[Quality indicators in the treatment of hemorrhoids]. / Qualitätsindikatoren bei der Therapie des Hämorrhoidalleidens.

BACKGROUND: A quality indicator is a quantitative measure that can be used to monitor and evaluate the quality of certain operative procedures that may influence the result of a therapy. An indicator is not a direct measure of quality, it is merely a tool to evaluate the performance of procedures and can indicate potential problem areas. MATERIAL AND METHODS: A literature search was performed for parameters which could be included as indicators of quality in the treatment of hemorrhoids. RESULTS AND CONCLUSION: In the treatment of benign diseases, such as hemorrhoids objective indicators (e.g. recurrence or survival rates in oncological diseases) cannot be used as quality indicators. Other indicators or core outcome factors must be used. From the patient's point of view other indicators are important (such as pain, complications, continence, days off work, etc.) than those for the colorectal surgeon, health insurance and healthcare provider. The most important indicators or outcome factors for treatment of hemorrhoids are postprocedural pain, patient satisfaction, complications, residual and recurrent symptoms, pain, quality of life, costs and duration of inability to work. In terms of outcome quality various quality indicators could be identified which also play a role in the guidelines; however, in this respect valid questionnaires or scores that enable a uniform assessment exist only in a few cases. In contrast, some indicators (e. g. costs, length of hospital stay) are strongly influenced by factors such as the healthcare system making these indicators unfeasible.

Perianal streptococcal dermatitis in adults: its association with pruritic anorectal diseases is mainly caused by group B Streptococci.

AIM: Although perianal streptococcal dermatitis (PSD) is well known in children, it has only rarely been documented in adults. The incidence and necessity for treatment may be underestimated. We have retrospectively identified adult patients with perianal streptococcal dermatitis. METHOD: Patients with streptococcal anal dermatitis were identified from a prospective office database. Treatment was with oral antibiotics according to the organism sensitivity. Additional concomitant anorectal disease was treated according to standard guidelines. Patients were compared with a control group, without eczema or erythema, for the presence of ß-haemolysing Streptococci on perianal swab. Demographic and microbiological data were assessed and compared between and within treatment and control groups. RESULTS: Fifty-three (22 female) patients older than 20 (mean = 49) years of age were diagnosed with perianal streptococcal dermatitis between 2005 and 2009. In most cases group B ß-haemolytic Streptococci were found. Fifty patients received antibiotics for 14 days. In 28 of 33 patients who had a post-treatment swab, the result was negative. Five patients showed Streptococci of different groups in the post-treatment swab. Of the 50 patients, 21 (42%) had no further anorectal complaint and 29 (58%) required continuing treatment for another anorectal condition. In the control group ß-haemolysing Streptococcus was found in 34%. Men over 60 years of age more often required no further anorectal treatment compared with women (P < 0.05). CONCLUSION: Perianal streptococcal dermatitis occurs in adult patients more often than reported. It is mainly caused by group B ß-haemolysing Streptococcus. Its diagnosis is important because it can cause serious systemic infections, especially in the elderly and in newborns. Antibiotics resolve the condition in a high proportion of patients.

[Long-term survival of curatively operated gastric cancer: influence of the gender and splenectomy]. / Langzeitüberleben nach kurativer Magenkarzinomoperation: Bedeutung des Geschlechts und der Splenektomie.

