[Irrigation drainage and fibrinolysis for treatment of parapneumonial pleural empyema]. / Spül-Drainage und Fibrinolyse zur Behandlung des metapneumonischen Pleuraempyems.

UNLABELLED: We report on our experiences on 336 patients suffering from manifest pleural empyema within a period of 10 years (1985-1995). Considering the pathogenesis, particularly the results of 218 patients with "parapneumonic pleural empyema" were analysed retrospectively. Definite healing could be achieved by chest tube placement and pleural irrigation in 201 patients (= 92.2%). Other 11 patients finally needed surgical interventions (= 5%). Only 6 patients could not be cured: An indwelling tube was palliatively inserted once and 5 patients died in the course of the medical treatment (mortality = 2.3%). Within the first years the irrigation therapy was performed using a single chest tube (n = 38%) but since 1989 a double-lumen drainage was used (n = 158). Since 1987 in most cases (n = 182) intrapleural medicinal fibrinolysis was performed by instillation of streptokinase (Varidase N). If outward invasively pretreated patients (n = 30) are analysed separately, a statistical dependency can be found between the duration and the way of treatment. Without significant difference between the groups (Gr) the average duration of treatment using a single tube without fibrinolysis (Gr1) was 31.8 days, but 26.5 days using a single tube combined with fibrinolysis (Gr2). A clear shortening of the duration is detectable if patients were treated with a combination of double lumen drainage and fibrinolysis: If 2 tubes were used (Gr4) the treatment lasted 20.6 days, using one double-lumen tube (Gr5) it took 19.8 days. There is a proof of significance at comparison of Gr4 with Gr1 (p = 0.005). Gr5 with Gr1 (p < 0.001) and Gr5 with Gr2 (p = 0.014) respectively. A significant longer duration of treatment (40.6 days, p < 0.001) is found for the group of the pretreated patients, if compared with the corresponding groups Gr4 or Gr5. CONCLUSION: Parapneumonic empyemas most often can be cured by irrigation drainage. The mortality is comparatively low. The shortest duration of treatment is needed using the combination of a double-lumen tube with intrapleural instillation of a fibrinolytic agent (Varidase N). Invasively pretreated patients need significantly longer durations at same form of treatment.

Pancreaticoduodenectomy for melanoma metastatic to the duodenum: a case report and review of the literature.

Although melanoma accounts for fewer than 5 per cent of cutaneous malignancies, it is responsible for more than 75 per cent of skin cancer deaths. Metastasis generally proceeds from regional lymph nodes to visceral organs, with the lungs, liver, brain, and bowel being most commonly affected. Herein, we report a case of malignant melanoma metastatic to the ampulla of Vater treated with a pancreaticoduodenectomy.

Hepatic cystadenoma: an unusual presentation.

A 53-yr-old woman with a history of hepatic cystadenoma 25 yr before presented with a simple hepatic cyst, which evolved over 9 yr into a complex cystadenoma with septations and internal bleeding. She was treated with a left hepatectomy. Review of the literature shows that hepatic cystadenomas, although rare, frequently can recur years later and have potential for malignant transformation. Histologic similarities of one variant with ovarian stroma raises interesting possibilities regarding the origin of these lesions. The best treatment results are obtained with radical excision.

High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation.

OBJECTIVE: We investigated whether a treatment according to a clinical algorithm could improve the low survival rates in acute respiratory distress syndrome (ARDS). DESIGN: Uncontrolled prospective trial. SETTING: One university hospital intensive care department. PATIENTS AND PARTICIPANTS: 122 patients with ARDS, consecutively admitted to the ICU. INTERVENTIONS: ARDS was treated according to a criteria-defined clinical algorithm. The algorithm distinguished two main treatment groups: The AT-sine-ECMO (advanced treatment without extracorporeal membrane oxygenation) groups (n = 73) received a treatment consisting of a set of advanced non-invasive treatment options, the ECMO treatment group (n = 49) received additional extracorporeal membrane oxygenation (ECMO) using heparin-coated systems. MEASUREMENTS AND RESULTS: The groups differed in both APACHE II (16 +/- 5 vs 18 +/- 5 points, p = 0.01) and Murray scores (3.2 +/- 0.3 vs 3.4 +/- 0.3 points, p = 0.0001), the duration of mechanical ventilation prior to admission (10 +/- 9 vs 13 +/- 9 days, p = 0.0151), and length of ICU stay in Berlin (31 +/- 17 vs 50 +/- 36 days, p = 0.0016). Initial PaO2/FIO2 was 86 +/- 27 mm Hg in AT-sine-ECMO patients that improved to 165 +/- 107 mm Hg on ICU day 1, while ECMO patients showed an initial PaO2/FIO2 of 67 +/- 28 mm Hg and improvement to 160 +/- 102 mm Hg was not reached until ICU day 13. QS/QT was significantly higher in the ECMO-treated group and exceeded 50% during the first 14 ICU days. The overall survival rate in our 122 ARDS patients was 75%. Survival rates were 89% in the AT-sine ECMO group and 55% in the ECMO treatment group (p = 0.0000). CONCLUSIONS: We conclude that patients with ARDS can be successfully treated with the clinical algorithm and high survival rates can be achieved.

