[Coma in the emergency room]. / Koma in der Notaufnahme.

Coma of unknown origin (CUO) is a frequent unspecific emergency symptom associated with a high mortality. A fast diagnostic work-up is essential given the wide spectrum of underlying diagnoses that are made up of approximately 50% primary central nervous system (CNS) pathologies and approximately 50% extracerebral, almost exclusively internal medical causes. Despite the high mortality associated with this symptom, there are currently no generally accepted management guidelines for adult patients presenting with CUO. We propose an interdisciplinary standard operating procedure (SOP) for patients with acute CUO as has been established in our maximum care hospital. The SOP is triggered by simple triage criteria that are sufficient to identify CUO patients before arrival in hospital. The in-hospital response team is led by a neurologist. Collaboration with nursing staff, internal medicine, anesthesiology, neurosurgery and trauma surgery is organized along structured pathways that include standardized laboratory tests, including cerebrospinal fluid (CSF), toxicology, computed tomography (CT) and CT angiography imaging (CTA). Our data suggest that neurologists and internists need to be placed at the beginning of the diagnostic work-up. Imaging should not just be carried out depending on the clinical syndrome because sensitivity, specificity and inter-rater reliability of the latter are not sufficient and because in many cases, multiple pathologies can be detected that could each explain CUO alone. Clinical examination, imaging and laboratory testing should be regarded as components of an integrative diagnostic approach and the final aetiological classification should only be made after the diagnostic work-up is complete.

FLAIR vascular hyperintensities in acute ICA and MCA infarction: a marker for mismatch and stroke severity?.

BACKGROUND: Vascular hyperintensities of brain-supplying arteries on stroke FLAIR MRI are common and represent slow flow or stasis. FLAIR vascular hyperintensities (FVH) are discussed as an independent marker for cerebral hypoperfusion, but the impact on infarct size and clinical outcome in acute stroke patients is controversial. This study evaluates the association of FVH with infarct morphology, clinical stroke severity and infarct growth in patients with symptomatic internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion. METHODS: MR images of 84 patients [median age 73 years (IQR 65-80), 56.0% male, median NIHSS 7 (IQR 3-13)] with acute stroke due to symptomatic ICA or MCA occlusion or stenosis were reviewed. Vessel occlusions were identified by MRA time of flight and graded with the TIMI score. Diffusion and perfusion deficit volumes on admission and FLAIR lesion volumes on discharge were assessed. The presence and number of FVH were evaluated according to MCA-ASPECT areas, and associations with MR volumes, morphology of infarction, recanalization status, presence of white matter disease and hemorrhagical transformation as well as with stroke severity (NIHSS), stroke etiology and thrombolysis rate were analyzed. RESULTS: FVH were detectable in 75 (89.3%) patients. The median number of FVH was 4 (IQR 2-7). Patients with FVH >4 presented with more severe strokes due to NIHSS (p = 0.021), had larger initial DWI lesions (p = 0.008), perfusion deficits (p = 0.001) and mismatch volumes/ratios (p = 0.005). The final infarct volume was larger (p = 0.005), and hemorrhagic transformation was more frequent (p = 0.029) in these patients. CONCLUSIONS: The presence of FVH indicates larger ischemic areas in brain parenchyma predominantly caused by proximal anterior circulation vessel occlusion. A high count of FVH might be a further surrogate marker for initial ischemic mismatch and stroke severity.

[Functional anatomy of the female pelvic floor: interdisciplinary continence and pelvic floor surgery]. / Funktionelle Anatomie des weiblichen Beckenbodens : Interdisziplinäre Kontinenz- und Beckenbodenchirurgie.

Knowledge of functional anatomy is a prerequisite for the safe and targeted reconstructive therapy of incontinence and the prolapse syndrome of the female pelvic floor. We illustrate the interaction of muscles and connective tissue of the pelvic floor with anatomical illustrations and demonstrate their impact on the function of the urethra, bladder, vagina, uterus and rectum. Examples for the therapeutic rationale for a surgical reconstruction of the pelvic floor are defined and justified from their functional anatomy.

[Chronic mesenteric ischemia with consecutive ischemic colitis. Suggestions for diagnosis and therapy]. / Chronische mesenteriale Ischämie mit konsekutiver ischämischer Kolonstenose. Vorschläge für diagnostisches und therapeutisches Vorgehen.

