Vago-splenic signal transduction of cardioprotection in humans.

BACKGROUND AND AIMS: The spleen serves as an important relay organ that releases cardioprotective factor(s) upon vagal activation during remote ischaemic conditioning (RIC) in rats and pigs. The translation of these findings to humans was attempted. METHODS: Remote ischaemic conditioning or electrical auricular tragus stimulation (ATS) were performed in 10 healthy young volunteers, 10 volunteers with splenectomy, and 20 matched controls. Venous blood samples were taken before and after RIC/ATS or placebo, and a plasma dialysate was infused into isolated perfused rat hearts subjected to global ischaemia/reperfusion. RESULTS: Neither left nor right RIC or ATS altered heart rate and heart rate variability in the study cohorts. With the plasma dialysate prepared before RIC or ATS, respectively, infarct size (% ventricular mass) in the recipient rat heart was 36 ± 6% (left RIC), 34 ± 3% (right RIC) or 31 ± 5% (left ATS), 35 ± 5% (right ATS), and decreased with the plasma dialysate from healthy volunteers after RIC or ATS to 20 ± 4% (left RIC), 23 ± 6% (right RIC) or to 19 ± 4% (left ATS), 26 ± 9% (right ATS); infarct size was still reduced with plasma dialysate 4 days after ATS and 9 days after RIC. In a subgroup of six healthy volunteers, such infarct size reduction was abrogated by intravenous atropine. Infarct size reduction by RIC or ATS was also abrogated in 10 volunteers with splenectomy, but not in their 20 matched controls. CONCLUSIONS: In humans, vagal innervation and the spleen as a relay organ are decisive for the cardioprotective signal transduction of RIC and ATS.

Oncologic long-term outcome of single-incision laparoscopic surgery (SILS) for colorectal cancer.

PURPOSE: Single-incision laparoscopic surgery (SILS) has been introduced as a less invasive alternative to multi-port laparoscopic surgery (MLS). MLS is widely accepted for the treatment of colorectal cancer, but there remains minimal evidence for the use of SILS. Thus, we compared both short- and long-term outcomes of SILS and open surgery (OS) in matched cohorts of colorectal cancer patients. METHODS: Some 910 patients had colorectal resections for cancer between 2006 and 2013, and 134 of them were operated on using SILS. Eighty of these SILS patients were compared to a cohort of patients who had open surgery that were matching in tumour stage and location, type of resection, sex, age and ASA Score. Disease-free survival at 5 years (5y-DFS) was the primary endpoint; morbidity and hospitalization were secondary parameters. The role of surgical training in SILS was also investigated. RESULTS: Clavien Dindo ≥ IIIb complications occurred in 13.8% in both groups. 5y-DSF were 82% after SILS and 70% after OS (p = 0.11). Local recurrence after rectal cancer tended to be lower after SILS (0/43 (SILS) vs. 4/35 (OS), p = 0.117). Length of stay was significantly shorter after SILS (10 vs. 14 days, p = 0.0004). The rate of operations performed by surgical residents was equivalent in both groups (44/80 (SILS) vs. 46/80 (OS), p = 0.75). CONCLUSION: The data demonstrates that SILS results in similar long-term oncological outcomes when compared to open surgery as well as morbidity rates. The hospital stay in the SILS group was shorter. SILS can also be incorporated in surgical training programmes.

How to reduce anastomotic leakage in colorectal surgery-report from German expert meeting.

