Prevention of anastomotic leak in rectal cancer surgery with local antibiotic decontamination: a prospective, randomized, double-blind, placebo-controlled single center trial.

PURPOSE: Anastomotic leak and other infectious complications are septic complications of rectal cancer surgery caused by bacteria. Data from registry analysis show a beneficial effect of local antimicrobial administration on anastomotic leaks, but data are inconsistent in recent clinical trials. Therefore, our aim was to study the efficacy of topical antibiotic treatment on the incidence of anastomotic leaks in rectal cancer surgery. METHODS: A prospective, randomized, double-blind and placebo-controlled, single center trial was conducted. Patients received either placebo and amphotericin B or decontamination with polymyxin B, tobramycin, vancomycin, and amphotericin B four times per day starting the day before surgery until postoperative day 7. If a protective ileostomy was created, a catheter was placed transanally and the medication was administered locally to the anastomotic site. All patients received an intravenous perioperative antibiotic prophylaxis. RESULTS: The trial had to be stopped for ethical reasons after first interim analysis with 80 patients instead of the initially planned 280 patients. Of the 40 patients randomized to receive placebo, eight (20%) developed anastomotic leak compared to only 2 (5%) in the treatment group of 40 patients (decontamination) with significant difference in the χ2 test (p = 0.0425). Twenty percent of the placebo group and 12.5% in the treatment group developed infectious complications not associated with anastomotic leak (p = 0.5312). One patient (2.5%) in the placebo group died (p = 0.3141). CONCLUSION: Local decontamination with polymyxin, tobramycin, vancomycin, and amphotericin B is safe and effective in the prevention of anastomotic leak in rectal cancer surgery.

[Inguinal hernia repair in TAPP technique in a day-case surgery setting - at what price?] / Ambulanter transabdomineller präperitonealer Leistenhernienverschluss (TAPP) ­ um welchen Preis?

BACKGROUND: TAPP surgery can be considered as a gold standard in inguinal hernia repair. Patients benefit of a faster reconvalescence and less pain compared to other techniques. TAPP surgery in Germany is performed in an in-patient setting routinely. However, according to European guidelines, inguinal hernia surgery should be considered as day-case surgery whenever possible. OBJECTIVES: The safety of day-case surgery was examined in relation to postoperative pain, complications, comorbidities, recurrent inguinal hernia and bilateral procedures. MATERIAL AND METHODS: In a retrospective, monocentric study we analyzed 522 elective inguinal hernia repairs using TAPP technique in a specialized hernia center. Supplemental data from Herniamed registry is analyzed. RESULTS: Parts of the procedures should be performed in an in-patient setting, whereas a much larger number of cases should be carried out as day-case surgeries. Logistic regression analyses show that "age", "bilateral procedures" and "comorbidities" affect the complication rate. "Age" and "recurrent inguinal hernia" are risk factors for an increased need for analgetic medication. Furthermore, we present an actual distribution of day-case vs. in-patient surgeries in inguinal hernia repair based on data from the Herniamed registry. CONCLUSION: A much larger part of procedures could safely be carried out as day-case surgeries. Based on a false incentive there is an incorrect steering in the German health system. These procedures cannot be carried out covering the costs as day-surgery cases. If there is no reevaluation of the proceeds of these procedures in a day-case surgery setting, the reasonable quality in treatment is compromised especially in inguinal hernia surgery.

[Use of biological meshes in abdominal wall reconstruction. Results of a survey in Germany]. / Einsatz biologischer Netze bei der Bauchdeckenrekonstruktion. Ergebnisse einer Umfrage in Deutschland.

BACKGROUND: Surgical treatment of incisional hernia includes implantation of a mesh. The use of synthetic grafts in contaminated fields results in an increased risk of infection. In these cases a potential advantage is described for biological repair material. Evidence for this problem is lacking; therefore, we initiated a survey among surgeons in Germany concerning this question. MATERIAL AND METHOD: A survey concerning indications, experience and techniques of using synthetic and biological meshes was sent to 60 surgical departments. The emphasis of the survey was on the differentiation of clean and contaminated fields. RESULTS: The survey was answered by 42 %. The use of biological repair material was preferred in clean-contaminated, contaminated and soiled fields. Synthetic meshes were preferred in clean, rarely in clean-contaminated and not in contaminated or soiled situations. Primary suture repair was chosen in clean fields and barely in contaminated fields. For closure of giant hernias a component separation technique (CST) was favored by the majority of respondents. A single stage repair was preferred by most of the surgeons even in cases with simultaneous stoma takedown. A total of 72 % of the respondents were satisfied with the use of biological repair material, but the reimbursement was considered to be inappropriate. DISCUSSION: Although the response rate was low, this survey gives an idea of the attitude towards the use of synthetic and biological meshes. Biological repair material is favored for hernia repair in contaminated or soiled fields. The advantage of this choice is a one stage repair despite the contamination. As the results of this survey are not able to provide arguments for the use of different meshes this question should be further investigated with a randomized controlled trial.

