Reactive hyperemia in patients with septic conditions.

In a prospective study microvascular reactivity was examined in 12 patients with septic conditions by means of the provocation of reactive hyperemia (RH) for evaluation of microcirculatory function. Data were compared with data from 10 nonseptic, postsurgical patients. At the time of the initial measurement, an adequate hyperemic response could be produced in all patients. In the further course of the disease, in nine of the 12 patients severe multiple organ failure developed. In spite of sufficient values for arterial blood pressure, oxygenation, and the clotting system, RH was absent in these patients (8 +/- 2 days after the initial measurement). Subsequently, seven of these nine patients died (4 +/- 2 days after the onset of microvascular nonreactivity). Until death, RH was absent in each patient, and at this time therapy-resistant hypoxemia, hypotension, and severe disturbances of the clotting system were present. In the two surviving patients RH was restored completely. These results indicate that (1) the septic state per se is not necessarily combined with impaired microvascular reactivity (rather, the absence of RH may be a sign of generally poor clinical conditions); (2) the absence of RH is not related to therapy-resistant hypotension, hypoxia, and severe clotting disorders but precedes these changes; and (3) provocation of RH may be of clinical use for early detection of microcirculatory malfunction in high-risk patients.

Altered hormonal activity in severely ill patients after injury or sepsis.

We studied the hormonal millieu and possibility of altered thyroid function in 25 patients in a surgical intensive care unit (ICU) who had severe life-threatening illnesses. Sixteen patients had septic complications and nine patients had multiple-system injuries. On admission to the ICU, serial measurements were begun of thyroxine (T4), triiodothyronine (T3), T4-binding globulin, thyrotropin (thyroid-stimulating hormone [TSH]), corticotropin (adrenocorticotropic hormone [ACTH]), cortisol, prolactin, human growth hormone, catecholamine, insulin and glucose, lactate, retinol-binding protein, prealbumin, and transferrin levels. All patients initially had low normal levels of T4 (4.5 +/- 2 micrograms/dL) and T3 (55 +/- 26 ng/dL), with normal TSH levels (2.3 +/- 2.3 microU/mL) (the "low T3 syndrome"). The 11 surviving patients had their levels increase to normal before leaving the ICU (T4, 7.0 +/- 2.1 micrograms/dL; T3, 110 +/- 48 ng/dL; and TSH, no change). The 14 patients who died showed further decreases before death (T4, 2.6 +/- 2.1 micrograms/dL; T3, 30.6 +/- 23.5 ng/dL; and TSH, 0.9 +/- 0.7 microU/mL). The corticotropin, cortisol, prolactin, and growth hormone levels were normal throughout the study. Catecholamine levels were high initially and decreased in surviving patients. Epinephrine levels increased greatly in nonsurvivors before death, and the norepinephrine-epinephrine ratio decreased from 5.7:1 to 2:1. After protirelin (thyroid-releasing hormone [TRH]) stimulation, the TSH level increased either minimally or not at all in six patients who eventually died. This indicates hypothalamic-pituitary dysregulation or suppression, and altered release and/or peripheral metabolism of T4. Whether this represents a deficiency of thyroid hormone for cell and organ function remains to be established.

The immune-enhancing effect of perioperative thymopentin administration in elderly patients undergoing major surgery.

The effects of perioperative administration of thymopentin (TP-5) on in vivo and in vitro measurements of cell-mediated immunity in elderly patients undergoing major surgery were investigated. A placebo-controlled study was conducted in 25 patients (mean age, 67 years) with congenital or acquired heart disease undergoing surgery with cardiopulmonary bypass. Patients were divided into three groups: Group 1 patients were given 50 mg of TP-5 subcutaneously two hours preoperatively. Group 2 patients were given 50 mg of TP-5 subcutaneously two hours preoperatively and 48 hours postoperatively. Group 3 patients were given placebo at corresponding times. Cell-mediated immunity measurements were the in vivo delayed-type hypersensitivity (DTH) response on day 0 and on day 7 to an antigen skin test battery. The in vitro studies included antigen cocktail-induced lymphocyte proliferation of peripheral blood mononuclear cells. The DTH response on day 7 after surgery was significantly suppressed in group 3 patients compared with the preoperative baseline value, while it remained unaltered in group 1 and 2 patients. There was a considerable difference of DTH measurements (number of positive antigen responses and sum of their mean diameters) between group 2 and 3 patients. Antigen cocktail-induced lymphocyte proliferation, following initial suppression in the majority of patients, was significantly different between the placebo group and patients in group 2 on day 7 after surgery. The data indicate that perioperative administration of TP-5 might be of considerable clinical utility in preventing a defective cellular immune response.

