[Comparative investigations on the organotropic carcinogenic effect of different N-nitroso compounds with rat after single and chronic treatment (author's transl)]. / Vergleichende Untersuchungen über die organotrope carcinogene Wirkung verschiedener N-Nitrosoverbindungen nach einmaliger bzw. langzeitiger Applikation bei Ratten.

After the gavage of 200 mg N-nitrosodiethylamine per kg body weight only kidney tumors developed while long-term administration of 10 ppm N-nitrosodiethylamine induced esophageal tumors and hepatocellular carcinomas in female rats (SIV 50). This change of the organ-specific carcinogenic effect is not observed in experiments with N-methyl-N-nitrosobenzylamines substituted with a methyl group at the phenyl moiety. Both chronic treatment and single doses induced tumors of the esophagus and the pharynx.

Sulbactam in combination with mezlocillin, piperacillin or cefotaxime: clinical and bacteriological findings in the treatment of serious bacterial infections.

An open, multicentre study was performed in hospital in-patients at a total of 12 German hospitals to investigate the efficacy and tolerability of sulbactam combined with mezlocillin, piperacillin or cefotaxime in severe bacterial infections. A total of 155 patients were recruited into the study, of whom 48 were suffering from respiratory tract infections, 66 from intra-abdominal infections, 34 from skin/soft tissue infections including postoperative wound infections, and five from complicated urinary tract infections. Fifty-five patients intravenously received 4 g mezlocillin and 1 g sulbactam three times daily, 52 received 4 g piperacillin and 1 g sulbactam three times daily, and 48 received 2 g cefotaxime and 1 g sulbactam three times daily. The antibiotic and sulbactam combination was administered in all cases by rapid intravenous infusion of both components together, over 20 min. The mean duration of treatment was 20 days. The criteria used to define the outcome of treatment as successful were clinical cure (complete disappearance of the signs and symptoms of infection seen before the start of treatment) or improvement (appreciable diminution or partial resolution of the initial signs and symptoms, no further antibiotic therapy required) and the elimination of the organisms isolated before the start of the study. Of the 153 clinically evaluable patient, 141 (92%) were classed as responders (a cure was obtained in 98 cases and improvement in 43 cases). No response to the study medication was seen in 12 patients (7.8%). The response rates of the combined antibiotic-sulbactam preparations were 91% for mezlocillin/sulbactam, 92% for piperacillin/sulbactam, and 93% for cefotaxime/sulbactam. These response rates are almost identical. A total of 106 patients (68.4%) were bacteriologically evaluable; a total of 192 bacterial organisms were identified in these patients before the start of treatment. Mixed infection was present in 55 patients. The causative organism initially isolated was eliminated in 96 patients (90%), accounting for 180 of 192 strains (94%). Persistence of the causative organism (12 strains) was seen in eight patients (7.6%). Superinfection (four strains) was seen in two patients (1.9%). The study medication was well tolerated; adverse drug effects were seen in only five patients (3.3%). Treatment was discontinued in one patient because of the adverse effect (exanthema). The combination of the beta-lactamase inhibitor sulbactam and a ureidopenicillin or cefotaxime was highly effiacious in patients with severe bacterial infections investigated in this study. The availability of sulbactam as a single-agent preparation opens up new avenues for flexible and cost-effective antibiotic therapy and is a valuable contribution to the control of bacterial resistance.

Functional results after laparoscopic rectopexy for rectal prolapse.

