[Histiocytosis in the dermatological context of the new classification]. / Histiozytäre Neoplasien im Kontext der aktuellen Klassifikation.

Histiocytoses comprises a heterogeneous group of inflammatory diseases for which dendritic cells and macrophages are the main cellular components. The inflammatory infiltrate can affect the skin and other organs, and clinical outcome varies from mild to lethal depending on the involved cell subset and organ infiltration as well as comorbidities. Until recently, the group of histiocytosis was divided into Langerhans cell histiocytosis, non-Langerhans cell histiocytosis and malignant histiocytosis. With the new classification from JF Emile et al., the subgroups were determined regarding clinical, histiopathological, radiological, phenotype, genetic, and molecular features. In this review, we explain the revised classification with emphasis on dermatological and molecular aspects.

Predictive value of PD-L1 based on mRNA level in the treatment of stage IV melanoma with ipilimumab.

INTRODUCTION: PD-L1 is established as a predictive marker for therapy of non-small cell lung cancer with pembrolizumab. Furthermore, PD-L1 positive melanoma has shown more favorable outcomes when treated with anti-PD1 antibodies and dacarbazine compared to PD-L1 negative melanoma. However, the role of PD-L1 expression with regard to response to checkpoint inhibition with anti-CTLA-4 is not clear, yet. In addition, the lack of standardization in the immunohistochemical assessment of PD-L1 makes the comparison of results difficult. In this study, we investigated the PD-L1 gene expression with a new fully automated technique via RT-PCR and correlated the findings with the response to the anti-CTLA-4 antibody ipilimumab. MATERIALS AND METHODS: Within a retrospective multi-center trial, PD-L1 gene expression was evaluated in 78 melanoma patients in a total of 111 pre-treatment tumor samples from 6 skin cancer centers and analyzed with regard to response to ipilimumab. For meaningful statistical analysis, the cohort was enriched for responders with 30 responders and 48 non-responders. Gene expression was assessed by quantitative RT-PCR after extracting mRNA from formalin-fixed paraffin embedded tumor tissue and correlated with results from immunohistochemical (IHC) stainings. RESULTS AND DISCUSSION: The evaluation of PD-L1 expression based on mRNA level is feasible. Correlation between PD-L1 expression as assessed by IHC and RT-PCR showed varying levels of concordance depending on the antibody employed. RT-PCR should be further investigated to measure PD-L1 expression, since it is a semi-quantitative method with observer-independent evaluation. With this approach, there was no statistical significant difference in the PD-L1 expression between responders and non-responders to the therapy with ipilimumab. The evaluation of PD-L1 expression based on mRNA level is feasible. Correlation between PD-L1 expression as assessed by IHC and RT-PCR showed varying levels of concordance depending on the antibody employed. RT-PCR should be further investigated to measure PD-L1 expression, since it is a semi-quantitative method with observer-independent evaluation. With this approach, there was no statistical significant difference in the PD-L1 expression between responders and non-responders to the therapy with ipilimumab.

Assessment of 0.5 T static field exposure effect on yeast and HEK cells using electrorotation.

This study aims to examine the influence of a 0.5 T static magnetic field (SMF) on yeast and human embryonic kidney (HEK) 293 cell using electrorotation (ROT). Following 48 h exposition to the SMF, no difference was noted between ROT spectra of unexposed and exposed yeast cells, which extend previous reports on the absence of SMF effects on yeast. We also compared the ROT spectrum and the extracted electrical characteristics of HEK cells exposed during 72 h to a 0.5 T uniform static magnetic field with those of unexposed cells. SMF potential effects on HEK proliferation kinetics and cell morphology were also assessed by using the trypan blue exclusion method and scanning electron microscopy, respectively. At last, no significant differences were observed between control and exposed HEK cells concerning electrical properties, growth, and morphology.

Dermatophyte identification in skin and hair samples using a simple and reliable nested polymerase chain reaction assay.