BACKGROUND: Despite advances in operative technique long-term survival of curatively operated gastric cancer patients still remains poor with 5-year-survival of 25 %. Gender differences have been recognized in patients with colorectal carcinoma with a higher 5-year-survival of women. The long time-survival of the individual patient is closely dependent on his immunofunction. If a splenectomy has to be carried out, the postoperative immunofunction will be affected considerably. Thus, the question arises as to how far gender and splenectomy influence the long time-survival after curative gastric cancer surgery. METHODS: In a retrospective analysis of 505 patients with gastric cancer who had been treated between the years 1992 and 2002, a curative resection, i. e. R0, could be performed in 243 patients (48.1 %) with a definite classified tumour stadium according to the UICC (1997). The sociodemographic, operative, histomorphologic and postoperative data of each patient were collected, stratified by gender and compared using log-rank-test (survival) and chi-square-test (distribution). Multivariate analysis was performed by cox regression. The level of significance was set at p < 0.05. RESULTS: The sociodemographic, histopathologic and operative data between the two genders were comparable. The morbidity between men and women was not significant. However the rate of postoperative sepsis was higher in men (p < 0.05). With regard to the long-term survival, no difference could be shown between the two groups. However, splenectomy had a significant effect on long time-survival. Women with preserved spleen had a significantly improved five-year-survival rate as compared to women undergoing splencetomy and men with preserved spleen (p < 0.05). Multivariate analysis revealed only the tumour stage as a predictor for long time-survival in men, whereas in women the extend of lymphadenectomy and sepsis also influenced long time-survival. CONCLUSION: Long time-survival of curatively operated gastric cancer patients is gender dependent in terms of splenectomy. Therefore, gender differences should be taken into account in analysing long-term data of oncological patients.

[Mass of the pelvis minor--the coloproctological point of view]. / Raumforderung im kleinen Becken--Sicht des Coloproktologen.

The pelvis minor is cranial defined by the promontory and caudal by the pelvic diaphragm. It contains the pelvic organs like the inner genital organs of women, the urinary bladder the rectum and parts of the anus. The rectum is the origin of benign and malign tumors. Most frequently you find under these tumors the benign adenoma and hamartoma and the malign like the rectal and anal cancer. The further diagnostic work up and following therapy relates to the histology and the anatomical location of the tumor.

Multimodal therapy of anal cancer added by new endosonographic-guided brachytherapy.

BACKGROUND: The most appropriate therapy for anal cancer is external beam radiotherapy (EBRT) combined with chemotherapy (CTX). The significance of additional brachytherapy is still under evaluation. We report on our experience of combined modality therapy of anal cancer and transrectal ultrasound (TRUS)-guided high-dose rate (HDR) afterloading therapy, referring to results of a study published in 1998 by the coauthors. METHODS: From 1993 to 2001, 50 patients with anal cancer were treated. After combined RCTX, HDR 2 x 4 Gy brachytherapy was administered based on TRUS imaging as a target. RESULTS: In five patients (10%), tumor recurrence occurred or the tumor did not respond to therapy, and four (8%) developed distant lymph nodes or organ metastases. Five patients (10%) had to undergo salvage abdominoperineal resection because of suspected recurrence. Specific disease-related 5-year survival was 82%. Therapy-associated complications in terms of sphincter necrosis and incontinence were observed in three patients (6%). CONCLUSIONS: TRUS-guided brachytherapy permits excellent local tumor control and results in minimal treatment-related morbidity. Consequently, TRUS-guided brachytherapy may be a useful addition to current combined modality treatment regimens for anal cancer.

Therapy of anastomotic leaks by means of covered self-expanding metallic stents after esophagogastrectomy.

BACKGROUND AND STUDY AIMS: The mortality rate for surgical revision of gastroesophageal anastomotic leakage after resection for cancer approximates 60 %. The efficacy of endoscopically placed covered metallic stents for treatment of gastroesophageal leakage was evaluated. PATIENTS AND METHODS: Between June 1996 and June 2002 we treated 21 patients with proven gastroesophageal leakage; 18 had anastomotic leakage and three patients had perforation for different reasons. The extent of the leaks ranged from one-quarter of the intestinal circumference to its complete dehiscence. The average time from surgery to detection of leakage was 6.1 days (range 3 - 15 days). Mortality, healing rate, length of hospital stay, and complications were assessed. RESULTS: The insertion of stents was performed endoscopically under radiological guidance without any complication in all patients. In 9.5 % (2/21) of patients complete sealing of the leak was not achieved. The mortality associated with anastomotic leakage was 23.8 % (5/21). In 80.1 % (17/21) patients complete healing of the leakage was achieved. The average hospital stay was 67 days (range 14 - 158 days). Of 23 stents, 13 (56.5 %) were removed, and three patients developed stenosis after removal. CONCLUSION: The treatment of gastroesophageal leakage with covered stents appears to reduce mortality and the complication rate associated with major leakage. Therefore this technique seems to be a reasonable alternative in the treatment of clinically relevant anastomotic leakage.

