[Bilateral well-leg compartment syndrome in a child after abdominal trauma : A review of the literature and treatment recommendations illustrated by a case study]. / Bilaterales Kompartmentsyndrom der Unterschenkel des Kindes nach Abdominaltrauma : Eine Literaturübersicht und Handlungsempfehlungen, veranschaulicht an einem Fallbeispiel.

This article reports a case of a bilateral well leg compartment syndrome (WLCS) in a 9-year-old girl who presented to the emergency room 24 h after blunt abdominal trauma and liver laceration. The abdomen was already packed on presentation. The patient presented a manifest compartment syndrome of both lower legs 48 h after the second look surgery and removal of the packing. Both tibial anterior and peroneal compartments had to be partially resected. In an analysis of literature only five cases of WLCS after surgery in a supine position were found. The young age of the patient and the intra-abdominal packing were identified as risk factors for increased intra-abdominal pressure and reperfusion was suspected to be the cause of the lower leg compartment syndrome.

The OTSC(®) proctology clip system for the closure of refractory anal fistulas.

BACKGROUND: To evaluate the efficacy of the over-the-scope clip (OTSC(®)) proctology set for the closure of refractory anal fistulas. METHODS: This retrospective single-center study included all consecutive patients undergoing an OTSC(®) proctology closure of anal fistulas between October 2012 and June 2014. The OTSC(®) was only used in refractory cases after previous fistula surgery, including patients with Crohn's disease, or multiple previous surgical approaches. RESULTS: There were ten patients (five males and five females) with a median age of 41 years (range 26-69 years). The etiology of the fistula was cryptoglandular in four patients, and perianal Crohn's disease in six patients (including one patient with an anovaginal fistula). The surgical procedure was technically successful in all patients. Permanent fistula closure was achieved in seven out of ten patients (70 %) within a median time of 72 days (range 31-109 days). Median total follow-up time was 230.5 days (range 156-523 days). There were three failures (30 %), including two cryptoglandular and one Crohn's disease-associated fistula. In all three cases, the OTSC(®) was lost spontaneously on days 22, 23, and 40, respectively. In three of the seven patients with successful closure, the OTSC(®) was removed after complete healing of the fistula. CONCLUSIONS: The novel OTSC(®) proctology system is a safe and effective method for the closure of even complex and recurrent fistulas.

[Anastomotic techniques for the gastrointestinal tract]. / Anastomosentechniken am GastrointestinaItrakt.

The correct suture technique for anastomoses of the gastrointestinal (GI) tract is a major task in the daily practice of surgery and a basic requirement for a successful operation. This article provides an overview of the surgical principles and techniques involved in the creation of intestinal anastomoses, including the differentiated use of various suturing aids in the GI tract. Hand sewn and stapled anastomotic techniques are illustrated and discussed. The ongoing discussion and question as to which technique is best for GI anastomoses remains unanswered as there is no obligatory standard, even though the requirements are well defined. An ideal anastomosis should fulfil the following criteria: it must be well vascularized, safe, tension-free and spillage from the operation field should be avoided.

Long-term results of calcineurin-free protocols with basiliximab induction in "old-to-old" programs.

INTRODUCTION: EuroTransplant old-to-old program allows patients older than 60 years to receive offers from donors older than 60. The long-term results of kidney transplantation in this model are still under discussion, due to the impaired kidney function of the donor and cumulative diseases in the recipient. HYPOTHESIS: Calcineurin-sparing protocols with IL-2 antibody induction (Simulect) may benefit long-term kidney function in these patients avoiding overimmunosuppression. The main outcome measures are: graft function and rejection rate during the first year after transplant. PATIENTS AND METHODS: A cohort of 15 consecutive older subjects were prospectively compared with 30 conventional cadaveric kidney transplants. Study patients were induced with Simulect (20 mg, 30 minutes before reperfusion and 4 days after transplantation) and steroids allowing the introduction of CsA to be delayed to the time at which the creatinine is below 3 mg/dL. Conventional patients were immunosuppresed with Tacrolimus (trough 8-12 ng/mL), MMF (1 g/d) and identical steroid tape. The graft and patient survival, kidney function in terms of diuresis, creatinine clearance, rejection episodes and grades were compared between both groups during the first year posttransplantation. RESULTS: Except for the age of the donors and recipients in both groups (72 vs 54 in donors, and 67 versus 52 years in recipients), no significant differences were observed. Patient survival rates were 97% in control patients and 100% in the Simulect group. Graft survival was 97% in the control group and 100% in the old-to-old study group. Acute rejection episodes were decreased among study patients (6.6% vs 13.2%), and corticoid sparing protocols were applied in 75% of Simulect patients but only 50% of control patients. All 44 patients and grafts showed excellent kidney function after one year with equal creatinine levels in both groups (mean 1.42). CONCLUSIONS: Calcineurin free protocols with IL-2 therapy as the main initial suppression allows patients in an old-to-old ET program to have superior results to conventional cadaveric kidney transplants.