BACKGROUND: Dermatophyte identification in tinea capitis is essential for choosing the appropriate treatment and in tinea infections to identify the possible source. The failure of fungi to grow in cultures frequently occurs, especially in cases of previous antifungal therapy. OBJECTIVES: To develop a rapid polymerase chain reaction (PCR) sequencing assay for dermatophyte identification in tinea capitis and tinea corporis. MATERIAL AND METHODS: Fungal DNA was extracted from hair and skin samples that were confirmed to be positive by direct mycological examination. Dermatophytes were identified by the sequence of a 28S ribosomal DNA subunit amplicon generated by nested PCR. RESULTS: Nested PCR was found to be necessary to obtain amplicons in substantial amounts for dermatophyte identification by sequencing. The results agreed with those of classical mycological identification in 14 of 23, 6 of 10, and 20 of 23 cases of tinea capitis, tinea corporis and tinea pedis, respectively, from which a dermatophyte was obtained in culture. In seven of the 56 cases, another dermatophyte was identified, revealing previous misidentification. A dermatophyte was identified in 12 of 18, three of five, and four of nine cases of tinea capitis, tinea corporis and tinea pedis, respectively, in cases in which no dermatophyte grew in culture. CONCLUSIONS: Although the gold standard dermatophyte identification from clinical samples remains fungal cultures, the assay developed in the present study is especially suitable for tinea capitis. Improved sensitivity for the identification of dermatophyte species was obtained as it is possible to identify the dermatophyte when the fungus fails to grow in cultures.

Bile duct injury and use of cholangiography during laparoscopic cholecystectomy.

BACKGROUND: Bile duct injury (BDI) remains the most serious complication of laparoscopic cholecystectomy (LC). A Swiss database was used to identify risk factors for BDI and to assess the effect of intraoperative cholangiography (IOC). METHODS: Data for patients from 114 Swiss institutions who underwent LC for acute or chronic cholecystitis between 1995 and 2005 were used in univariable and logistic regression analyses. RESULTS: In total 31 838 patients, mean(s.d.) age 54·4(15·9) years, were analysed. The incidence of BDI was 0·3 per cent (101 patients), which did not change over time (P = 0·560). Univariable analysis revealed that male patients had a higher risk of BDI (0·5 per cent versus 0·2 per cent in female patients; P = 0·001), as did patients whose operation lasted at least 150 min (1·1 per cent versus 0·1 per cent for operating time of less than 150 min; P < 0·001). Logistic regression confirmed male sex (odds ratio (OR) 1·89, 95 per cent confidence interval 1·27 to 2·81) and prolonged surgery (OR 12·60, 10·87 to 23·81) as independent risk factors. Comparison of groups with and without intraoperative cholangiography showed no difference in the incidence of BDI (both 0·3 per cent; P = 0·755) and BDIs missed during surgery (10 versus 8 per cent; P = 0·737). CONCLUSION: Male sex and prolonged laparoscopic surgery are independent risk factors for BDI during LC. Frequent use of IOC does not seem to reduce BDI or the number of injuries missed during surgery.

Endoscopic retroperitoneal neurectomy for chronic pain after groin surgery.

BACKGROUND: Chronic postoperative pain after inguinal surgery remains a difficult problem. The role of minimally invasive surgery in this complex setting is still unexplored. METHODS: Between January 1997 and January 2007, 34 men and five women with a mean(s.d.) age of 47(16) years underwent endoscopic retroperitoneal neurectomy (ERN) for chronic neuropathic groin pain due to genitofemoral nerve with or without ilioinguinal nerve entrapment. Follow-up data were obtained 1 and 12 months after surgery. RESULTS: At both timepoints after ERN, the severity of chronic postoperative groin pain at rest and during daily activities, and the rate of occupational disability, were significantly decreased in 27 of the 39 patients compared with preoperative values (all P < 0.001). CONCLUSION: ERN for chronic postoperative genitofemoral nerve entrapment neuropathy was successful in the majority of patients selected for the procedure. This minimally invasive approach allows simultaneous neurectomy of genitofemoral and ilioinguinal nerves.

Incidence of clinical pulmonary embolism after laparoscopic surgery.

