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.

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.

[Sacrococcygeal chordoma. Radical operation, a problem]. / Das sacrococcygeale Chordom Die Radikaloperation ein Problem

A sacrococcygeal chordoma was observed over a 7-year follow-up period. Primarily there were only local recurrences. The long-term results of the treatment of sacrococcygeal chordoma are bad. The indication of hemipelvectomy or hemicorporectomy as surgical treatment is therefore discussed.

[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.

[Hip dislocation with femur head fracture]. / Die Hüftluxation mit Hüftkopffraktur.

It is talked about the classification, the therapy and the late results of the traumatic dislocation of the hip joint with a fracture of the femoral head. Twelve patients with an average age of 36 years (from 18 to 77 years) were treated between the years 1972 and 1982. The rarer anterior dislocation of the hip including a fracture of the femoral head should be specifically classified, in order not to cause any errors for the therapeutic and prognostic assessment following the Pipkin classification. Type I and II with posterior dislocation justify a closed trial of reposition. The miscarried trial, and a continuing fragmental dislocation with a disturbance of the joint's function, or fragments participating in the load area of the femoral head necessitate an open reposition. Small fragments may be taken away, the larger ones require the screwing osteosynthesis. Smaller fragments from the load area must be sustained in an anterior dislocation ("IIb"). The type III injury gives primarily--in exceptional cases sometimes secondarily--an indication for an alloplastic false hip joint. Injuries of type IV should be restored operatively, respectively, it is necessary to perform a secondary operation to set in an endoprosthetic substitute. With the operative therapy--that is: 5 times extirpation of fragments, 4 times screwing osteosynthesis of the femoral head, twice screwing osteosynthesis of the acetabulum--we obtained good results in injuries of type I, II and IV. We performed 3 times a primary total false hip joint in type III injuries.

[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.

[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.

[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.

[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.

[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.

[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.

[The liver concentration of cephradin and cephacetril and their elimination in the bile]. / Die Lebergewebekonzentration von Cephradin und Cephacetril sowie deren Gallenausscheidung

Liver biopsies and serum samples were collected after intravenous application of 2 g cephradin (n = 13) or 2 g cephacetril (n = 11) during surgery. There was no difference in the serum levels of cephradin and cephacetril. 30 min. after i.v. application of cephradin the liver tissue concentration was 72.62 mcg/g. 30 min. after i.v. cephacetril the liver tissue concentration was 5.83 mcg/g. The quotient of liver tissue concentration to serum concentration for cephradin was between 0.36 and 0.83, and for cephacetril between 0.02 and 0.16. The excretion of cephradin and cephacetril in human bile was studied by collecting bile samples from the common bile duct via T-tube drainage (n = 17). Cholecystomized patients were given 2 g of antibiotics intravenously. Serum levels of cephradin were 263 mcg/ml 5 min after application, and 22 mcg/ml after 240 min. Serum levels of cephradin were 263 mcg/ml 5 min after application, and 22 mcg/ml after 240 min. Serum levels of cephacetril were 193 mcg/ml 5 min after application, and 27 mcg/ml after 240 min. The highest levels of cephradin in the bile were found 75 min after injection at a concentration of 86.4 mcg/ml; the highest level for cephacetril was 21.8 mcg/ml at 15 min. In patients with hyperbilirubinaemia cephradin reached a mean maximum concentration of 29.6 mcg/ml in bile samples, in comparison to 117.4 mcg/ml in normal patients, while no difference was seen with cephacetril. After intravenous administration of 2 g cephradin biliary concentration are achieved which may be sufficiently high to be effective not only against the very sensitive gram-positive organisms, but also against most strains of E. coli, Klebsiella and indol-negative Proteus. Cephradin is effective in the treatment of cholangitis and intrahepatic abscesses, as was observed in 18 patients. A free bile-flow is essential.

[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.

[Indication and technic of interlocking nailing of the femur]. / Indikation und Technik der Verriegelungsnagelung am Oberschenkel.

Between 1973 and 1982 we treated 569 fractures of the femoral shaft by means of osteosynthesis. The internal nailing was performed in 41.6%. We used an interlocking nailing in 170 cases, 116 times statically and 54 times dynamically. An open reposition was performed in 48.2%. With only a very small incision we exposed the area of the fracture to insert the reamer guide under control of the fingers into the distal part of the femoral shaft. By using this technique there is no danger of disposing the fragments in order to achieve stabilisation in the correct position. 52.4% of the patients were younger than 30 years and 25.9% older than 30 years and 25.9% older than 60 years. In all cases we observed an osseous healing, twice a secondary cancellous bone craft was necessary. As complications we had an infection rate of 2.9%, loosening of the bolt in 0.6%, axial malalignment greater than 10 degrees in 0.6%, a rotary malalignment greater than 10 degrees in 1.2%. We did not observe any refracture. Less complications can be observed in interlocking nailing in comparison with plate osteosynthesis. Technique, indication, mistakes, and dangers as well as careful timing of operation are discussed. In open fractures delayed osteosynthesis by means of interlocking nailing is to be preferred to primary plate osteosynthesis. Fractures fixed by interlocking nailing had comparatively less complications in fracture healing and especially no more shortenings and rotation deformities, but the advantage of early full weightbearing. The interlocking nail has a very important value in the management of femoral shaft fractures.

[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.

[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.

[Ender nailing of subcapital fractures of the femur neck (Garden I)]. / Ender-Nagelung subkapitaler Schenkelhalsbrüche (Garden I).

In the period between 1968 and 1982 we observed 441 subcapital fractures of the femoral neck, 55 times a tight impaction in valgus position. Including the year 1976 a conservative treatment was employed (group I); from 1977 onwards operations with the Ender-nailing technique were performed (group II). The patients' average age was 81 to 84 years. In 7 out of 32 cases the conservative functional treatment led to disimpacted fractures between the 5th and 54th day after the accident. Neither a slightly gaping fracture line nor an up to ten-degree antecurvatoral position are a radiologic-morphological criterion for a prognostic assessment. For that reason we performed the Ender-nailing operation in 23 cases from 1977 on. Under immediate postoperative and complete load it was only once we obtained a partial dislocation of fracture which had a compact osseous healing up in varus deformity. A cranial displacement of the nails caused by the operation was observed three times. All patients regained their ability to walk. Until the end of the first year of the accident there was no case of death, nor could we perceive any total necrosis of the femoral head. One pseudarthrosis was found after conservative treatment. The average clinical treatment was 42 respectively 21 days. We transferred 19 out of 32 respectively 7 out of 23 patients to a convalescent hospital. The impacted subcapital fracture of the femoral neck should nowadays be treated operatively. The Ender-nailing technique represents a simple, gentle, and a low-risk procedure for surgical stabilization.

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.