[Implementation of a standardized perioperative pain management concept in three hospitals of a consortium]. / Implementierung eines standardisierten perioperativen Schmerzmanagementkonzepts in drei Krankenhäusern eines Klinikverbundes.

BACKGROUND: Provision of sufficient perioperative pain therapy is an obligation in the clinical management of patients suffering from pain. The implementation of a standardized pain management concept was planned to be introduced in the clinical routine. The results of three hospitals are shown. MATERIAL AND METHODS: The concept included tools which gave information about legal aspects and basic fundamentals of pain relief, management modules regarding agreements on the implementation of perioperative pain therapy, instruments to measure pain intensity, assigning accountability and documentation modules. Questionnaires were carried out according to Picker. RESULTS: The project revealed that, according to the Picker questionnaire, about 50% of the patients treated in the hospitals had pain, 30-40% still had intensive pain during the stay in hospital and 90% of the patients received pain relief medication within 10 min of the request. More than 78% of the patients thought the hospital staff did their best to relieve the pain and over 92% found the pain treatment adequate. CONCLUSION: It was possible to implement a standardized perioperative pain therapy concept in three hospitals of a consortium. Whether an adequate pain relief can be improved with the help of standard measurements and documentation, could not be evaluated in this study.

Ambulatory long-term pH monitoring in pigs.

BACKGROUND: pH monitoring has been established as the "gold standard" in the diagnosis of gastroesophageal reflux. Evaluation of experimental antireflux therapy should therefore also include this technique, but a suitable technique in an experimental model did not exist so far. The aim of our study was to establish a reliable method for the evaluation of an experimental reflux model in pigs. METHODS: A total of 33 German Landrace pigs with an average body weight of 56 (50.2-67.2) kg were included. pH monitoring was performed before and after open cardiomyotomy in each animal. All manipulations were performed under general anesthesia. After manometric localization of the gastroesophageal high-pressure zone, a standard pH probe was inserted into the pharynx through a small needle-punctured canal on the side of the animal's snout and placed under endoscopic guidance with the proximal sensor 3 cm above the lower esophageal sphincter (LES) and the distal sensor in the stomach for reference. The harness to carry the pH recorder on the animal's back consisted of a modified belly strap that enabled the animal to move around without limitation. For analysis the same threshold levels were defined as in humans. Gastroesophageal reflux was induced by cardiomyotomy. RESULTS: The placement of the standard pH probe was possible in all cases. Inserting the probe on the side of the snout left the animals free to nuzzle, which complies with the normal habits of pigs, without breaking the probes and without being compromised in their natural behavior. Repeated punctures for multiple measurements were easily feasible. We performed up to three examinations in each individual animal. Recording was performed for 48 h. A mean number of 67.3 (+/-9.7) acidic refluxes were registered. The mean number of long acidic refluxes was 3.2 (+/-0.75). For an average total time of 75.5 (+/-14.3) min the pH was below 4 accounting for a fraction time pH below 4 of 3.5% (+/-0.68%). Following cardiomyotomy the number of acidic refluxes increased significantly to 166.1 (+/-21.8) and the number of long refluxes to 17.74 (+/-3.35). The total time of pH below 4 increased to 371.3 (+/-62) min so that the fraction time pH below 4 was 14.5% ( p = 0.0006). CONCLUSION: pH monitoring should be mandatory in any investigation of antireflux therapy. Our method is easy and secure to perform. It is suitable for other gastrointestinal investigations (Bilitec, long-term manometry) that could be carried out using the same technique. The described data represent the basis for other investigations of experimental antireflux therapy.

[Gastric substitute following gastrectomy]. / Magenersatz nach Gastrektomie.

Gastric substitute following gastrectomy. Following gastrectomy a variety of different reconstructive alternatives with different advantages and disadvantages have been proposed. Direct termino-lateral esophagojejunostomy with preservation of the duodenal passage or roux-en-Y jejuno-jejunostomy may be considered as current standard route of reconstruction. With current knowledge formation of a jejunal reservoir with a pouch length of 15 cm seems to be advantageous over simple roux-en-Y reconstruction. Preservation of the duodenal passage offers objective biochemical advantages, while its clinical implications have yet to be confirmed. True long term results of randomised studies are still pending. Thus, the technically easier pouch formation using the roux-en-Y reconstruction may currently be favored. Jejunoplicatio as an antirefluxive component of reconstruction is optional. Its value may well lie in the securement of a critical esophagojejunal anastomosis.

[Laparoscopic 2/3 resection of the stomach with intracorporal Roux-en-Y anastomosis]. / Laparoskopische 2/3-Resektion des Magens mit intracorporaler Anastomose nach Y-Roux.