BACKGROUND: This study aimed to determine the incidence of pulmonary embolism (PE) following laparoscopic surgery and its potential risk factors. METHODS: Data concerning 44 453 patients from 114 surgical institutions were collected by the Swiss Association of Laparoscopic and Thoracoscopic Surgery. The incidence of postoperative PE despite thromboprophylaxis was evaluated and potential risk factors were assessed singly, and then in a consecutive stepwise logistic multiple regression analysis. RESULTS: Among 44 453 patients assessed, 55.8 per cent were female and 44.2 per cent were male. Interventions included cholecystectomy (52.8 per cent), hernia repair (17.7 per cent), appendicectomy (12.4 per cent), colonic surgery (4.6 per cent) and oesophageal surgery (5.5 per cent). Postoperative PE occurred in 86 patients (0.2 per cent), and the incidence tended to decrease during this study (P = 0.016). A total of 149 patients died (0.3 per cent) of which nine (6.0 per cent) were due to PE. Significant predictive risk factors were female sex (P < 0.001), age (P < 0.001), weight above 90 kg (P < 0.001), emergency procedure (P < 0.001) and operating time exceeding 150 min (P < 0.001). CONCLUSION: The low incidence of PE after laparoscopy, with a further decrease over the past decade, suggests a tendency towards improved perioperative thromboembolic risk management.

Hepatic carbohydrate metabolism in rats after laparotomy and laparoscopy.

BACKGROUND: Portal venous and mesenteric blood flow are reduced by 40-60% in humans and animals during laparoscopic surgery compared to laparotomy. Little is known about whether these intraabdominal micro- and macrocirculatory changes are associated with alterations in the hepatic energy metabolism. METHODS: We operated on male Sprague-Dawley rats, performing either laparoscopy (CO2, 6 mmHg; n = 27) or laparotomy (n = 28), and compared the results with two control groups: intraperitoneal (i.p.) endotoxin administration (n = 28, positive control) and anesthesia only (n = 28, negative control). We investigated the impact of the two different surgical techniques on daily food intake, body weight gain, glycogen content in the liver, levels of blood glucose, and liver function tests (LFTs) on postoperative days 1, 2, 4, and 8. Local (hepatic) and systemic inflammatory responses (interleukin-6 and tumor necrosis factor-alpha) during the postoperative time course were also determined. Data were analyzed using the Kruskal-Wallis test or univariate analysis of variance. RESULTS: Body weight gain, food intake, liver and spleen weights, as well as LFTs [except aspartate aminotransferase (AST)] did not differ among the four groups. The significant increase in the AST level following laparoscopy compared to the anesthesia-only group was found on postoperative days 1 and 2; however, a similar difference was not detected after laparotomy or i.p. endotoxin injection. Laparoscopy showed no alterations in the hepatic glycogen stores compared to anesthesia only, whereas laparotomy and endotoxinemia significantly reduced the hepatic glycogen stores on postoperative days 2 and 4. The systemic postoperative inflammatory response did not differ between laparotomy and laparoscopy, but it was higher in both groups than in anesthesia only. In rats treated with endotoxin, the systemic inflammatory response was even higher than in the two surgical groups. The hepatic inflammatory response did not differ between the four groups. CONCLUSION: This study shows a significant postoperative decrease in the hepatic glycogen content after laparotomy and i.p. endotoxin injection but not after laparoscopy. Food intake and inflammatory response cannot explain this difference between the two surgical groups, which suggests that alterations in the postsurgical hormonal stress response are the most likely explanation for these findings.

Laparoscopic cholecystectomy in acute cholecystitis: indication, technique, risk and outcome.

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the treatment of choice for symptomatic cholelithiasis. However, the laparoscopic approach has remained controversial for patients with acute cholecystitis (AC) because of technical difficulties that, compared with open cholecystectomy (OC), might lead to higher complication rates, particularly common bile duct (CBD) injuries and infection. METHODS: We reviewed recent clinical findings on feasibility, safety and potential benefits of LC in patients with AC. An electronic search using the PubMed and MEDLINE databases was performed using the terms laparoscopic cholecystectomy, open cholecystectomy and acute cholecystitis. Pertinent references from articles and books not identified by the search engines were also retrieved. Relevant surgical textbooks were also reviewed. CONCLUSIONS: The early laparoscopic approach has been shown to be technically feasible and at least equally as safe as the open approach. However, extensive inflammation, adhesions and consequent increased oozing can make laparoscopic dissection of Calot's triangle and recognition of the biliary anatomy hazardous and difficult. Therefore, conversion to OC remains an important treatment option to secure patient safety in such difficult conditions. The question of whether intraoperative cholangiography (IOC) should be used routinely or only selectively has never been resolved. Proponents for each side have put forward compelling arguments.

Trans- and retroperitoneal endoscopic adrenalectomy: experience in 26 consecutive adrenalectomies.

