Prevention of anastomotic leak in rectal cancer surgery with local antibiotic decontamination: a prospective, randomized, double-blind, placebo-controlled single center trial.

PURPOSE: Anastomotic leak and other infectious complications are septic complications of rectal cancer surgery caused by bacteria. Data from registry analysis show a beneficial effect of local antimicrobial administration on anastomotic leaks, but data are inconsistent in recent clinical trials. Therefore, our aim was to study the efficacy of topical antibiotic treatment on the incidence of anastomotic leaks in rectal cancer surgery. METHODS: A prospective, randomized, double-blind and placebo-controlled, single center trial was conducted. Patients received either placebo and amphotericin B or decontamination with polymyxin B, tobramycin, vancomycin, and amphotericin B four times per day starting the day before surgery until postoperative day 7. If a protective ileostomy was created, a catheter was placed transanally and the medication was administered locally to the anastomotic site. All patients received an intravenous perioperative antibiotic prophylaxis. RESULTS: The trial had to be stopped for ethical reasons after first interim analysis with 80 patients instead of the initially planned 280 patients. Of the 40 patients randomized to receive placebo, eight (20%) developed anastomotic leak compared to only 2 (5%) in the treatment group of 40 patients (decontamination) with significant difference in the χ2 test (p = 0.0425). Twenty percent of the placebo group and 12.5% in the treatment group developed infectious complications not associated with anastomotic leak (p = 0.5312). One patient (2.5%) in the placebo group died (p = 0.3141). CONCLUSION: Local decontamination with polymyxin, tobramycin, vancomycin, and amphotericin B is safe and effective in the prevention of anastomotic leak in rectal cancer surgery.

Cartilage survival of the knee strongly depends on malalignment: a survival analysis from the Osteoarthritis Initiative (OAI).

PURPOSE: Progression of osteoarthritis over time is poorly understood. The aim of the current study was to establish a timeline of "cartilage survival rate" per subregion of the knee in relation to mechanical alignment of the lower extremity. The study hypothesized that there are differences in progression of osteoarthritis between varus, valgus and physiologic lower extremity alignment. METHODS: Based on hip-knee-ankle standing radiographs at baseline, 234 knees had physiologic (180° ± 3°, mean 179.7°), 158 knees had varus (< 177°; mean 174.5°) and 66 knees valgus (> 183°; mean 185.2°) alignment (consecutive knees of the OAI "Index Knee" group, n = 458; mean age 61.7; 264 females). The Osteoarthritis Initiative (OAI; a multi-center, longitudinal, prospective observational study of knee osteoarthritis [30] using MRIs) defines progressive OA as a mean decrease of cartilage thickness of 136 µm/year and a mean decrease of cartilage volume by 5% over 1 year (DESS sequences, MRI). A Kaplan-Meier curve was generated for osteoarthritis progression based on OAI criteria. RESULTS: Osteoarthritis progression based on volume decrease of 5% in varus knees occurred after 30.8 months (medial femoral condyle), after 37 months (medial tibia), after 42.9 months (lateral femoral condyle) and 43.4 months (lateral tibia), respectively. In a valgus alignment progression was detectable after 31.5 months (lateral tibia), after 36.2 months (lateral femoral condyle), after 40.4 months (medial femoral condyle) and 43.8 months (medial tibia), respectively. The physiological alignment shows a progression after 37.8 months (medial femoral condyle), after 41.6 months (lateral tibia), after 41.7 months (medial tibia) and after 43 months (lateral femoral condyle), respectively. CONCLUSION: Based on data from the OAI, the rate and location (subregion) of osteoarthritis progression of the knee is strongly associated with lower extremity mechanical alignment. LEVEL OF EVIDENCE: Level I (prognostic study).

Predictive values of WOMAC, KOOS, and SF-12 score for knee arthroplasty: data from the OAI.

