[Histological investigation of the micromorphological effects of the application of a laser needle--results of an animal experiment]. / Histologische Untersuchungen zu mikromorphologischen Einflüssen von Lasernadelstrahlung--Ergebnisse einer tierexperimentellen Untersuchung.

In an experimental animal study (Sus scrofa domesticus) we investigated the effects of the new technique of laser needle stimulation (wavelength: 685 nm; energy density: 4.6 kJ/cm2 per point; application duration: 20 min). The results revealed changes in microcirculatory parameters of the skin resulting in an increase in blood flow. However, the quality and intensity of the laser light did not induce micromorphological alterations in the skin.

Partial splenectomy in cystic fibrosis patients with hypersplenism.

We report three cystic fibrosis (CF) patients with hypersplenism who underwent partial splenectomy. The postoperative course was uneventful in two patients; one patient developed a complication necessitating resection of the rest of the spleen. Haematological parameters improved and oesophageal varices regressed in all patients. On follow up, one patient showed a normal spleen, the other a normally functioning accessory spleen; the third patient again developed splenomegaly with hypersplenism. Partial splenectomy is a promising therapeutic option for CF patients with hypersplenism.

Nonoperative treatment of blunt splenic injury.

A spleen-preserving program was implemented at the author's institution during the mid-1980s using a five-part injury-grading scale that is similar and comparable to the AAST classification. Since that time, all patients with splenic injuries admitted to the Department of Surgery at the Karl-Franzens University Hospital in Graz, a level I trauma center, have been prospectively evaluated with respect to splenic preservation. Analysis of the relation of the severity of organ injury to the use of nonoperative management showed that degree I or II injuries were treated nonoperatively, whereas degree III and IV injuries were usually treated with adhesives, partial resection, or mesh splenorrhaphy; only degree V injuries almost always required splenectomy. With increasing experience in nonoperative management of splenic injuries the initial criteria have become less rigid, and there is now a tendency to attempt it in patients who formerly would have undergone surgery.

Long-term decrease of CD4+CD45RA+ T cells and impaired primary immune response after post-traumatic splenectomy.

Congenital or acquired absence of the spleen and functional hyposplenism are associated with abnormalities of host defence such as an increased susceptibility to infection with encapsulated bacteria. The effects of the lack of the spleen on cell-mediated immunity are largely unknown. In the present study we have investigated peripheral blood lymphocyte subpopulations in healthy adults who had undergone splenectomy because of severe abdominal trauma > 4 years before the study. The results show a significant reduction in the percentage of CD4+ T cells due to a selective and long-term decrease in the percentage of CD4+CD45RA+ lymphocytes, the CD4+ T-cell subset mainly involved in primary immune responses to newly encountered antigens. Levels of the reciprocal CD45RO+CD4+ T-cell subset were comparable between splenectomized and control individuals, as were lymphoproliferative responses and IFN-gamma production to recall antigens. Decreased levels of CD4+CD45RA+ cells were accompanied by an impairment in primary immune responsiveness, as assessed by investigating T-cell proliferation to stimulation with keyhole limpet haemocyanin and by measuring antibody responses following primary immunization with a clinically relevant T-dependent antigen, hepatitis A vaccine, in vivo. These findings suggest a possible role of the spleen in the generation, maintenance and/or differentiation of naive, unprimed T cells or their precursors, which might have a possible functional relevance for primary immune responses following splenectomy.

Laparoscopic cholecystectomy using 2-mm instruments.

Today, laparoscopic cholecystectomy is the method of choice for treatment of symptomatic gallbladder disorders. It minimizes effects of the operation that are independent of the gallbladder, such as trauma to the abdominal wall and other soft tissue. The surgical wounds were even smaller when 2-mm trocars were used. Laparoscopic cholecystectomy using 2-mm instruments was performed in a consecutive series of 14 patients with symptomatic gallstones. The procedure was completed in 12 cases, with conversion to open surgery in two cases. Intraoperative cholangiography was always performed. The postoperative course was always uneventful. The cosmetic effect was highly satisfactory. The procedure using 2-mm instruments could be indicated in selected patients with uncomplicated gallstone disease.

Hemostatic methods for the management of spleen and liver injuries.

The spleen and liver are the most frequently injured organs during blunt and penetrating abdominal trauma. Emergency laparotomy is crucial for early control of bleeding and to prevent "secondary" injury as a result of physiologic splanchnic vasoconstriction and free oxygen radicals. Altogether 98 patients with spleen and liver injuries were treated over an 8-year period. Primary orthotopic spleen preservation could be achieved in 46 of 63 patients. In 58 patients with hepatic trauma, hemostatic treatment was chosen based on the severity of the injury. Nonoperative management was used for four splenic and seven hepatic trauma patients. The most commonly used techniques were fibrin sealing, suturing, and débridement for hepatic injury and mesh splenorrhaphy, fibrin glue, and partial resection with a TA stapler for splenic injury. The death of patients with complex injuries was mainly due to preclinical massive blood loss and multiple organ failure.