The incidence of acute mesenteric ischaemia has decreased over the last few years. However, cases of chronic mesenteric ischaemia have grown in number, as this disease is the most frequent disorder of the large intestine in the elderly. The typical clinical presentation of ischaemic colitis develops gradually and only becomes recognisable in the late stage of the disease. We present a 51-year-old woman with a history of unexplained abdominal pain. Multislice CT demonstrated an irregular stenosis of the truncus coeliacus and superior mesenteric artery. A Riolan's anastomosis was present and showed excellent perfusion. After a hemicolectomy 6 years previously, different radiologic procedures and endoscopy revealed a structural tumour at the colon transversum we suspected to be malignant. A sequential procedure was conducted. In a first vascular intervention, the truncus coeliacus was reconstructed with a vein patch, and the mesenteric superior artery was replanted. The second laparotomy was performed for revision of the superior mesenteric artery and resection of the intestinal tumour. However, no carcinoma was found in histological examination. In fact, the individual multidisciplinary considerations play an important role in determining the best treatment strategy, if intervention is warranted. Based on our experience, sequential intervention with a common clinical pathway is the safest and most suitable and economic procedure for curing complex pathologies.

[Primary gastric lymphoma]. / Primäre Magenlymphome.

Primary gastric lymphoma derives from a secondary MALT system developing after a reaction of the immune system, e.g. following chronic gastritis induced by Helicobacter pylori. Morphologically, follicular hyperplasia is found in the gastric mucosa. The pathoetiologic model confirms the transformation of a malignant lymphoma from low grade to high grade by demonstrating increasing autonomous proliferation and, finally, uncontrolled dissemination. Modern diagnostic tools are essential for staging and planning an adequate therapeutic strategy. At present, the therapeutic strategies regarding primary lymphoma are under discussion. Nevertheless, the consensus of international medical and surgical associations still recommends surgical therapy with curative intention for low-grade malignant lymphomas staged I 2-II 2. In cases of high-grade malignant lymphoma, conservative therapy is supposed to be similarly successful. The recent success of noninvasive therapeutic concepts seems to justify the application of triple eradication medication in case of Hp infection as well as radio- and chemotherapy in low- and high-grade malignant lymphomas. However, in cases of nonremission or therapy-associated complications such as uncontrollable bleeding or tumor perforation, surgery is the only therapeutic option. Regarding the oncological aspects of lymphoma growth, surgery should then be performed in order to achieve R0 resection.

Two large liver abscesses complicating Crohn's disease.

A 20-year-old woman with active Crohn's disease had an abrupt onset of high fever accompanied by an elevation of serum gamma-glutamyltransferase and alkaline phosphatase. Her past medical history included a course of corticosteroid therapy for 7.5 months and a resection of the terminal ileum and the cecum 2 months before admission. At that time an ileoascendostomy had been performed, revealing a walled-off perforation of the colon into the retroperitoneal space. Sonography revealed 2 large abscesses in the right lobe of the liver. After beginning antibiotics, ultrasound-guided percutaneous aspiration and drainage with a pigtail catheter were performed for both abscesses leading to a rapid reduction of their size and an improvement in the patients general condition. Liver abscess represents a rare complication of Crohn's disease. A review of the literature is presented.

["Field cancerization"--an additional phenomenon in development of colon tumors? K-ras codon 12 mutations in normal colonic mucosa of patients with colorectal neoplasms]. / "Field cancerization"--ein zusätzliches Phänomen in der Entwicklung von Colontumoren? K-ras-Codon-12-Mutationen in normaler Colonmucosa von Patienten mit colorectalen Neoplasien.

INTRODUCTION: The c-K-ras2-gene (K-ras) encodes the p21ras protein, which participates in the transduction of mitogenic signals from the cell surface to the nucleus. About 40-50% of colorectal cancers bear a point mutation of the K-ras codon 12 within exon I, leading to activation of the K-ras oncogene. METHODS: Using a polymerase chain reaction (PCR)-based two-step restriction fragment length polymorphism (2sRFLP)-technique, we assessed the frequency of point mutations in the first or second base of K-ras codon 12 in patients suffering from colorectal carcinoma, adenoma, and their normal colon mucosa, respectively. RESULTS: Similar to other investigators, we found mutations in 7 out of 17 (41%) colorectal carcinomas and 1 out of 4 (25%) adenomas. Using this very sensitive 2sRFLP technique (detection level = 0.2% of mutated cells), we were able to find K-ras codon 12 mutations in normal mucosa in 4 out of 18 (22.2%) patients with colorectal neoplasia. CONCLUSIONS: This result can be explained by the phenomenon of "field cancerization" or by a local micrometastasis of K-ras-positive tumor cells.