AIMS: Anastomotic leakage is one of the most worrisome complications in colorectal surgery. An expert meeting was organized to discuss and find a consensus on various aspects of the surgical management of colorectal disease with a possible impact on anastomotic leakage. METHODS: A three-step Delphi-method was used to find consensus recommendations. RESULTS: Strong consensus was achieved for the use of mechanical bowel preparation and oral antibiotics prior to colorectal resections, the abundance of non-selective NSAIDs, the preoperative treatment of severe iron deficiency anemia, and for attempting to improve the patients' general performance in the case of frailty. Concerning technical aspects of rectal resection, there was a strong consensus in regard to routinely mobilizing the splenic flexure, to dividing the inferior mesenteric vein, and to using air leak tests to check anastomotic integrity. There was also a strong consensus on not to oversew the stapled anastomoses routinely, to use protective ileostomies for low rectal and intersphincteric, but not for high-rectal anastomoses. Furthermore, a consensus was reached in regard to using CT-scans with rectal contrast enema to evaluate suspected anastomotic leakage as well as measuring C-reactive protein routinely to monitor the postoperative course after colorectal resections. No consensus was found concerning the indication and technique for testing bowel perfusion, the routine use of endoscopy to check the integrity of the anastomosis, the placement of transanal drains for rectal anastomoses and the management of anastomotic leakage with peritonitis. CONCLUSION: Consensus could be found for several practice details in the perioperative management in colorectal surgery that might have an influence on anastomotic leakage.

Single-Incision Laparoscopic versus Open Sigmoidectomy for Diverticular Disease: A Disease-Stratified Matched-Pair Analysis.

BACKGROUND: Single-incision laparoscopic surgery (SILS) is a variant of laparoscopic surgery, especially for diverticular disease (DD), but there are very little data comparing SILS to standard surgical procedures for DD, and most studies on DD surgery do not declare the disease stage. We compared SILS to open sigmoidectomy for DD in a stage-stratified matched-pair analysis to validate the significance of SILS. METHODS: All patients with SILS or conventional sigmoidectomy for diverticulitis of a single visceral surgery department were subject to a matched-pair analysis stratified by age, sex, body mass index, previous abdominal surgery, and the stage of DD. RESULTS: Fifty-five pairs were included. In total, 84/110 (76%) had complicated stages of DD. ASA stages were higher in the laparotomy group; the proportion of elective operations was similar (SILS 78%, open: 71%). In the SILS group, length of hospital stay (LoS; 10.2 vs. 16.7 days) and duration of intensive or intermediate care (IMC; 1.8 vs. 3.7 days) were shorter, blood transfusions were reduced (0.1 vs. 0.4 units) and less patients received opioids postoperatively (75 vs. 98%). The day of first defecation, stoma rate, and rates of morbidity and mortality were similar. CONCLUSIONS: SILS equals open sigmoidectomy regarding complications with advantages regarding pain, LoS, IMC/intensive care unit treatment, and blood transfusion.

[Smoldering diverticultis - still a type of chronic recurrent diverticulitis with good indication for surgery? - Surgery for smoldering diverticulitis]. / Smoldering-Divertikulitis ­ doch eine Form der chronisch-rezidivierenden Divertikulitis mit guter Operationsindikation?

BACKGROUND: Elective surgery for recurrent uncomplicated diverticulitis is a matter of debate. "Smoldering diverticulitis" (SmD) describes a subtype of the disease which is characterized by frequently relapsing symptoms triggered by a "smoldering fire-like" ongoing inflammatory process. The aim of this study was to investigate the value of surgery in these patients. METHODS: Forty-four patients with the clinical signs of SmD were selected from a prospective database of 393 patients with elective surgery for diverticulitis. They were compared for morbidity and the effect of surgery on quality of life (QL) (Gastrointestinal QL-Index (GLQI)) with a group of 95 patients who had elective surgery for perforated diverticulitis. RESULTS: Morbidity was equivalent in both groups with shorter durations of surgery in the SmD group (159 (65-301) vs. 174 (100-443) minutes, p = 0.031). Six months after surgery, a significant improvement of QL was found in the SmD group (GLQI 115 (72-143) vs. 98 (56-139) preoperatively, p = 0.018). In the control groups, only a non-significant improvement of the preoperatively less suppressed quality of life was noted. Approximately 80 % of the patients were satisfied with the outcome of surgery. CONCLUSION: In patients with SmD like chronic recurrent disease surgery is effective to improve quality of life.

Single-port laparoscopic resection for diverticular disease: experiences with more than 300 consecutive patients.

