias are presented. Follow-up examinations could be performed on 175 patients, representing 88.8% of 197 patients who underwent surgery for recurrent hernias. Shouldice's technique for hernia repair proved to be the treatment of choice for recurrent groin hernias with a recurrence rate of 2.9% (5/175). Early postoperative complications occurred up to the 14th day following surgery. Frequently they could not be documented due to an average postoperative hospitalization period of 6.2 days only. The rates of postoperative complications were 8.1% prior dismission and 12.6% within two weeks after the operation respectively.

[Abdominal compartment syndrome: prevention and treatment]. / Abdominelles Kompartmentsyndrom: Vermeidung und Behandlung.

UNLABELLED: Abdominal compartment syndrome is defined by increased intraabdominal pressure above 20 mmHg with increased pulmonary peak pressure and oliguria. In primary abdominal compartment syndrome the increased intraabdominal pressure is caused directly by peritonitis, ileus or abdominal and pelvic trauma. Secondary compartment syndrome is a result of forced closure of the abdominal wall after abdominal surgery. The effects are decreased cardiac output, pulmonary atelectasis, oliguria to anuria and hepatic as well as intestinal reduction of perfusion. Effective monitoring is done by standardised measuring of urinary bladder pressure. Normal values are between 0 and 7 cm H2O, after elective laparotomies 5-12 cm H(2)0. Above 25 cm H(2)0 they are definitely pathological. For the prevention and therapy of manifested abdominal compartment syndrome the application of a laparostomy using a resorbable mesh is recommended. Between 1988 and 1999 we applied a laparostomy to lower the intraabdominal pressure in 377 patients. In 16% of the cases it was indicated by primary abdominal compartment syndrome with a bladder pressure of 31 +/- 4 cm H(2)0 preoperatively, which could be lowered to 17 +/- 4 cm H(2)0 by laparostomy. An early reconstruction of the abdominal wall could be performed in 18% of the cases. CONCLUSIONS: The abdominal compartment syndrome is an often underestimated problem in abdominal surgery involving multiple organ systems. The temporary laparostomy lowering intraabdominal pressure rather than a forced closure of the abdominal wall should be used in all circumstances.

[Results of Parks postanal repair in idiopathic anal insufficiency]. / Ergebnisse der posterioren Raffung nach Parks bei der idiopathischen analen Inkontinenz.

To assess the functional results of postanal repair of faecal incontinence we carried out clinical, physiological and radiological studies in 31 patients. Continence was improved in 26 (84%) patients, 19 (62%) of whom regained normal continence at a minimum of 12 months follow-up. A successful clinical outcome after postanal repair does appear to be related more to an improvement in sphincter pressures than to any reduction of the anorectal angle.

[Cremaster resection in Shouldice repair. A prospective controlled bicenter study]. / Cremasterresektion bei Shouldice-Reparation. Eine prospektiv kontrollierte Bicenter-Studie.

The aim of this prospective controlled trial was to determine the value of the resection of the cremaster muscle in Shouldice's hernia repair. 237 Shouldice operations with resection of the cremaster muscle of the Department of Surgery of the RWTH of Aachen were compared with 153 Shouldice repairs without resection of the cremaster muscle of the Department of Surgery of the Elisabeth Hospital in Essen. A comparable follow-up of 12 to 26 months in both groups revealed no significant differences in postoperative complications. In the group without resection of the cremaster muscle four indirect recurrent hernias were diagnosed. In the group with resection of the cremaster muscle no indirect recurrent hernia was detected, only one direct recurrent hernia was documented. The significantly elevated rate of recurrent hernias (p less than 0.05) and the occurrence of atypical indirect recurrent hernias in the group without resection of the cremaster muscle demonstrate the important influence on the technique of repair. Based on our results the resection of the cremaster muscle in an essential part of Shouldice's hernia repair.

[Preserving autonomic nerves in rectal surgery. Results of surgical preparation on human cadavers with fixed pelvic sections]. / Schonung autonomer Nerven in der Rectumchirurgie. Ergebnisse der Präparation an Leichen und fixierten Beckenpräparaten.

