Exocrine pancreatic function after recovery from necrotizing pancreatitis.

The aim of the present study was to investigate the exocrine pancreatic function after recovery from necrotizing pancreatitis. The exocrine function was analysed in 53 patients who had recovered from their first attack of necrotizing pancreatitis. In a group of 23 patients (Group A), three follow-up studies were performed between four weeks and 12 months after recovery from acute pancreatitis. A second group of 30 patients (Group B) was submitted to only one function test 18 months after recovery from acute necrotizing pancreatitis. Exocrine pancreatic function was observed after endogenous stimulation using the Lundh test meal. In Group A, after four weeks 74% of the patients had mild-to-moderate insufficiency, while 26% suffered from severe impairment of pancreatic function. Twelve months after recovery, only 16% of the patients showed a normal pancreatic response, while 84% still had pancreatic insufficiency of variable severity. In Group B, 13% of the patients showed a normal pancreatic response, while mild-to-moderate insufficiency was observed in 81%. Severe pancreatic insufficiency was measured only in 6% of these patients. After recovery from necrotizing pancreatitis persistent global or dissociated functional insufficiency is found in 80-85% of the cases. Individual pancreatic enzyme secretion varies quiet considerably during the course of recovery in the follow-up period.

Dumb-bell ganglioneuroma of the spine misinterpreted as progressive idiopathic scoliosis. Case report.

A giant ganglioneuroma generating a progressive scoliosis in a 16-year-old girl is presented. The interval between the start of the orthopaedic treatment and the diagnosis of the true nature of the disease was more than 4 years, thus allowing the development of a giant partly intracanalicularly partly retroperitonealy expanding tumor mass. The report emphasizes and describes the combined neurosurgical, general surgical and orthopaedic surgical treatment and presents the results of light- and electron microsopical, immunohistochemical and quantitative neurochemical investigations of the resected tumor.

[Segmental colonic stenosis in intestinal metastasis of breast carcinoma. A contribution to the differential diagnosis of colitis]. / Segmentale Kolonstenosen bei intestinal metastasierendem Mammakarzinom. Ein Beitrag zur Differentialdiagnose der Kolitis.

Four years after mastectomy for a scirrhous carcinoma a 71-year-old woman developed diarrhoea. Crohn's disease was suspected. At endoscopy a stenosis of the sigmoid colon was found which could not be passed: the mucosa was normal looking. Gastrointestinal radiography revealed segmental subtotal stenoses of the colon with linitis plastica, typical for tumour-caused infiltration, as well as indentations in the small intestine by mesenteric metastases. The diagnosis was confirmed by computed tomography and, finally, operation. Chemotherapy failed to produce any regression of the colon stenoses, and the patient died from mechanical ileus. In case of a similar history and colon stenoses of uncertain aetiology the possibility of intestinal metastases should be considered in the differential diagnosis.

[Ultrasonics in acute appendicitis. A prospective study]. / Sonographie bei akuter Appendizitis. Eine prospektive Studie.

In a prospective study 404 unselected patients suspected of having acute appendicitis were examined by ultrasound, the results being compared with the initial clinical findings. Acute appendicitis was established in 27.2%, confirmed by histology. The overall accuracy of ultrasonography in relation to the diagnosis of appendicitis was 95.5%, 95.1% when positive, 95.7% when negative. An acutely inflamed appendix could not be demonstrated by ultrasound in 13 patients (sensitivity 88.2%), while in five there was a false-positive ultrasound result (specificity 98.3%). Complicated appendicitis with perforation occurred in 22 patients (20%): ultrasound sensitivity in this situation was 91%. Especially when the clinical picture was unclear (34.5% of all cases of appendicitis) a definitive diagnosis of acute appendicitis was made both earlier and more certainly by ultrasonography. Further-more, in many instances ultrasound was able to demonstrate other serious disease in the differential diagnosis from acute appendicitis. Negative laparotomy rate was lowered from 21.9% to 11.4% by taking into account ultrasonographic findings. Thus ultrasonography proved to be an important method as an imaging technique and in the differential diagnosis of acute appendicitis.

Apoprotein AII in acute pancreatitis: intriguing improvement in the prediction of fatal outcome.

In spite of significant advances in the past decade, assessing of severe prognosis in acute pancreatitis remains an improvable problem. Actually the standardized means are clinical, multiple laboratory and peritoneal lavage. In a series of 20 subsequent cases of acute pancreatitis with a lethality of 30%, apolipoprotein AII has proven to be a predictor of fatal outcome with a sensitivity in the range of all other methods together. Competitive replacement of Apo AII by serum amyloid like substance A as an indicator for the amount of necrosis would explain this relation. Whether this suggestion can be confirmed by ongoing work or not, apolipoprotein AII merits attention in this context.