BACKGROUND: Single-port laparoscopic surgery (SILS) is a new minimally invasive technique, which has been developed to minimize the surgical access trauma. For colorectal resection, the access trauma can be limited to the one incision, which is needed for specimen extraction anyways, but dissection might be more demanding than in multiport laparoscopic surgery. The aim of this study was to evaluate the usefulness of SILS for the treatment of diverticular disease of the sigmoid colon. METHODS: Between July 2009 and December 2013, a total of 329 consecutive patients with intended SILS sigmoid colectomy for complicated or frequently recurring diverticulitis were studied. Clinical data were collected in a prospective database. Telephone follow-ups were performed to evaluate long-term morbidity and quality of life. RESULTS: Of the 329 patients (139 male) with intended SILS sigmoid colectomy, 309 were successfully operated on in SILS technique, while 20 (6.1%) were converted to open surgery. The mean duration of surgery was 153.5 (65-434) min. Total morbidity rate was 18.3%. Anastomotic leakage was the most serious complication occurring in 13 patients (leak rate 4%) with one consecutive death (mortality rate 0.3%). Quality of life had significantly improved 6 months after surgery in comparison with the preoperative value. At a mean follow-up of 18.6 months, 16 patients (4.9%) had incisional hernia and one patient had recurrent diverticulitis. CONCLUSION: In spite of almost 5% incisional hernia 6 months after surgery, single-incision sigmoid colectomy for diverticulitis is feasible and save and is therefore an alternative to multiport laparoscopic surgery. Further trials are necessary to evaluate its benefits over multiport laparoscopic surgery.

Single-incision laparoscopic surgery for colorectal malignancy--results of a matched-pair comparison to conventional surgery.

BACKGROUND: Single-incision laparoscopic surgery (SILS) is a new minimally invasive technique which has frequently been applied for treatment of benign colorectal diseases. However, there is still little experience with this technique for the treatment of colorectal cancer. METHODS: Sixty-eight patients with SILS resections for colon (n = 25) or rectal cancer (n = 43) were compared to a group of conventionally operated patients who were matched for surgical procedure, tumor stage and tumor location, and the use of preoperative radiochemotherapy. RESULTS: Both groups were comparable for lymph node harvest, specimen length, and the duration of surgery. No significant differences were observed for the number of positive circumferential resection margins, or the distance of the tumor to both the aboral or lateral resection margin, but two positive resection margins were only present after SILS and not after conventional surgery. Hospitalization tended to be shorter after SILS (p = 0.097). Overall, morbidity was equivalent between the two groups, with a difference for colon cancer where it was significantly lower after SILS as compared to open surgery (p = 0.025) mainly due to a lower rate of wound complications. CONCLUSION: SILS might be an acceptable alternative to open surgery for the treatment of colon cancer. For rectal cancer, no apparent benefit could be documented. As no sufficient data on the oncologic quality are available, single-incision laparoscopic surgery can yet not be recommended for the treatment of rectal cancer out of clinical trials.

Topography of the extrinsic internal anal sphincter nerve supply during laparoscopic-assisted TAMIS TME: five key zones of risk from the surgeons' view.

PURPOSE: Sparing the extrinsic autonomic innervation of the internal anal sphincter during total mesorectal excision is important for the preservation of anal sphincter function. This study electrophysiologically confirmed the topography of the internal anal sphincter nerve supply during laparoscopic-assisted transanal minimally invasive surgery for total mesorectal excision. METHODS: This prospective study was conducted at two large multispecialty referral centers. Six patients (five males and one female) aged between 45 and 65 years with low rectal cancer (≤5 cm from the anal verge) were enrolled. Surgery was performed under electric stimulation of the pelvic autonomic nerves with observation of the electromyographic signals of the internal anal sphincter. RESULTS: The minimally invasive transanal surgical approach enabled advantageous visualization of the pelvic autonomic nerves in all patients. In particular, extrinsic innervation to the internal anal sphincter near the levator muscle was consciously spared under electrophysiological confirmation. The evoked absolute electromyographic amplitudes of the internal anal sphincter during transanal minimally invasive surgery were significantly lower than the initial results of the laparoscopic approach [3.7 µV (interquartile range 2.4; 5.7) vs. 4.3 µV (interquartile range 3.1; 8.6); p = 0.002]. Five key zones of risk for pelvic autonomic nerve damage were identified. No complications occurred. CONCLUSIONS: The electromyographic results of this preliminary study indicate advantages for sparing the internal anal sphincter innervation during transanal minimally invasive mesorectal dissection considering the specific in situ neuroanatomical topography.