Alteration of monocyte function following major injury.

The macrophage exerts its stimulatory and regulatory functions within the specific immune response via the interleukin 1 (IL-1) and prostaglandin E2 (PGE2), respectively. In a screening study of macrophage-related variables following injury, a total of 58 patients (mean age, 32 years; mean injury Severity Score, 38), macrophagic phenotyping with the monoclonal antibody Leu M3 and serial measuring of the antagonistic monokines IL-1 and PGE2 and of the macrophage-activating lymphokine interferon gamma were carried out on posttrauma days 0, 1, 3, 5, 7, 10, 14, and 21. The posttraumatic course was characterized by significant monocytosis, showing a peak value of 32% of Leu M3-positive cells compared with 15% of these cells in normal control subjects. During the posttrauma course, the macrophagic PGE2 output was significantly elevated up to eightfold on days 5 and 7 compared with that of control subjects (0.441 +/- 0.14 ng/mL vs 0.052 +/- 0.01 ng/mL). Conversely, macrophagic IL-1 synthesis was significantly suppressed until day 10. Levels of interferon gamma were suppressed to a significant degree during the two-day observation period, with a trend to slow recovery at the end of week 3. These data suggest that a negative regulatory macrophagic function may be the event initiating posttraumatic immunosuppression. To restore impaired macrophagic T-helper cell interaction, cyclo-oxygenase inhibition and substitution of interferon gamma may be useful to potentiate facilitatory macrophagic function and to block inhibitory macrophagic activity.

Low-dose glucose infusion in patients who have undergone surgery. Possible cause of a muscular energy deficit.

To evaluate the effect of the glucose-induced insulin release on peripheral substrate metabolism, we studied muscle metabolism in seven patients after elective surgery and in four healthy volunteers combining the forearm and the euglycemic glucose clamp technique (insulin infusion, 0.2 mU/kg per minute). Arterial and deep venous concentrations of substrates and hormones were determined in the basal period and during steady state of the infusion period. After 90 minutes of insulin infusion, the whole-body glucose infusion rate was significantly lower in patients who had elective surgery, although plasma insulin concentrations were comparable. In both groups this was related to a reduced supply of free fatty acids and ketones in muscle. In controls the resulting lack of substrates in muscle appeared to be compensated by an enhanced uptake of glucose, not seen in the patients who had elective surgery. Surprisingly, as indicated by the significantly reduced lactate production (-0.15 +/- 0.05 vs -0.62 +/- 0.32 mumol/100 g per minute basal), in this group the glucose taken up was oxidized aerobically to a greater extent. However, the total resulting energy gain was small. Thus, a peripheral energy deficit might arise favoring increased oxidation of amino acids. To avoid this undesired side effect, only those substrates should be administered that minimize pancreatic insulin release.

Intraoperative biochemical localization of insulinomas by quick radioimmunoassay.

In patients with organic hyperinsulinism, intraoperative determination of insulin concentrations in veins draining the pancreas might help localize the tumor. We have developed a radioimmunoassay measuring insulin within 30 minutes. At operation, blood samples are taken at various sites in the splenic, superior mesenteric and portal veins for insulin determinations. In all six patients, the highest insulin concentrations correlated with the site of the tumor. Also, small insulinomas less than 1 cm in diameter could be found. In one patient the tumor appeared to secrete mainly proinsulin. By this procedure we hope to avoid blind distal resection of the pancreas and possibly invasive preoperative diagnostic procedures.

Arterial deepvenous difference of lipoproteins in skeletal muscle of patients in postoperative state: effects of medium chain triglyceride emulsion.

The effect of fat infusion with medium chain triglycerides (MCT) and long chain triglycerides (LCT) on serum lipoproteins before and after passage through the skeletal muscle was investigated with the forearm technic in eight patients after abdominal operation. All lipoprotein fractions were enriched with triglycerides and phospholipids from infused artificial fat particles with the consequence of significantly increased ratios of TG/PL and TG/apo B in VLDL, of TG/apo B in LDL and TG/apo A-I in HDL. Uptake and release of lipoprotein components by skeletal muscle are given by arterial-deepvenous differences considering the blood flow rates. The positive arterial-deepvenous difference of VLDL triglycerides after 4-hr infusion is interpreted as cleavage and uptake of infused MCT by the muscle. The release of LDL is more pronounced after the fat infusion than before, suggesting a degradation and enhanced catabolism of artificial fat particles. HDL release may be also a consequence of catabolism of artificial TG/PL-particles. These results indicate an uptake of MCT/LCT emulsion by the skeletal muscle.