[Observations on the use of TachoSil® in cholecystectomy - a multicentre, prospective, single-arm cohort study]. / Anwendungsbeobachtung zu TachoSil® bei der Cholezystektomie - Eine multizentrische prospektive einarmige Kohortenstudie.

An observational study on TachoSil® as used in the gall bladder surgery and an analysis of the experience obtained by employing a haemostatic agent in one of the most common procedures in general and visceral surgery have been carried out. The aim of the study was to answer the following questions. When is TachoSil® in routine use? Does TachoSil® have a positive effect on the perioperative course? Is TachoSil® suitable for the routine application in difficult cholecystectomy? In the present single-arm prospective cohort study only departments with specialisation in general and visceral surgery of 40 clinics in Germany participated. Although 500 planned interventions were to be documented in 2007, only 169 operations were actually reported. The numerical results were statistically analysed and summarised. Before the operation was carried out a classification according to the bleeding history was performed. The surgery was performed in the open, laparoscopic or converted modes. During the intervention the surgeon decided about the application of TachoSil® on the basis of a risk index. According to the collected data, it was significant that TachoSil® was used more frequently when either a cholecystectomy was performed in the open mode or on conversion from laparoscopic to the open mode. Also it was significant that TachoSil® was chosen when a patient had a defect in blood coagulation or when the cholecystectomy was part of a multivisceral resection. 59.7% of the patients where TachoSil® was used had a known risk of haemorrage. 12.4 % of the patients where TachoSil was used underwent at least one intervention to compensate intraoperative blood loss before (10.1 % blood transfusion, 4.7 % blood substitutes). In 97 % TachoSil® was used as a haemostatic agent, in 30.2 % it was chosen to prevent a biliary leak and in 11.24 % to augment vulnerable tissue (multiple answers possible). Concerning laparoscopic cholecystectomy, it was significant that the surgeons decided to take middle-sized patches (4.8 × 4.8 cm) more frequently. Only in 6 cases were the small-sized patches (3 × 2.5 cm) chosen. 90.5 % of the patches were placed in the liver bed. In 5.3 % of the cases the position was not documented. In 4.1 % the patch was placed upon the hepatoduodenal ligament or a suture of the bile duct. To conclude, in difficult cholecystectomies and cholecystectomies as part of multivisceral resection, the use of TachoSil® is an option for experts to secure the seam, to prevent a bile leakage and to control bleeding in the surgical areas.

[Titanised polypropylene meshes: first clinical experience with the implantation in TAPP technique and the results of a survey in 22 German surgical departments]. / Titanisiertes Polypropylenenetz: erste klinische Beobachtungen nach Implantation in TAPP Technik und Ergebnisse einer Umfrage an 22 Chirurgischen Kliniken.