Single-incision laparoscopic surgery for diverticulitis in overweight patients.

AIM: Single-incision laparoscopic surgery (SILS) has been introduced as a new technique for the treatment of various colorectal diseases. Recurrent or complicated diverticulitis of the sigmoid colon is a frequent indication for minimally invasive sigmoid colectomy. The aim of this study was to investigate the impact of obesity on the outcome of SILS sigmoid colectomy. METHODS: From September 2009 to October 2014, data from 377 patients who had intended SILS sigmoid colectomy for diverticulitis at our institution were collected in a prospective database. The patients were categorized in the following subgroups: group 1 (normal weight, body mass index (BMI) < 25 kg/m(2)), group 2 (overweight, BMI 25-29.9 kg/m(2)), group 3 (obesity, BMI 30-34.9 kg/m(2)), and group 4 (morbid obesity, BMI > 35 kg/m(2)). RESULTS: The groups were equivalent for sex, age, status of diverticulitis, the presence of acute inflammation in the specimen, and the percentage of teaching operations, but the percentage of patients with accompanying diseases was significantly more frequent in groups 2, 3, and 4 (p = 0.04, 0.008, and 0.018, respectively). As compared to group 1, the conversion rate was significantly increased in groups 2 and 4 (2.3 vs. 9.3% (p = 0.013) and 2.3 vs. 12.5% (p = 0.017), respectively). The duration of surgery, hospitalization, and morbidity did not differ between the four groups. CONCLUSION: Up to a body mass index of 35 kg/m(2), increased body weight does not significantly reduce the feasibility and outcome of single-incision laparoscopic surgery for diverticulitis.

Long-term outcome of laparoscopic ileocecal resection for Crohn's disease before the era of biologics.

BACKGROUND: Crohn's disease (CD) of the terminal ileum not responding to standard medical treatment is more and more treated with biologics instead of surgery. In order to get more information on the results of surgery, we analyzed the outcome of laparoscopic ileocecal resection (LICR) performed before the widespread use of these drugs. METHODS: Chart reviews and telephone follow-ups were performed on 119 patients treated with laparoscopic ileocecal resection for CD. Follow-ups were performed at a median of 58 (17-124) and 113(69-164) months. Symptomatic restenosis requiring surgery or endoscopic dilatation was the primary endpoint. We further analyzed risk factors of recurrence. RESULTS: Of the 119 patients initially treated, 18 required surgery (n = 14) or endoscopic dilatation (n = 4). The calculated rates of re-intervention were 10 und 17.5 % at 5 and 10 years, respectively. Ninety percent of the patients had a Crohn-specific medication treatment at the time of surgery, but only 51.4 und 46.9 % at FU 1 und 2, respectively. Smoking increased the risk of recurrence (OR 3.7, P = 0.011). CONCLUSION: The data demonstrate excellent long-term results of LICR for CD of the terminal ileum. Surgery should be considered as a first choice treatment in many patients with ileocecal CD not responding to conventional treatment.

Antibodies against tumor necrosis factor (TNF) induce T-cell apoptosis in patients with inflammatory bowel diseases via TNF receptor 2 and intestinal CD14⁺ macrophages.