PURPOSE: A number of validated scores are available to monitor clinical outcome after knee arthroplasty. The current study examines whether WOMAC, KOOS, or SF-12 scores have a predictive value to identify patients that require total knee arthroplasty within 1 year. METHODS: The Osteoarthritis Initiative includes 4684 patients in two groups: incidence subcohort (Group A, n = 3284) and progression subcohort (Group B, n = 1400). A total of 278 patients reached the endpoint "unilateral knee replacement" (Group A = 96; Group B = 182). WOMAC, KOOS, and SF-12 scores at the maximum of 12 months prior to surgery were used to analyse predictive values. ROC analysis and the diagnostic accuracy for these scores were reported. RESULTS: Group A: WOMAC and KOOS score as well as the "physical component summary" of SF-12 showed an area under the curve (AUC) between 0.8 and 0.9 (high diagnostic evidence) to predict total knee replacement. The KOOS "symptoms" (0.67) and SF12 "function" (0.79) showed lower values. The KOOS QoL score showed the highest predictive value with an AUC of 0.84 (CI 95% 0.77-0.91, p < 0.001) resulting in a sensitivity of 0.88 and a specificity of 0.72. Similar numbers were achieved by the total WOMAC score with an AUC of 0.85 (CI 95% 0.82-0.88, p < 0.001) resulting in a sensitivity of 0.77 and a specificity of 0.82. The SF-12 physical component score had an AUC of 0.83 (CI 95% 0.79-0.87, p < 0.001) resulting in a sensitivity of 0.87 and a specificity of 0.68. Different combinations of scores increase the positive likelihood ratio (up to 18) and specificity (up to 0.97). Group B scores showed lower AUCs, sensitivities and specificities. CONCLUSIONS: Combinations of WOMAC, KOOS, or SF-12 scores accurately predict patients that require knee arthroplasty within 1 year. In addition to other clinical parameters (physical examination, radiographs), they can guide patient and surgeon during the treatment of arthritis of the knee. LEVEL OF EVIDENCE: II.

Does the tibia component design affect the need for offset stems in revision total knee arthroplasty?

INTRODUCTION: The stem/keel location varies between anatomic and symmetric revision tibial baseplates. The current study investigates the impact of an anatomic versus symmetric stem location on the need for offset couplers in revision total knee arthroplasty. MATERIALS AND METHODS: Hip to ankle standing radiographs and lateral radiographs of 75 patients were analyzed using digital templating software. The offset in the anterior-posterior as well as medial-lateral plane between the center of the tibial diaphysis and the stem of the tibial baseplate were determined for an anatomic and symmetric tibial baseplate, respectively. Measurements were repeated for 4 resection levels: tip of fibular head (0), 10 mm (1), 15 mm (2) and 20 mm (3) below the tip of the fibula head. RESULTS: Anatomic tibial baseplates require less offset for resection levels up to the tip of the fibula: total offset 2.28 versus 5.44 mm (p < 0.001). However, for defects that result in resection levels below the tip of the fibula symmetric tibial baseplates require less offset: resection level 1: 3.18 versus 2.4 mm (p = 0.008), 2: 4.81 versus 1.67 mm (p < 0.001) and resection level 3: 5.66 versus 1.52 mm (P < 0.001). CONCLUSION: The current study suggests that while asymmetric anatomic tibial baseplates have benefits for revisions with minimal bone loss, symmetric tibial baseplates require less offset when larger bone defects are encountered.

[Posttraumatic adhesive ileus following pelvic ring fracture]. / Posttraumatischer Briden-Ileus nach Beckenringfrakturen.

We report on two cases of posttraumatic ileus after pelvic ring fracture in two patients aged 73 and 74 years, respectively. Although all conservative measures were exhausted, in both cases the ileus resulted in additional operative procedures and a significant extension of the hospital stay. Intraoperatively both patients presented with a mechanical ileus caused by adhesions which were unapparent for decades. Only the trauma-related motility disorder led to a clinical manifestation. Pathophysiological mechanisms and their implications on prophylaxis and therapy are discussed.

The CR-POSSUM Risk Calculator Predicts Failure of Enhanced Recovery after Colorectal Surgery.

