[Sigmoid diverticulitis -- indications for surgery and choice of procedure]. / Indikationen zur Sigmaresektion bei Divertikulitis. Wann wird operiert?

The first attack of uncomplicated diverticulitis is treated conservatively. Sigmoid resection is indicated for recurrent diverticulitis, in patients with manifest stenosis or fistula and for such emergencies as perforation, ileus or bleeding. Early surgery after the first episode is recommended for patients under 50 years of age, or immunocompromised patients. This is particularly true for patients with radiological signs of severe diverticulitis. Today elective sigmoid resection is a laparoscopic procedure. Properly carried out, the operation effects a definitive cure. The morbidity and mortality of the operation is low, and re-operations for recurrent diverticulitis are the exception. In the emergency situation a two-stage procedure is often necessary.

Inflammatory consequences of the translocation of bacteria and endotoxin to mesenteric lymph nodes.

BACKGROUND: Translocation of intestinal bacteria to mesenteric lymph nodes (MLNs) has been documented in humans under a variety of circumstances, yet its clinical significance remains to be established. The aim of this study was to correlate detectable translocation to MLNs of bacteria and endotoxin with local and systemic signs of inflammation. METHODS: From each of 10 patients with carcinoma of the cecal region two MLNs were harvested prior to resection. The presence of bacteria and endotoxin in the lymphatic tissue and blood was determined by culture methods and DNA preparation (PCR) and by a Limulus assay, respectively. Inflammatory mediators were determined in plasma and in MLN homogenates. RESULTS: Viable bacteria were detected in MLNs of 7 patients and in 9 of 20 lymph nodes. PCR revealed traces of bacteria in 4 patients and in 6 of their MLNs. Combining both modalities, the translocation rate was 80% and 55% for patients and MLNs, respectively. There was no detectable bacteremia. Endotoxin was found in the plasma of 7 patients and in 9 MLNs from 5 patients. There was no correlation between culture findings and endotoxin concentrations. Moreover, bacteriological data did not correspond to local or systemic inflammation. The group of MLN with detectable endotoxin differed significantly from LPS-negative nodes with respect to interleukin-6, interleukin-10, and sCD14. Systemic concentrations of endotoxin and inflammatory parameters did not correspond to levels within MLNs. CONCLUSION: Translocation to MLNs occurs in patients with cecal carcinoma. This, however, seems not to be of major clinical significance if no additional physiologic insults are encountered. Irrespective of the presence of bacteria, there are variations in inflammatory reactions between lymph nodes from one and the same patient, probably reflecting fluctuating response mechanisms to low-grade translocation.

Evidence-based surgery: diverticulitis--a surgical disease?

Sigmoid diverticulitis is an increasingly common disorder. While there is no gender difference, the incidence increases with age. Many reports have been published on the topic, but there is no consensus on certain aspects of treatment. We conducted a literature search covering the past 30 years and report our own data. Two major areas of controversy exist. One concerns indications for elective surgery for symptomatic diverticulitis. The consensus is that there is no indication for prophylactic surgery. The first attack should be treated conservatively; elective surgery is considered following a second attack, but in immunocompromised patients earlier. The second controversy concerns surgical strategy in peritonitis from perforation. Three-stage operations have generally been abandoned. The question is whether to perform a sigmoid resection with primary anastomosis. One end of the spectrum is recent perforation which can be treated safely by resection and anastomosis. The other end is advanced feculent peritonitis in high-risk patients. In this situation a Hartmann procedure is recommended. Although data from prospective randomized studies are lacking, there seem to be indicators in the individual situation that allow a rational selection of the appropriate procedure. Diverticulitis can thus be treated surgically for a broad range of its forms of presentation.

[Abdominal surgery in advanced age. Indications and prognosis exemplified by stomach, bile duct, colon and hernia surgery]. / Abdominalchirurgie im Alter. Indikation und Prognose am Beispiel der Magen-, Gallenwegs-, Kolon- und Hernienchirurgie.

The increased risk of morbidity and mortality associated with abdominal surgery in the aged is determined by the number and severity of accompanying diseases and the emergency situation. Age per se is not a risk factor. Limitation of the risk requires an age-oriented treatment plan, which must take account of the specific problems of the geriatric patient in the pre-, intra-, and postoperative phases. Emergency operations should be avoided as far as possible. The aim of geriatric surgery is not merely to prolong life, but also to secure adequate quality of life. To accomplish this, it may occasionally be necessary to forgo surgical radicality in favor of a palliative procedure. The results of abdominal surgery in the elderly are presented on the basis of exemplary cases of stomach, biliary, colonic and hernial surgery.

[Therapeutic possibilities in therapy-resistant ulcers--surgical aspects]. / Therapiemöglichkeiten beim therapierefraktären Ulkus--chirurgische Aspekte.

Indications for surgery and choice of procedure in complicated or chronic gastroduodenal ulcer refractory to conservative treatment are presented. Operations in emergency states are undisputed although they carry a tenfold higher mortality rate than elective procedures. Therefore in spite of effective pharmacotherapy groups at risk have to be identified by interdisciplinary therapeutic concepts in order to enable elective operation on time. Next to patient and ulcer data the efficacy of various procedures has to be considered. The standardized operative techniques and their associated respective rates of complications and recurrence are compared with those of pharmacotherapy.