BACKGROUND & AIMS: The anti-tumor necrosis factor (TNF) antibodies infliximab, adalimumab, and certolizumab pegol have proven clinical efficacy in Crohn's disease. Here, we assessed the effects of anti-TNF antibodies on apoptosis in inflammatory bowel disease (IBD). METHODS: CD14(+) macrophages and CD4(+) T cells were isolated from peripheral blood and lamina propria mononuclear cells from patients with IBD and control patients. Cell surface markers and apoptosis were assessed by immunohistology and fluorescence-activated cell sorting techniques. RESULTS: Lamina propria CD14(+) macrophages showed significantly more frequent and higher membrane-bound TNF (mTNF) expression than CD4(+) T cells in IBD, whereas mTNF-dependent signaling proteins such as TNF receptor (TNFR) 2, TNFR-associated factor (TRAF) 2, and nuclear factor κB were induced in IBD mucosal CD4(+) T cells. Most anti-TNF antibodies did not induce T-cell apoptosis in purified peripheral or mucosal CD4(+) T cells. However, in contrast to etanercept, administration of all clinically effective anti-TNF antibodies resulted in a significant induction of T-cell apoptosis in IBD when lamina propria CD4(+) T cells expressing TNFR2(+) were cocultured with mTNF(+) CD14(+) intestinal macrophages. In contrast, no effects in control patients were noted. T-cell apoptosis in IBD occurred in vivo after treatment with adalimumab and infliximab, was critically dependent on TNFR2 signaling, and could be prevented via interleukin-6 signal transduction. Blockade of interleukin-6R signaling augmented anti-TNF-induced T-cell apoptosis in IBD. CONCLUSIONS: Clinically effective anti-TNF antibodies are able to induce T-cell apoptosis in IBD only when mucosal TNFR2(+) T cells are cocultured with mTNF-expressing CD14(+) macrophages. The finding that anti-TNF antibodies induce apoptosis indirectly by targeting the mTNF/TNFR2 pathway may have important implications for the development of new therapeutic strategies in IBD.

Perianal Fistula-Associated Carcinoma in Crohn's Disease: A Multicentre Retrospective Case Control Study.

BACKGROUND AND AIMS: Carcinoma associated with perianal fistula in Crohn's disease is a pending threat for patients. This study aimed to improve understanding and facilitate development of diagnostic and therapeutic strategies. METHODS: A retrospective case-control study was conducted at four German hospitals. The analysis included 40 patients with proven malignancy associated with perianal Crohn's fistulas and 40 randomly selected controls with fistulizing perianal Crohn's disease. Differences between groups were analysed and multivariate calculations were performed to describe risk factors for oncological outcomes. RESULTS: Histology revealed adenocarcinoma in 33/40 patients and squamous cell carcinoma in 7/40 patients. Compared to fistula patients without carcinoma, patients with malignancies associated with fistula had a diagnosis of Crohn's disease at younger age. Crohn's disease lasted longer in patients with malignancy [25.8 ± 9.0 vs 19.6 ± 10.4; p = 0.006]. Fistula-related findings differed significantly between the two groups. Signs of complicated and severe fistulation including complex anatomy and chronic activity occurred significantly more often in patients with malignancy associated with fistula. Significant multivariate hazard ratios for overall mortality and progression-free survival were shown for histological type of cancer, metastatic disease and R1 resection. Overall survival was 45.1 ± 28.6 months and the 5-year survival rate was 65%. CONCLUSIONS: In patients with adenocarcinoma or squamous cell carcinoma associated with perianal fistula in Crohn's disease, fistula characteristics determine the risk of malignancy. Early diagnosis influences outcomes, while treatment of chronic fistula activity may be key to preventing malignancy. Expert multimodal therapy is paramount for successful treatment of perianal fistula-associated malignancies.

Intraoperative pelvic nerve stimulation performed under continuous electromyography of the internal anal sphincter.

PURPOSE: The aim of this animal study was to investigate the effect of intraoperative pelvic nerve stimulation on internal anal sphincter electromyographic signals in order to evaluate its possible use for neuromonitoring during nerve-sparing pelvic surgery. METHODS: Eight pigs underwent low anterior rectal resection. The intersphincteric space was exposed, and the internal (IAS) and external anal sphincter (EAS) were identified. Electromyography of both sphincters was performed with bipolar needle electrodes. Intermittent bipolar electric stimulation of the inferior hypogastric plexus and the pelvic splanchnic nerves was carried out bilaterally. The recorded signals were analyzed in its frequency spectrum. RESULTS: In all animals, electromyographic recordings of IAS and EAS were successful. Intraoperative nerve stimulation resulted in a sudden amplitude increase in the time-based electromyographic signals of IAS (1.0 (0.5-9.0) µV vs. 4.0 (1.0-113.0) µV) and EAS (p < 0.001). The frequency spectrum of IAS in the resting state ranged from 0.15 to 5 Hz with highest activity in median at 0.77 Hz (46 cycles/min). Pelvic nerve stimulation resulted in an extended spectrum ranging from 0.15 to 20 Hz. EAS signals showed higher frequencies mainly in a range of 50 to 350 Hz. However, after muscle relaxation with pancuronium bromide, only the low frequency spectrum of the IAS signals was still present. CONCLUSIONS: Intraoperative verification of IAS function by stimulation of pelvic autonomic nerves is possible. The IAS electromyographic response could be used to monitor pelvic autonomic nerve preservation.

Laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy for diverticular disease? A prospective randomized trial on postoperative pain and analgesic consumption.

PURPOSE: Laparoscopic-assisted sigmoidectomy is an attractive but sometimes challenging operative technique for the treatment of diverticulitis of the sigmoid colon. The aim of this study was to compare, with respect to early postoperative analgesic demand and postoperative pain, laparoscopic-assisted sigmoidectomy with a laparoscopic-facilitated technique. In the laparascopic-facilitated technique, the sigmoid colon is removed conventionally via a cosmetically inconspicuous incision after prior laparoscopic mobilization. PATIENTS AND METHODS: Patients subjected to elective sigmoidectomy for diverticulitis were randomized to either laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy. All patients had piritramide-based, patient-controlled analgesia. The cumulative postoperative consumption over 96 hours was defined as the primary end point. Postoperative pain, fatigue, pulmonary function, and resumption of bowel function were secondary endpoints. RESULTS: : Forty-five patients were randomized according to the protocol to laparoscopic-assisted sigmoidectomy (n = 22) or laparoscopic-facilitated sigmoidectomy (n = 23). The analgesic consumption between the two groups was equivalent (61.3 (9-171) mg piritramide/96 hours vs. 64.3 (18-150) mg piritramide/96 hours; P = 0.827). Patients with laparoscopic-assisted sigmoidectomy had lower pain levels on Day one and Day two. Cumulative pain levels over 96 hours and over the whole 7-day observation period, however, were not significantly different, although postoperative fatigue and pulmonary function were significantly different. Duration of surgery was slightly shorter for laparoscopic-assisted sigmoidectomy (127 (47-200) vs. 135 (60-239) minutes; P = 0.28), but recovery of bowel activity was faster after laparoscopic-facilitated surgery. There was no significant difference in morbidity. CONCLUSION: Overall, the postoperative outcome was roughly equivalent after both techniques of laparoscopic sigmoidectomy. Therefore, laparoscopic-facilitated sigmoidectomy could be considered as an alternative to laparoscopic-assisted sigmoidectomy in technically difficult cases of diverticulitis subjected to laparoscopic surgery.

The colon J-pouch as a cause of evacuation disorders after rectal resection: myth or fact?

BACKGROUND: Colon J-pouch (JCP) reconstructions result in a better functional outcome than straight coloanal anastomosis (SCA) in terms of continence and frequency of defecation after rectal resection but might be associated with more evacuation difficulties. In order to evaluate this hypothesis, we systematically reviewed the literature to collect data on evacuation disorders after rectal resection in randomized or otherwise comparative trials. MATERIALS AND METHODS: Randomized controlled trials and comparative trials evaluating CJP versus SCA, latero-terminal anastomosis (LTA), and transverse coloplasty pouch (TCP) were ascertained by methodical search using Medline, Embase, and PubMed. Pooled estimates of outcomes were calculated for early-, intermediate-, and long-term follow-up. Primary meta-analysis outcomes were sensation of incomplete evacuation, prolonged evacuation, use of laxatives, use of enemas and suppositories, and stool fragmentation. RESULTS: When compared to SCA, CJP was associated with significantly less "prolongation of evacuation" but more "use of laxatives" in the intermediate-term follow-up, while both less "sensation of incomplete evacuation" and less "fragmentation" was found after CJP in the long-term. When compared to TCP, CJP was associated with significantly less fragmentation in the intermediate-term follow-up. CONCLUSIONS: Evacuation disorders are a unique problem of low anterior resection and are not specifically related to the colon J-pouch.