[Is sphincter-plasty for treatment of fecal incontinence in patients older than 60 justified?]. / Ist die Sphinkterplastik zur Behandlung der Fäkalen Inkontinenz bei Patienten älter als 60 Jahre gerechtfertigt?

Overlapping sphincteroplasty is the method of choice for isolated anterior sphincter defects. Patients over 60 years of age can undergo this operation with similar good results as in younger patients. However, preoperative physiologic assessment of the pelvic floor is necessary for a good postoperative outcome.

Neuroendocrine tumours in various organ systems in a ten-year period.

Neuroendocrine cells are present in various organ systems. These widely distributed cells as well as their histogenetically related tumours can produce various peptides and peptide hormones. From 1984 to 1993, 349 neuroendocrine tumours were found among 511,382 histological diagnoses at the Institute of Pathology of the Medical School of the Karl Franzens University in Graz. In 30% carcinoid of the appendix was diagnosed, in 16% carcinoid of the colorectum, in 9% carcinoid of the small intestine and in 2% duodenal carcinoid. Carcinoid of the stomach was detected in 14%. Seven of these cases showed microcarcinoidosis and five of them were combined with an adenocarcinoma. Carcinoid of the oesophagus was present in 1%, neuroendocrine pancreatic tumours in 6%. Neuroendocrine tumours of the bronchial system were found in 12%, medullary thyroid cancer in 5%. In 1% a Merkel-cell tumour was diagnosed. Other more rare localizations of neuroendocrine tumours were the uterus, ovary, breast, testes, epididymis, anal region and the upper respiratory tract.

Laparoscopic partial splenic resection.

Twenty domestic pigs with an average weight of 30 kg were subjected to laparoscopic partial splenic resection with the aim of determining the feasibility, reliability, and safety of this procedure. Unlike the human spleen, the pig spleen is perpendicular to the body's long axis, and it is long and slender. The parenchyma was severed through the middle third, where the organ is thickest. An 18-mm trocar with a 60-mm Endopath linear cutter was used for the resection. The tissue was removed with a 33-mm trocar. The operation was successfully concluded in all animals. No capsule tears occurred as a result of applying the stapler. Optimal hemostasis was achieved on the resected edges in all animals. Although these findings cannot be extended to human surgery without reservations, we suggest that diagnostic partial resection and minor cyst resections are ideal initial indications for this minimally invasive approach.

Laparoscopic removal of a large laparotomy pad forgotten in situ.

Objects forgotten during surgery are still an important complication with ethical and forensic implications. This case report describes a splenectomized patient with type II Hodgkin's disease. A large laparotomy pad (68 x 48 cm) forgotten in situ during a staging operation 6 months previously was removed laparoscopically. In asplenic patients with a permanent immune deficiency it is especially advantageous to perform surgery via the "closed" route whenever possible.

[A new concept in imaging pelvic recurrence of curatively operated rectal carcinoma--image fusion of nuclear magnetic resonance tomography and anti-CEA immunoscintigraphy (SPECT): technique and clinical example]. / Ein neues Konzept der Darstellung pelviner Rezidive nach kurativoperiertem Rektumkarzinom-Bildverschmelzung von Kernspintomographie und Anti-CEA-Immunschichtszintigraphie (SPECT): Technik und klinisches Beispiel.

We present a new technique of image fusion (IF) of magnetic resonance imaging (MRT) and anti-CEA-immunoscintigraphy (Behring 431/26) and single photon emission computed tomography (SPECT). We performed SPECT and MRT within 8 hours on the same day. Glucagon intravenously was used to reduce artefacts due to intestinal motility. Before image fusion we analysed the SPECT and MRT images independently of each other. The MRT and SPECT were connected by a local area network (LAN) to a Gateway computer, which is also used as a picture archive. There a program automatically starts, translates the MRT data from the ACR/NEMA format to the Elscint one and these data are sent for image fusion to the nuclear medicine computer Elscint SP1. By means of a clinical example we present anatomic concordant superimposition and explain the findings and the clinical value of our technique. This system and technique are equally applicable to other digital imaging investigations. By IF, on the basis of the certain evidence of the tracer depot of a pathological lesion diagnosed by MRT and the reliability of the anatomical assignment of a focal lesion diagnosed by SPECT, early detection of local recurrence after surgical treatment of rectal cancer, the correct localisation of recurrent disease and its distinction from non-malignant tissue becomes possible. This enables planning of further therapeutical strategies.

Partial splenic resection using the TA-stapler.

Since 1987, we have used the TA-stapler for 15 partial resections of the spleen. The cases included 5 second- to third-degree traumatic ruptures, 4 splenic cysts, 3 injuries resulting from accidents during upper-abdominal surgery, 2 diagnostic resections, and 1 intralienal pancreatic cyst. The TA-55 stapler was used 14 times and the TA-90 once. No patient developed postoperative bleeding or required further surgery. Postoperative laboratory chemistry and scintigraphy findings were within the limits indicative of normal function in all cases. The TA-stapler expands the technical possibilities for organ-conserving splenic surgery.