OBJECTIVE: To assess our current concept and results of transperitoneal laparoscopic adrenalectomy (TPLA) and retroperitoneal endoscopic adrenalectomy (ERA) for a variety of benign disorders of the adrenal glands. BACKGROUND DATA: According to the literature, minimal invasive adrenalectomy has shown to be a safe and effective surgical alternative to open adrenalectomy. Both, transperitoneal and retroperitoneal endoscopic minimal invasive access are currently used for surgical removal of benign adrenal tumors. There is still some debate about the indications and the access used for a minimal invasive approach. PATIENTS AND METHODS: Treatment and clinical outcome of all patients who underwent either transperitoneal laparoscopic or endoscopic retroperitoneal adrenalectomies for benign diseases from February 1997 to August 2002 were analyzed retrospectively. RESULTS: Twenty-six minimal invasive adrenalectomies were performed in 23 patients with a mean age of 57 years. Whereas 11 patients underwent unilateral right- sided ERA, unilateral TPLA was performed in 9 patients on the left side. Three patients had bilateral TPLA. The mean operating time for unilateral ERA and TPLA was 114 and 79 min, respectively. Bilateral TPLA was prolonged to 223 min operating time. There were only two minor postoperative complications. The mean hospital stay for unilateral TPLA, ERA and bilateral TPLA was 4.7, 5 and 6 days, respectively. There was no mortality. CONCLUSION: Both, ERA and TPLA are safe and clinically effective treatment modalities for benign disorders of the adrenal glands. We currently favor a transperitoneal laparoscopic approach for bilateral and left-sided adrenal tumors, whereas right-sided tumors <8 cm are removed by a retroperitoneal approach. Large right-sided tumors >8 cm are better removed by transperitoneal access.

Right hemihepatectomy for bile duct injury following laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) has become the treatment of choice for patients with symptomatic cholecystolithiasis. But with the introduction of this technique, the incidence of bile duct injuries has increased. We report the case of a 33-year-old man who was transferred from an affiliated hospital to our department for the treatment of a bile duct injury 2 weeks after LC. Prior to transfer, a laparotomy had been performed, with insertion of a T-tube and a Robinson drain on day 5 after LC. Endoscopic retrograde cholangiography (ERC) on admission day revealed an extensive defect of the right biliary system, which could not be treated endoscopically. An emergency laparotomy had to be performed at night for acute bleeding from the portal vein. Due to massive inflammation in the porta hepatis and intraparenchymal destruction of the right bile duct, liver resection was performed 2 days later, after the patient had stabilized in the intensive care unit (ICU). The patient had a prolonged postoperative course, but he finally recovered well from these operations. In conclusion, the management of bile duct injuries should include ultrasound to detect and drain fluid collections and ERC to classify the injury. Emergency laparotomy should never be performed without these examinations, since the majority of bile duct injuries can be treated endoscopically. Surgery for this serious complication should always be performed at specialized centers for hepatobiliary surgery.

Incidence and management of Mirizzi syndrome during laparoscopic cholecystectomy.

BACKGROUND: Benign extrinsic obstruction of the hepatic duct, known as "Mirizzi syndrome" (MS), is an uncommon complication of longstanding cholelithiasis. Since laparoscopic cholecystectomy (LC) replaced the open approach, Mirizzi syndrome has regained the interest of biliary surgeons. METHODS: The Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS) prospectively collected the data on 13,023 patients undergoing LC between 1995 and 1999. This database was investigated with special regard to patients with Mirizzi syndrome. RESULTS: There were 39 patients (14 men and 25 women; mean age, 61 years) with MS (incidence, 0.3%). Thirty-four patients had type 1 MS and five had type 2. A gallbladder carcinoma was found in four patients (incidence, 11%). In the type 1 group, 23 patients underwent cholecystectomy only, 10 patients had a bile duct exploration and T-tube insertion, and one patient had a Roux-en-Y reconstruction. In three patients with type 2, a hepaticojejunostomy was performed; two others underwent simple closure and drainage (via T-tube) of the biliary fistula. The conversion rate was 74% (24 of 34 patients) in the type 1 group and 100% (five of five patients) for type 2. The overall complication rate was 18%. There were no deaths. CONCLUSIONS: Although MS is rarely encountered during LC, it must be recognized intraoperatively. Conversion to an open approach is often needed, and prior to any surgical intervention, gallbladder cancer must be excluded.