Modified ileocecal interposition. The final sphincter-saving solution after failed salvage surgery for anastomotic complications of low anterior resection.

INTRODUCTION: Reversal of low Hartmann's procedures can be a challenging operation. We report on the successful treatment of patients who have already had prior salvage surgery for complications of a low colorectal anastomosis presenting with active fistulas from the rectal remnant. METHODS: An ileocolic segment was mobilized with the neurovascular pedicle of the ileocolic artery and turned counterclockwise into the pelvis. The fistulas were cured and a hand-sutured colo-anal anastomosis was performed at the level of the dentate line. Almost the entire length of the remnant colon was preserved. RESULTS: There was no morbidity. The functional outcome was good or reasonable and the subjective satisfaction with the outcome was very high. CONCLUSION: We conclude that an ileocolic segment is an excellent substitute for reversal of low Hartmann's procedures even in patients in whom prior salvage surgery has failed. As the functional outcome is slightly inferior to other alternatives for rectal replacement, its use should be restricted to patients with complex local situations or in whom alternative reconstructions would result in significant loss of bowel length.

Pharmacokinetics and tissue penetration of moxifloxacin in intervention therapy for intra-abdominal abscess.

BACKGROUND AND OBJECTIVE: Intra-abdominal abscesses are usually polymicrobial and involve a variety of aerobic and anaerobic organisms. Thus, in addition to adequate drainage, empirical coverage with broad-spectrum antimicrobials is central to the management of such abscesses and an understanding of pharmacokinetic properties can be valuable when selecting antimicrobial agents. The present study examined the penetration of the fluoroquinolone antimicrobial moxifloxacin into abdominal abscess fluid in patients with an intra-abdominal abscess. METHODS: This was a non-randomized, open-label, single-centre trial. Eight patients with CT or ultrasound evidence of a localized intra-abdominal abscess requiring interventional drainage without signs of generalized peritonitis were considered suitable candidates for pharmacokinetic analysis. Each patient received a single dose of moxifloxacin 400 mg by intravenous infusion. Paired samples of blood and abscess fluid were collected over 24 hours for pharmacokinetic analysis. RESULTS: Following intravenous infusion, moxifloxacin penetrated and accumulated in intra-abdominal abscess fluid. The abscess fluid/plasma concentration ratio increased continuously from 0.083 (95% CI 0.047, 0.147) at 2 hours after administration to 1.66 (95% CI 0.935, 2.946) at 24 hours; concentrations in abscess fluid tended to exceed those in plasma after 12-24 hours. Half-life and mean residence time were longer in abscess fluid than in plasma, suggesting that moxifloxacin accumulates in abscess fluid. The abscess fluid/plasma concentration ratio continued to increase throughout the 24-hour sampling period, indicating that equilibrium between plasma and abscess fluid was not reached during this time. High intersubject variability for total moxifloxacin concentrations in intra-abdominal abscess fluid was noted, suggesting that abscess wall permeability is likely to be the parameter most strongly influencing moxifloxacin pharmacokinetics in abscess fluid. Comparison of the study results with data obtained from other in vitro studies suggested that abscess fluid concentrations above the minimum inhibitory concentrations for pathogens commonly isolated in intra-abdominal infections were maintained for approximately 8 hours after administration in this study. CONCLUSIONS: Moxifloxacin penetrates intra-abdominal abscesses after interventional drainage. Based on the pharmacokinetic data, moxifloxacin is a good candidate therapy for use in patients with intra-abdominal abscesses undergoing CT-guided percutaneous drainage and may also prove valuable in the general systemic management of intra-abdominal abscesses in the future.

Achalasia--if surgical treatment fails: analysis of remedial surgery.

INTRODUCTION: Heller myotomy leads to good-excellent long-term results in 90% of patients with achalasia and thereby has evolved to the "first-line" therapy. Failure of surgical treatment, however, remains an urgent problem which has been discussed controversially recently. MATERIALS AND METHODS: A systematic review of the literature was performed to analyze the long-term results of failures after Heller's operation with emphasis on treatment by remedial myotomy. DISCUSSION: Other reinterventions and their causes after failure of surgical treatment in patients with achalasia are discussed.