Development of gallstone surgery in Germany.

BACKGROUND: The aim of this study was to evaluate the development and outcome of laparoscopic gallstone surgery in Germany in a nationwide representative survey. METHODS: A written questionnaire, which included 111 structured items about diagnostic and therapeutic approaches, number of procedures, complications, and mortality, was sent to 449 randomly selected German surgeons (20% of the registered German general surgeons) annually from 1991 to 1994. RESULTS: A total number of 72,455 operations for gallstone disease was reported. The frequency of laparoscopic cholecystectomies increased from 24. 9% in 1991 to 65.3% in 1993. In 1994, 92% of the polled surgeons were using the laparoscopic approach as compared with 10% in 1991. The results demonstrated significantly lower morbidity (6% vs. 9%) and mortality figures (0.14-0.45%) than for the open procedure. The percentage of common bile duct (CBD) injuries was significantly higher for the laparoscopic group than for the open treatment group (0.7% vs. 0.4%). In 1993 the data shows a significant decrease in surgical complications such as bleeding, CBD injuries, and relaparotomy rate for the laparoscopic procedures. No changes were seen in the mortality rate. CONCLUSIONS: These results show learning curves that project a positive trend in the overall risk incurred by laparoscopic cholecystectomy in Germany during the past few years. This can be seen as an effect of better training and experience. Obviously, CBD injuries and technical problems especially have passed their peak of incidence.

[Current status of gallstone surgery in Germany. Results of a survey and retrospective analysis of 27,403 interventions--open vs. laparoscopic surgery]. / Aktueller Stand der Gallensteinchirurgie in Deutschland. Umfrageergebnisse und retrospektive Analyse von 27,403 Eingriffen--offene vs. laparoskopische Chirurgie.

Based on a representative poll, which included a retrospective data analysis, the current surgical approach to gallstone disease in Germany is presented. A total of 25,955 procedures in 1991 is analysed. 24.9% of all cholecystectomies were done laparoscopically. In 1992, already 81.4% of all surgeons reported own experiences with this new technique. Comparing open procedures with laparoscopic cholecystectomy the latter showed a lower incidence of complications (6.8 vs 8.7%) and perioperative death (0.14 vs. 0.43%). In contrast, relaparotomies were more frequent in the laparoscopy group (1.48 vs. 0.84%). The diagnostic and therapeutic approach for common bile duct stones is currently changing. There is a tendency towards less invasive endoscopic and laparoscopic procedures and towards their combination, respectively.

Surgical interventions for bile duct stones.

Based on our experience of 420 common bile duct procedures for stone disease and a literature review, it is evident that treatment of common duct stones today is based on a wide variety of non-operative and surgical methods which are still being developed. The mode of treatment is basically related to the time of diagnosis. Methods also differ depending on the localization of calculi, on inflammatory complications of stone disease, and whether combined or isolated cholecystocholedocholithiasis is present. At the moment, traditional operative methods as well as newly developed advanced techniques have to be evaluated. Selection of patients and their appropriate surgical and non-surgical treatment is an important issue to be further developed in the next few years. Therefore, therapeutic indications and definitive therapy present a much more demanding challenge for the surgeon than in the period when only open surgery was available.

The place of lithotripsy and surgery in the management of gallstone disease.

In summary, 10% to 20% of all symptomatic and uncomplicated gallbladder stones can be treated by ESWL under the current entry criteria. Further, ESWL is suitable for patients with bile duct stones in whom the primary endoscopic approach is not successful (about 10%). The algorithm in Figure 7 shows the therapeutic modalities that may be employed if the least invasive therapy is chosen. The different methods shown in this diagram are usually carried out by different specialists including surgeons, gastroenterologists, or radiologists. Therefore, an interdisciplinary approach is desirable. The technology of shock wave therapy of gallbladder stones will be improved in the future, for example the efficacy of stone fragmentation while maintaining a low level of discomfort for the patient. Moreover, repeated shock wave treatments may increase the success rate in patients with multiple stones and possibly in those with slightly calcified stones as well. Repeated procedures for recurrent stones appear feasible. Long-term follow-up studies are needed to define the place of ESWL in the management of gallstone disease. Surgery of the gallbladder remains the "gold standard" of curative therapy of gallbladder stones, against which ESWL and other nonsurgical techniques have to be evaluated. For the therapy of bile duct stones, ESWL is a helpful and effective nonsurgical adjunct.