The place of lithotripsy and surgery in the management of gallstone disease.

In summary, 10% to 20% of all symptomatic and uncomplicated gallbladder stones can be treated by ESWL under the current entry criteria. Further, ESWL is suitable for patients with bile duct stones in whom the primary endoscopic approach is not successful (about 10%). The algorithm in Figure 7 shows the therapeutic modalities that may be employed if the least invasive therapy is chosen. The different methods shown in this diagram are usually carried out by different specialists including surgeons, gastroenterologists, or radiologists. Therefore, an interdisciplinary approach is desirable. The technology of shock wave therapy of gallbladder stones will be improved in the future, for example the efficacy of stone fragmentation while maintaining a low level of discomfort for the patient. Moreover, repeated shock wave treatments may increase the success rate in patients with multiple stones and possibly in those with slightly calcified stones as well. Repeated procedures for recurrent stones appear feasible. Long-term follow-up studies are needed to define the place of ESWL in the management of gallstone disease. Surgery of the gallbladder remains the "gold standard" of curative therapy of gallbladder stones, against which ESWL and other nonsurgical techniques have to be evaluated. For the therapy of bile duct stones, ESWL is a helpful and effective nonsurgical adjunct.

[Current status of gallstone surgery in Germany. Results of a survey and retrospective analysis of 27,403 interventions--open vs. laparoscopic surgery]. / Aktueller Stand der Gallensteinchirurgie in Deutschland. Umfrageergebnisse und retrospektive Analyse von 27,403 Eingriffen--offene vs. laparoskopische Chirurgie.

Based on a representative poll, which included a retrospective data analysis, the current surgical approach to gallstone disease in Germany is presented. A total of 25,955 procedures in 1991 is analysed. 24.9% of all cholecystectomies were done laparoscopically. In 1992, already 81.4% of all surgeons reported own experiences with this new technique. Comparing open procedures with laparoscopic cholecystectomy the latter showed a lower incidence of complications (6.8 vs 8.7%) and perioperative death (0.14 vs. 0.43%). In contrast, relaparotomies were more frequent in the laparoscopy group (1.48 vs. 0.84%). The diagnostic and therapeutic approach for common bile duct stones is currently changing. There is a tendency towards less invasive endoscopic and laparoscopic procedures and towards their combination, respectively.

[Tracheoesophageal fistula after blunt thoracic trauma: recognition and treatment]. / Die tracheo-oesophageale Fistel nach stumpfem Thoraxtrauma: Erkennung und Behandlung.

Three cases of tracheoesophageal fistula as a result of nonpenetrating chest trauma were surgically repaired. Another 31 cases were found in the literature. 'Thrown against a steering wheel' was the cause of injury in the majority of patients. Though the fistula became characteristically symptomatic 3 to 7 days after the accident, the diagnosis was often delayed for several months. No patient recovered without operation. After demarcation of the area of contusion and necrosis, especially in the esophagus wall, surgical repair is the therapy of choice.

[Hemostasis with a new infrared-sapphire-coagulator (ISC-81). First clinical studies]. / Blutstillung mit einem neuen Infrarot-Saphir-Coagulator (ISC-81) Erste klinische Erfahrungen.

A new infrared sapphire coagulator (ISC-81) has been developed for the hemostasis of parenchymatous hemorrhage. Upon absorption by the bleeding tissue, light is converted into thermal energy thus causing coagulation and hemostasis. The light is transmitted to the bleeding tissue via a sapphire crystal, which is nonadhesive and of high thermal resistance. For application on flat surfaces or in ruptured tissues, either a cylindrical or a wedge-shaped crystal can be used. Up to now the ISC-81 has been used successfully on 22 patients, most of whom had hemorrhages from ruptured spleens or livers.

[Interdisciplinary treatment of gallstones: surgery, endoscopy, lithotripsy. Report of experiences after 4 years]. / Interdisziplinäre Behandlung des Gallensteinleidens: Chirurgie, Endoskopie, Lithotripsie. Erfahrungsbericht nach 4 Jahren.