[Current therapeutic strategy in primary intestinal non-Hodgkin's lymphoma]. / Aktuelle therapeutische Strategie des primären Intestinalen Non-Hodgkin-Lymphoms.

Of all surgical interventions of intestinal non-Hodgkin's lymphomas 58% (15 or 26 patients) are performed in an emergency situation. In 42% of cases, examination by ultrasonography, endosonography, intestinoscopy. Sellink's enema, thoracic, abdominal/pelvic CT and bone marrow puncture could determine the stage preoperatively. This could also be done by examining the regional and juxtaregional lymph nodes or performing a liver biopsy intraoperatively. Crucial for the therapy is in all cases the adequate staging even in emergency situations. Only special knowledge of the intestinal non-Hodgkin's lymphoma can lead to the necessary stage-adapted multimodal therapy--operation/irradiation/chemotherapy.

[Perspectives of virtual control of visceral surgery interventions in open MRI]. / Perspektiven der virtuellen Kontrolle viszeralchirurgischer Eingriffe im offenen MRT.

Since July 1997 we have operated on 23 patients with different visceral surgical diagnoses in an open-configured Magnetic Resonance System (MRI). Among them we found 7 patients with benign soft tissue tumors, 5 patients with anal fistulas, 1 patient with an abscess on the pelvic wall, 1 patient with a rectocele, 1 patient with an inoperable, restrictive oesophageal carcinoma, and 8 patients with metastatic lesions in the liver. In the last 8 patients we performed MRI-guided laser-induced interstitial thermotherapy, in one patient in an open development. We did not face any postoperative complications. The median duration of the intervention was 2 hours, pre- and postscans included. Our experiences show that it is possible to carry out visceral surgical interventions in the open-configured MRI. The main indications we see now are anal fistulas, soft tissue tumors and MRI-guided laser-induced interstitial thermotherapy of liver metastases.

[Therapy planning and surgical indications for Crohn-associated anal fistulas]. / Therapieplanung und Operationsindikation Crohn-assoziierter Analfisteln.

A prospective study conducted from April 1988 to April 1998 in 83 patients with anal fistulas associated Crohn's diseases registers and evaluates data regarding the type of fistula, the planned therapy, the operative procedure, and the therapy itself. The choice of the operation time with special regard to the type of fistula and the presence of proctitis as well as the interdisciplinary management in cooperation with the gastroenterologist and the strict observance of the operative procedure for the different types of fistulas enable individually defined surgical treatment of anal fistulas associated with Crohn's disease. It is important that the primary intervention be performed by a surgeon who is experienced in classifying the different types of fistulas because of the recurrence rate of 23% and the required interval between the first and final surgical intervention and so that patients are well informed.

[Perioperative therapy of HIV infections]. / Perioperative Therapie bei HIV-Infektionen.

A meta-analysis of the literature demonstrates high operation complication rates in HIV-positive patients. Own experience connected with a general hospital in San Francisco, University of California, indicates that such an analysis provides the surgeon with the possibility of optimizing the treatment of HIV-positive patients in the perioperative phase.

How reproducible are measures of the anal sphincter muscle diameter by endoanal ultrasound?

UNLABELLED: Anal endosonography is an imaging technique for the anal sphincter system and offers analysis of its muscular integrity. It is generally assumed that measurement of the thickness of muscle layers is provided by sonography; however, reproducibility of such measurements have not yet been investigated. METHODS: Study 1: In 10 healthy volunteers, endoanal ultrasound was performed independently by two experienced investigators with two different ultrasound machines, and thickness of the muscle layers of the internal and external anal sphincter was assessed in the position of the intermediate dorsal anal canal in a randomized cross-over fashion. Study 2: In a study of similar design, sonography was performed in nine healthy volunteers by two investigators independently using a single ultrasound machine in three standardized positions (proximal/intermediate/distal anal canal) and the sphincter layers assessed in the left, right, and dorsal segment. RESULTS: Study 1: Both the same investigator with different ultrasound scanners and different investigators with the same machine failed to obtain reproducible results with respect to internal and external anal sphincter muscle layer diameter (four bivariate correlations, all with p > 0.05). Study 2: Standardization of the probe position did not improve the agreement (2 x 9 bivariate correlations, all but two p > 0.05). CONCLUSION: At present, therefore, endoanal ultrasound does not provide reliable morphometric data on anal sphincter muscle diameter. This could explain previously conflicting observations of associations between anal sphincter morphometry and function.