AIMS: To determine predictors of failed enhanced recovery after surgery (ERAS) in patients after elective colorectal surgery. METHODS: A cohort of 55 patients undergoing elective colorectal surgery was monitored prospectively. Perioperative care was based on a previously established protocol for ERAS. Pre-, intra-, and postoperative parameters were analyzed to elicit predictors of ERAS failure. ERAS failure was defined as prolonged hospital stay (> 7 days). The risk calculator CR-POSSUM was evaluated for its clinical utility. RESULTS: Body mass index (BMI) or the American Society of Anesthesiologists score (ASA) was not associated with ERAS failure on univariate analysis, but patients that failed ERAS were significantly older (64 y vs 54 y; p = 0.023). Prolonged length of stay (>7 days) was also associated with an open approach (p = 0.009), intraoperative nasogastric tube placement (p = 0.005), blood loss > 500 ml (p = 0.008), stoma formation (p = 0.006) and insertion of more than one intraabdominal drain during surgery (p = 0.005). Postoperative continuation of intravenous fluids (p = 0.027), reinsertion of urinary catheter (p = 0.045) and postoperative ileus (p = 0.020) were also strongly associated with delayed discharge on univariate analysis. After multivariate analysis the preoperative parameters CR-POSSUM score (p = 0.022), increasing BMI (p = 0.014) and preoperative albumin level (p = 0.031) were all independently associated with failure of ERAS. CONCLUSIONS: A variety of perioperative factors contribute to failure of ERAS in routine practice. CR-POSSUM can help to identify patients at risk for possible failure of ERAS. This may help to optimize avoidable factors, or accommodate those patients likely to require a longer post-operative stay.

The CR-POSSUM Risk Calculator Predicts Failure of Enhanced Recovery after Colorectal Surgery.

AIMS: To determine predictors of failed enhanced recovery after surgery (ERAS) in patients after elective colorectal surgery. METHODS: A cohort of 55 patients undergoing elective colorectal surgery was monitored prospectively. Perioperative care was based on a previously established protocol for ERAS. Pre-, intra-, and postoperative parameters were analyzed to elicit predictors of ERAS failure. ERAS failure was defined as prolonged hospital stay (> 7 days). The risk calculator CR-POSSUM was evaluated for its clinical utility. RESULTS: Body mass index (BMI) or the American Society of Anesthesiologists score (ASA) was not associated with ERAS failure on univariate analysis, but patients that failed ERAS were significantly older (64 y vs 54 y ; p = 0.023). Prolonged length of stay (> 7 days) was also associated with an open approach (p = 0.009), intraoperative nasogastric tube placement (p = 0.005), blood loss > 500 ml (p = 0.008), stoma formation (p = 0.006) and insertion of more than one intraabdominal drain during surgery (p = 0.005). Postoperative continuation of intravenous fluids (p = 0.027), reinsertion of urinary catheter (p = 0.045) and postoperative ileus (p = 0.020) were also strongly associated with delayed discharge on univariate analysis. After multivariate analysis the preoperative parameters CR-POSSUM score (p = 0.022), increasing BMI (p = 0.014) and preoperative albumin level (p = 0.031) were all independently associated with failure of ERAS. CONCLUSIONS: A variety of perioperative factors contribute to failure of ERAS in routine practice. CR-POSSUM can help to identify patients at risk for possible failure of ERAS. This may help to optimize avoidable factors, or accommodate those patients likely to require a longer post-operative stay.

[Improving continuing medical education: a valuable investment for the future of surgery]. / Verbesserung der Weiterbildung: Eine wertvolle Investition in die Zukunft der Chirurgie.

At present, surgery in Germany is suffering from the problem of poor attractivity jeopardizing nationwide availability of competent and high quality surgical care in the future. The causes for this have been repeatedly attributed to structural problems, above all in medical training and continuing medical education. In this article, we present the results of questionnaires of the National Society of German Surgeons and the German National Chamber of Physicians, identify the specific problem, and finally analyse them in an attempt to show how surgical training can be optimised and the attractivity of this specialty can be improved. In this context, the "Grosshadern Concept" for continuing surgical education is introduced as an example for an established and good functioning training curriculum.

[Learning from aviation - how to increase patient safety in surgery]. / Kann die Chirurgie wirklich von der Luftfahrt lernen?