UNLABELLED: Titanised polypropylene meshes for the treatment of inguinal hernias are available since 2001. The reduced weight of the mesh, the increased size of the net meshes amounting to 1 mm, and the titan surface are supposed to improve the tissue compatibility and lower the risk of post implant mesh dislocation. AIM: It was the aim of the study to examine the characteristics of the mesh concerning the feasability for implantation in TAPP technique as well as the tolerability of titanised polypropylene meshes under short term observation. PATIENTS AND METHODS: 80 titanised polypropylene meshes were implanted in TAPP technique into patients with inguinal hernias. The operation, the clinical course and complications were prospectively documented including a median follow up of 2 months.A survey of 22 German surgical departments was carried out. In a period of 8.3 months each institution gained experience with a median of 83 titanised polypropylene meshes in the treatment of inguinal hernias. The characteristics of the departments, certain aspects of implantation technique and reported complications were evaluated. RESULTS: The median operation time amounted to 52 minutes. In 5 patients umbilical hernias were simultaneously repaired. In our own series in 2/3 (rd) of the cases the 35 g/m (2) and in 1/3 (rd) of the cases the 16 g/m (2) version of the mesh was used. 17 % of the meshes in our series were not fixed with staples. Only minor reversible complications occurred in our patient group. Mesh related major complications were observed neither in our patients nor in the patients of the departments we surveyed. None of our patients required analgesic medication. Postoperatively 89 % of the patients were highly satisfied with the operation. The heavier version of the mesh was used more often by surgeons of the other departments. Only in 3 departments both versions of the mesh were used regularly. The trend to use less or no staples at all could also be observed at the other departments. CONCLUSION: The implantation of the titanised polypropylene meshes for the repair of inguinal hernia in TAPP technique is feasable. The intraoperative handling and the early clinical results are good. There were no major or mesh related complications or incompatibilities. Whether the rate of recurrence is comparable to conventional meshes and whether chronic pain syndromes can be reduced must be evaluated in long-term studies.

Rifampin and Triclosan but not silver is effective in preventing bacterial infection of vascular dacron graft material.

OBJECTIVES: To evaluate the efficacy of silver- or Triclosan-coated prosthetic material compared to Rifampin bonded Dacron concerning their resistance to infection following subcutaneous implantation and contamination with Staphylococcus aureus. DESIGN: Animal experimental study in mice. MATERIAL AND METHODS: Thirty-six C3H/HcN mice (Charles River Lab., Sulzfeld, Germany) with a weight between 24 and 27 g were randomised into six groups counting six animals each. Group I: control, gel-sealed dacron graft, group II: gel-sealed dacron graft and local contamination, group III: Intergard-Silver-prosthesis and contamination, group IV: silver/gel-sealed dacron prosthesis (test graft) and contamination, group V: Rifampin-bonded gel-sealed graft and contamination, group VI: Triclosan/collagen-coated dacron graft and contamination. Dacron graft material 0.8x1 cm was subcutaneously implanted in mice. Local contamination with 2x10(7)/0.2 ml S. aureus ATCC 25923 was carried out in groups II to VI. On day 14 the animals were killed and the grafts were explanted. The microscopic, histologic and microbiological evaluation of the graft material and the perigraft tissue was performed. RESULTS: In control group I no case of infection was detected. In group II, 6 of 6 animals showed infection. In group III (Intergard-Silver) and group IV (silver/gel-test graft) were 6 of 6, in group V (Rifampin) only 1 of 6 grafts and in group VI (Triclosan) 4 of 6 grafts were infected. The difference between the low rate of infection in group V (Rifampin) in comparison to the completely infected groups III and IV (Silver) as well as the control group II was significant. Treatment of grafts with Triclosan could prevent infection only in 1/3 of the cases in group IV. CONCLUSION: Silver coating failed to prevent graft infection material. A potential antimicrobial property was evident for Triclosan whereas Rifampin-bonded grafts exhibit a significantly reduced infection rate. Thus, silver-coated vascular grafts cannot ensure protection from vascular graft infection.

[Experimental examination concerning the efficacy of silver-coated Dacron prostheses in vascular graft infections following subcutaneous implantation in a standardized infection model]. / Experimentelle Unterschung der Effizienz von silberbeschichteten Gefäss-Dacronprothesen nach subcutaner Implantation im standardisierten in vivo-Infektionsmodell.

UNLABELLED: It was the aim of the study to examine the efficacy of silver coated prostheses in comparison to Rifampin in impregnated prostheses in the prevention of vascular graft infections. MATERIAL AND METHODS: 24 C3H/HcN mice with a bodyweight between 24 and 27 grams were assigned to four different groups. GROUP I: control gel-sealed Dacron graft (Uni-Graft DV) (6), GROUP II: gel-sealed Dacron graft (Uni-Graft DV) contaminated locally with 2 x 10(7) CFU/1.2 ml Staphylococcus aureus ATCC 25923 (6), GROUP III: silver prosthesis (Intergard Silver) contaminated locally with 2 x 10(7) CFU/0.2 ml Staphylococcus aureus ATCC 25923 (6), GROUP IV: Rifampin impregnated prosthesis contaminated locally with 2 x 10(7) CFU/0.2 ml Staphylococcus aureus ATCC 25923 (6). 14 days after primary operation all animals were euthanized and the grafts harvested. Specimens were examined for signs of infections by histology and microbiology. RESULTS: At termination of the trial on day 14 none of the grafts of group I were contaminated. 6 out of 6 grafts in group II, 6 out of 6 grafts in group III and 1 out of 6 grafts in group IV presented with infected grafts. The use of antimicrobial Rifampin could significantly prevent infection after bacterial challenge in group IV. CONCLUSION: The silver protected prosthesis (Intergard Silver) seems to be not effective in protecting vascular infection in vivo. However, the Rifampin group showed excellent results. In conclusion Rifampin bonded gelatin-sealed Dacron grafts are significantly more resistant to bacteremic infection than are silver/collagen-coated Dacron grafts.