Can the use of an endoscopic Congo red test decrease the incidence of incomplete proximal gastric vagotomy?

The endoscopic Congo red test allows accurate and rapid evaluation of the completeness of vagotomy and may result in a lower incidence of postoperative incomplete vagotomy. This report describes 44 patients tested during proximal gastric vagotomy. Evidence of incomplete vagotomy was found in over 95% at the conclusion of the conventional operation. Importantly, the test was a guide to further operative maneuvers which abolished the evidence of incomplete vagotomy upon subsequent testing. The endoscopic Congo red test satisfies the requirements for an ideal test for complete vagotomy: it is easily performed, does not require special equipment, and can be repeated several times if necessary to verify that desired effects have been achieved. The wider use of this test, therefore, appears justified.

Significance of histamine formation and release in the development of endotoxic shock: proof of current concepts by randomized controlled studies in rats.

The significance of histamine in the initiation and progression of septic (endotoxic) shock is still uncertain. Increased new formation and increased release of histamine are the two hypotheses currently considered as the basis for a causal relationship. Both hypotheses were tested in a standardized rat model of endotoxic shock. Several randomized controlled studies were performed with inhibitors of histamine formation (histidine decarboxylase inhibitors) and of its action via receptors (H1 and H2 receptor antagonists). Two inhibitors of histamine formation (alpha-methylhistidine and alpha-fluoromethylhistidine) in a wide range of doses exerted no significant effects on survival curves for rats in endotoxic shock, despite enzyme inhibition in vitro and in homogenates of liver obtained from rats immediately after death. In addition, three H1 and three H2 receptor antagonists, which were selected on the basis of markedly different antihistaminic efficacies and of defined non-antihistaminic (nonspecific) efficacies, gave no indications of specific histamine-mediated effects on survival parameters in these studies when tested either singly or in various combinations. Thus, histamine cannot be shown to be a predominant factor in the lethal outcome of endotoxic shock in rats.

[Mediators in septic shock: strategies of securing them and assessment of their causal significance]. / Mediatoren beim septischen Schock: Strategien zu ihrer Sicherung und zur Einschätzung ihrer kausalen Bedeutung.

More than 100 different mediators are discussed as being responsible for the progression of the septic shock syndrome. A new concept is described to establish the causal role of a single mediator by using a decision tree which excludes different non-causal associations (different kinds of bias and chance). By definition of several criteria and methodological standards, the published studies on mediator release/formation could be analysed and evaluated (meta-analysis). Furthermore, the classical concept of one cause--one disease (Koch-Dale) is extended to a concept of multiple determining factors. The role of a single mediator can be assessed quantitatively by notation of conditional probabilities in the presence of other causal factors. A mediator can be classified as a necessary, sufficient or contributory determinant in septic shock. Improved therapeutic concepts can be expected from this approach.

Experience with the endoscopic test for completeness of vagotomy. Results of application in two medical centers.

The need for a practicable and reliable test for completeness of vagotomy has been previously recognized. Until recently, all of the tests for completeness of vagotomy required cumbersome or delicate equipment or had deficiencies which prevented routine use. Recently we have modified the endoscopic Congo red test (ECRT) to allow more rapid and accurate performance; furthermore, we have found that the routine use of this test has affected the performance of proximal gastric vagotomy in our medical centers. At this time, we report the application of the ECRT in 41 patients at two medical centers, including patients from the University of Illinois at Chicago and the University of Marburg. The SIMPLIFIED ECRT, which is completed in less than five minutes, avoids the 15-20 minute delay required with other tests for complete vagotomy; it is the only test for complete vagotomy which can be performed intra- and postoperatively. To our knowledge, the test has not been performed previously in Europe. The similarity of results following ECRT in both settings reinforces our view that intraoperative testing affects the performance of vagotomy, and is useful in teaching aspects of operative vagotomy. The endoscopic test appears to be the test of choice for determining completeness of vagotomy.

[Ultrasound-guided fine-needle puncture in the diagnosis and therapy of liver and spleen abscesses]. / Ultraschall-geführte Feinnadelpunktionen in der Diagnostik und Therapie von Leber- und Milzabszessen.

A total of 41 diagnostic and therapeutic fine-needle aspiration punctures were performed under ultrasound control in 28 patients with solitary or multiple abscesses of liver (26) or spleen (2). Nonoperative measures (drainage-fine needle puncture, local and systemic antibiotics) cured 19 patients; in nine, primary surgical abscess drainage was performed. One operated patient with multiple liver abscesses died of generalized sepsis (mortality rate 3.6%). All 14 hepatic or splenic abscesses in which percutaneous fine-needle drainage was performed, including local and systemic antibiotic administration, were treated successfully. In two of 41 fine-needle aspiration punctures bleeding complications were recorded but did not require any treatment. The method was reliable and effective in the definitive diagnosis and treatment of hepatic and splenic abscesses, with a lower complication and mortality rate than surgical drainage.