Cost-effectiveness analysis of basixilimab induction and calcineurin-sparing protocols in "old to old" programs using Markov models.

INTRODUCTION: Markov models are employed in economic analyses to evaluate all possible expectations in a dilemna. The introduction of a new clinical protocol (basiliximab induction with calcineurin-sparing protocols) for a group of kidney transplant recipients receiving organs from marginal donors was validated with a Markov simulation model. HYPOTHESIS: Calcineurin-sparing protocols using anti-IL-2/antibody induction (Simulect) show a beneficial effect on initial kidney function, reducing transplantation costs reception based upon mean length of stay, mean admission cost, and incidences of delayed graft function and complications during the first month after transplant. PATIENTS AND METHODS: A Markov simulation model was established following three different chains. A calcineurin-free regimen with basiliximab induction (chain A), a calcineurin-sparing protocol with basiliximab induction (chain B), and a conventional immunosuppressive regimen (chain C). After designing the Markov chain and cohorts, 31 patients from the "old to old" program were assigned to each chain eight to chain A, (eight to chain B, and 15 to chain C). A month after transplantation a cost-benefit study was performed guided by the three branches of the Markov model. RESULTS: The Markov model showed a benefit of induction therapies in elderly patients. A cost-benefit model showed that after a month there was a clear benefit from Calcineurin=free plus basiliximab induction therapies, with a slight benefit from calcineurin-sparing protocols. CONCLUSIONS: Markov models are extremely useful when introducing new clinical therapies. In our transplant program, a cost-effective analysis of outcomes in old patients using the Markov model showed a clear benefit of calcineurin-sparing protocols with basixilimab induction.

Calcineurin-free protocols with basiliximab induction allow patients included in "old to old" programs achieve standard kidney transplant function.

INTRODUCTION: The EuroTransplant "old to old" program establishes that patients older than 60 years can receive offers of organs from donors older than 60 years. The compromised function of these organs makes it a priority to preserve their initial kidney function. HYPOTHESIS: Calcineurin-sparing protocols using anti-IL-2 receptor (IL-2R) antibody induction (Simulect) may benefit initial kidney function in these patients, as assessed by the rates of delayed graft function and of rejection during the first month after transplant. PATIENTS AND METHODS: A cohort of 15 consecutive elderly patients were prospectively compared with 30 cadaveric kidney transplants in younger recipients. Study patients were induced with Simulect (20 mg, 30 minutes before reperfusion and 4 days after transplantation) and steroids, delaying the introduction of CsA until the serum creatinine was below 3 mg/dL. The other cohort of patients were immunosuppressed with tacrolimus (trough 8 to 12), mycophenolats mofetil (MMF, 1 g/d), and an identical taper of steroids. The analysis compared donor and recipient ages, mean cold ischemic time, incidence of initial kidney function (diuresis in the first 24 h) serum creatinine levels, glomerular filtration rate (GFR), number of dialysis sessions, and rejection rate in the two groups. RESULTS: Except for the donor and recipient ages (72 vs 54 in donors, and 67 versus 52 years in recipients), no significant differences were observed between the groups among the rates of acute rejection (6.6% vs 13.2%), delayed graft function (13.2% required dialysis), or infection (6.6%). Within 1 month all 45 grafts showed primary function with equal creatinine levels (mean 1.65). CONCLUSIONS: Calcineurin-free protocols using IL-2 therapy as the initial suppression allow patients in the "old to old" ET program to display equal results to cadaveric kidney transplants with initial treatment with calcineurin antagonists.

Acetyl-11-keto-beta-boswellic acid, a constituent of a herbal medicine from Boswellia serrata resin, attenuates experimental ileitis.