We investigated the functional results after laparoscopic rectopexy for rectal prolapse in 29 patients at least 12 months postoperatively. Twenty patients were evaluated completely pre- and postoperatively (median 22 months postoperatively, range 12 to 54 months). Six patients were interviewed by telephone, two patients were lost to follow-up, and one patient died of causes unrelated to rectal prolapse. Patients underwent a proctologic examination, anoscopy, rigid sigmoidoscopy, fluoroscopic defecography, and anorectal manometry pre- and postoperatively, and an additional standardized interview postoperatively. Anorectal manometry showed a significant increase in maximum anal resting and squeeze pressures postoperatively (resting pressure 72 +/- 8 vs. 95 +/- 13 mm Hg, pre- vs. postoperatively; P = 0.046; squeeze pressure 105 +/- 17 vs. 142 +/- 19 mm Hg, pre- vs. postoperatively; P = 0.035), and continence improved postoperatively (Wexner incontinence score 6.0 +/- 1.0 vs. 3.9 +/- 0.8 pre- vs. postoperatively, P = 0.02). Twenty (77%) of 26 patients were satisfied with the operative result, but functional morbidity was observed in four patients, with two patients complaining of severe evacuation problems. Rectal prolapse recurred in one patient 42 months postoperatively (recurrence rate 1 [3.8%] of 26 patients). Functional results were very similar to those obtained after open rectopexy, with symptoms of prolapse and incontinence improved in the great majority of patients.

Technique and results of transanal endoscopic microsurgery in early rectal cancer.

The anatomy of the pelvis makes it difficult to perform local excisions in the rectum when the tumor is some distance from the anal verge. We have, therefore, developed a new minimally invasive technique for tumor resection. A rectoscope with a 40-mm diameter permits tumor resection under stereoscopic control in the gas-dilated rectal cavity. Excisions in full-thickness technique up to segmental resections with end-to-end anastomosis can be performed. In selected cases, local excision of a small rectal cancer can be regarded as appropriate treatment. However, most local resections of carcinomas are performed when removal of an adenoma is planned, and the postoperative histology shows a carcinoma. Since 1983, we have operated on 326 patients, 274 who have been enrolled in a prospective clinical trial. Definitive histologic examination proved that 74 of these tumors were carcinomas. The rate of severe complications in patients with carcinomas was 9%, and the mortality rate was 0%. The advantages of this new technique are: The stereoscopic magnified view in the gas-dilated rectum allows precise surgery in an operative field that is otherwise difficult to reach. During the postoperative period, minimal discomfort and pain result in a short hospitalization.

Endoscopic microsurgical dissection of the esophagus (EMDE).

This paper presents endoscopic microsurgical dissection of the esophagus (EMDE), a surgical technique for the therapy of esophageal cancer which improves blunt esophageal dissection with the aim of reducing postoperative morbidity and mortality. A mediastinoscope with integrated operative instrument channel, fibre bundles, optic and rinsing channel has been developed whereby precise and atraumatic esophageal dissection is possible via a cervical access incision. Between 1989 and 1993, 37 patients were operated on using the EMDE technique and are compared with 48 patients operated on during the same period by the thoraco-abdominal route. The operative duration was reduced by the new technique, and although the number of severe complications was not significantly different between both groups, the rate of pulmonary and cardiac complications was reduced. The mortality rate was 10% for EMDE patients and 14% for the thoraco-abdominal procedure, and there was no difference in the long-term survival rate. As distinct from procedures requiring a thoracotomy for esophageal dissection, EMDE permits ventilation of both lungs throughout the entire operation and reduces the total operative trauma.

[Experimental and clinical studies of the efficacy of an antimicrobial incision drape]. / Experimentelle und klinische Untersuchungen zur Wirksamkeit einer antimikrobiell ausgerüsteten Incisionsfolie.

The antibacterial activity of an antimicrobial incise drape containing povidone-iodine was compared to a normal drape by experimental and clinical investigations. In vitro, no difference in the survival rate of six bacterial species depending on the kind of the drape, could be demonstrated. Clinical studies by contact cultures, postoperatively taken from the skin after removal of the drape, yielded no significant difference in the recolonisation of the skin during the operations. The importance of the preoperative, antimicrobial preparations of the skin is discussed.

[Local therapy of rectum carcinoma. A prospective follow-up study]. / Die lokale Therapie des Rektumcarcinoms. Eine prospektive Beobachtungsstudie.