[Experimental study of antiseptic (tauroline, taurolidine) and antibiotic (sulmycin implant) drugs in vascular prosthesis infections in a standardized infection model]. / Experimentelle Untersuchung antiseptischer (Taurolin, Taurolidin) und antibiotischer (Sulmycin -Implant) Substanzen bei Gefässprotheseninfektionen im standardisierten Infektionsmodell.

UNLABELLED: It was the aim to examine whether local application of antiseptic and antibiotic substances is an effective treatment of vascular graft infection. MATERIAL AND METHODS: 19 pigs with a bodyweight between 20 and 30 kg were assigned to three different groups. Group I: control (6), group II: local treatment with Sulmycin implant, group (6) III: local treatment with Taurolin (Taurolidine) (7). An unprotected vascular graft was inserted in the right femoral artery of all pigs. After finishing the proximal and distal anastomosis and prior to closure of the incision, the vascular grafts were contaminated locally with 2 x 10(7) CFU/ml Staphylococcus aureus ATCC 29213. Seven days later all animals received another unprotected vascular prosthesis with or without additional treatment according to groups I, II, III. 28 days after primary operation the animals were euthanized and the grafts harvested. The specimens were examined for signs of infection by histology and microbiology. RESULTS: After the primary operation all animals presented with infected vascular prosthesis. At termination of the trial on day 28 all grafts of group I were contaminated, 5 out of 6 grafts in group II, and 5 out of 7 in group III presented with infected grafts. There was no significant statistical difference between the groups. Infection could not be prevented by the antimicrobial agents used. The primary infecting organism Staphylococcus aureus, however, was eliminated in all cases. CONCLUSIONS: Both antimicrobial substances examined were not effective in the treatment of vascular graft infection, but might be used as adjuvant therapy of vascular graft infection, whereby Sulmycin implant seems to be more effective regarding the incorporation of the prosthesis.

The prevention and treatment of vascular graft infection with a Triclosan (Irgasan)-bonded Dacron graft: an experimental study in the pig.

OBJECTIVES: to evaluate the role of Triclosan (Irgasan(R)) in the prevention of prosthetic graft infection. MATERIAL AND METHODS: fifty-one pigs were assigned randomly to six groups. Group I (graft) and II (graft and Triclosan) were control groups. Groups III (graft) and IV (grafts and Triclosan) were contaminated with 2 x 10(7)CFU/ml S. aureus. Groups V (graft) and VI (graft and Triclosan) were intraoperatively contaminated with 2 x 10(7)CFU/ml S. aureus and reoperated on after 7 days. Remaining animals were sacrificed on day 28. The end point of the investigation was vascular graft infection, defined as the bacteriological and/or histological proof of infection. Results in both control groups no vascular graft infections were detected in Groups I and II. All of the group III animals presented but none of the group IV developed a graft infection (p <0.02). All of the group V animals presented and 10 of 12 animals developed a graft infection. CONCLUSION: in this animal model Triclosan bonding appears effective in preventing prosthetic graft infection. However, the in situ replacement of Triclosan-protected grafts was not successful in the treatment of graft infection.

The femoral hernia: an ideal approach for the transabdominal preperitoneal technique (TAPP).