The gum resin extract from Boswellia serrata (H15), an herbal product, was recently shown to have positive therapeutic effects in inflammatory bowel disease (IBD). However, the mechanisms and constituents responsible for these effects are poorly understood. This study examined the effect of the Boswellia extract and its single constituent acetyl-11-keto-beta-boswellic acid (AKBA) on leukocyte-endothelial cell interactions in an experimental model of IBD. Ileitis was induced by two subcutaneous injections of indomethacin (7.5 mg/kg) in Sprague-Dawley rats 24 h apart. Rats also received oral treatment with the Boswellia extract (H15) or AKBA at two different doses (low and high) equivalent to recommendations in human disease over 2 days. Controls received only the carriers NaHCO3 (subcutaneously) and tylose (orally). Effects of treatment were assessed by intravital microscopy in ileal submucosal venules for changes in the number of rolling and adherent leukocytes and by macroscopic and histological scoring. Increased leukocyte-endothelial cell adhesive interactions and severe tissue injury accompanied indomethacin-induced ileitis. Treatment with the Boswellia extract or AKBA resulted in a dose-dependent decrease in rolling (up to 90%) and adherent (up to 98%) leukocytes. High-dose Boswellia extract as well as both low- and high-dose AKBA significantly attenuated tissue injury scores. Oral therapy with the Boswellia extract or AKBA significantly reduces macroscopic and microcirculatory inflammatory features normally associated with indomethacin administration, indicating that the anti-inflammatory actions of the Boswellia extract in IBD may be due in part to boswellic acids such as AKBA.

Effect of anti-CD11b (alphaM-MAC-1) and anti-CD54 (ICAM-1) monoclonal antibodies on indomethacin induced chronic ileitis in rats.

Leukocyte emigration from blood to sites of inflammation involves sequential interaction of specific adhesion molecules expressed by both leukocytes and endothelial cells. The central steps in leukocyte-endothelial adhesive interactions are leukocyte rolling, sticking, and transmigration. This study investigated the effect of monoclonal antibodies against CD54 (ICAM-1) and CD11b (alphaM-chain of MAC-1) on intestinal inflammation. Anti-CD54 and anti-CD11b were tested in rats with indomethacin-induced chronic ileitis. Macroscopic changes were assessed by a modified version of the Wallace et al. score. Leukocyte rolling and sticking were investigated by intravital microscopy. Results show that indomethacin administration led to a chronic inflammatory response characterized by significant increase (P<0.05) in rolling (from 5.41+/-2.87 to 32.41+/-15.03 100 microm(-1) s(-1)) and sticking (from 0.16+/-0.18 to 9.11+/-5.3 100 microm(-1) s(-1)) leukocytes. After antibody treatment only the anti-CD11b group showed significant (P<0.05) reduction in rolling (from 32.41+/-15.03 to 6.6+/-2.7 100 microm(-1) s-1) and sticking (from 9.11+/-5.3 to 0.07+/-0.09 100 microm(-1) s-1) leukocytes. This was also the case for macroscopic changes. Indomethacin led to a rise in the Wallace score from 0 to 4.29+/-0.76 points (P<0.05) and anti-CD11b to a reduction from 4.29+/-0.76 to 1.29+/-1.11 points (P<0.05). Anti-CD54 and combined anti-CD11b/CD54 administration was not followed by significant changes. Therefore we suggest that leukocyte-based CD11b but not endothelial-based CD54 contributes most to leukocyte adhesion in the setting of indomethacin-induced ileitis in rats.

[Measuring blood flow velocity in healthy and indomethacin-induced inflammation in rat small intestine serosa with FITC-marked erythrocytes]. / Flussgeschwindigkeitsmessung an gesunder und Indomethacinentzündeter Rattendünndarmserosa mittels FITC-markierter Erythrozyten.

Intravital microscopy was performed in normal and indomethacin-induced intestinal inflammation at serosal postcapillary venules of the small bowel in rats. Standard parameters of microcirculation as red blood cell velocity, diameter of venules, blood flow and adherent leucocytes were successfully investigated using FITC-labelled red blood cells. Since postcapillary venules are responsible for the venous drainage of the inflammed small bowel segments this method is reliable and effective for further investigation of intestinal microcirculation under special conditions such as intestinal inflammation.