[The current view of surgical treatment of diverticular disease]. / Soucasný pohled na chirurgickou lécbu divertikulární choroby.

AIM: The aim of our prospective dynamic cohort trial is the evaluation of indication for surgery for diverticular disease and the evaluation of morbidity and mortality. MATERIAL AND METHOD: All patients operated for diverticular disease and its complications were involved in the study. The conservatively treated patients were not involved. 104 patients with diverticular disease and its complication were operated from August 2007 till July 2008.46 men and 58 women at average age of 63.9 (31-85) years were in this group. 78 patients were electively operated in noninflammatory stage of diverticular disease. 3 patients of them had colovesical or enterocolical fistulas. An elective laparoscopic colon sigmoid resection was performed by 74 patients and a laparoscopic left hemicolectomy was performed by 4 patients. An end-to-end stapled colorectal suture was performed by all patients. An excision of fistula from urinary bladder and a segment resection of small bowel were performed in the case of fistula presence. In connection with previously repeated diverticulitis attacks or after previous surgeries, adhesiolysis was performed by 23 patients. 26 patients were operated for acute complication of diverticular disease. 24 patients of this group were operated for acute diverticulitis and 2 patients for diverticular bleeding. 23 colon sigmoideum resections, 2 left hemicolectomies, and once ileocecal resection were performed. The primary bowel suture was performed by 20 patients and Hartmaruts operation was performed by 4 patients. RESULTS: The indication for surgery follows the classification according to Hansen and Stock. The abdominal postoperative complications (wound infection, anastomotic leak, prolongated bowel atonia, and others) occurred by elective operated group in 9% and by acute operated group in 26.9%. The overall abdominal postoperative complications occurred in all the involved patients in 13.4%. The extraabdominal postoperative complications (urinary infection or retention, cardiopulmonary complications, trombosis/embolia, postoperative qualitative conscious disorder, renal insufficiency, and others) occurred by elective group in 19.6% and by acute operated group in 50%. Overall extraabdominal postoperative complications occurred in all involved patients in 26.90%. The mortality was 0%. The conversion rate in elective group was 3.8% (3 pts.). An anastomosis leak occurred once (1%) by elective operated patient. An acute reoperation with resection according to Hartmann was performed. A small bowel loop perforation by coincidental adhesiolysis occurred once. A small bowel defect was identified and sutured by early laparoscopic reoperation. The conversion rate in acute group was 23.1% (6 pts.). The colonoscopy was necessary on 3rd day by 1 patient after left hemicolectomy for splenic flexure bleeding. This examination revealed bleeding from diverticulum in hepatic flexure. An endoscopic treatment was performed. An abscess in small pelvis occurred by this patient (12th postoperative day) and open drainage was performed. There was no anastomosis leak in group with acutely operated patients. CONCLUSION: The usage of standard classification is suitable for operation's indication for diverticular disease and its complications. It helps to determine the type and operation's strategy. The acute complicated diveticulitis has high morbidity and mortality. The early indication of selected patients with diverticular disease for elective colon sigmoideum resection protects against possible complication in the case of next attack of diverticulitis. It concerns the patients with recidivated uncomplicated and complicated forms of disease as well. The primary conservative treatment with percutaneous CT navigated drainage allows a postponed elective surgery. The primary resection with suture is better than the two stage surgery. The primary laparoscopic resection is safe procedure in almost all the cases. The primary suture can be safely performed in all elective cases for uncomplicated diverticulitis, chronic fistulas, obstruction, for primarily conservatively treated stages Hinchey I and II and possibly for all the selected patients with Hinchey III and IV stages with MPI lower as 21.

Endothelial microparticles as a diagnostic aid in Churg-Strauss vasculitis-induced cardiomyopathy.

Churg-Strauss Syndrome (CSS) is characterized by allergic rhinitis, asthma and prominent blood and tissue eosinophilia. Although CSS can affect any organ system, isolated cardiac manifestation is a rare feature that is often characterized by rapidly progressive congestive heart failure. We present the case of a 48-year-old woman with acute dyspnoea and chest pain. Her past medical history was significant for asthma and frequently relapsing minimal-change glomerulonephritis. Echocardiogram and coronary angiography revealed cardiomyopathy and coronary small-vessel vasculitis in the presence of blood eosinophilia and elevated IgE. In the absence of infective agents, neoplastic diseases and further vasculitic manifestations, a flow cytometry-based analysis of markedly elevated endothelial microparticles supported the diagnosis of CSS. Cardiomyopathy resolved completely after initiation of immunosuppressive treatment with corticosteroids and cyclophosphamide pulses. Elevated endothelial, leukocytic and platelet-derived microparticles decreased during follow-up and closely paralleled vasculitic activity. Endothelial microparticles might be an additional tool to diagnose and monitor cases of suspected vasculitic cardiac involvement in CSS.

Good manufacturing practice-compliant validation and preparation of BM cells for the therapy of acute myocardial infarction.

BACKGROUND: Intracoronary application of BM-derived cells for the treatment of acute myocardial infarction (AMI) is currently being studied intensively. Simultaneously, strict legal requirements surround the production of cells for clinical studies. Thus good manufacturing practice (GMP)-compliant collection and preparation of BM for patients with AMI was established by the Cytonet group. METHODS: As well as fulfillment of standard GMP requirements, including a manufacturing license, validation of the preparation process and the final product was performed. Whole blood (n=6) and BM (n=3) validation samples were processed under GMP conditions by gelafundin or hydroxyethylstarch sedimentation in order to reduce erythrocytes/platelets and volume and to achieve specifications defined in advance. Special attention was paid to the free potassium (<6 mmol/L), some rheologically relevant cellular characteristics (hematocrit <0.45, platelets <450 x 10(6)/mL) and the sterility of the final product. RESULTS: The data were reviewed and GMP compliance was confirmed by the German authorities (Paul-Ehrlich Institute). Forty-five BM cell preparations for clinical use were carried out following the validated methodology and standards. Additionally three selections of CD34+ BM cells for infusion were performed. All specification limits were met. Discussion In conclusion, preparation of BM cells for intracoronary application is feasible under GMP conditions. As the results of sterility testing may not be available at the time of intracoronary application, the highest possible standards to avoid bacterial and other contaminations have to be applied. The increased expense of the GMP-compliant process can be justified by higher safety for patients and better control of the final product.