Delayed hypersensitivity skin tests and subsequent renal transplant outcome.

BACKGROUND: Some studies in the literature have supported, while others have denied, the relationship between results of delayed hypersensitivity skin tests (DHST), renal allograft and patient survival rates. Several factors contribute to the unreliability of these studies. For example, most of these studies were performed in the precyclosporine era, furthermore, other variables which influence renal allografts and patient survival rates were not controlled in those studies. OBJECTIVE: The purpose of this study was to investigate the relationship between results of DHST performed in the pretransplant period with the subsequent renal transplant outcome in the cyclosporine era. METHODS: The study included 103 first cadaveric renal transplant recipients. DHST were performed during pretransplant evaluation by intradermal injections of a battery of recall antigens. Based on skin-test results, the patients were assigned to two groups--those with a positive skin test (STP+) and those with a negative (anergic) skin test. These two groups were compared with each other regarding allograft survival, patient survival, and other variables known to influence survival rates. RESULTS: The mean age, sex and racial distribution, degree of HLA matches between recipients and donors, number of acute rejection episodes, and number of patients with acute tubular necrosis were similar between the two groups. Renal allograft survival rates in the anergic group at 6 months, 1 year, 2 years, and 3 years were 97%, 90%, 84%, and 57%, respectively. The survival rate for renal allografts in the STP+ group for the same time points was 90%, 86%, 80%, and 72%, respectively. Patient survival rates for the anergic group at 6 months, 1 year, 2 years, and 3 years were 95%, 94%, 89%, and 85%, respectively, while those for the STP+ group were 98%, 98%, 98%, and 97% respectively. Differences between the STP+ and anergic groups, with regard to patient and allograft survival rates, were not significant. CONCLUSION: We conclude that DHST is not helpful in predicting outcome of patient or renal allograft survival rates over a 3-year time period.

Conduction block as an early sign of reversible injury in ischemic monomelic neuropathy.

We report three patients with reversible motor conduction block in the forearm associated with ischemic monomelic neuropathy (IMN), which occurred in two patients following placement of brachial artery-cephalic vein shunts for hemodialysis. In the third patient, IMN resulted from spontaneous, probably embolic, brachial artery occlusion. Conduction block was observed shortly after the onset of symptoms, and preferentially involved the median nerve. Slowing of conduction velocity was seen in the same nerve segments. Electrophysiologic resolution, correlating with clinical improvement following treatment, occurred promptly in one patient and over several weeks in the others. Recognition of conduction block is important in the evaluation of IMN, and indicates the need for prompt treatment of likely reversible nerve injury.

["Single-shot" antibiotic prophylaxis in thoracic surgery; reduction of the postoperative infection rate]. / "Single-shot"-Antibiotikaprophylaxe in der Thoraxchirurgie; Senkung der postoperativen Infektionsrate.

A prospective, controlled and randomised trial was started to detect the effectivity of a "single-shot" antibiotic prophylaxis in thoracic surgery using cefuroxime. Therefore 200 unselected patients, consecutively scheduled for major thoracic surgery except endoscopic procedures or mediastinoscopy were enrolled in this study and randomized into either the control group (no antibiotics perioperatively; n = 100) or the prophylaxis group (one dose of 1.5 g cefuroxime i.v. at induction of anaesthesia; n = 100). Clinical signs correlated with infection, radiological findings and the results of repeated microbiological examinations were recorded and a comparative statistical analysis was done. Compared to controls the prophylaxis group had fewer (not significant) infections of the wound, the pleural cavity and the urinary tract and fewer patients of this group showed "pronounced infiltration" in daily taken chest roentgenograms (significant), clinical signs for pneumonia and pathologic sputum findings, or new bacterial colonisation of sputum specimens on the first postoperative day, whereas bacteria, isolated from tracheal aspirates, immediately taken after intubation disappeared more often. Specimens of pleural fluid taken postoperatively were less often positive for bacteria. Fewer patients were treated with antibiotics in the postoperative course and the courses were shorter in the prophylaxis group compared to controls. Considering the risk factor "positive microbiological culture" in preoperative tracheal aspirates, patients of the prophylaxis group showed much more seldom new radiological "infiltration" (statistically highly significant) and, in addition, had lower white blood cell counts (significant) and lower mean maximal body temperatures. The results of our trial confirm the preventive effect of "single-shot" antibiotic prophylaxis in thoracic surgery against infections.