BACKGROUND: We designed a study to determine the rate of intra- and postoperative complications as well as the rate of recurrences in elective operated femoral hernias treated via the laparoscopic technique. METHODS: Between 1993 and 1998, we performed 1,097 operations in our department using the laparoscopic transabdominal preperitoneal (TAPP) technique. Femoral hernias amounted to only 4.6% (51 cases) of these patients. The male/female ratio was 1:2. The data concerning the operations and pre- and postoperative treatment were recorded prospectively. The patients were followed up at 2 weeks and 1 year after the operation. RESULTS: We encountered one intraoperative bladder lesion, one subcutaneous port site infection, two postoperative hematomas that required reoperation, and two nerve irritation syndromes, which disappeared spontaneously after 6 months. Two patients developed an ileus; one required laparoscopic reintervention, and the other was treated with conventional open reoperation and intestinal resection. There were no recurrences. CONCLUSIONS: The application of the laparoscopic approach to the treatment of femoral hernias using the TAPP technique in nonemergency situations is highly effective. To date, we have seen no recurrences. Although the rate of major complications is low, current surgical techniques need to be perfected to avoid the type of complication recognized in this study.

Binding kinetics of triclosan (Irgasan) to alloplastic vascular grafts: an in vitro study.

The aim of this study was to investigate the binding kinetics of triclosan (Irgasan) to alloplastic vascular grafts and to examine its antimicrobial activity against various microbial pathogens in vitro. Vascular grafts made by Intergard (Intervascular), Fluoropassiv (Vascutek), and Gore-tex (Gore) were examined. Grafts were incubated in 10 g/L triclosan (Irgasan), dried, sterilized, and incubated in RPMI medium. One-centimeter segments of the grafts were resected under sterile conditions at intervals of minutes, then hours, followed by days and up to 4 weeks. Samples were stored frozen at -20 degrees C for the measurement of triclosan bound to the vascular graft by high-performance liquid chromatography (HPLC). The binding kinetics under perfusion conditions were determined for Intergard grafts, which were perfused with 50 mL of nutrient medium for 24 hr. Samples were taken at various time intervals for the measurement of triclosan. The antimicrobial activity of triclosan against Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans as well as Enterococcus faecium was determined. Triclosan effectively binds to vascular graft without the use of intermediate binding substances. It stayed on the graft for the duration of 4 weeks. Under both static and perfusion conditions, the binding kinetics are similar. Triclosan binds most effectively to Intergard grafts, less so to Fluoropassiv grafts, and not at all to Gore-tex material. Antimicrobial activity of triclosan is very effective against S. aureus and E. faecium but not against P. aeruginosa.

[Experience with the transabdominal preperitoneal (TAPP) technique regarding recurrent hernia]. / Erfahrungen mit der laparoskopischen transabdominellen präperitonealen (TAPP) Technik bei Versorgung von "Rezidiv-Leisten-Hernien".

INTRODUCTION: It was our aim to evaluate the results of laparoscopic transabdominal preperitoneal hernia repair (TAPP) with regard to recurrent hernias treated in our department. METHODS: Included were 276 operations for first or subsequent recurrence of inguinal hernia previously treated with suture repair. All final repairs were carried out using the TAPP technique. The data were collected prospectively. The patients were examined 2 weeks and 1 year postoperatively. The rate of follow-up amounted to 78.1 % at 1 year after operation. RESULTS: Perioperative complications were monitored prospectively and divided into intraoperative, minor and major. The overall complication rate amounted to 9 %, major complications 5.3 %. The re-recurrence rate was 0.4 %. CONCLUSIONS: Because of the general advantages of laparoscopic surgery and the low recurrence rate we prefer laparoscopic hernioplasty using the TAPP technique.

[Transabdominal preperitoneal hernia repair (TAPP). Results of 1,000 completed operations]. / Die transabdominelle präperitoneale Hernioplastik (TAPP). Ergebnisse nach 1000 durchgeführten Operationen.

It was the aim of this report to evaluate the laparoscopic transabdominal preperitoneal hernia repair (TAPP) which has been standardized at our department. Along with the demographic characterisation of 795 patients with 1000 inguinal hernia repairs we report about complications and early recurrences. The patient data were collected prospectively. The rate of follow-up amounted to 79.9% with an average follow-up of 1 year. The complications were divided into intraoperative, minor, major, as well as severe ones. In 30 repairs minor complications (3%) were detected. Major (n = 28) and severe (n = 9) complications were detected in 3.7% of the cases. There were two deaths, 3 patients with an intestinal obstruction due to adhesions (2 segmental small bowel resections), two patients with testicular atrophy, two mesh infections, two trocar hernias, 6 surgical revisions for removal of hematomas, one exploration of a testicle, 4 diagnostic laparoscopies for suspected recurrences with a negative result, and 15 patients with a nerve irritation syndrome. The early rate of recurrence was 0.7%. In 6 cases primary hernias had been repaired and in one case a recurrent hernia. The recurrent hernias became apparent in an average of 2 years (minimum 2.5 months, maximum 36 months) after surgery. The results of the clinical study demonstrate an acceptable rate of complications and a low rate of early recurrences. Based on these data we recommend the laparoscopic transabdominal preperitoneal technique and see an ideal indication in the case of bilateral, recurrent and femoral hernias.