Induced histidine decarboxylase in endotoxic shock: identification of the enzyme in rat liver and influence of its inhibitors on survival parameters.

The hypothesis of a causal relationship between a progressive and unrestrained increase of tissue histamine formation by activation of an inducible histidine decarboxylase (HDC) and lethality in endotoxic shock (Schayer's 'induced histamine concept') was tested in a standardized rat endotoxic shock model. Initial enzyme identification studies in the rat shock liver (8 hrs after endotoxin challenge) clearly demonstrate that the 'induced' histidine decarboxylase is an acid (specific) HDC. The succeeding randomized, controlled study with appropriate inhibitors of the enzyme, alpha-methyl-histidine (competitive inhibitor) and alpha-fluoromethyl-histidine (irreversible inhibitor) using doses of 2, 20 or 100 mg/kg showed no significant effect on the survival rate of rats in endotoxin shock. The survival rate of the non-treated endotoxin control group (NaCl) was 25%; all methylprednisolone treated rats (50 mg/kg) survived. Thus, the 'induced' histamine is not a predominant factor (necessary or sufficient determinant) for the lethal outcome in rat endotoxic shock. The protective effect of MP is not predominantly due to the inhibition of the 'induced' histidine decarboxylase. The use of HDC-inhibitors as the appropriate instruments for evaluation of the significance of this mechanism is discussed.

[Pancreatitis: conservative therapy]. / Pankreatitis: konservative therapie.

The treatment of acute pancreatitis is primary conservative independent of the degree of severeness. The aim of our multimodal concept of therapy (stomach tube, catheterisation of urinary bladder, closed peritoneal dialysis, analgetics--peridural catheter-, substitution of volume-electrolytes, colloides, protein, plasma, blood-, antibiotics, heparin H2-receptor blocker, early artificial respiration, insulin, parenteral nutrition-glucose, amino acids, fat-, hemofiltration/-dialysis, percutaneous drainage of liquid formations) is to postpone or to avoid an operation. Only the erosion bleeding or a locally conditioned sepsis ask for an emergency operation. The lethality of the degrees II (n = 30) and III (n = 39) could be decreased to 20.3% in the last 7 years. The follow-up of 55 patients with severe pancreatitis was free of clinical symptoms in 80% with normal exocrine and endocrine function of pancreas. This confirms that the organ itself is mostly intact even in severe cases of pancreatitis, in hemorrhagic-necrotic pancreatitis.

[Successful treatment of several metachronous pulmonary metastases of a chondroblastic osteosarcoma]. / Erfolgreiche Behandlung mehrerer metachroner pulmonaler Metastasen eines chondroblastischen Osteosarkoms.

The case of an 11-year-old girl suffering from chondroblastic osteosarcoma of the left tibia head is reported. Within 19 months following the amputation of the thigh and during intensive chemotherapy a total of 7 pulmonary metastases were diagnosed and resected in 3 sessions. The patient has been free of any metastases for 5 years.

[Early operation for acute gallbladder as a therapeutic principle]. / Die Frühoperation der "akuten Galle" als therapeutisches Prinzip.

Between 1 January 1969 and 30 June 1984 904 patients with acute cholecystitis were treated as inpatients. Including 1976, initial treatment was conservative, and interval operation was recommended after 6-8 weeks. Commencing in 1977 early operation was preferred. Immediate operation within a few hours after admission and preparation for operation was done only in threatening or demonstrable complications of acute cholecystitis. Multimorbidity was highest (39%) in conservatively treated patients (n = 204), it was 26% in immediately operated patients (n = 201) and 23% in patients operated in the interval (n = 199). Early operation (n = 300) was associated with a multimorbidity of only 13%. Postoperative complications occurred most frequently (33%) after immediate operation, and in only 11% after early operation. Exploration of the choledochus was required in 27% of immediately operated cases and in only 19% of early and interval operations. Mortality after exclusively conservative treatment was 3%, after immediate operation 16%, after interval operation 3% and after early operation only 1.3%. Follow-up assessment of 137 primarily non-operated patients (7-15 years) showed a mortality of 48% on subsequently necessary immediate operation (16 out of 33 patients). No symptoms were seen in 14 out of 32 patients, only two of them had no gallstones. The high reliability of establishing the diagnosis (98% correct diagnosis) justifies early operation as preferred concept of treatment. Primary conservative treatment of acute cholecystitis and subsequently planned interval operation should be limited to justifiable exceptions.

