[Comparative study of the cost-effectiveness of initial therapy with imipenem/cilastatin in secondary peritonitis]. / Vergleichende Untersuchung zum Kosten-/Effektivitätsverhältnis einer initialen Therapie mit Imipenem/Cilastatin bei der sekundären Peritonitis.

The total costs of the hospital treatment of patients with secondary peritonitis were investigated with a prospective, randomized, multicenter study. Moreover, the cost-effectiveness of an initial therapy with Imipenem/Cilastatin was compared to selected alternative antibiotic regimens. Altogether 154 patients (77 Imipenem/Cilastatin group, 77 alternative group) that displayed Mannheim Peritonitis Scores between 16 and 26 (average 20.8) were analyzed. The average total cost of treatment was DM 11,140 per patient (range DM 2794-45,526). Patients receiving an initial therapy with Imipenem/Cilastatin incurred average costs of DM 10,455, while patients with alternative regimens caused average costs of DM 11,826. The difference between the two treatment groups was statistically significant (P = 0.037).

Overview on compression anastomoses: biofragmentable anastomosis ring multicenter prospective trial of 1666 anastomoses.

This study represents a European prospective clinical multicenter trial and was undertaken to evaluate the applicability of the biofragmentable anastomosis ring (BAR) as a routine anastomotic tool in teaching hospitals. The trial results analyzed consisted of 1666 BAR anastomoses performed in 1360 patients from March 1989 to May 1996 in the upper (1042 anastomoses) and lower (624 anastomoses) gastrointestinal (GI) tract. Only patients selected for elective procedures and having previously undergone orthograde bowel cleansing were entered into the trial. In the upper GI tract six anastomoses (0.58%) developed clinically relevant and radiologically detectable leaks with indications for reoperation. In the lower GI tract 42 (6.73%) anastomoses showed a radiologically detectable leak with clinical manifestations in 28 cases (4.48%). Reoperation was performed in 18 cases (2.80%). The overall leakage rate with clinical relevance was 2.04%. Three gastrojejunostomy episodes of bleeding were observed (0.18%) at the BAR anastomotic site. During the early postoperative course there was no ileus due to obstruction of a BAR anastomosis. Reintroduction of diet after the operation was not delayed. In two centers a follow-up evaluation reported no BAR-related late anastomotic stenoses. There were no intraoperative deaths, but 54 patients died postoperatively. Peritonitis following anastomotic leakage was responsible for postoperative deaths in four cases; three of them were related to BAR anastomoses. In conclusion, the BAR anastomotic procedure is an established, rapid, simple to learn, highly standardized, safe technique with the advantage of no persistent foreign material in the anastomotic region and therefore no induction of stenosis. At present, the application of anastomoses in various segments of the GI tract, from the stomach to the middle third of the rectum, can be recommended.

[Transanal compression anastomosis in the lower rectum with a biofragmentable anastomosis ring (Valtrac). Surgical technique and initial clinical experiences]. / Transanale Kompressionsanastomose im tiefen Rectum mit einem biofragmentierbaren Anastomosenring (Valtrac). Operationstechnik und erste klinische Erfahrungen.

In a pilot clinical study the practicability and postoperative course were investigated after compression anastomoses in the lower rectum using a new Valtrac application device. In all 15 patients the transanal compression anastomosis using a biofragmentable anastomosis ring was possible. Most difficult was the creation of the distal purse-string suture to fix the Valtrac ring in the rectum. Using this device the possible distal margin of the anastomosis is about two centimeters to the anal canal. There were no complications with clinical relevance for the postoperative course. Radiological leakages on day 8-10 postoperatively occurred in three patients. The new transanal application device for anastomoses in the lower rectum is a possible alternative to standard anastomoses procedure. Clinical studies hat to demonstrate a possible advantage in patients outcome after using this new operative technique in the lower rectum.

[Healing of the anastomosis in various suture techniques in the gastrointestinal tract. Physiology, experimental and clinical results]. / Anastomosenheilung bei verschiedenen Nahtverfahren im Gastrointestinaltrakt. Physiologie, experimentelle und klinische Ergebnisse.

