[Colo-anal anastomosis: improvement of early function outcome by reconstruction with the colonic pouch]. / Coloanale Anastomose: Verbesserung der funktionellen Frühergebnisse durch Rekonstruktion mit Colonpouch.

INTRODUCTION: Early functional outcome after ultra-low anterior resection with coloanal anastomosis (CAA) may be improved by construction of a colonic pouch. The aim of this prospective observational study was to compare results of colonic pouch-anal anastomosis (CPAA) with conventional CAA including the learning curve. METHODS: From February 1996 through May 1998, 45 consecutive patients underwent CAA or CPAA following radical rectal resection for cancer. The technique of resection was identical in both groups, and all patients received a diverting stoma. The colonic pouch was constructed using linear staplers. Three and 12 months following stoma closure subjective continence and bowel habits were assessed; anal manometry was performed at 3 months. RESULTS: 20 patients with CPAA (9 F, 11 M, age 62 +/- 9 years) were compared to 25 CAA patients (11 f, 14 m, age 64 +/- 10 years). There was no mortality, and morbidity was comparable between groups. Three months following stoma closure, in the CPAA group bowel frequency was significantly diminished (1.4 vs 5.8; P < 0.0001), fewer patients had liquid motions (0/20 vs 12/25 patients; P < 0.0001), and more were continent (20/20 vs 4/25; P < 0.001) and able to defer defaecation (20/20 vs 2/25; P < 0.0001). Functional anal canal length was significantly shorter in CPAA patients (2.9 vs 3.5 cm; P < 0.008). Although at 12 months follow-up continence had improved in patients with CAA, bowel frequency (2.5 vs 1.3; P < 0.002), and number of patients with liquid motions (10/25 vs 0/20; P < 0.007) and passive incontinence (12/25 vs 0/20; P < 0.0001) were still significantly higher than the CPAA group. CONCLUSION: Even including the learning curve, CPAA may yield superior functional results at 3 months and 1 year compared to conventional CAA without increasing morbidity.

Severe acute pancreatitis causes alterations in HLA-DR and CD14 expression on peripheral blood monocytes independently of surgical treatment.

OBJECTIVE: To find out if the severity of acute pancreatitis or the surgical treatment of severe acute pancreatitis influences HLA-DR and CD14 expression on peripheral blood monocytes. DESIGN: Prospective open study. SETTING: University hospital, Austria. SUBJECTS: 9 consecutive patients with severe acute pancreatitis in need of operative treatment, 5 patients with mild acute pancreatitis, and 7 healthy volunteers. INTERVENTIONS: Samples of 5 ml blood were taken daily into endotoxin free tubes at same time points. Surgical treatment for severe acute pancreatitis consisted of blunt necrosectomy, operative lavage, laparostomy, and open drainage. MAIN OUTCOME MEASURES: Correlation between HLA-DR and CD14 expression on peripheral blood monocytes on the one hand and the severity of acute pancreatitis and operative treatment of severe acute pancreatitis, on the other. RESULTS: In patients with severe acute pancreatitis expression of HLA-DR and CD14 was significantly downregulated both before and after operation (p < 0.0001; ANOVA), compared with patients with mild acute pancreatitis or healthy controls. However the expression of the two cell surface markers was not affected either by the first operation, or by the reoperations. CONCLUSION: These findings suggest that in acute pancreatitis the expression of cell surface markers on peripheral blood monocytes is related to the severity of disease but is not influenced by operative treatment.

[Liver transplantation in acute liver failure]. / Lebertransplantation bei akutem Leberversagen.