[Endoluminal therapy of neoplastic changes of the gastrointestinal tract: questionable and reliable aspects. Early stomach carcinoma: surgical treatment]. / Endoluminale Therapie von neoplastischen Veränderungen des Gastrointestinaltraktes: Fragliches und Gesichertes. Magenfrühkarzinom: Chirurgisch.

Early gastric cancer (EGC) is defined as gastric carcinoma limited to the mucosa and submucosa of the gastric wall, corresponding to UICC stage pT1a or pT1b. The overall prognosis is excellent, with 5-year survival rates up to 95% reported by Japanese institutions as well as in some series from Europe and the USA. However, the therapeutic concept still is indifferent. New staging methods and advances in the endoscopic and laparoscopic treatment opened new fields of therapeutic approaches. Therefore, referring to the results of japanese studies, for defined subtypes of EGC an endoscopic approach can be recommended. This, however, is related to a close follow up of these patients. In case of a surgical resection, radical D2-lymphadenectomy should be performed, especially in patients with submucosal invasion.

Gender differences in sepsis: genetically determined?

In the pathogenesis of sepsis, tumor necrosis factor (TNF) release and host reaction may be genetically determined as demonstrated for TNFbeta Ncol polymorphism. Gender differences are considered as another important prognostic variable in patients with sepsis with better survival for women. The effect of sexual dimorphism on the genetic background of sepsis, however, is unknown. In a prospective study at two university hospital surgical intensive care units, (Bonn and Kiel), the role of the genomic marker TNFbeta Ncol polymorphism was evaluated with respect to gender. Two-hundred and one patients (68 women and 133 men) with severe sepsis were evaluated. A fragment of genomic DNA including the polymorphic site of the restriction enzyme Ncol was amplified by means of polymerase chain reaction. The genotype of each patient was determined after Ncol digestion of the amplified product. The genotype distribution of patients homozygous for TNFB1, heterozygous or homozygous for TNFB2 was comparable between men and women with severe sepsis. In women, no difference in survival rate was found between the different genotypes, while mortality rate was significantly increased in men homozygous for TNFB2 compared with the other genotypes (P < 0.05; P < 0.01, chi2 test). Overall, survival rate was higher for women (P < 0.05) but was not significantly different between men and women with respect to genotypes (P = 0.07 for TNFB2/B2). Poor prognosis of surgical sepsis can be determined by male gender and the genomic marker TNFbeta Ncol polymorphism which should be considered for further therapeutic interventions in sepsis.

Gender-related therapy: early IL-10 administration after hemorrhage restores immune function in males but not in females.

Recent experimental studies have found gender differences in the immune response after hemorrhagic shock with an enhanced immune function and lower mortality after subsequent sepsis in females than in males. Interleukin-10 (IL-10) has been shown to play a potential role in the treatment of early proinflammatory state after hemorrhagic shock. Although studies showed beneficial effects of the treatment with IL-10, it remains unclear whether the effects are gender related. To study this, male and female CBA/J mice were subjected to hemorrhage (35+/-5 mmHg for 90 min and fluid resuscitation) or sham operation. At resuscitation, each received either recombinant murine IL-10 (rmIL-10) or placebo i.p. At 48 h after resuscitation, peritoneal macrophages (pMphi) and splenocytes were harvested. IL-1beta and IL-12 release by pMphi and splenocyte proliferation and splenocyte IL-2 and interferon (IFN)-gamma release capacity were assessed. Interleukin-10 plasma levels were not increased after rmIL-10 treatment. The results indicate that rmIL-10 treatment restores depressed immune response (splenocyte proliferation, IFN-gamma, IL-1beta in males after hemorrhagic shock. In contrast, the immune responses after shock in females were not influenced by rmIL-10, with the exception of depressed splenocyte proliferation. In addition, sham-operated male mice treated with rmIL-10 showed immune depression compared with the placebo group. Thus, administration of rmIL-10 during resuscitation after hemorrhage produces salutary effects on the depressed immune responses in males but did not further enhance the immune functions in females under those conditions.