In a patient with recurrent ulcer disease under medication, which was complicated by episodes of bleeding, a laparoscopic partial gastric resection with intracorporal Roux-en-Y anastomosis was performed. The operation was completed within 3 h with blood loss < 10 ml. The postoperative hospital stay of 6 days was uncomplicated as was the further follow-up (2 months so far). This operation and the study of results published in the literature showed us that a gastric resection can certainly be performed laparoscopically in the appropriate patient.

[Pancreatico-bronchial fistula with communication to a pseudoaneurysm of the arteria lienalis as a rare complication in chronic pancreatitis]. / Pankreatikobronchiale Fistel mit Anschluss an ein Pseudoaneurysma der Arteria lienalis als seltene Komplikationen einer chronischen Pankreatitis.

Thoracic manifestations of internal pancreatic fistulas caused by chronic pancreatitis are rare conditions. The three main types of these manifestations are mediastinal pseudocysts, pancreatico pleural fistulas and pancreaticobronchial fistulas. We report on one patient with the clinical presentation of all three thoracic internal pancreatic fistulas with a communication to a pseudoaneurysm of the splenic artery caused by chronic alcohol-related pancreatitis. Conservative therapy over four weeks was not successful. Resection of the pseudoaneurysm, debridement of the mediastinal pseudocyst and duodenum preserving resection of the pancreas treated all complications and prevents recurrence in this patient with chronic pancreatitis.

[Multi-media CD-ROM: a new medium for improving information dissemination]. / Multimedia CD-ROM: Ein neues Medium zur Verbesserung der Wissensvermittlung.

New media can be used in medicine for effective and prompt imparting of knowledge. We present a multimedia CD-ROM providing up to date congress information.

Successful surgical treatment of liver and kidney metastases 25 years after a primary lacrimal gland tumor.

Among primary lacrimal gland tumors the adenoid-cystic carcinoma is the most common malignant epithelial lesion. We present a unique case of hepatic and renal metastases surgically treated 25 years after excision of a primary adenoid-cystic carcinoma of the lacrimal gland and after resection of intracranial and pulmonary metastases. The clinical and pathological features of this malignant tumor are discussed. To our knowledge this is the longest reported survival of a patient with such a tumor.

[Right-sided hemihepatectomy in echinococcosis of the liver in pregnancy]. / Rechtsseitige Hemihepatektomie bei Leberechinococcus während der Gravidität.

The treatment of symptomatic echinococcal disease of the liver during pregnancy is a rare, but difficult problem. A 42 year old, pregnant woman with obstructive jaundice and acute cholangitis due to extensive echinococcus cysticus infection of the right hepatic lobe is presented. A formal, right hemihepatectomy was successfully performed.

Rat liver injury induced by hypoxic ischemia and reperfusion: protective action by somatostatin and two derivatives.

Natural somatostatin and two synthetic derivatives (octreotide, 008) were tested for their ability to prevent hypoxic ischemic cell injury of the isolated perfused rat liver. The cyclic octapeptide octreotide is known to have endocrine and cytoprotective activities, whereas the cyclic hexapeptide 008 exerts protective actions without any endocrine effects. In isolated perfused rat livers flow rate was reduced and oxygen supply interrupted for 180 min. Then the livers were normoxically reperfused for 30 min. LDH and GLDH activity as well as Ca2+ concentration was determined in the effluent. Hypoxic ischemia led to a substantial enzyme release from the liver and to a strong Ca2+ influx. Pretreatment with somatostatin, octreotide and 008 significantly reduced LDH and GLDH release (P < 0.001). The somatostatins significantly increased the Ca(2+)-influx into the hypoxic, ischemic perfused rat liver (P < 0.001). Ca(2+)-influx is known to be an essential factor in the final common pathway of cell death induced by hypoxic ischemia. Even though the administration of the somatostatins was associated with an enhanced Ca(2+)-influx, the somatostatins reduced hypoxic ischemic liver injury.

Microcirculatory changes in sodium taurocholate-induced pancreatitis in rats.

Using an in vivo microscopy technique, we studied the microcirculatory changes in sodium taurocholate-induced pancreatitis in rats. With a computerized image analyzer system, blood flow, vascular permeability changes, and capillary densities were measured. Intraductal infusion of 0.4 ml saline had only minor effects on the microcirculation. Various concentrations and volumes of sodium taurocholate solutions were infused into the pancreatic duct. Sodium taurocholate (0.4 ml, 4%) led to increased vascular permeability preceding stasis within 232 +/- 47 s, followed by hemorrhagic necrosis in the head of the pancreas. In the corpus close to the tail of the pancreas capillary blood flow was maintained. In conclusion, this study shows that the microcirculation of the pancreas can be excellently investigated with in vivo microscopy. With this method, tremendous distribution disturbances of the microcirculation in the pancreas can be seen in the course of acute pancreatitis. Vascular permeability changes and stasis of the microcirculation represent the primary microcirculatory events in acute pancreatitis induced by sodium taurocholate in the areas where hemorrhagic necrosis occurs.