New and further development of anastomoses induce new orientation for selection and indication of the several suture procedures in the gastrointestinal tract. Based on the wound healing principles, the different techniques are evaluated experimentally and in clinical tests. The results allow to discriminate indications for the different suture techniques. For the gastrointestinal tract the technique of choice is the serosubmucous single row suture with an absorbable 4.0 monofilament. For the esophagus and rectum, the stapled anastomosis offers more safety and better practicability than manual sutures. Studies have shown comparable results in colonic surgery for compression ring anastomoses. Additional procedures are of minor importance for the safety of anastomoses.

[Use of surgical staplers on the upper gastrointestinal tract]. / Der Einsatz von Klammernahtgeräten im oberen Gastrointestinaltrakt.

Mechanic or stapled anastomoses of hollow organs represent a safe and attractive alternative to the manual suture. The rate of complications for the duodenal stump closure by linear staplers is minimal with leakages below 1%; the same is true for the jejunum. In esophagogastrostomies which are often performed cervically, the stapler offers more safety compared to manual sutures, but the rate of stenoses is higher with about 15%. Stenoses have been observed especially with smaller magazines (25 mm diameter). For esophagojejunostomies safety is much greater with mechanic staplers than with manual sutures. Only most experienced surgeons would achieve the same results with the same low rate of leakages of less than 10%; stenoses do not have clinical relevance.

[Use of surgical staplers in the lower gastrointestinal tract]. / Einsatz von Klammernahtgeräten im unteren Gastrointestinaltrakt.

Practicability and indication for continuity preserving surgery increase by the use of staplers in the lower gastrointestinal tract. The mean rate of complications for the deep colorectal and colo-anal anastomosis decreased. Locoregional relapses occur as often as with other techniques, when the criteria of radicality have been observed. Stenoses are prevalently due to complications of extraperitoneal anastomoses. In higher large bowel sections, only a few surgeons favor the use of staplers, as the risk for the patient increases without offering particular advantages. The double stapling technique in deep anterior resection is possible for small tumors and a large pelvis. For colonic pouches linear staplers are completed by circular staplers for the subsequent pouchanal anastomosis. Studies are running, actually, regarding indication of the colonic pouch.

[Duration of wound healing and tissue resistance as important criteria for selecting suture materials in colon surgery]. / Wundheilungsdauer und Gewebewiderstand als wichtige Kriterien für die Wahl des Nahtmaterials in der Colonchirurgie.

The modern absorbable suture materials are well introduced in colonic surgery. Surgeon's intension is to reduce foreign body reactions by using small sized sutures and will be limited by the suture holding capacity of the tissue. Suture holding capacity of the human colon is about 9 +/- 2 N. Wound healing of colon anastomoses normally lasts 10 to 12 days. The braided absorbable suture materials Dexon, Dexon plus and Vicryl (size 3-0 USP) have a knot breaking strength of about 10 N after 12 days implantation in the human colon, the monofilament absorbable sutures PDS and Maxon have about 20 N resting strength after implantation. These results document that the size 3-0 USP (2-metric) should be the lowest limit for the braided absorbable suture materials used in colonic surgery.

[Randomized study comparing long-chain (LCT) and medium-chain (MCT) triglycerides as caloric carriers in postoperative nutritional therapy]. / Randomisierte Studie zum Vergleich zwischen langkettigen (LCT) und mittelkettigen (MCT) Triglyzeriden als Kalorienträger in der postoperativen Ernährungstherapie.