Streptococcus pneumoniae peritonitis postpartum.

A peritonitis caused by an ascending infection is a rare complication postpartum. A 37-year-old woman presented with a secondary peritonitis due to Streptococcus pneumoniae. The patient had given birth to a healthy boy 4 weeks before and showed no symptoms of a bronchitis on admission. An operation was performed after the patient developed an acute abdomen, showing a diffuse peritonitis. High vaginal swabs and blood cultures taken on admission were positive for S. pneumoniae as well as the specimen taken during the operation. Thus we concluded that this was a case of an ascending infection. After antibiotic therapy with penicillin the patient could be discharged 8 days after the operation.

Reversal of sexual dimorphism in splenic T lymphocyte responses after trauma-hemorrhage with aging.

Previous studies have demonstrated that hemorrhagic shock produces immunodepression in young male mice, whereas the immunoresponsiveness in young proestrus female mice is enhanced under such conditions. This sexually dimorphic immune response to hemorrhage appears to be related to high estrogen and testosterone levels in females and males, respectively. Nonetheless, it is unknown what impact the age-related decline in the sex steroid levels has on the immune response after hemorrhage. To study this, young (2-3 mo) and aged (18-19 mo) male and female CBA/J NIA mice were subjected to laparotomy (i.e., soft tissue trauma) and hemorrhage (35 +/- 5 mmHg for 90 min and fluid resuscitation) or sham operation. Twenty-four hours later, splenocyte responses were assessed in vitro. Splenic T lymphocyte responses [i.e., proliferation, interleukin-2 (IL-2) and interferon-gamma (IFN-gamma) release] were depressed in young males and enhanced in young females after trauma-hemorrhage. In contrast, in the aged male and female groups these parameters of splenocyte function were reversed after trauma-hemorrhage (i.e., increased proliferation and IL-2 release in aged males compared with suppressed proliferation and IFN-gamma release in aged females). Furthermore, the release of the immunosuppressive cytokine IL-10 inversely correlated with the age- and gender-related changes in splenocyte responses after trauma-hemorrhage. Thus the sexually dimorphic immune response in young males and females to trauma-hemorrhage appears to reverse as sex hormone levels decline with age.

Immune dysfunction following trauma-haemorrhage: influence of gender and age.

Recent studies indicate that young female proestrus mice show an enhanced immune response following trauma-haemorrhage, as opposed to the immunodepression observed in males of comparable age. Testosterone is suggested as the cause of immunodepression in males, whereas oestradiol seems to be responsible for the enhanced immune response in females, however, sex hormone levels decrease with age. To determine if the sexual dimorphism in immune responses observed in young mice following trauma-haemorrhage changes with age, young (2-3 months) and aged (18-19 months) male and female CBA/J NIA mice were subjected to soft-tissue trauma (laparatomy) and haemorrhage (35+5 mmHg for 90 min and fluid resuscitation) or sham operation. Mice were killed 24 h later, and whole blood, as well as splenic and peritoneal macrophages (Mstraight phi) obtained. Plasma 17beta-oestradiol and free testosterone decreased in aged females and males, respectively. Mstraight phi from young females had enhanced IL-1beta and suppressed IL-10 production following trauma-haemorrhage, while aged females had unchanged production IL-1beta and IL-6 production and enhanced IL-10 release. In contrast, IL-1beta and IL-6 production by Mbeta from young males was suppressed and IL-10 production enhanced following trauma-haemorrhage, whereas Mstraight phi from aged males produced elevated levels of IL-1beta and IL-6 and suppressed levels of IL-10 following trauma-haemorrhage. Thus, the gender-related changes in the immune response to trauma-haemorrhage were reversed in aged mice.

Gender differences in human sepsis.