Sequential therapy--a prospective randomized trial of MALG versus OKT3 for prophylactic immunosuppression in cadaver renal allograft recipients.

We prospectively studied the use of prophylactic Minnesota antilymphocyte globulin vs. OKT3 in kidney transplant recipients. Between 7/1/87 and 9/1/90, 138 adult kidney and 35 kidney-pancreas recipients were randomized after stratification for age (18-49 vs. greater than or equal to 50), diabetes (diabetic vs. nondiabetic), transplant number (1 vs. greater than 1) and, for retransplants, the length of survival of the first graft (less than 1 year vs. greater than or equal to 1 year), and then randomized to receive 7 days of either MALG (20 mg/kg/day) or OKT3 (5 mg/day). Immunosuppression was otherwise identical in both groups; prednisone and azathioprine started on the day of surgery, and cyclosporine started on postoperative day 6. Minimum follow-up was 9 months. There was no difference in one- and two-year actuarial patient or graft survival rates, incidence of rejection, or serum creatinine level. MALG was associated with a higher incidence of cytomegalovirus; it was statistically significant in the subgroup of CMV seronegative recipients of kidneys from seropositive donors (P less than .05). OKT3 was more expensive and was associated with significantly more side effects: fever (P less than .0001), dyspnea (P = .04), and acute respiratory distress syndrome (ARDS) (P = .02).

Major thoracic surgery during long-term extracorporeal lung assist for treatment of severe adult respiratory distress syndrome (ARDS).

Surgery in patients treated with extracorporeal lung assist (ELA) carries a high risk of life threatening bleeding complications caused by the need for systemic anticoagulation. A case report describing a successful surgical intervention for the repair of a broncho-pleural leakage by thoracotomy during ELA is presented. A newly developed heparin coated extracorporeal system was used in a patient being treated for severe adult respiratory distress syndrome (ARDS) after left sided pneumectomy. The heparin coated system allowed discontinuation of systemic heparinization intraoperatively without coagulation complications related to the extracorporeal system. This procedure was followed by resolution of the ARDS.

Management of penetrating colon injuries. A prospective randomized trial.

Fifty-six patients with penetrating colon injuries were entered into a randomized prospective study. Management of the colon injury was not dependent on the number of associated injuries, amount of fecal contamination, shock, or blood requirements. Twenty-eight patients were treated with primary repair or resection and anastomosis and 28 patients were treated by diversion (24 colostomy, 3 ileostomy, 1 jejunostomy). The average Penetrating Abdominal Trauma Index score was 23.9 for the diversion group and 26 for the primary repair group. There were five (17.9%) septic-related complications in the diversion group. This included four intra-abdominal abscesses and one subcutaneous wound infection. There were six (21.4%) septic-related complications in the primary repair group. This included one wound infection, two positive blood cultures, and three intra-abdominal abscesses. There were no episodes of suture line failure in the primary repair/anastomosis group. The authors conclude that, independent of associated risk factors, primary repair or resection and anastomosis should be considered for treatment of all patients in the civilian population with penetrating colon wounds.

The impact of HLA matching on graft survival and on sensitization after a failed transplant--evidence that failure of poorly matched renal transplants does not result in increased sensitization.

There are costs (both financial and ethical) to distributing kidneys by HLA-match (time, transportation, repeat crossmatch; possibly bypassing a more deserving recipient). Arguments favoring matching include better short- and long-term survival, and decreased panel-reactive antibody (PRA) if a well-matched vs. poorly matched transplant fails. We studied these phenomena in a single institution. Since 1970, 1329 patients received cadaver (CAD) transplants; for those with defined antigens (n = 1316) there was no difference in 10-year graft survival in those with a less than or equal to 1 AB match vs. those with greater than 1 AB match or those with less than or equal to 1 AB mismatch (mm) vs. greater than 1 AB mm. Similarly there was no difference in those with less than or equal to 2 BDR mm vs. greater than 2 BDR mm. In fact, those with less than ABDR mm had worse 10-year graft survival (55%) than those with greater than or equal to 3 ABDR mm (61%) (P = .001). For patients with function greater than 6 months there was no difference in long-term outcome based on HLA match or mm. These findings were similar for patients both with and without CsA immunosuppression, and for primary and retransplants. A total of 382 patients transplanted since 1980 have lost their grafts (146 died with function). All had received pretransplant transfusions. Of 236 alive after graft loss, 64 had no postgraft failure PRAs (22 out of state, 23 chose to remain on dialysis, 19 died less than 3 months after graft loss); 172 had PRAs after failure; 106 (62%) have been retransplanted. Mean peak PRA in those retransplanted was 23 +/- 31 (range 0-100) vs. 46 +/- 39 (range 0-100) in those not retransplanted (P less than .05). Patients were stratified by PRA prior to first transplant (0%, 1-20%, greater than 20%). For recipients with 0% PRA, failure of a CAD transplant (n = 58) was no more likely to result in an increase of PRA than failure of a living-related donor (LRD) transplant (n = 49) (NS). For those with an increase, mean increase was 45% +/- 34 after LRD transplant and 41% +/- 28 after CAD transplant (NS). The proportion developing PRA greater than or equal to 60% was not different after a failed LRD (7/49) or CAD (11/58) transplant (NS). Other subgroups had similar results. AZA or CsA immunosuppression did not affect development of increased PRA after a failed graft.(ABSTRACT TRUNCATED AT 400 WORDS)