During the last years attempts have been made to draw lessons from aviation to increase patient safety in medicine. In particular similar conditions are present in surgery as pilots and surgeons may have to support high physical and mental pressure. The use of a few safety instruments from aviation is feasible in an attempt to increase safety in surgery. First a "root caused" accident research may be established. This is achievable by morbidity and mortality conferences and critical incident reporting systems (CIRS). Second, standard operating procedures may assure a uniform mental model of team members. Furthermore, crew resource management illustrates a strategy and attitude concept, which is applicable in all situations. Safety instruments from aviation, therefore, seem to have a high potential to increase safety in surgery when properly employed.

Quality of life after coloanal anastomosis and abdominoperineal resection for distal rectal cancers: sphincter preservation vs quality of life.

AIM: A permanent colostomy is considered to have an adverse impact on quality of life (QOL). However, functional outcomes following sphincter preservation also affect QOL. Our aim was to determine differences in QOL of patients undergoing coloanal anastomosis (CAA) or abdominoperineal resection (APR) for distal rectal cancer. METHOD: Eighty-five patients underwent CAA (72 with intestinal continuity and 13 with a stoma because of complications) and 83 patients underwent APR for a distal rectal cancer between 1995 and 2001 at a single institution and responded to our survey. QOL was evaluated using the EORTC QLQ-C30 and QLQ-CR38. RESULTS: Patients with CAA were younger than APR patients (mean age 57 vs 62 years, P < 0.001), but gender distribution, tumour stage and proportion of subjects receiving radiotherapy was not significantly different. Patients undergoing CAA had higher scores (better QOL) for physical functioning; lower scores (fewer symptoms) for fatigue, pain, financial difficulties, weight loss and chemotherapy side effects; and higher scores (more symptoms) for constipation and gastrointestinal symptoms compared with APR patients. CAA patients had higher scores (better QOL) for body image in men but not in women. Sexual functioning scores in men and women were lower (worse QOL) in CAA patients compared with APR patients. CONCLUSIONS: QOL after APR is comparable to sphincter preservation, although there are some differences that need to be considered. QOL and functional results should be taken into account with the oncological outcome when devising management strategy for distal rectal cancer.

Effect of chronic, extrinsic denervation on functional NANC innervation with vasoactive intestinal polypeptide and substance P in longitudinal muscle of rat jejunum.

Intestinal denervation contributes to enteric motor dysfunction after intestinal transplantation [small bowel transplantation (SBT)]. Our aim was to determine long-term effects of extrinsic denervation on functional non-adrenergic, non-cholinergic innervation with vasoactive intestinal polypeptide (VIP) and substance P. Contractile activity of jejunal longitudinal muscle from six age-matched, naïve control rats (NC) and eight rats 1 year after syngeneic SBT were studied in tissue chambers. Spontaneous contractile activity did not differ between groups. Exogenous VIP inhibited contractile activity dose-dependently in both groups, greater in NC than in SBT. The VIP antagonist ([D-p-Cl-Phe(6),Leu(17)]-VIP) and the nitric oxide synthase inhibitor l-N(G)-nitro arginine prevented inhibition by exogenous VIP and electrical field stimulation (EFS) in both groups. Exogenous substance P increased contractile activity dose-dependently, greater in NC than in SBT. The substance P antagonist ([D-Pro(2),D-Trp(7,9)]-substance P) inhibited effects of exogenous substance P and increased the EFS-induced inhibitory response. Immunohistofluorescence showed staining for tyrosine hydroxylase in the jejunoileum 1 year after SBT suggesting sympathetic reinnervation. In rat jejunal longitudinal muscle after chronic denervation, response to exogenous VIP and substance P is decreased, while endogenous release of both neurotransmitters is preserved. These alterations in excitatory and inhibitory pathways occur despite extrinsic reinnervation and might contribute to enteric motor dysfunction after SBT.

Risk of fecal diversion in complicated perianal Crohn's disease.