Today, several methods of treatment for gall stone disease exist besides standard surgical procedures: endoscopy, lithotripsy, litholysis or a combination of the above. During the last four years 1786 patients were treated using an interdisciplinary approach. Cholecystectomy was still the most frequent method of treatment for symptomatic cholecystolithiasis (n = 1369) with low morbidity (4.3%) and lethality (0.28%). Probably less than 20% of all cases fulfill the strict selection criteria for extracorporeal shock wave lithotripsy (ESWL). All alternative methods of treatment in which the gallbladder is preserved have an increased risk for gall stone recurrence. Only after the long-term follow-up results of ESWL are known, the recurrence rate can be assessed. In most cases, bile duct stones (n = 417) were removed by endoscopy, if necessary in combination with ESWL (n = 310, stone removal: 95%, lethality: 0.3%). However, in low risk patients with concurrent cholecystolithiasis surgery was still the method of choice (n = 107, stone removal: 96%, lethality: 0/107). It seems not so important as to who performs the non-surgical procedures in the treatment of gall stones - the surgeon, internist or radiologist. Moreover, an interdisciplinary approach should be sought.

[Treatment of the polytraumatized patient in a clinic]. / Die Behandlung des Polytraumatisierten in einem Klinikum.

433 patients (mean age 33.3 years) with multiple injuries were treated from 1978 to 8/1982. Classification of the injuries was done according the S(skeleton)A(abdomen)T(thorax)scheme. The overall mortality was 18%. The cause of death were CNS-injuries in 50% of the patients. Besides CNS-injuries single and multiple organ failure were limiting the prognosis. In all cases of organ failure the lung was affected. Two patterns of multiple organ failure were found. Significant factors were shock, massive blood transfusions and abdominal trauma--but as well as errors in the treatment. Still improvement of the survival rate of the polytraumatised patients must be achieved in the future. Besides aggressive shock therapy and prevention of posttraumatic pulmonary insufficiency through earliest respiratory support we emphasize a strict strategy of treatment priorities. Based upon an intensive training especially in trauma care the surgeon will be able to recognize complications earlier and thus increase the chance of survival of the polytraumatised patient.

[Disease picture and operative therapy in multiple endocrine adenomatoses (MEA sydrome)]. / Krankheitsbilder und operative Therapie bei multiplen endokrinen Adenomatosen (MEA-Syndrome).

We have outlined the symptoms, diagnostic procedures and operative treatment of "multiple endocrine adenomatosis" (MEA I, IIa und IIb). The priority of the operative procedure whenever two or more clinical syndromes in a patient with MEA are present and the possibility of multiple tumors has to be considered carefully. When there is a tumor of an endocrine organ, it should always bethought about the MEA-syndrome. We report about 9 patients seen in our hospital.

[Trachea reconstruction in inflammatory stenosis and tumors]. / Trachea-Rekonstruktionen bei entzündlichen Stenosen und Tumoren.

Primary resection of the trachea and direct anastomosis is indicated whenever inflammatory stenoses and tumors of the trachea are present. In our own series of 27 patients operated upon there were 17 stenoses by scars, two malacias of the trachea, six adenoid-cystic carcinomas, one adenoma of the bronchus and one chondroma. One patient died on the 16th postoperative day from stress-ulcer bleeding. Another patient died three months after the resection of the trachea following reoperation from a recurrence of the stenosis. There was bleeding out of the tracheostoma with aspiration. One patient had a stenosis of the cricoid three years after the tracheal resection had been performed. The stenosis could be treated successfully by reconstructive surgery. None of the other 24 patients had complications. Data on the late results are given. New reports in the literature and our own experience indicate that a tracheal resection with a direct anastomosis seems to be a standardized procedure. Using the right indication for the operation good early and late results can be achieved.

[Surgical treatment of inflammatory diseases of the colon : ulcerative colitis, Crohn's disease, diverticulitis]. / Il trattamento chirurgico delle malattie infiammatorie del colon: colite ulcerosa, morbo di Crohn, diverticolite.

Operations and follow-up examinations were conducted on 106 patients with ulcerative colitis, 33 with colitis Crohn, and 163 with diverticulitis, at the University Clinics of Cologne and Munich. Overall mortality rates were 24.5% (n = 26), 6.1% (n = 2) and 16% (n = 26), respectively. In the surgical treatment of ulcerative colitis the possibility of malignant degeneration and, in the case of Crohn's disease, prevention of recurrences must be taken into consideration. Whether Crohn's disease is a precancerous conditions remains to be clarified. Choosing the optimal time for operative intervention is as important in diverticulitis as in ulcerative colitis. Because of the possibility of complications and the high risk of operation, early intervention is recommended for diverticulitis.