[Laparoscopic ileostomy and colostomy in Crohn disease patients]. / Laparoskopische Ileostomie und Colostomie bei Morbus-Crohn-Patienten.

The indications, operative procedure, postoperative complications and advantages of laparoscopic ileostomy and colostomy as compared with "open" enterostomy are described and demonstrated in our own patients with Crohn's disease. Major indications for laparoscopic enterostomy in patients with Crohn's disease are stenosis, fecal incontinence and complex anal fistulas in those with severe Crohn's proctitis. Most Crohn patients tolerate laparoscopic enterostomy and an increasing number demand this minimally invasive technique. The period of convalescence is much shorter and complications in connection with laparotomy are minimized.

[Sigmoid diverticulitis in immunosuppressive drug therapy]. / Sigmadiverticulitis unter medikamentöser Immunsuppression.

In a retrospective study we evaluated the data of 92 patients (41 women, 51 men, age median: 63 years) with diverticulitis of the sigma who were treated surgically in our clinic from January 1986 till December 1992. Twelve patients (13%) suffered from suppression of the immune system due to a corticoid therapy (n = 3), chemotherapy (n = 1), combination of corticoid therapy and chemotherapy (n = 1), combination of chemotherapy and azathioprine, leucopenia due to carbimazole therapy as a side effect (n = 1) and immunosuppression with prednisone, azathioprine and cyclosporine after renal and heart transplantations (n = 5). The therapy was Hartmann's procedure in 5 patients, drainage and loop colostomy in one patient, sigma resection with primary anastomosis without a protective enterostomy in 5 patients and with a loop ileostomy in one patient. One patient died in the early postoperative course. Sigma diverticulitis in immunosuppressed patients is a well-known problem especially in large clinics with organ transplantation units. In contrast to reports from up to the eighties we found no significant difference in the postoperative morbidity and mortality after surgical treatment of acute sigma diverticulitis in immunosuppressed patients compared to non immunosuppressed patients.

Treatment of anovaginal fistulas with an anocutaneous flap in patients with Crohn's disease.

We report on a new and simple operative technique for closure of anovaginal fistulas with an anocutaneous flap in patients with Crohn's disease. From January 1989 till December 1990 this operation was performed in 10 women with Crohn's disease. Seven of the ten patients suffered from Crohn's proctitis. In these patients a protective enterostomy was applied before the operative closure of the fistula. All fistulas healed primarily. Within a median follow up of 18 months (7-24 months) a relapse occurred in 3 patients; two of these were treated successfully with fibrin injection in one case and a further operative closure of the fistula using the same procedure in the second case. In the third patient a seton was placed into the recurrent fistula track, which is still present after 4 weeks.

Human intestinal diamine oxidase (DAO) activity in Crohn's disease: a new marker for disease assessment?

The key-enzyme for the metabolism of diamines in man is diamine oxidase (DAO). Its highest activities are in the intestinal mucosa, localized in the cytoplasm of the mature enterocytes of the small and large bowel. If the gut is affected by inflammation in Crohn's disease macroscopical changes are observed. This prospective study investigated if these mucosal alterations are also reflected in changes of mucosal diamine oxidase activity and/or mucosal histamine content respectively. Twenty patients (12 female, 8 male; age: means = 31, range 18-49 years) undergoing gut resection because of complications in Crohn's disease (Jan.-Dec. 1988) formed the basis of the study. Tissue samples of the resected material from areas inflamed and histologically not involved in the disease were investigated for diamine oxidase activities and histamine content. Diamine oxidase activities in the mucosa obtained from the macroscopically normal proximal (155.6; (76-393) mU/g (means, range)) and distal (132; (58.5-295) mU/g) resection margins were similar to our previous findings. In all patients, however, samples from the diseased mucosa had significantly (ca. 50%) lower diamine oxidase activities (74.5; (5-262) mU/g) compared to the healthy tissue. Similar differences were found in material obtained either from whole intestinal wall or from the mucosa. The determination of diamine oxidase activity constitutes possibly a more unambiguous and earlier parameter for assessing the extent of the inflamed area than histological disease presentations. Using biopsies the necessary extent of resection could be estimated before operation: this may influence operative strategies and help in the definition of the minimum amount of inflamed gut to be removed.