The purpose of the study was to determine the overall risk of a permanent stoma in patients with complicated perianal Crohn's disease, and to identify risk factors predicting stoma carriage. A total of 102 consecutive patients presented with the first manifestation of complicated perianal Crohn's disease in our outpatient department between 1992 and 1995. Ninety-seven patients (95%) could be followed up at a median of 16 years after first diagnosis of Crohn's disease. Patients were sent a standardized questionnaire and patient charts were reviewed with respect to the recurrence of perianal abscesses or fistulas and surgical treatment, including fecal diversion. Factors predictive of permanent stoma carriage were determined by univariate and multivariate analysis. Thirty of 97 patients (31%) with complicated perianal Crohn's disease eventually required a permanent stoma. The median time from first diagnosis of Crohn's disease to permanent fecal diversion was 8.5 years (range 0-23 years). Temporary fecal diversion became necessary in 51 of 97 patients (53%), but could be successfully removed in 24 of 51 patients (47%). Increased rates of permanent fecal diversion were observed in 54% of patients with complex perianal fistulas and in 54% of patients with rectovaginal fistulas, as well as in patients that had undergone subtotal colon resection (60%), left-sided colon resection (83%), or rectal resection (92%). An increased risk for permanent stoma carriage was identified by multivariate analysis for complex perianal fistulas (odds ratio [OR] 5; 95% confidence interval [CI] 2-18), temporary fecal diversion (OR 8; 95% CI 2-35), fecal incontinence (OR 21, 95% CI 3-165), or rectal resection (OR 30; 95% CI 3-179). Local drainage, setons, and temporary stoma for deep and complicated fistulas in Crohn's disease, followed by a rectal advancement flap, may result in closing of the stoma in 47% of the time. The risk of permanent fecal diversion was substantial in patients with complicated perianal Crohn's disease, with patients requiring a colorectal resection or suffering from fecal incontinence carrying a particularly high risk for permanent fecal diversion. In contrast, patients with perianal Crohn's disease who required surgery for small bowel disease or a segmental colon resection carried no risk of a permanent stoma.

Differential activation of afferent neuronal and inflammatory pathways during small bowel obstruction (SBO).

BACKGROUND: Small bowel obstruction (SBO) is a potentially life-threatening condition which may be caused by a variety of pathologies such as postoperative adhesions or malignant diseases. Little is known on alterations in gut physiology during SBO, although its comprehension is essential to improve treatment which may help to prevent subsequent organ failure prior to surgical resolution. We aimed to investigate afferent nerve sensitivity and intestinal inflammatory response during SBO to identify possible targets of treatment. METHODS: C57Bl6 mice were anesthetized, and a midline laparotomy was performed. A small bowel loop was ligated 5 cm proximal to ileo-cecal valve to induce SBO. Control animals received a sham midline laparotomy. SBO animals and controls were sacrificed after 3, 9, or 24 h (each n = 6). A dilated segment of small intestine located 1.5 cm oral to the ligature was prepared for multi-unit mesenteric afferent nerve recordings in vitro. Histological assessment of leukocyte infiltration was performed by myeloperoxidase (MPO). Pro-inflammatory cytokine expression was quantified by RT-PCR. Data are mean ± SEM. KEY RESULTS: Afferent firing to serosal 5-HT (500 µM) peaked at 3.9 ± 0.2 impulse/s 24 h after induction of SBO compared to 2.4 ± 0.1 impulse/s in sham controls (p < 0.05). Serosal bradykinin (0.5 µM) led to an increase in peak afferent firing of 5.3 ± 0.5 impulse/s in 24 h SBO animals compared to 3.5 ± 0.2 impulse/s in sham controls (p < 0.05). No differences in 5-HT and BK sensitivity were observed in 3 and 9 h SBO animals compared to controls. Continuous mechanical ramp distension of the intestinal loop was followed by a pressure-dependent rise in afferent nerve discharge that was reduced in 3 h SBO animals compared to sham controls (p < 0.05). MPO stains showed a rise in leukocyte infiltration of the intestine in SBO animals at 9 and 24 h (p < 0.05). Il-6 but not TNF-a gene expression was increased at 9 and 24 h in SBO animals compared to sham controls (p < 0.05). CONCLUSIONS & INFERENCES: Afferent nerve sensitivity is increased 24 h after induction of SBO. SBO led to a delayed onset intestinal inflammatory response. Inflammatory mediators released during this inflammatory response may be responsible for a later increase in afferent sensitivity. Agents with anti-inflammatory action may, therefore, have a beneficial effect during SBO and may subsequently help to prevent possible organ dysfunction.