Local therapy of rectal carcinoma with the method of TEM was performed in 98 patients during the period from August 1, 1989 to January 31, 1994. 56 of the patients had pT1, 27 pT2, and 15 pT3 tumours. There was no lethality. The rate of complications, which required operative intervention, was 8%. No lymph node metastases were found in the specimens of the patients with pT1 tumours, who were re-resected, because the margin of the primary specimen were judged to be not free of tumour. In the specimens of the re-resected patients with pT2 carcinomas, lymph node involvement was more common than remnants of the primary tumour. Two of the patients with local therapy of pT1 low-risk carcinomas developed a recurrence so far. A secondary procedure for cure according to oncologic criteria could be performed in both cases. In selected cases the local therapy of rectal carcinoma avoids the high morbidity and mortality of the classical operation. Live quality will be improved, especially if an artificial anus can be avoided. In case of a recurrence the chance of a secondary procedure for cure is not to be underestimated.

[Follow-up results of laparoscopic cholecystectomy]. / Spätergebnisse nach laparoskopischer Cholecystektomie.

Following a laparoscopic cholecystectomy 400 patients have been interviewed with a questionnaire on the late results of the surgery (15 to 40 months postop.). The cholecystectomies had been performed within the time from March 7, 1990 to April 30, 1992 in Tübingen. After a mean of 16.8 days the patients returned to work, while they themselves felt reduced for an average of 10.6 days. 11.9% of the patients complained of slight wound healing problems and in 3.1% wound infections have been registered. Although 97% of the patients were satisfied with the results of surgery, 8.7% still complained of upper abdominal trouble. Slight persistent problems like light pain or flatulence have been reported by 19%.

[Sulbactam in combination with mezlocillin, piperacillin or cefotaxime. Clinical and bacteriological results in the treatment of severe bacterial infections]. / Sulbactam in Kombination mit Mezlocillin, Piperacillin oder Cefotaxim. Klinische und bakteriologische Ergebnisse bei der Behandlung schwerer bakterieller Infektionen.

An open multicenter study on inpatients of 12 german hospitals was performed to investigate efficacy and safety of sulbactam in combination with mezlocillin, piperacillin or cefotaxim in severe bacterial infections. In total 155 patients were enrolled. The following infections were diagnosed: 48 lower respiratory tract infections, 66 intraabdominal infections, 34 skin/soft tissue infections including post operative wound infections and 5 complicated urinary tract infections. 55 patients received 3 daily doses of 4 g mezlocillin + 1 g sulbactam, 52 patients received 3 daily doses of 4 g piperacillin + 1 g sulbactam and 48 patients received 3 daily doses of 2 g cefotaxim + 1 g sulbactam. Antibiotics and sulbactam were administered concomitantly via intravenous short infusion. Mean duration of therapy was 8 days. Endpoints for assessment of therapeutic efficacy were cure (complete resolution of pretreatment signs and symptoms of the infection) or improvement (marked reduction or partial disappearance or pretreatment signs and symptoms, no further antibiotic therapy required) as well as eradication of pretreatment pathogens. 141 (92%) of 153 evaluable patients were successfully treated (98 cures and 43 improvements), therapy failed in 12 patients (7.8%). Success rates of the 3 sulbactam combinations were almost identical: 91% for mezlocillin/sulbactam, 92% for piperacillin/sulbactam and 93% for cefotaxim/sulbactam. 106 patients (68.4%) were also bacteriologically evaluable. In these patients 192 bacterial pathogens were isolated prior to study therapy, 55 patients had mixed infections. In 96 patients (90%) pretreatment pathogens were eradicated (180 strains = 94%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Laparoscopic cholecystectomy]. / Laparoskopische Cholezystektomie.