Acute hepatic failure is characterized by jaundice and hepatic encephalopathy within eight weeks after the onset of disease. Although acute hepatic failure is a rare occurrence, its rapid progression and high mortality (50 to 90%, depending on the etiology of disease) necessitate immediate intervention. In the absence of causal therapy, orthotopic liver transplantation is currently the only definitive and effective means of treating acute hepatic failure in Europe, acute hepatic failure accounts for 11% of all liver transplantations. At the University department of transplantation surgery in Vienna a total of 27 patients with acute hepatic failure underwent 31 liver transplantations in the last 10 years (1.1.1987 to 31.12.1996). Twenty (74%) of the 27 patients survived the acute event and were discharged from hospital in good general condition after a median postoperative stay of 25 days (range 14-81 days). Seven patients (26%) died between the first and 34th postoperative day (median 26 days) in the intensive care unit, although all potential modern options of intensive care and surgery were used. The causes of death were irreversible cerebral edema (n = 3), multiple organ failure due to bacterial sepsis (n = 3) and uncontrollable haemolysis (n = 1). With a 3-year graft survival rate of 70% the 3-year patient survival rate was 74%. A retrospective analysis of our patients revealed that the postoperative graft function and the incidence of re-transplantation were significant prognostic factors (p < 0.05) for survival following orthotopic liver transplantation for acute hepatic failure. In the absence of further prognostically relevant preoperative indices and in consideration of the potentially fulminant progression of disease, we strongly recommend that any patient, in whom acute hepatic failure is suspected, is immediately transferred to a specialized center with experience both in the conservative treatment of acute hepatic failure and emergency liver transplantation.

[Revision of diffuse peritonitis: planned versus on demand]. / Revision bei diffuser Peritonitis: geplant v. on-demand.

Planned and "on-demand' reoperations are well-established concepts in the management of severe diffuse peritonitis. Both concepts were applied at our surgical department and reviewed with regard to specific complications and lethality. In the period between 1 January 1989 and 31 May 1994, 62 patients with the diagnosis of diffuse peritonitis underwent operative treatment at our surgical department. The mean age of the 29 female and 33 male patients was 58.2 years (range 17-93 years). The origin of peritonitis was the stomach in 8.1%, duodenum in 16.1%, small intestine in 12.9%, large intestine in 41.9% and the pancreas in 16.1%. Among these 62 patients, 15 were reoperated upon according to plan and 47 were reoperated upon on demand. The intraoperatively gained Mannheim peritonitis index and the Apache II score were similar in both groups. The average number of reoperations was five in the group of planned revisions and three in the group of on-demand revisions. Also lethality was similar in both groups. Regarding lethality, only the age of the patient (P < 0.03) and the preoperative Apache II score (P < 0.01) reached statistical significance. As expected, eradication of the infectious source was the precondition of survival regardless of the type of reoperation. Regarding our results, we conclude that planned or on-demand reoperations lead to similar results in the treatment of diffuse peritonitis. The crucial point for success is that elimination of the infection source take place as soon as possible.

Risk factors for development of panel reactive antibodies and their impact on kidney transplantation outcome.

The impact of potential risk factors for development of panel reactive antibodies (PRA) in 1078 cadaveric kidney graft recipients was investigated in a multivariate analysis. Multiple transplantation, transfusion of more than five blood units and more than two pregnancies were revealed as factors with a significant independent impact on the formation of high levels of PRA. Multiple transplantation and polytransfusion also affected primary non-function, initial function and long-term graft survival at 1, 3 and 5 years. Incidence of early rejection (within 30 days) was significantly increased with repeated transplantation and decreased with a full-house HLA match. However, these effects on transplantation outcome could only be observed when risk factors lead to the formation of antibodies. In patients with risk factors present, but without subsequent sensitization, the graft survival expectation was the same as in patients in whom risk factors were absent.

Orthotopic liver transplantation in the management of end stage liver disease: the University of Vienna experience.

Two hundred and eight orthotopic liver transplantations (OLT) were performed in 191 patients at the I Department of Surgery, University of Vienna from 1982-1990. The most frequent indications were hepatocellular carcinoma, alcoholic cirrhosis, posthepatic cirrhosis, primary biliary cirrhosis, and fulminant hepatic failure. Patients with malignancy constituted 33.8% of cases. The overall results showed a 64% one-year and 58% two-year survival; best results were seen in patients with primary biliary cirrhosis and the poorest long-term results were in malignancy. There were 23 postoperative deaths (11%). Primary non-function was seen in 14 (7%) cases; acute rejection episodes were seen in 62% of patients. The presence of a well organised cadaver organ procurement system in eastern Austria with upto 41 donors per million population per year ensures that the 57% growth rate in OLT achieved in 1990 will be maintained with even better results.