Long-term outcome following treatment of Adamantinoma and Osteofibrous dysplasia of long bones.

INTRODUCTION: Adamantinoma (AD) is an ultimately rare, low-grade malignant bone tumor. In most cases it occurs in the tibia of young adults. Osteofibrous dysplasia (OFD) is a rare, benign, lesion that is typically seen in children. Histopathology, ultrastructure, and cytogenetics indicate that these lesions are closely related. Yet, etiology remains a matter of debate. Local recurrence rates are high for both entities as published in literature and long-term outcomes are scarce, due to the rarity of the disease. HYPOTHESIS: AD should be treated by En-Bloc resection while ODF can be treated by curettage or by observation. Consequently, the aim of the present study was to answer following questions: Were local recurrence rates of both entities different based on a retrospective review within a tertiary referral center for orthopedic oncology? MATERIAL AND METHODS: In a retrospective cohort study, 10 patients with AD and 5 patients with OFD (including 1 patient with OFD-like-AD) were reviewed. Primary surgeries for patients with AD were: En-bloc resection in 7, curettage in 2 and amputation in 1. In the OFD group, only 2 patients underwent surgery by curettage. Mean follow-up was 16 years (range: 2-47 years). Nine patients had a minimum follow-up of 10 years (mean: 23 years; range: 10-47 years). RESULTS: Four patients with AD (40%) and 2 patients with OFD (40%) - all of them following surgical removal - suffered from local recurrence. In the "En bloc" resection group of AD, there were 2 LR (29%). All patients of both groups treated with curettage showed LR. One patient with AD had metastasis at time of diagnosis and died of disease. Another patient with AD was diagnosed with metastasis 67 months after surgery and was still alive with disease at latest follow-up (77 month). DISCUSSION: The overall prognosis of AD and OFD is good, yet local recurrence rates are high, irrespective of surgical strategy. While an internationally standardized treatment regime is still missing, a more radical surgical approach should be considered, especially when treating AD. LEVEL OF EVIDENCE: Retrospective study; Level IV.

Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon.

INTRODUCTION: The indication for surgery after conservative treatment of acute diverticulitis is still under debate. This is partly as a result of limited data on the outcome of conservative management in the long run. We therefore aimed to determine the long-term results of conservative treatment for acute diverticulitis. METHODS: The records of all patients treated at our institution for diverticulitis between 1985 and 1991 were reviewed (n=363, median age 64 years, range 29-93). Patients who received conservative treatment were interviewed in 1996 and 2002 [follow-up time 7 years 2 months (range 58-127 months) and 13 years 4 months (range 130-196 months). RESULTS: A total of 252 patients (69%) were treated conservatively, whereas 111 (31%) were operated on. At the first follow-up, 85 patients treated conservatively had died, one of them from bleeding diverticula. A recurrence of symptoms was reported by 78 of the remaining 167 patients, and 13 underwent surgery. At the second follow-up, one patient had died from sepsis after perforation during another episode of diverticulitis. Thirty-one of the 85 patients interviewed reported symptoms and 12 had been operated on. In summary, at the second follow-up interview, 34% of patients treated initially had had a recurrence and 10% had undergone surgery. No predictive factors for the recurrence of symptoms or later surgery could be determined. CONCLUSION: Despite a high rate of recurrences after conservative treatment of acute diverticulitis, lethal complications are rare. Surgery should thus mainly be undertaken to achieve relief of symptoms rather than to prevent death from complications.

Modulation of intestinal afferent nerve sensitivity to inflammatory mediators following systemic endotoxin in mice.

