Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis.

BACKGROUND: The importance of inflammation markers in predicting perforation in acute sigmoid diverticulitis is not well known. Predicting perforation by clinical examination alone may be hazardous. If perforation is suspected, then appropriate diagnostic tools such as computed tomography (CT) are indicated, and surgical intervention might be necessary. METHODS: A cohort of consecutive patients with acute sigmoid diverticulitis diagnosed by CT and with complete laboratory findings (n = 247) were retrospectively divided into two groups, one with perforation (n = 86) and another without (n = 161). The latest values of C-reactive protein (CRP), white blood cell count (WBC), and serum bilirubin, as well as the activity of the alkaline phosphatase (AP) measured during the 48 h period before the CT scan, were assessed. RESULTS: In the Wilcoxon rank sum test CRP and WBC correlate significantly (p < 0.05) with perforation in acute sigmoid diverticulitis, whereas the logistic regression model shows only CRP to correlate significantly (p = 0.001) with perforation. The sensitivities/specificities for perforation are 98%/5% for elevated CRP (>5 mg/l), 86%/27% for a CRP higher than 50 mg/l, 44%/81% for a CRP higher than 150 mg/l, 28%/93% for a CRP higher than 200 mg/l, 88%/44% for elevated WBC (>10 × 10(9)/l), 35%/90% for hyperbilirubinemia (>20 µmol/l), and 35%/91% for elevated AP (>110 U/l). CONCLUSIONS: A CRP below 50 mg/l suggests a perforation to be unlikely in acute sigmoid diverticulitis, whereas a CRP higher than 200 mg/l is a strong indicator of perforation.

[Early operation in radiologically negative adhesion ileus]. / Frühoperation bei radiologisch negativem Bridenileus.

From January 1987 to December 1990 46 patients underwent laparotomy for mechanical ileus by adhesive bands at the Bürgerspital Solothurn. Supine and upright X-ray films of the abdomen had been taken in all cases. 31 patients presented typical radiographic signs. In 15 patients (32.8%) no air-fluid levels and no distention of small bowel loops were visible initially. Despite negative X-ray signs 7 of these patients underwent surgery within a median of 2 hours after hospital admission. Six times the indication was based on clinical findings alone and once on further examinations. On average symptoms had been present for 9 hours. The rate of resection was 14%. Eight cases underwent primary clinical observation. This resulted in a median delay to operation of 23 hours and a rate of resection of 50%. The 31 cases with initially positive radiologic findings had a lower rate of resection (25%) despite of a significantly (p = 0.011) longer duration of symptoms (46 hours) before admission. Diagnostic problems arise especially when X-ray signs are negative. Our cases confirm, that negative radiographs can not exclude the presence of an ileus. Quite to the contrary this group accumulates a significantly higher (p = 0.004) number of strangulation ileus. The accentuated pain leads to a significantly (p = 0.011) earlier hospital admission at a time when X-ray signs are not yet visible. Because of the real danger of intestinal necrosis the typical clinical symptoms and signs should lead to surgery without waiting for the later appearance of air-fluid levels.(ABSTRACT TRUNCATED AT 250 WORDS)

[Femoropopliteal venous bypass in distal duplication of the great saphenous vein with bridge veins. Case report]. / Femoropoplitealer Venenbypass bei distaler Doppelanlage der V. saphena magna mit Brückenvenen. Case report.

A 74-year-old patient with peripheral arterial obstructive disease II B presented a full-length obstruction of the superficial femoral artery and additionally a segmental 10 cm long obstruction of the deep femoral artery. The arteries of the calf were patent. In this situation a bypass with an autologous vein was taken in advice. At surgery in December 1988 the great saphenous vein from the contralateral leg was prepared. It was found to be duplicated and contained numerous bridging veins. The duplication was maintained to compensate for the difference of calibre. The proximal anastomosis was done with the double-lumen graft including in between a split bridging vein. This arrangement provided favourable anatomic and functional outlets to the two saphenous branches. At follow-up in January 1990 the patient was fully reintegrated and had an unlimited walking distance. Doppler sonography showed normal closing pressure in the peripheral arteries. The intravenous digitalized subtraction angiography demonstrated regular perfusion of both branches of the duplicate bypass.

[Duodenopancreatectomy. Continuous single pancreaticojejunostomy (video)]. / Duodenopankreatektomie. Fortlaufende einreihige Pankreatojejunostomie (Video).

From 1972 to January 1988 42 pancreato-duodenectomies were performed. There was no hospital death. In the last 7 patients the pancreatojejunostomy was done over-and-over in one row. In one of those patients the anastomosis had to be redone later on using an identical technique. The video shows selectioned steps in resection and reconstruction, in detail the preparation of the pancreatic stump as well as the anastomosis itself. In 2 cases there was massive secondary gastrointestinal hemorrhage. The bleeding artery could be localized by selective angiography to the jejunal side of the pancreatic anastomosis in 1 case, to the jejuno-jejunostomy in the other patient. Definitive hemostasis was accomplished by reoperation. The one row over-and-over-anastomosis is done without problems in the situation of a fibrotic pancreas and dilatation of pancreatic duct (3 patients). It is suitable too, when alterations of the pancreas are missing (5 cases).

Age-related involution and terminal disorganization of the human thymus.

The terminal involution pattern of the human thymus was studied based on autopsy cases (both sexes, age range 63-91 years). Large sections through the entire thymic fat body were examined with the help of both conventional histological and immunohistochemical techniques. The findings demonstrate that thymic atrophy in old humans (a) goes far beyond the degree of involution observed in small rodents; (b) results in a system of thin, branching, in part interrupted, non-keratinizing epithelial plates containing no typical Hassall bodies; (c) concerns all components of the thymus except fat tissue which progressively replaces original thymic structures; and (d) involves various types of disorganization of individual lobules with T and B lymphocytes often located outside rather than within epithelial remnants. Effects of low-level radiation on this final regression of the human thymus are unknown.

Involution patterns of the human thymus. I Size of the cortical area as a function of age.

Thymic tissue obtained at autopsy from 123 victims of sudden death, ranging from neonates to individuals older than 80 years and predominantly male, was studied with histometric techniques, i.e. a combination of test point analysis and planimetry on unit optical fields. The pattern of 'natural' age-dependent involution of the thymic cortex was examined using computerized mathematical models. The range of variations of results was greatest in children and young adults, followed by the very old, then the middle age group. In a first approximation, regression for thymic cortical volume in individuals older than 15 years corresponded better to a negative exponential than to a negative linear function of age. Best fits for the data suggest at least a two-component negative exponential function of age, with a steeper slope of the regression for individuals beyond the age of 30 years. Extrapolation on a log-normal plot of regression lines for thymic cortical involution points to near-zero values at an age range below the estimated maximum human life span, corresponding to the steepest slope of survival curves in Western Europe.