Renal transplantation.

Results of renal transplantation have markedly improved in the last decade. Patients previously defined as high risk (those aged greater than 50 years, infants, diabetics, and those with extra renal disease processes) can now be transplanted with excellent outcomes. Living related donors are preferred because of the improved success rates.

Renal transplantation in infants.

The timing of renal transplantation in infants is controversial. Between 1965 and 1989, 79 transplants in 75 infants less than 2 years old were performed: 23 who were 12 months or younger, 52 who were older than 12 months; 63 donors were living related, 1 was living unrelated, and 15 were cadaver donors; 75 were primary transplants and 4 were retransplants. Infants were considered for transplantation when they were on, or about to begin, dialysis. All had intra-abdominal transplants with arterial anastomosis to the distal aorta. Sixty-four per cent are alive with functioning grafts. The most frequent etiologies of renal failure were hypoplasia (32%) and obstructive uropathy (20%); oxalosis was the etiology in 11%. Since 1983 patient survival has been 95% and 91% at 1 and 5 years; graft survival has been 86% and 73% at 1 and 5 years. For cyclosporine immunosuppressed patients, patient survival is 100% at 1 and 5 years; graft survival is 96% and 82% at 1 and 5 years. There was no difference in outcome between infants who were 12 months or younger versus those who were aged 12 to 24 months; similarly there was no difference between infants and older children. Sixteen (21%) patients died: 5 after operation from coagulopathy (1) and infection (4); and 11 late from postsplenectomy sepsis (4), recurrent oxalosis (3), infection (2), and other causes (2). Routine splenectomy is no longer done. There has not been a death from infection in patients transplanted since 1983. Rejection was the most common cause of graft loss (in 15 patients); other causes included death (with function) (7), recurrent oxalosis (3), and technical complications (3). Overall 52% of patients have not had a rejection episode; mean creatinine level in patients with functioning grafts is 0.8 +/- 0.2 mg/dL. Common postoperative problems include fever, atelectasis, and ileus. At the time of their transplants, the infants were small for age; but with a successful transplant, their growth, head circumference, and development have improved. Transplantation in infants requires an intensive multidisciplinary approach but yields excellent short- and long-term survival rates that are no different from those seen in older children or adults. Living donors should be used whenever possible. Patients with a successful transplantation experience improved growth and development, with excellent rehabilitation.

Effects of papaverine on smooth muscle cell morphology and vein graft preparation.

Venous injury following mechanical distension and its late sequelae were studied in a canine model. Jugular vein segments distended without and with papaverine (60 mg/100 ml) were compared with nondistended vein segments after they had been placed into the arterial circulation for 1 to 12 months. Arteriography showed no significant statistical discrepancy in luminal diameter of the three vein segments. Complete reendothelialization had occurred in all vein grafts at the time of harvesting. Similar histocytologic features existed in the nondistended segments and in the portion distended with human plasma protein fraction (Plasmanate) plus papaverine (150 to 300 mm Hg). The intimal-medial hyperplasia was characterized by an increase in fibrocellular layers with an elaboration of vasa vasorum. Conversely, collagen and extracellular matrix replaced the myocyte, producing medial fibrosis in vein mechanically distended with Plasmanate alone. Papaverine prevented mechanical stimulation of smooth muscle cells to overproduce extracellular connective tissue elements. Mechanical stretching of intimal and medial myocytes induced fibrogenesis and fibroplasia. Papaverine is useful in vein preparation; it protects the endothelium and smooth muscle cells in the intima and media and prevents leukocyte infiltration and medial fibrosis.