BACKGROUND: Endotoxin exposure may be followed by visceral hypersensitvity but potential mechanisms are not fully explored. We aimed to test the hypothesis that mast cells and the cyclooxygenase pathway (COX) mediate modulation of afferent nerve sensitivity following systemic endotoxin. METHODS: C57Bl6 mice received endotoxin injection i.p. to induce systemic inflammation. Control animals received normal saline. Extracellular multi-unit afferent nerve discharge was recorded from jejunal mesenteric nerves in vitro. Afferent nerve response to 5-hydroxytryptamine (5-HT, 250 µmol/L), bradykinin (BK, 0.5 µmol/L), and to mechanical ramp distension of the intestinal lumen from 0 to 60 cmH2O were recorded 2 h following endotoxin administration. KEY RESULTS: Following endotoxin administration peak afferent discharge to 5-HT and BK was increased compared to controls (p < 0.05). Pre-perfusion with the mast cell stabilizer Doxantrazole (10(-4) M), or the cyclooxygenase inhibitor Naproxen inhibited the increased response to 5-HT and BK (p < 0.05 vs endotoxin pretreatment). Mechanosensitivity during luminal ramp distension from 10 to 60 cmH2O was increased following endotoxin pretreatment compared to controls (p < 0.05). This increase in sensitivity following endotoxin was no longer observed after Doxantrazole or Naproxen administration for pressures from 10 to 30 cmH2O (p < 0.05). Selective COX-2 inhibition by NS398 (10 µM) but not COX-1 inhibition by SC560 (300 µM) reduced increased afferent discharge in endotoxin pretreated animals to 5-HT, BK and mechanical ramp distension from 10 to 40 cmH2O (all p < 0.05). CONCLUSIONS & INFERENCES: Systemic endotoxin sensitizes mesenteric afferent nerve fibers to 5-HT, BK and mechanical stimuli. The underlying mechanism responsible for this sensitization seems to involve mast cells and the COX-2 pathway.

Neostigmine increases postoperative colonic motility in patients undergoing colorectal surgery.

BACKGROUND: Gastrointestinal motility is frequently impaired after abdominal surgery. We investigated the effects of neostigmine on colonic motility in patients after colorectal surgery and in healthy volunteers. METHODS: Colonic motility was recorded by a manometry/barostat system in 12 patients after left colonic or rectal resection during baseline and after the intravenous administration of increasing doses of neostigmine on postoperative days 1, 2, and 3. In addition, colonic motility was recorded in 7 healthy volunteers. RESULTS: Neostigmine increased the colonic motility index. This increase was from 135 +/- 28 mm Hg/min at baseline to 574 +/- 219 mm Hg/min after administration of 5 microg/kg neostigmine on day 3 after surgery (mean +/- SEM, P <.05). In healthy volunteers, neostigmine at a dose of 5 microg/kg increased the colonic motility index from 184 +/- 73 to 446 +/- 114 mm Hg/min (P <.05). Barostat bag volumes decreased dose-dependently after neostigmine administration in patients as well as in volunteers, indicating an increase in colonic tone. CONCLUSIONS: Colonic motility and tone increased after neostigmine administration at a dose of 5 microg/kg in postoperative patients and in healthy volunteers. Neostigmine can be used to stimulate colonic motility after colorectal surgery and has a similar effect postoperatively as in healthy volunteers.

Arterial injures in the Emergency Room Practice of Traumatic Surgery.

Background. Although arterial injuries occur rarely (1,15%), they often lead to serious consequences (13% limb amputation), and can be the cause of patient deaths (9%).
Material and methods. The research involved 23 cases of traumatic injury to arteries in patients admitten for traumatic surgery to the Emergency Room at the Traumatology Clinic of the Jagiellonian University's Collegium's Medicum from 1997 to 2000.
Results. The article presents the surgical methods and outcomes for the various cases reported. In two cases of damage to the abdominal artery the patient did not survive; two patients with damage to the popliteal artery and one patient with a damaged femoral artery, the limb could not be saved. In the remaining cases good results were obtained.
Conclusions. The most important factors influencing outcome in the treatment of traumatic artery damage are the localization and nature of the injury and the time that elapses from the moment of injury until the patient arrives in the operating theater. For this reason it is essential that the trauma team have a physician with experience in vascular surgery.