Stem cell therapy: a new perspective in the treatment of patients with acute myocardial infarction.

Experimental studies suggest that cardiac transfer of stem and progenitor cells can have a favorable impact on tissue perfusion and contractile performance after acute myocardial infarction (AMI). While the mechanistic background of stem cell therapy is still intensely debated, the concept of cell therapy has already been introduced into the clinical setting, where small, mostly uncontrolled trials indicate that stem cell therapy may be feasible in patients. The overall clinical experience also suggests that stem cell therapy can be safely performed, if the right cell type is used in the right clinical setting. Preliminary efficacy data indicate that stem cells have the potential to enhance myocardial perfusion and/or contractile performance in patients with AMI. The field now is rapidly moving towards intermediate-size, double-blinded trials to gather more safety and efficacy data. Ultimately, large outcome trials will have to be conducted. At the same time, continued basic research to elucidate the underlying mechanism of stem cell therapy is needed.

Validity of SEP monitoring in carotid surgery. Review and own results.

OBJECTIVE: The sensitivity of intraoperative monitoring by means of somatosensory evoked potentials (SEP) in carotid surgery is to be examined. EXPERIMENTAL DESIGN: Prospective clinical investigation. In addition, the influence of circulatory parameters on SEP curves will also be tested. SETTING: Department of Surgery of a university clinic. MATERIALS AND METHODS: A total of 200 patients underwent intraoperative monitoring by means of somatosensory evoked potentials (SEP) during carotid endarterectomy between March 1, 1991 and August 1, 1994. MEASURES: In order to exclude blood pressure variations as a cause for amplitude changes the blood pressure and pulse were documented during the entire phase of preparation and clamping. RESULTS: A significant correlation could not be established between parameters of circulation and amplitude changes (r = 0.0026; p = 0.62). In seven cases of intraoperative amplitude reduction of more than 50% a stroke has been avoided by inserting a shunt. Despite the lack of an amplitude reduction, a watershed stroke of A.cerebri media and A.cerebri posterior occurred in two instances. Taking this into consideration the sensitivity of monitoring is 99.0% at a specificity of 100%. CONCLUSIONS: SEP-monitoring in carotid endarterectomy is simple to execute and is superior in sensitivity to EEG analysis. To avoid artefaction by anesthesia, a standard injection anesthesia is recommended. Farfield potentials should also be derived to avoid watershed infarctions.

[Evaluation of the aorta and supra-aortic vessels with spiral CT and 3-dimensional vascular reconstruction after operation of aortic isthmus stenosis]. / Beurteilung von Aorta und supraaortalen Gefässen mittels Spiral-CT und dreidimensionaler Gefässrekonstruktion nach Operation einer Aortenisthmusstenose.

Aneurysm formation, restenosis, and hypertension are well known complications after surgery for coarctation of the aorta (CoA). In order to assess long-term results, 46 patients were studied by spiral computed tomography and three-dimensional reconstruction after an interval ranging from 1 to 21 years (median 10 years) after surgery for coarctation. Spiral computed tomography showed pathological changes of the aorta in the majority of patients. Typical findings were ectasy or aneurysm formation of the ascending aorta, hypoplastic aortic arch, ectasy or aneurysm formation of the supraaortic vessels, circumscript aneurysm of the descending aorta at the side of surgery, restenosis of the descending aorta and malformations and anomalies of arterial vessels. In order to initiate adequate treatment of such specific complications as restenosis, aneurysm and/or arterial hypertension, regular controls are necessary in patients after surgery for aortic coarctation. In addition to clinical examination and besides magnetic resonance imaging and angiography, spiral computed tomography is an effective non-invasive imaging method for follow-up.

Pharmacokinetics of ciprofloxacin in elderly patients.

For perioperative prophylaxis 200 mg ciprofloxacin were administered as a short intravenous infusion to 17 patients aged 57-84 years before transurethral resection (TUR-P) or transvesicular enucleation (TVP) of the prostate. 13 patients were injected simultaneously with 2.5 g ioxitalamic acid i.v. to determine the kidney function. In 11 patients the plasma concentrations were assayed and the pharmacokinetic parameters calculated. At the end of infusion the concentrations of ciprofloxacin in plasma reached 4.2 +/- 0.8 microgram/ml and decreased after a fast distribution period (plasma half-life 0.20 +/- 0.09 h) with a terminal half-life of 4.2 +/- 1.3 h to 0.2 +/- 0.09 microgram/ml after 10 h. The apparent volume of distribution in steady state was 183 +/- 45% of body weight, the plasma clearance 457 +/- 146 ml/min/70 kg. The average concentrations in prostatic adenoma tissue were at all sampling times higher (2fold) than in plasma. The mean concentrations in prostatic secretion were about half of the respective plasma concentrations. High concentrations of the concomitantly administered ioxitalamic acid in prostatic secretion are considered as an indicator of urinary contamination. In those patients high ciprofloxacin concentrations in prostatic secretion are not reliable.