The aim of the study was to investigate the effect of a new 20% fat emulsion, containing 50% MCT and 50% LCT in comparison to a 20% fat emulsion containing only LCT, in the postoperative period. The possible influence on nitrogen loss, protein synthesis and fat metabolism was estimated. 20 patients after elective colon surgery were included in the trial. Parenteral nutrition was carried out for 5 days with two isonitrogenic and isocaloric nutritional regimens including either MCT/LCT or only LCT fat emulsions. Fat emulsions were administered over a period of 12 h with a total fat supply rate of 0.12 g/kg B.W./h. Blood samples for determination of protein synthesis, triglyceride and ketone bodies were taken under fat infusion as well as before and after infusion. 24-h urine samples were taken to measure nitrogen balance. Our results showed no difference in protein levels between the MCT- and LCT group. The 5-day nitrogen balance showed a significant increase in the MCT group (p less than 0.05, Mann-Whitney U-test). At the end of the infusion period triglyceride levels in the MCT group (mean value 244 +/- 15 mg%) differed significantly compared to the LCT group (m = 190 +/- 24 mg%). 2 h later triglycerides in both groups fell to basal levels. beta-Hydroxybutyrate (beta-HB) and aceto acetate (Ac-ac) concentrations showed significant differences between both groups. After 12 h infusion the MCT group had a mean level of 210 mumol/l beta-HB and 180 mumol/l Ac-ac vs. 90 mumol/l beta-HB and 120 mumol/l Ac-ac in the LCT group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Maxon and PDS--evaluation and physical and biologic properties of monofilament absorbable suture materials]. / Maxon und PDS--Bewertung physikalischer und biologischer Eigenschaften monofiler, absorbierbarer Nahtmaterialien.

The physical parameters of monofilament absorbable sutures (Maxon and PDS) were studied. Compared to PDS Maxon proved somewhat more unwieldy, however, it required less complicated knot combinations for a secure placement than PDS did. In vivo experiments on rats showed a slight tissue reaction and a dissolution time of 120-180 days for Maxon and 180-240 days for PDS. With Maxon, tensile strength was measurable for 42-49 days, while the period for PDS amounted to 65-80 days. New indications for these materials are discussed, two parameters, easy knot formation and atraumatic passage through the tissue, especially favor the use of Maxon for one-row all-layer sutures in the gastrointestinal tract.

[Review of the physical and surgical technical properties of modern monofilament suture materials]. / Ubersicht physikalischer und handhabungstechnischer Eigenschaften moderner, monofiler Nahtmaterialien.

This paper documents the differences among 8 monofile sutures in important functions such as linear tensile strength, bending stiffness, knot security and irreversible elongation. The results show that two materials (Prolene and Gore-Tex) do not seem to be as suitable as the other materials for long-term tensile loads. The lowest bending stiffness was that of Seralon. The highest knot security can already be reached with three loops of Novafil. Novafil has also got the highest maximal elongation. The knowledge of the different applications of suture materials tested in important practical functions, is the supposition to the right and secure use of suture materials.

[Comparison of the physical parameters and handling properties of short-duration and middle-duration absorbable suture materials]. / Vergleich von physikalischen Parametern und Handhabungseigenschaften kurzfristig und mittelfristig absorbierbarer Nahtmaterialien.

In recent years the structure and coating of rapidly absorbable suture materials (RAS) have been changed: Dexon S----Dexon plus, Vicryl III----Vicryl IV. Medium fast absorbable sutures (MAS) have been introduced: Maxon and PDS. Being important clinical parameters, the knotting qualities were investigated, for instance knot holding capacity in dry and in NaCl or blood incubated sutures. The newest generations of RAS require more complicated configurations of knots than the initial products. After incubation in blood the knotting qualities improved only with Dexon plus.

[Nutrition physiologic, immunologic and clinical parameters in prospective randomized patients by enteral or parenteral nutrition therapy following large intestine operations]. / Ernährungsphysiologische, immunologische und klinische Parameter bei prospektiv randomisierten Patienten unter enteraler oder parenteraler Ernährungstherapie nach Dickdarmoperationen.

In a prospectively randomized study with 60 patients differences between enteral and parenteral nutrition were investigated especially with regard to short living proteins, immunoglobulins and clinical complications. Prealbumine as well as fibronectin and transferrin increased faster in enteral nourished patients postoperatively than in the parenterally nourished group. With this observation a reduced weight loss correlates in the enterally nourished group. From the immunoglobulins only IgM was significantly increased after enteral nutrition. An accumulation of postoperative infections seems to be in context with a delayed increase of IgM in the parenteral nourished group.

[Pathophysiologic aspects, progressive and new developments in absorbable fully synthetic suture materials]. / Pathophysiologische Aspekte, Weiter- und Neuentwicklungen der absorbierbaren vollsynthetischen Nahtmaterialien.