Laparoscopic cholecystectomy has been accepted clinically in a very short time. Following an intensive training-course for manual dexterity clinical experience should be achieved in carefully selected cases. After a certain number of cholecystectomies the majority of cholecystectomies can be performed laparoscopically. The complication rate of laparoscopic cholecystectomy in the hand of a well trained surgeon seams to be comparable or even smaller than in conventional procedure. The patients have significantly less pain and bodily activity starts early. The postoperative time in hospital in our clinic is two to three days. The rehabilitation-time could be shortened.

[Free mobile intra-abdominal "tumor"]. / Frei beweglicher "Tumor" im Abdomen.

The rare condition of an accidentally discovered 3 cm sized tumor in the abdomen is reported which was completely free and migrating within the abdominal cavity. Initially it was detected by ultrasound and thereafter reconfirmed in several CT scans over 2.5 years. Surprisingly the tumor was localized at different sites. Finally it was removed laparoscopically. Histopathology revealed that it was most probably a calcified appendix epiploicum separated from the colon.

[Acute carpal tunnel syndrome in a patient with Marfan syndrome]. / Akutes Karpaltunnelsyndrom bei Marfan-Syndrom.

Acute carpal tunnel syndrome (ACTS) is rare and is mostly the result of fractures of the distal radius or the carpal bones. This paper gives the first report of an ACTS following contusion of the wrist as the result of an extensive haematoma of the flexor tendon sheath, which did not appear until 50 hours after the injury was sustained but then developed rapidly. The patient suffers from Marfan syndrome. This disease is associated with pathologic changes to the major vessels, and especially the aorta, and of the smaller peripheral vessels. It is assumed that the haematoma arose from an aneurysm of such a small vessel. The treatment of choice in ACTS is emergency incision of the carpal tunnel.

Benefit and advantage to clinicians of a computer-assisted microbiological diagnosis and database system.

Computer-assisted diagnostic systems may accelerate transmission of microbiological reports and facilitate evaluation of the epidemiological situation and thus improve the collaboration between microbiologists and clinicians. This possible benefit is demonstrated by four examples. It became evident that incidences of pathogens in urinary tract and respiratory tract infections varied within a great range, depending on patient groups and clinical departments involved. Even within a department, different incidences of penicillin G and oxacillin-resistant coagulase-negative staphylococci were demonstrated. An apparent homogeneity of distribution of pathogenic bacteria in a hospital tends to be the result of a nondiscriminating overall evaluation, thus necessarily misleading the clinician especially in empirical chemotherapy. In the last example the evaluation of susceptibility testing revealed changing patterns of some pathogens during the observation period. By rapid exchange of data between the laboratories and the clinical departments supplying the clinicians with information relevant for actual therapeutical decisions, an empiric therapy may change into a so-called calculated therapy based upon data directly related to the site of infection, department and susceptibility patterns.

[Uses and advantages of a computer-assisted microbiologic diagnosis and database system for antibiotic therapy in surgery]. / Nutzen und Vorteile eines computergesteuerten mikrobiologischen Diagnose- und Datenerfassungssystems für die Antibioticatherapie in der Chirurgie.

To demonstrate the value of a computer assisted microbiological diagnosis and database system for clinical use, epidemiological aspects of three important infections were investigated: urinary tract, respiratory tract and wound infections. The first two examples presented revealed significant differences in incidence of pathogens between a single patient group and the overall statistic. The third example demonstrates that even within a department susceptibility patterns of staphylococcus epidermidis were changing in dependence of the ward investigated. In the last example the evaluation of susceptibility testing revealed changing patterns of some pathogens during the observation periods. By means of a computer assisted diagnosis and database on file at the moment of diagnosis thus allowing statistical evaluations at every time within a few hours. The clinician provided with actual data concerning his ward or department may administer an empiric therapy according to the real situation. Besides this, automated susceptibility testing may shorten the time required for diagnosis up to 24 h, thus further contributing to a more rational antimicrobial therapy. In conclusion computer assisted diagnosis and automated instruments support the clinician by means of actual epidemiological data and rapid reporting in choosing and controlling antimicrobial therapy.