Immunoprotective effects of cyclooxygenase inhibition in patients with major surgical trauma.

Dysfunctional monocytes (M phi), exerting their inhibitory functions via prostaglandin E2 (PGE2), have been implicated in the depression of immune responses following major surgical, accidental, and burn trauma. A randomized prospective study of the PG-synthetase inhibitor indomethacin (Indo) was performed in 43 patients undergoing major surgical procedures, to evaluate its efficacy in correcting postoperative abnormalities of the cell-mediated immune system (CMI) and preventing infectious morbidity and mortality. Patients, following gastrectomy (GX) or reconstruction of the abdominal aorta (AG), in the treated group (PIndo), received 100 mg IV of Indo 6 hours postoperatively and 3 x 50 mg IV Indo over 24 hours on postoperative days (D) 1,2,3,4. The rate of infectious complications was recorded. Parameters of CMI evaluated preoperatively (D0) and on D1,D3,D5,D7 were: Delayed type hypersensitivity (DTH) response to recall antigens, mitogen-induced lymphocyte proliferation (LP), interleukin 2 (IL-2) synthesis, and phenotyping of mononuclear blood leukocytes (PBMC's) with the monoclonal antibodies for CD3+, CD4+, IL-2 receptor (IL-2R)+ and LeuM3+ receptor sites. In contrast to the group of untreated patients (Pc), PIndo did not show a depression of their preoperative DTH responses, and they also showed a lower rate of early opportunistic infections. The in vitro test of CMI revealed that there was a higher LP capacity in PBMC's of PIndo (p less than 0.05); the postoperative profile of IL-2 synthesis was not statistically different between the groups. Indomethacin administration resulted in a considerable alleviation of postoperative monocytosis (p less than 0.05) and in a protective effect on lymphocyte receptor expression of CD3+, CD4+, and IL-2R+ cells. From these data it is concluded that in vivo cyclooxygenase inhibition may be useful to prevent impairment of CMI, a crucial predisposing factor of the high susceptibility to postoperative infection.

Surgical intervention following fragmentation of gallstones by extracorporeal shock waves.

Five cases of surgical intervention following extracorporeal shock wave lithotripsy (ESWL) of gallbladder and bile duct stones are reported. This represents an incidence of surgical intervention in 1% of patients with gallbladder stones and in 9% of patients with common bile duct stones who underwent ESWL during a two-and-a-half-year investigation period. There was no mortality. In 2 patients with gallbladder stones and persistent colic after ESWL, elective cholecystectomy was performed. There was no evidence of macroscopic or microscopic damage or bleeding within the wall of the gallbladder. Furthermore, no damage to the liver, common bile duct, duodenum, or stomach was noted. ESWL was applied in 34 patients with common bile duct stones in whom endoscopic sphincterotomy and stone extraction had proved ineffective. Three (9%) of these patients required surgery. In 1 patient, a Dormia basket got stuck and the basket, together with the stone, were removed by choledochotomy. In a second patient, rupture of a juxtapapillary diverticulum occurred 10 days after ESWL and 2 days after endoscopic extraction of stone fragments. At laparotomy, the retroperitoneum was drained. In a third patient with gallbladder and common bile duct stones, acute cholecystitis developed after lithotripsy of common bile duct stones. Cholecystectomy was performed and a t-tube was inserted in the bile duct. In all patients, the postoperative course was uneventful. In our experience, ESWL is a safe procedure with no mortality and an infrequent need for surgical intervention.

[Interdisciplinary treatment of gallstones: surgery, endoscopy, lithotripsy. Report of experiences after 4 years]. / Interdisziplinäre Behandlung des Gallensteinleidens: Chirurgie, Endoskopie, Lithotripsie. Erfahrungsbericht nach 4 Jahren.