[Surgical therapy of chronic anal fissure--do additional proctologic operations impair continence?]. / Die chirurgische Therapie der chronischen Analfissur--Beeinträchtigen proktologische Zusatzoperationen die Kontinenzleistung?

78 patients with chronic anal fissures have been mainly operated on by lateral internal sphincterotomy (LATS). Continence have been evaluated by questionnaire at least 9 months postoperatively. Patient without any additional proctological operation had minor disturbances of continence in 17%. Patient with additional operations had disturbances of continence in 30%. Especially the subgroup of patients with LATS and haemorrhoidectomy had bad results. In this group only 45% were fully continent.

Perforation of the cecum by a toothpick. Case report and review of the literature.

Perforation of the colon can have any number of causes. Most often, it is the result of carcinoma or diverticulitis; specific inflammatory disease of the large intestine is a less common cause. Other possibilities are iatrogenic perforation, perforation as a result of blunt or penetrating abdominal trauma, and ingestion of a foreign body. A case of perforation of the cecum by a toothpick 3 weeks after consumption of a beef olive is reported; possible diagnostic problems, other conditions that need to be considered in the differential diagnosis and treatment are discussed.

Malignant fibrous histiocytoma of the mesentery--a rare cause of abdominal pain. Case report with a review of literature.

Malignant fibrous histiocytoma (MFH) is a tumor most frequently occurring in lower and upper extremities and in retroperitoneum. This paper presents the extremely rare case of a 55-year-old male patient with a MFH of storiform pleomorphic subtype originating from the mesentery. Sonography, computed tomography as well as endoscopy and ERCP did not reveal the diagnosis. Finally the tumor was diagnosed by laparoscopy with biopsy and histological examination. Two months after diagnosis of the tumor the patient died of bronchopneumony and heart failure contracted during a generalisation of MFH.

Tuberculosis of the small bowel with perforation and hematogenous spread in a renal transplant recipient.

A 41-year-old male was admitted because of acute abdomen. A flat plate of the abdomen suggested pneumoperitoneum and a chest X-ray an infiltrate in the right upper lobe. The patient was a renal allograft recipient and was on immunosuppressive therapy with azathioprine, cyclosporine and steroids. At laparatomy inflammatory thickening of the bowel wall was found in the terminal ileum with necrotic areas and two sites of perforation. The involved terminal ileum was removed together with a right hemicolectomy. The resected segment showed exudative ileal tuberculosis and fibrinous and purulent peritonitis. During the postoperative period rapid hematogenous spread of tuberculosis developed with progressive reduction of respiratory function followed by ARDS. Autopsy revealed tuberculosis in all organs including the transplanted kidney.

Non-systemic diffuse lymphangiomatosis of spleen and liver.

We present a 27-year-old woman with non-systemic diffuse lymphangiomatosis of spleen and liver. The tumour consisted of capillary and cavernous lymphatic vessels located in abundant fibrous tissue. The vascular endothelium showed immunoreactivity for factor VIII-related antigen. A basal lamina could be demonstrated immunohistochemically and by electronmicroscopy.

Malignant mesenchymoma: a very rare tumor of the peritoneum. Case report with a review of the literature.

We report the case of an 82-year-old male patient with a malignant mesenchymoma. The tumor arose from the parietal peritoneum closely attached to the ascending colon. It consisted of a larger liposarcomatous and a smaller leiomyosarcomatous component which was demonstrated by immunohistochemistry. To our knowledge this is the first report of a malignant mesenchymoma of this histological composition originating from the parietal peritoneum. The tumor was completely removed surgically, which is the treatment of choice for such tumors. In agreement with other authors, we believe that malignant mesenchymomas arise from a primitive mesenchymal cell with the capacity for totipotent differentiation.

[Amputation of the leg in arterial occlusive disease]. / Amputationen der unteren Extremität bei arterieller Verschlusskrankheit.

The until recently held opinion that above-knee amputations were the method of choice for treating stage IV chronic occlusive arterial disease, is outdated. Determining the appropriate level for amputation in patients with peripheral arterial obstruction is difficult, and requires much experience. Successful fitting of a prosthetic device and subsequent rehabilitation depend not only on the patient's bodily and emotional reserves, but also on the operative technique employed. The more distal the amputation, the better is the prognosis for satisfactory prosthetic function and social reintegration. A total of 280 amputations on 268 patients was performed over a 48-month period. In 181 patients (68%) primary healing occurred without complications. Total mortality was 10%, occurring mainly in the group of above-knee amputees. The majority of local wound complications was found in transmetatarsal resections and below-knee amputations. A total of 42 patients (15%) underwent re-amputation. Only half of the above-knee amputees could be fitted with a prosthesis and rehabilitated, whereas nearly all patients amputated more distally experienced satisfactory outcomes in this respect.

TA-stapler resection of congenital splenic cyst. Case report.

Splenic cysts are uncommon. Primary (true, epithelial) and secondary (false, non-epithelial) forms may be distinguished, the latter being more usual. Organ-preserving resection of a primary mesothelial splenic cyst, using a TA-stapler, is described and alternative techniques of splenic preservation are discussed.