[Gallstones--surgical aspects]. / Gallensteinleiden--chirurgische Aspekte.

Between 10% to 15% of the adult population develop gallstones. Therefore, cholecystectomy is among the most common operations in general surgery. The diagnosis of cholelithiasis depends on the patient's history, clinical findings, laboratory tests and ultrasound examination. Once diagnosis of symptomatic gallbladder disease has been confirmed, laparoscopic cholecystectomy is the treatment of choice. Its advantages in comparison with open surgery are decreased morbidity, costs and hospital stay. Open cholecystectomy is still the treatment of choice for complicated gallstone disease (i.e. cancer, Mirizzi's syndrome, severe inflammation) and in high-risk patients. In case of acute cholecystitis, early laparoscopic cholecystectomy is a safe procedure and is associated with the same benefits as for symptomatic disease.

Technique and value of staging laparoscopy.

Despite significant improvements in preoperative tumor staging due to sophisticated new imaging and interventional techniques, peritoneal tumor spread and occult liver and lymph node metastases are only detected during surgery in some patients. Newer treatment modalities using neoadjuvant regimens are only given if occult tumor spread is excluded. Diagnostic laparoscopy has therefore been introduced to prevent patients with advanced tumor disease from unnecessary laparotomy and as a diagnostic tool in neoadjuvant treatment protocols. Laparoscopic ultrasound represents an important technical improvement in diagnostic laparoscopy. The main indication for diagnostic laparoscopy is therefore exact tumor staging, especially in terms of peritoneal, liver, and lymphatic tumor spread, whereas determination of local tumor resectability is not the main issue. The aim of the current review is to summarize the technique of staging laparoscopy and to discuss its clinical value for a variety of gastrointestinal malignancies.

[Combination of plate and external fixator for biological osteosynthesis of comminuted fractures]. / Kombination von Platte und Fixateur externe zur biologischen Osteosynthese von Mehrfragmentfrakturen.

In a comminuted fracture, a unilateral plate doesn't always give enough stability because the contralateral cortex cannot be used as a buttress. New plate systems as the Locking Compression Plate (LCP) may solve this problem. Another method to stabilize the contralateral cortex is by using an External Fixator (EF) in addition to a conventional platte either on the opposite side of the plate or on the ipsilateral side over the plate. By doing so, a half frame of an EF acts as a substitute for the damaged cortex. This method is easily available and may also be considered when a conventional plate osteosynthesis must be mechanically improved after the conventional plate is already put in place. With this combination of a plate with a EF we treated twelve patients with comminuted fractures of the tibia, the humerus and the femur. Eleven fractures healed without further operations or complications. In one case, there was a superficial wound infection with Staph. epidermidis that lead to an early metal removal, but healing of the fracture was not impaired. We also tested this set-up in a model and found, that the additional EF increased the stiffness of the plate by 73% for axial load. The combination of a plate and a contralateral EP is a useful way to treat comminuted fractures biologically achieving enough stability to allow early motion of the adjacent joints and fast healing of the fracture. Especially for fractures adjacent to a joint, this method is an alternative to an intramedullary nail.

Randomized controlled trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice repair.

BACKGROUND: There is a scarcity of data on long-term results after laparoscopic hernia repair. Herein we report on the outcome of a group of patients who were followed up for 5 years in a multicenter study on hernia repair. METHODS: A total of 100 patients with 127 hernias were randomized to undergo either transabdominal preperitoneal (TAPP) or Shouldice hernia repair. Follow-up was by clinical examination and standardized questionnaire. RESULTS: Of the 100 patients who underwent surgery, 84 were available for follow-up at 5 years. The TAPP procedure was less painful than the Shouldice repair, with fewer patients receiving narcotic analgesics. The median time to return to 100% activity was shorter in the laparoscopic group (21 days) than in the Shouldice group (40 days). Up to 60 months after the operation, the complication rate was lower in laparoscopically repaired hernias (19/66) than in the open group (25/61). There were two recurrences (3.9%) in the TAPP group and five in the Shouldice group (10.2%). CONCLUSION: The TAPP hernia repair yields comparable or better results than Shouldice herniorrhaphy in terms of postoperative pain, recovery, and recurrence rate.

Predictive factors for the type of surgery in acute cholecystitis.