Today, several methods of treatment for gall stone disease exist besides standard surgical procedures: endoscopy, lithotripsy, litholysis or a combination of the above. During the last four years 1786 patients were treated using an interdisciplinary approach. Cholecystectomy was still the most frequent method of treatment for symptomatic cholecystolithiasis (n = 1369) with low morbidity (4.3%) and lethality (0.28%). Probably less than 20% of all cases fulfill the strict selection criteria for extracorporeal shock wave lithotripsy (ESWL). All alternative methods of treatment in which the gallbladder is preserved have an increased risk for gall stone recurrence. Only after the long-term follow-up results of ESWL are known, the recurrence rate can be assessed. In most cases, bile duct stones (n = 417) were removed by endoscopy, if necessary in combination with ESWL (n = 310, stone removal: 95%, lethality: 0.3%). However, in low risk patients with concurrent cholecystolithiasis surgery was still the method of choice (n = 107, stone removal: 96%, lethality: 0/107). It seems not so important as to who performs the non-surgical procedures in the treatment of gall stones - the surgeon, internist or radiologist. Moreover, an interdisciplinary approach should be sought.

[Does the lithotripter change gallstone surgery?]. / Andert der Lithotripter die Gallensteinchirurgie?

Extracorporeal shock-wave lithotripsy (ESWL) is a new method for treating gallstones. ESWL is an alternative method to cholecystectomy for treating symptomatic gallbladder stones--complicated cases excluded--in about 15% of all cases. The risk of stone recurrence with all its consequences (symptoms, complications, late mortality) has to be weighed against the higher morbidity and mortality of surgical treatment. ESWL can be used for bile duct stones instead of endoscopy. Concrements cannot be removed mechanically (10-20%) have been treated with a high success rate (80%) using ESWL. In summary, at present ESWL is restricted to a small number of selected cases.

Terminal B-cell maturation and immunoglobulin (Ig) synthesis in vitro in patients with major injury.

This study evaluated B-lymphocyte function in 30 patients following major trauma with frequent screening over a period of 21 days post-trauma. Peripheral blood mononuclear cells (PBMC) were phenotyped with monoclonal antibodies and in vitro B-cell function was tested both for unstimulated cells (spontaneous) and following stimulation with pokeweed mitogen (PWM). The capacity for terminal B-cell maturation into plasma cells was assessed by the number of cells bearing cytoplasmic immunoglobulin (CIg+). Although the number of circulating B cells in the trauma patients was not decreased following injury (12 +/- 2%), the number of CIg+ cells was significantly decreased (0.2 +/- 0.1 to 3.0 +/- 1.5) compared to controls (5 +/- 1) up to 21 days post-trauma (p less than or equal to 0.01). Spontaneous B-cell synthesis of IgA, IgM, and IgG was significantly depressed on day 1, but IgA was within normal range (159 +/- 30 ng/ml) by day 3, and IgA levels were supranormal (118 to 300% of control) on days 5-10 before returning to normal on days 14 to 21. Synthesis of IgG was 100 +/- 20 ng/ml on day 3 (control, 165 +/- 31 ng/ml), and IgG levels were supranormal (+45 to +139%) thereafter. On the other hand, IgM synthesis was decreased on all days studied (120 +/- 35 to 220 +/- 70 ng/ml) compared to controls (366 +/- 105 ng/ml). Synthesis of all Ig subclasses in PWM cultures followed a similar pattern. There was a marked monocytosis (30 +/- 2% LeuM3 + PBMC's) compared to control values (13 +/- 2% LeuM3+ PBMC's).(ABSTRACT TRUNCATED AT 250 WORDS)

The immune-enhancing effect of perioperative thymopentin administration in elderly patients undergoing major surgery.