[General infection prevention in abdominal surgery with special reference to intestinal decontamination]. / Allgemeine Infektionsprophylaxe in der Abdominalchirurgie unter besonderer Berücksichtigung der intestinalen Dekontamination.

In surgery prophylaxis for infection is necessary, because patients are immunocompromised due to the underlying disease and the operation while at the same time being increasingly exposed to potentially pathogenic germs. Prophylaxis is based on the control of endogenous and exogenous microorganisms. For this purpose either systemic or locally active topical agents may be employed. Systemically active substances are applied with the aim to kill and eliminate invasive microorganisms in deep tissue levels, either by their own biological activity or by stimulating specific or unspecific host immune reactions. Local topical measures in contrast are to prevent the primary contact between microorganisms and host. The central pillar of systemic measures is the perioperative systemic antibiotic prophylaxis, immunonutrition is beginning to gain importance, and in the future possibly substances such as G-CSF, which directly stimulate the immune system, may be employed. Standard topical measures are sterilization and desinfection while decontamination of the digestive tract has until now not found a wide spread acceptance. For certain indications especially high risk surgical resections with anastomoses at the level of the oesophagus or the lower rectum it is possible to eliminate endogenous intestinal microorganisms effectively using topical decontamination in combination with systemic antibiotics and improve the surgical results, especially anastomotic healing.

[The Janeway laparoscopic gastrostomy in palliative surgery]. / Die laparoskopische Gastrostomie nach Janeway in der palliativen Chirurgie.

For the creation of a gastrostomy percutaneous endoscopic technique should be the method of first choice. If impossible a laparoscopic procedure should be preferred to a conventional one. Laparoscopic Janeway-gastrostomy might have some advantages compared to Kader-Stamm-Fistulas. We present the results with this method which we have used since 1993 in 12 patients. The postoperative course of these patients with mainly malignant diseases of ENT (n = 4), esophagus (n = 3) and thyroid gland (n = 3) as well as two non-malignant underlying diseases is presented and discussed in the light of recent publications. The Janeway-gastrostomy is an effective, easily feasable and safe procedure that ensures a good palliation also due to easy handling and care.

Alleles of the alpha-1-antitrypsin phenotype in patients with aortic aneurysms.

OBJECTIVE: To examine the possible significance of homo- or heterozygous alpha-1-antitrypsin deficiency in the pathogenesis of aortic aneurysms (AA). DESIGN: Prospective investigation. SETTING: University hospital. PATIENTS: 300 controls representing the general population in our region of Southern Germany and 126 patients with aneurysmectomy and graft insertion. METHODS: The alpha-1-antitrypsin phenotype was determined by employing isoelectric focusing. Each patient was also evaluated for hypertension, lipometabolic dysfunction, smoking, hyperuricemia, and diabetes mellitus. MAIN OUTCOME MEASURES: The frequency and distribution of alpha-1-antitrypsin phenotypes and risk factors. RESULTS: 115 of 126 patients presented with one or several of the conventional risk factors: hypertension (61.5%), lipometabolic dysfunction (36.9%), smoking (58.4%), hyperuricemia (13.8%), or diabetes mellitus (6.9%). The following frequencies of alpha-1-antitrypsin phenotypes were determined: PiMM (82.5%), PiMV (4.7%), PiML (1.5%), PiMS (7.1%), PiSS (0.7%), PiMZ (3.0%). Indeed, when compared to the general population (control group) the percentage of the normal PiMM phenotypes was lower in the group of patients with AA (p<0.001). However, in our study this significant difference was not primarily due to the presence of patients homozygous or heterozygous for deficiency alleles PiMS, PiSS and PiMZ (p=0.0523) as has been previously reported, but rather to the high prevalence of the variants PiMV (p<0.005). CONCLUSIONS: Our study suggests that not only Pi-deficiency alleles, previously identified as being associated with AA, but also that Pi variants may play a pivotal role in the pathogenesis of AA.