[The role of coagulase negative staphylococci in mixed infections: association testing as an in vitro model]. / Die Rolle coagulasenegativer Staphylokokken in Mischinfektionen: Assoziationstestungen als in-vitro-Modell.

Infections due to coagulase negative staphylococci (CNS) are of growing concern mainly in patients hospitalized in intensive care units (ICU). The ability of CNS to adhere and to grow on plastic devices and resistance to many antibiotics, including oxacillin, contributes to their pathogenicity. Using the computer assisted system of the Medical Microbiology Department, the incidences of different pathogens and the coincidence of CNS with other bacteria were evaluated in a surgical department. Staphylococcus aureus revealed to be the predominant pathogen; however, CNS showed an increasing incidence in wound specimens and blood cultures of patients on the ICU. Coincidence of CNS with S. aureus and the nine most frequent species of gram negative bacteria could be shown in 6%. To investigate the influence of beta-lactamases produced by CNS in mixed infections, association experiments were performed. Association means a controlled growth of two or even more bacteria in a susceptibility testing system, either a broth dilution method or an automated broth disk elution method (Cobas Bact). The association experiments showed a significant increase of amoxicillin MIC's of the pathogen associated with CNS. Addition of clavulanic acid restored activity of amoxicillin. It could be shown that in mixed infections CNS may contribute to the failure of antibiotic regimens by production of beta-lactamases.

[Massive hemorrhage from an "esophageal tumor": thoracic aortic aneurysm rupturing into the esophagus]. / Massive Blutung aus einem "Osophagustumor": In die Speiseröhre rupturiertes thorakales Aortenaneurysma.

We report on an arteriosclerotic aneurysm of the descending aorta penetrating into the esophagus. On endoscopy it mimicked a bleeding esophageal tumour. The typical clinical course of aortoesophageal fistulas (AEF) exhibits Chiari's triad of midthoracic pain, sentinel arterial hemorrhage, usually hematomesis, and final exsanguination after a symptom-free interval. The various causes of AEF are discussed together with the respective diagnostic and therapeutic problems.

[Endoscopic surgery of the upper gastrointestinal tract]. / Endoskopische Chirurgie am oberen Gastrointestinaltrakt.

Clinical application of laparoscopic cholecystectomy was followed by a lot of other endoscopic procedures for the surgical treatment of diseases of the upper gastrointestinal tract. In cases of disorders of esophageal motility traditional procedures can be performed endoscopically. Remarkable experiences were published concerning the cardiomyotomy, and fundoplication. Endoscopic operations could be shown to be a suitable treatment of benign and malignant tumours of the esophagus. Also the nowadays very rarely indicated vagotomy can be performed laparoscopically having good results. During the last year a few new operations could be added by using endoscopic linear staplers for resections and anastomoses such as gastostomies, jejunostomies, gastroenterostomies and even BII resections. In general surgeons are enabled to perform a great variety of procedures by the use of endoscopic techniques.

[Minimally invasive surgery of the colon and rectum]. / Minimal invasive Chirurgie des Kolon und Rektum.

In the period from 1.8.89 to 1.7.92 140 adenomas and 63 carcinomas were locally resected from the rectosigmoid area with the instruments of TEM. The mortality was 0.5%, the rate of dehiscence of the suture 9.8%. 75% of these were treated conservatively. One of the 29 patients with locally resected pTl-low risk-carcinoma developed a recurrence so far. The rate of recurrent adenomas was 1.4%. From 7.1.1992 to 24.5.1993 21 procedures in colorectal surgery were performed laparoscopically or in a combined laparoscopic transanal operation. The mortality was zero. 1 case of suture dehiscence, 2 cases of crural phlebothrombosis and 1 lesion of the left ureter were observed. The use of TEM in the combined procedure means an extension of the range of minimally invasive colorectal surgery to the lower rectum.