The effects of perioperative administration of thymopentin (TP-5) on in vivo and in vitro measurements of cell-mediated immunity in elderly patients undergoing major surgery were investigated. A placebo-controlled study was conducted in 25 patients (mean age, 67 years) with congenital or acquired heart disease undergoing surgery with cardiopulmonary bypass. Patients were divided into three groups: Group 1 patients were given 50 mg of TP-5 subcutaneously two hours preoperatively. Group 2 patients were given 50 mg of TP-5 subcutaneously two hours preoperatively and 48 hours postoperatively. Group 3 patients were given placebo at corresponding times. Cell-mediated immunity measurements were the in vivo delayed-type hypersensitivity (DTH) response on day 0 and on day 7 to an antigen skin test battery. The in vitro studies included antigen cocktail-induced lymphocyte proliferation of peripheral blood mononuclear cells. The DTH response on day 7 after surgery was significantly suppressed in group 3 patients compared with the preoperative baseline value, while it remained unaltered in group 1 and 2 patients. There was a considerable difference of DTH measurements (number of positive antigen responses and sum of their mean diameters) between group 2 and 3 patients. Antigen cocktail-induced lymphocyte proliferation, following initial suppression in the majority of patients, was significantly different between the placebo group and patients in group 2 on day 7 after surgery. The data indicate that perioperative administration of TP-5 might be of considerable clinical utility in preventing a defective cellular immune response.

A retrospective analysis of 3 year's experience of an interdisciplinary approach to gallstone disease including shock-waves.

1206 patients with gallstone disease were treated between January 1985 and December 1987, using an interdisciplinary concept that included surgery, endoscopic sphincterotomy, and extracorporeal shock-wave lithotripsy (ESWL). Twenty-five per cent of the patients who were admitted for gallbladder stones were treated by ESWL, whereas 75% underwent surgery. Mortality of elective treatment for gallbladder stones amounted to 0.25% (0.4% in surgery, 0% in ESWL). Postoperative complication rate was low (4.2% in surgery, 7.0% in ESWL). After ESWL treatment, 80% of the patients were free of stones after a follow-up period of 1 year. Recurrence rate in these patients amounted up to 10%; in seven of 70 patients, mean follow-up period was 6 months after complete disappearance of stones. Twenty-seven per cent of all patients who were admitted for bile duct stones underwent surgery, whereas in the other 73%, calculi were removed via endoscopy. ESWL treatment was used additionally, if necessary. Fragments were left behind in three of 75 patients (4.0%) after surgical treatment, and in 7 of 200 patients (3.5%) after endoscopic and ESWL treatment, respectively. In the latter group, three patients (1.5%) required an additional operation. There were no deaths in either of the groups. The use of ESWL for treatment of gallbladder stones needs to be evaluated in long-term follow-up studies. Thus far, surgery remains the dominating method. Endoscopic procedures, eventually combined with ESWL, represent the preferred treatment for patients with bile duct stones.

Arterial deepvenous difference of lipoproteins in skeletal muscle of patients in postoperative state: effects of medium chain triglyceride emulsion.

The effect of fat infusion with medium chain triglycerides (MCT) and long chain triglycerides (LCT) on serum lipoproteins before and after passage through the skeletal muscle was investigated with the forearm technic in eight patients after abdominal operation. All lipoprotein fractions were enriched with triglycerides and phospholipids from infused artificial fat particles with the consequence of significantly increased ratios of TG/PL and TG/apo B in VLDL, of TG/apo B in LDL and TG/apo A-I in HDL. Uptake and release of lipoprotein components by skeletal muscle are given by arterial-deepvenous differences considering the blood flow rates. The positive arterial-deepvenous difference of VLDL triglycerides after 4-hr infusion is interpreted as cleavage and uptake of infused MCT by the muscle. The release of LDL is more pronounced after the fat infusion than before, suggesting a degradation and enhanced catabolism of artificial fat particles. HDL release may be also a consequence of catabolism of artificial TG/PL-particles. These results indicate an uptake of MCT/LCT emulsion by the skeletal muscle.

Reactive hyperemia in patients with septic conditions.

In a prospective study microvascular reactivity was examined in 12 patients with septic conditions by means of the provocation of reactive hyperemia (RH) for evaluation of microcirculatory function. Data were compared with data from 10 nonseptic, postsurgical patients. At the time of the initial measurement, an adequate hyperemic response could be produced in all patients. In the further course of the disease, in nine of the 12 patients severe multiple organ failure developed. In spite of sufficient values for arterial blood pressure, oxygenation, and the clotting system, RH was absent in these patients (8 +/- 2 days after the initial measurement). Subsequently, seven of these nine patients died (4 +/- 2 days after the onset of microvascular nonreactivity). Until death, RH was absent in each patient, and at this time therapy-resistant hypoxemia, hypotension, and severe disturbances of the clotting system were present. In the two surviving patients RH was restored completely. These results indicate that (1) the septic state per se is not necessarily combined with impaired microvascular reactivity (rather, the absence of RH may be a sign of generally poor clinical conditions); (2) the absence of RH is not related to therapy-resistant hypotension, hypoxia, and severe clotting disorders but precedes these changes; and (3) provocation of RH may be of clinical use for early detection of microcirculatory malfunction in high-risk patients.