[Advantages of computerized tomography diagnosis in acetabular fractures]. / Vorteile der Computertomographie-Diagnostik bei Acetabulumfrakturen.

There is a comparison of conventional radiographs and computed tomography in 23 patients presenting acetabular fracture. Four patients were treated conservatively because of their CT-findings. The result was successful. Surgery took place in 19 patients. Intraoperative findings verified CT-diagnosis in all cases, while diagnosis with conventional radiographs in 3 projections had to be corrected in 8 of 19 cases. Advantages of CT in acetabular fracture: 1. always manageable, 2. correct topography of fracture, 3. discovery of small especially intraarticular bone fragments, 4. judgement of congruity of the joint, 5. clear decision of management. 6. definite surgical approach. In conclusion, the CT-scanning of acetabular fractures is preferable for correct classification as opposed to conventional radiographs; if only plain X-ray films are available CT-scanning is to be required.

A controlled study on the use of intravenous fat in patients suffering from acute attacks of pancreatitis.

Thirty-one acute attacks of pancreatitis in 27 patients were studied. 15 attacks were treated with standard therapeutic measurements alone, and 16 attacks were, in addition, treated with intravenous infusions of a commercial fat emulsion (Intralipid). Fat infusions were started on the 2nd day after admission in a dose of 1,5 g fat/kg B.W./24 h. There was a tendency of quicker alleviation of pain in the controls, but the amounts of analgesics and antispasmodics required by these patients were higher. With regard to all other variables, which are commonly used to characterize the course of acute attacks of pancreatitis, we did not observe significant differences between the controls and the patients treated with fat. We conclude that intravenous infusions of fat in the dosage used in this study does not influence the course of acute attacks of pancreatitis.

[Significance of oxygen hyperventilation in bronchofiberscopy in intensive medicine]. / Die Bedeutung der Sauerstoffhyperventilation während der Bronchofiberskopie in der Intensivmedizin.

In 25 patients (group I = 15 patients, group II = 10 patients) we examined the influence of bronchoscopic aspiration on lung function. PaO2 and PaCO2 were measured before, during, and after bronchoscopic aspiration. In all cases the insertion of the bronchofiberscope was performed by means of a transnasal tube. In 15 patients of Group I an increase in PaO2 followed, and because of this we could reduce FiO2 after bronchoscopic examination. The 10 patients of Group II were hyperventilated before and during the examination (AMV = 150 ml/kg body weight, FiO2 = 1.0). Hyperventilation increased in 10 patients the PaO2 from 53 (43-121) mmHg to 112 (96-225) mmHg. During bronchoscopy PaO2 decreased from 154 (96-225) mmHg to 102 (70-196) mmHg in 8 of the 10 patients. Two patients showed an increase in PaCO2. A third patient had an obvious increase in PaCO2 from 53 to 65 mmHg. Only 24 hours later we observed normalization of PaCO2 and an increase in PaO2. According to these results, hyperventilation (FiO2 = 1.0) during bronchoscopic examination is necessary in intensive care patients. Insertion of the bronchoscope should be performed via tracheal tube. Strict monitoring is imperative.

[Results of multiple surgical therapy in pronounced acne conglobata]. / Ergebnisse der mehrzeitigen chirurgischen Therapie bei ausgeprägter Akne conglobata.

Acne conglobata - hidradenitis suppurativa - as a particular form of acne vulgaris is, in its pronounced, chronic progressive form, incontrollable by conservative means. Smaller foci of infection need only a local excision of skin and subcutis followed by primary wound closure or secondary healing. When large areas are involved, a generous excision including removal of the fistula system is followed by a 1-3 week intermediary phase with hydrotherapy and antiseptic local treatment. Clean granulation is waited upon and covered in a second session with a skin grafting. In the area of joints, a third session with flap-plastic under sterile conditions is necessary, if limitations to motility are present or are threatened by scar contracture. From 1975-1982, 14 patients with pronounced acne conglobata were successfully treated by a surgical procedure in multiple sittings. All patients could, in this manner, be rehabilitated both professionally and socially.

[Functional treatment of extensor tendon injury of the hand]. / Funktionelle Behandlung der Strecksehnenverletzung an der Hand.

We have treated 73 patients with 107 injuries of the extensor tendon. We started with an elastic dynamic splinting means = 9 (2-27) days after operation. The duration of functional treatment was means = 40 (13-103) days. Infections were only seen in severe cases (12.3%), and there was no rupture of the sutured tendon. Good or excellent functions were found in 92% of the patients. To sum up, primary extensor tendon repair will provide superior functional results at all levels of injury by postoperative dynamic splinting.