Polyglycolic acid (PGA) sutures and Polyglactin-910 sutures show only minimal tissue reaction, nearly no scar formation and no immunological reactions. PGA sutures of the third generation have the same advantages, but surgical handling is to much improved that they may be technically employed in unfavourable locations, e.g. gastrointestinal tract and respiratory organs. PGA sutures of the third generation and the new monofil Polydioxanon suture need special knot techniques.

[Second generation of absorbable suture material. Tissue reaction and indication (author's transl)]. / Absorbierbare Nahtmaterialien der 2. Generation. Gewebeverhalten und erweiterte Indikationen.

Polyglycolic acid (PGA) sutures have proved to be superior than other, nonabsorbable suture materials: a higher traction capacity and knot-tearing security, a defined and nearly linear decrease of traction capacity, no immunological reactions, very little capillarity, minimal tissue reaction, nearly no scar formation, and a bactericidal effect. PGA sutures of the second generation have the same advantages, but surgical handling is so much improved that they may be technically employed in unfavorable locations. In the surgery of gastrointestinal tract and respiratory organs there is a trend to connect all layers with one suture.

[In vivo studies on the tensile strength loss of absorbable synthetic threads]. / Untersuchungen in vivo zum linearen Reissfestigkeitsverlust von absorbierbaren vollsynthetischen Fäden.

In a total of eight experimental groups, PGS, PGS-S, PGS-C, and polyglactin 910 sutures were implanted subcutaneously in rats. The sutures were either sterile or contaminated with staphylococcus. They were removed after 7, 14, 21, and in two groups after 28 days. The linear loss of tensile strength was tested by means of an electronic tensile strength measuring machine. In four additional groups, the same studies were carried out with paraffinized PGS sutures and in localizations in stomach, duodenum and colon. The diameter of the filament has an effect on the loss of tensile strength: initially more rapid in fine filaments and later, retarded in comparison to thicker filaments. Coating of the suture has almost no influence on tensile strength, although contaminated sutures show a comparative decrease. In intraenteral localizations, loss of tensile strength can be expected to occur much more rapidly than in subcutaneous ones. Paraffinization does not delay decrease in tensile strength. Polyglactin 910 sutures of the second generation employed subcutaneously, show a much higher loss of tensile strength on the day 7 than PGS sutures; by day 28 the relationship is reversed.

[Controlled experimental histological and microbiological studies on the inhibitory effect of polyglycolic acid sutures in infections]. / Kontrollierte experimentelle histologische und mikrobiologische Untersuchungen zur Hemmwirkung von Polyglycolsäurefäden bei Infektionen.

In the first experimental series, 3-0 PGS sutures which had been contaminated with staphylococcus aureus were situated in rat muscle in vivo. After periods of 20, 30, 40, 50, and 60 days, these sutures were removed and investigated histologically. After 20 days, the tissue surrounding the suture surface was much inflamed, showing inflammation cells and bacteriae, whereas after 60 days no signs of inflammation were to be seen. By hydrolysis of the PGS thread to the monomere glycolic acid, a bacteriostatic and bactericidal milieu seems to develop. In the second experimental series, purely in vitro, the fungicidal and bactericidal properties of glycolic acid were proved microbiologically. Furthermore, in two investigations PGS did not show fungicidal or bactericidal properties. When using PGS sutures, inhibition of the growth of fungi and bacteriae is based on the hydrolysis of PGS to glycolic acid.

[In vivo investigations on suture reactions under sterile and not sterile conditions. Comparison of absorbable and nonabsorbable suture materials (author's transl)]. / In-vivo-Untersuchungen bei Nahtreaktionen an sterilen und infizierten absorbierbaren und nicht absorbierbaren chirurgischen Nahtmaterialien.

Suture materials from plant and animal substances are increasingly being replaced by synthetics. Among the nonabsorbable materials, synthetics are much superior regarding infection, threading and knot strength. A coating can improve management, which is currently more favourable with silk and cotton. Absorbable polyglycolic-acid sutures enable controlled reduction of thread breaking, but catgut sutures do not. Absorption is significantly accelerated by infections, while pH-fluctuation is less important. For infected tissue, monofile or pseudomonofile sutures are most suitable.