BACKGROUND: In animal studies, gender differences were related to hormonal and immunologic changes that were associated with an increased susceptibility to sepsis in males. OBJECTIVE: In a prospective study, gender differences in patients with surgical sepsis were evaluated in terms of survival, sex hormones, and proinflammatory as well as anti-inflammatory mediators. SETTING: Surgical intensive care unit of a university hospital. PATIENTS: Fifty-two patients (19 women and 33 men) with surgical sepsis. MEASUREMENTS AND MAIN RESULTS: In a prospective study, tumor necrosis factor alpha and interleukin 6 bioactivity and plasma levels of interleukin 10 (using enzyme-linked immunosorbent assay), total testosterone, and 17-beta estradiol (using radioimmunoassay) were determined on days 1, 3, 5, 7, 10, and 14 after diagnosis of sepsis. There were no differences in characteristics of patients in age (mean age, 55.4 years for women and 53.1 years for men) or cause and severity of sepsis (Acute Physiology and Chronic Health Evaluation II score, 17.3 for women and 18.5 for men; multiple organ dysfunction score, 9.9 vs 10.8, respectively). Although no difference could be found in the multiple organ dysfunction score from day 1 to day 28, the prognosis of sepsis was significantly different in women compared with men. Hospital-mortality rate was 70% (23 of 33 patients) in male and 26% (5 of 19) in female patients (P<.008, log-rank test). Bioactivity of tumor necrosis factor continuously increased in men after diagnosis of sepsis, with significantly elevated levels on day 10 (P<.05, Mann-Whitney U test with Bonferroni correction), whereas no difference was found for interleukin 6 bioactivity. Women displayed enhanced interleukin 10 levels compared with men from day 1 to day 10 that reached a significant difference on days 3 and 5 (P<.05). Total testosterone levels were below the normal range for men, and estradiol levels were initially increased in both men and postmenopausal women, with higher levels for women. CONCLUSIONS: In this prospective study, gender differences were confirmed in human sepsis, with a significantly better prognosis for women, which may be related to increased levels of anti-inflammatory mediators. The hypothetical different ratio of proinflammatory and anti-inflammatory mediators may be important for further therapeutic interventions in sepsis.

Glutamine dipeptides-supplemented parenteral nutrition reverses gut mucosal structure and interleukin-6 release of rat intestinal mononuclear cells after hemorrhagic shock.

Glutamine is an essential substrate for gut mucosal structure, but the role for gut immune function is not fully known. To determine the effect on gut cytokine release in relation to bacterial translocation and gut morphology, a nonlethal hemorrhagic shock (30 min, 30 mmHg) was performed in male Wistar rats followed by 4 days of different way of feeding. A conventional total parenteral nutrition (TPN) solution was compared with an isocaloric and isonitrogenous TPN solution supplemented with alanin-L-glutamine and glycyl-L-glutamine. An enteral chow-fed control group was included. Gut mononuclear cells and splenic macrophages were obtained and endotoxin-induced supernatant tumor necrosis factor-alpha (TNF) and interleukin-6 (IL-6) bioactivity was measured. Histological specimen of the small bowel were taken and mesenteric lymph nodes (MLN) were separated. Enteral feeding following hemorrhagic shock was accompanied by a normal mucosal structure and no bacterial translocation could be detected. TPN was characterized by suppression of cytokine release in gut mononuclear cells and splenic macrophages compared with the enteral-fed control (p < .05). Decreased TNF and IL-6 release was associated with a significantly increased mucosal injury score (p < .05) and a high incidence of bacterial translocation to MLN (66%, p < .05 vs. control). Supplementation of glutamine-dipeptides did not prevent TPN-induced bacterial translocation to MLN (p < .05 vs. control) but significantly improved mucosal injury (p < .05 vs. TPN). Down-regulation of TNF release in TPN-fed rats could not be reversed by glutamine dipeptides while IL-6 release was significantly increased compared with TPN-fed animals (p < .05), and no difference to enteral-fed controls could be found. Enteral nutrition following hemorrhagic shock is superior to parenteral nutrition with regard to mucosal structure, cytokine release, and bacterial translocation. Supplementation of TPN with glutamine dipeptides could reverse TPN-induced suppression of IL-6 release and improved mucosal structure, which may be beneficial in various disease conditions in which TPN is an integrated part of patients management.