Alteration of monocyte function following major injury.

The macrophage exerts its stimulatory and regulatory functions within the specific immune response via the interleukin 1 (IL-1) and prostaglandin E2 (PGE2), respectively. In a screening study of macrophage-related variables following injury, a total of 58 patients (mean age, 32 years; mean injury Severity Score, 38), macrophagic phenotyping with the monoclonal antibody Leu M3 and serial measuring of the antagonistic monokines IL-1 and PGE2 and of the macrophage-activating lymphokine interferon gamma were carried out on posttrauma days 0, 1, 3, 5, 7, 10, 14, and 21. The posttraumatic course was characterized by significant monocytosis, showing a peak value of 32% of Leu M3-positive cells compared with 15% of these cells in normal control subjects. During the posttrauma course, the macrophagic PGE2 output was significantly elevated up to eightfold on days 5 and 7 compared with that of control subjects (0.441 +/- 0.14 ng/mL vs 0.052 +/- 0.01 ng/mL). Conversely, macrophagic IL-1 synthesis was significantly suppressed until day 10. Levels of interferon gamma were suppressed to a significant degree during the two-day observation period, with a trend to slow recovery at the end of week 3. These data suggest that a negative regulatory macrophagic function may be the event initiating posttraumatic immunosuppression. To restore impaired macrophagic T-helper cell interaction, cyclo-oxygenase inhibition and substitution of interferon gamma may be useful to potentiate facilitatory macrophagic function and to block inhibitory macrophagic activity.

Minor role of ketone bodies in energy metabolism by skeletal muscle tissue during the postoperative course.

To evaluate changes of peripheral ketone body (KB) metabolism after operation, muscle metabolism in postsurgical patients was studied at 3 hours (SI) and 24 hours (SII) after surgery by the forearm catheter technique. Data were compared to those of equivalent fasted controls (CI, CII). In a manner consistent with enhanced mobilization of endogenous substrate stores, arterial concentrations of free fatty acids (FFA), 3-hydroxybutyrate (3-HOB), and acetoacetate (AcAc) were markedly elevated immediately after surgery. This increase was accompanied by a rise in muscular utilization of AcAc (SI: 0.21 +/- 0.05 mumol/100 g/min; CI: 0.08 +/- 0.05, p less than 0.05) and 3-HOB (SI: 0.24 +/- 0.06 mumol/100 g/min; CI: 0.11 +/- 0.01, p less than 0.05). Surprisingly, on the first postoperative day, concentrations of AcAc and 3-HOB fell below those of fasting controls. Concomitantly, the utilization rate of AcAc by muscle (SII: 0.07 +/- 0.03 mumol/100 g/min; CII: 0.27 +/- 0.04, p less than 0.05) was significantly lower in patients than in controls. Reduction of the fractional extraction rate of AcAc (SI: 38.4 +/- 3.8%; SII: 24.0 +/- 6.1%, p less than 0.05), as well as a net production of 3-HOB by muscle (SII: -0.08 +/- 0.05 mumol/100 g/min; CII: 0.49 +/- 0.13, p less than 0.05) 24 hours after surgery indicated a reduced peripheral capacity for KB removal. Since this finding was related to a significantly higher rate of muscular glycerol production (SII: -0.13 +/- 0.03 mumol/100 g/min; CII: -0.06 +/- 0.02, p less than 0.05), one may suggest that increased intramuscular availability of FFA from triglyceride hydrolysis was responsible for the impairment of peripheral KB utilization. These results indicate that KBs contribute little to energy metabolism in skeletal muscle tissue in the late postoperative phase.