[Risk factors and pathogenic microorganisms in patients with insufficient esophagojejunostomy after gastrectomy]. / Risikofaktoren und pathogene Mikroorganismen bei Patienten mit insuffizienter Osophago-Jejunostomie nach Gastrektomie.

UNLABELLED: It was the aim of the study to find by retrospective analysis of data from totally gastrectomized patients risk factors for the development of esophago-jejunal anastomotic leakage, that may be avoidable or influenced therapeutically. PATIENTS AND METHODS: The study design was retrospective involving 838 patients with total gastrectomy for gastric cancer from the years 1973-1993. In 134 cases leakage of the esophago-jejunostomy occurred. The relative risk for the development of leakage associated with individual parameters was determined by comparing the data from 704 patients without leakage to the data from 134 patients presenting with this complication. For a subgroup of 86 patients with anastomotic leakage microbiological data of swabs taken from the anastomoses were available, which were evaluated with respect to potentially pathogenic bacilli. RESULTS: The overall leakage rate of esophago-jejunal anastomoses was 15.9% (n = 134). The mortality rate during this time period amounted to 14.3%. Leakage was a most highly significant factor for mortality (p = 0.0001). Significant risk factors for leakage of the esophago-jejunostomy were tumors of the cardia, splenectomy, a duration of operating time of more than 5 hours and manual suture technique compared to stapler anastomoses. Tumor unrelated associated disease, tumor stage and a history of other preexisting gastric diseases were not associated with an increased relative risk. At the time of the initial clinical manifestation of leakage the following pathogenic bacilli could be isolated from leaking anastomoses with decreasing incidence: E. coli, S. aureus, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella pneumoniae a.o. The bacterial spectrum has not changed during the observation period of 20 years. SUMMARY: With the exception of the choice of suture techniques the identified clinical risk factors cannot be avoided or influenced therapeutically due to a lack of potentially curative treatment alternatives. In contrast potentially pathogenic bacilli associated with leakage can be prevented from coming in contact with anastomoses thereby preventing infection and leakage.

[Laparoscopic splenectomy--surgical and hematological results in the first 35 consecutive patients]. / Laparoskopische Splenektomie--operative und hämatologische Resultate bei den ersten 35 konsekutiven Patienten.

UNLABELLED: Aim of the present study: Laparoscopy offers a novel surgical approach for splenectomy. This prospective study with 35 patients requiring splenectomy examines the surgical and hematologic as well as oncologic safety of this procedure. METHODS: In 35 patients (16 male, 19 female) hematologic, surgical and clinical data were obtained prospectively to evaluate the surgical and hematologic as well as oncologic safety of laparoscopic splenectomy. Long-term follow-up data are available for 23 patients at a median of 17 months postoperatively. RESULTS: Mean operation time was 130.0 +/- 8.5 minutes and despite of blood loss > or = 1000 ml (n = 5) no significant intraoperative complications were observed. Mean blood loss was 460.0 +/- 69.2 ml and blood transfusions were necessary in 3 cases (8.6%; 1 x autologous blood). Mean organ weight was 270.5 +/- 34.7 g. Mean hospital stay postoperatively was 4.3 +/- 0.3 days and 2 revisions were necessary (5.7%). A significant rise in platelet count from 114.8 +/- 14.6 G/l to 235.0 +/- 23.6 G/l was observed postoperatively which could be confirmed in long-term follow-up (213.4 +/- 32.0 G/l; p < 0.05). Thrombocytopenic patients also showed this significant rise in platelet count. The initially significant fall in hemoglobin from 13.5 +/- 0.4 g/dl to 10.9 +/- 0.3 g/dl returned to 14.0 +/- 0.4 g/dl at follow-up. Anemic patients showed a significant rise of hemoglobin at follow-up evaluation (p < 0.05). In this series of 35 consecutive patients to conversion was necessary, no mortality was observed, perioperative morbidity was 2.9% and hematologic success could be achieved in 20 (85.7%) patients available for follow-up evaluation. CONCLUSIONS: Laparoscopic splenectomy is a safe and successful surgical procedure in patients requiring splenectomy for benign hematologic diseases. This approach offers the advantages of minimal invasive surgery and should be considered in all patients requiring splenectomy.