BACKGROUND: Whereas early cholecystectomy is accepted as the optimal timing for surgery, the best treatment modality for acute cholecystitis (AC) is still under debate. In this series, we aimed to assess the current treatment of AC in a single institution. In addition, preoperative criteria were defined predicting the severity of inflammation. METHODS: From January 1995 to June 1999, 236 patients undergoing cholecystectomy for AC were prospectively evaluated. Outcome measures were the treatment modality, the severity of inflammation, white blood cell (WBC) count, C-reactive protein (CRP), morbidity, and hospital stay. RESULTS: There were 115 laparoscopic cholecystectomies (LC), 77 primary open cholecystectomies (OC), and 44 conversions (CON) to OC. Patients with LC were significantly younger, in better condition, with a shorter duration of symptoms and lower CRP levels and WBC counts compared with OC and CON (P <0.001). Postoperative complications, reinterventions, and mean hospital stay were significantly increased after OC and CON (P <0.001). Overall mortality was 2.5%. Advanced AC was predominantly found in OC and CON (P <0.001). Patients with advanced AC were significantly older, predominantly male, and had a prolonged duration of symptoms as well as increased CRP levels and WBC counts (P <0.001). The conversion rate increased from 10% for mild AC up to 48% for necrotizing AC. CONCLUSIONS: Based on laboratory (CRP, WBC), demographic (age, sex), and individual (American Society of Anesthesiologists classification, duration of symptoms) findings, it is possible to reliably predict the severity of inflammation. Therefore, an individualized surgical approach can be used for each patient and type of AC.

Incidence, risk factors, and prevention of biliary tract injuries during laparoscopic cholecystectomy in Switzerland.

Bile duct injury (BDI) during laparoscopic cholecystectomy (LC) which may result in patient disability or death are reported to occur more frequently when compared to open surgery. The aim of this nationwide prospective study beyond the laparoscopic learning curve was to analyze the incidence, risk factors, and management of major BDI. During a 3-year period (1995-1997) 130 items of all LC data were collected on a central computer system from 84 surgical institutions in Switzerland by the Swiss Association of Laparoscopic and Thoracoscopic Surgery and evaluated for major BDIs. Simple biliary leakage was excluded from analysis. There were 12,111 patients with a mean age of 55 years (3-98 years) enrolled in the study. The overall BDI incidence was 0.3%, 0.18% for symptomatic gallstones, and 0.36% for acute cholecystitis. In cases of severe chronic cholecystitis with shrunken gallbladder, the incidence was as high as 3%. Morbidity and mortality rates were significantly increased in BDIs. BDI was recognized intraoperatively in 80.6%, in 64% of cases by help of intraoperative cholangiography. Immediate surgical repair was performed laparoscopically (suture or T-drainage) in 21%; in 79%, open repair (34% simple suture, 66% Roux-en-Y reconstruction) was needed. The BDI incidence did not decrease during the last 7 years. In 47%, BDIs were caused by experienced laparoscopic surgeons, perhaps because they tend to operate on more difficult patients. In conclusion, the incidence of major BDIs remains constant in Switzerland at a level of 0.3%, which is still higher when compared to open surgery. However, most cases are now detected intraoperatively and immediately repaired which ensures a good long-term outcome. For preventing such injuries, exact anatomical knowledge with its variants and a meticulous surgical dissecting technique especially in case of acute inflammation or shrunken gallbladder are mandatory.

Non-occlusive small bowel necrosis during gastric tube feeding: a case report.

Small bowel necrosis is known as a rare, but serious complication of jejunal tube feeding. We report a case of non-occlusive small bowel necrosis with gastric tube feeding. The patient had a moderate multiple trauma with head injury. Abdominal distension developed after several days of uneventful nasogastric tube feeding. At laparotomy patchy necrosis of the small bowel was found without signs of bowel obstruction or impaired mesenteric perfusion. The patient recovered after a prolonged ICU stay. In this case the large doses of clonidine, given due to an alcohol withdrawal syndrome, were suspected to be a major contributing factor to the development of the small bowel necrosis by impairing gut motility and mucosal perfusion. We conclude that, first, small bowel necrosis can occur after primarily uneventful enteral feeding, even with gastric feeding; second, clonidine can dramatically impair gastrointestinal function in critically ill patients by impairing gut motility and mucosal perfusion.