INTRODUCTION: Preservation of sexual function and voiding capacity after rectal cancer surgery has increased after adopting the technique of nerve-sparing dissection and total mesorectal excision. Still the rate of sexual and urinary dysfunction ranges between 25 and 67%. The precise locations where nerve damage occurs have not been looked at systematically. MATERIAL AND METHODS: In ten human corpses and two formalin-fixed human pelvises the autonomous pelvic nerves were isolated. Their relation according to surgical mobilization of the rectum were photodocumented. RESULTS: Pelvic autonomous nerves are clearly defined structures with only minor interindividual variability. The inferior mesenteric plexus forms a dense network around the inferior mesenteric artery (AMI) to a distance of 5 cm from the aorta. The distance between the lateral rectum and the pelvic plexus is only 2-3 mm. The anterior rectum is almost directly adherent to the neurovascular bundle, separated only by Denonvillier's fascia. The parasympathetic branches of the sacral segments S2-S5 cannot be isolated using the standard surgical approach. CONCLUSION: (1) The nomenclature of fascias and the course of the autonomous pelvic nerves is not clearly defined in the literature; (2) a high tie of the AMI leads to damage of the sympathetic nerves; (3) the narrow space between the anterior and lateral rectum makes sharp dissection under direct vision necessary; (4) fascias and nerves can be used as guiding structures during mobilization; (5) a preservation of selected parasympathetic roots in the small pelvis is not feasible using the standard surgical approach.

[Weakly malignant leiomyosarcoma of the inferior vena cava. A case report]. / Niedrigmalignes Leiomyosarkom der V. cava inferior Ein Fallbericht.

Primary vascular leiomyosarcomas of the great vessels are rare and the most common localization is the inferior vena cava. Due to nonspecific clinical signs, diagnosis is often made during operation or autopsy. At present, a radical tumor resection is the first choice of treatment. This is a case report of a 49-year-old woman who suffered from abdominal pain for 10 years because of a weakly malignant leiomyosarcoma of the inferior vena cava. A radical tumor resection and reconstruction with a prosthetic vascular graft were performed. Diagnosis, therapy, and prognosis are discussed.

[Acute lung failure]. / Das akute Lungenversagen.

Ever-increasing knowledge of the pathomechanisms and the phasic pathogenesis of ARDS has increased the demand for adequate monitoring and has modified therapeutic strategies. The influence of monitoring by double indicator dilution technique (COLD system) with the close measurement of extravascular lung water on the diagnosis and therapy of ARDS is presented. Pressure-controlled ventilation (< 35 cm H2O) in combination with moderate PEEP, kinetic therapy (prone position) and elective CVVH already in the early stages of ARDS can be regarded as the standard therapy. The effectiveness of NO inhalation, prostaglandins and radical scavengers still has to be improved in controlled clinical trials.

The use of synthetic absorbable suture materials (polyglycolic acid and polydioxanone) in the low pressure circulatory system of growing organisms.

Synthetic absorbable sutures were used for surgery in the cardiovascular low pressure system of growing beagle dogs. Right atrial incisions were closed with this material in 20 dogs. In another 20 dogs caval anastomoses were performed in continuous suture technique. Repeated angiographies and histological examination were performed after observation periods between 5 and 180 days. No clinical complications occurred. Postoperatively patent anastomoses grew with the surrounding tissue, while stenotic anastomoses attained normal luminal diameter after suture absorption. Synthetic absorbable suture materials are recommended for use in the cardiovascular low pressure system, especially in the correction of congenital anomalies.

[Monitoring critically ill intensive care patients by semi-invasive COLD (Cardiac-Output-Liver-Diseases) monitoring instead of pulmonary artery catheterization]. / Uberwachung kritisch kranker Intensivpatienten durch halbinvasives COLD-Monitoring anstelle Pulmonalis-Katheterisierung.

The routine application of an arterial thermal-dye-dilution technique (so called COLD-Monitoring) offers new perspectives in the hemodynamic management of critically ill patients using a small invasive technique. COLD-Monitoring employs a computerized analysis of a double-indicator (temperature and dye) dilution technique which requires only a central venous catheter and a special fibre optic catheter with a temperature probe applied to the femoral artery. Especially in critically ill patients with septic course or multiple organ failure (MOF) COLD-monitoring serves to exactly measure volume and therefore distribution, to objectify capillary leakage by extravascular lung water index, to check the excretoric liver-function by plasma-deviation-rate of ICG and to perform a well controlled epinephrine therapy by measuring cardiac function index and systemic vascular resistance index.