The coeliac aneurysm: a rare cause of abdominal pain.

Visceral artery aneurysms (VAA) represent 0.1-0.2% of all vascular aneurysms. For VAA's etiology, congenital or arteriosclerotic factors, media defects, infections, vasculitis and trauma are discussed. Ultrasound, CT scan and magnetic resonance imaging underline the diagnosis of VAA. The low perioperative morbidity and mortality and the excellent surgical longterm results justify the prophylactic therapy also from asymptomatic VAA because the mortality of ruptured VAA is close to 100%. The radiological interventional treatment is indicated for only selected patients whereas an advantage is not verified yet.

[Analysis of vascular complications in intra-venous drug addicts after puncture of femoral vessels]. / Untersuchung von Gefässkomplikationen nach Punktion der Femoralgefässe bei intravenösem Drogenabusus.

BACKGROUND: Intravenous drug abuse is a global social and health care problem. Vascular complications following intravascular inguinal self-injection of addictive drugs are rarely seen. An efficient therapeutic concept is needed because, besides the risk of vascular injuries, infections ranging up to systemic inflammatory response syndrome or sepsis might occur. METHODS: This was a single center retrospective analysis of vascular complications in drug addicts from 1994 to 2002 in an university hospital. A systematic literature review in MEDLINE was performed with the following key words: 1 vascular, 2 complications, 3 drugs, 4 addicts, 5 mycotic aneurysms. RESULTS: 10 patients with a long lasting history of i. v. drug abuse (median: 16.1 years, range: 10-28 years) and vascular complications were included in this study. The mean age was 40.2 years (range 32-50 years). 5 patients showed pain and tumescence of the inguinal region at the time of admission. 7/10 patients had a poor general health and nutritional status. 2 patients had a hepatitis-B- and C-infection, 7 patients were hepatitis C Ag positive. All patients were HIV negative. 1 patient had an older deep venous leg thrombosis that was treated conservatively. In six cases, we saw an intraoperative arterial bleeding; in five cases pseudoaneurysms. The patients were treated with 5 venous interpositions, 4 venous patch plastics, 1 end-to-end anastomosis and 2 prosthetic grafts. 3 thrombectomies were performed. One time we performed a ligation of the pseudoaneurysm without reconstruction. Six reconstructions were covered with a biological seal. One thigh amputation was necessary; no patient died. In 2 patients with severe problems, we performed 11 operative revisions. The systematic literature review in MEDLINE showed no evidenced based therapy regimen. CONCLUSION: We favour the resection of the aneurysm including a radical debridement of the wound with secondary wound healing. In the case of an isolated aneurysm of the arteria femoralis superficialis or the arteria profunda femoris, a ligation or excision without reconstruction is possible with a low risk of postoperative complications. A reconstruction with autologous material is necessary in the case of aneurysms of the common femoral artery or its bifurcation. The reconstructed vessel should be covered with a biological seal, e. g. omentum majus. If there is no autologous material available for the reconstruction, we recommend the ligation without reconstruction, because the results after implantation of artificial vascular prostheses are not satisfying.

[Liver transplantation in Germany]. / Lebertransplantation in Deutschland.

As in other western countries the major challenge of liver transplantation in Germany is to expand the number of liver transplantations in respect to the increasing disparity of qualified patients on the waiting list and the still static availability of brain death donor organs. The problem of death on the waiting list has become overt since the German transplantation law has been installed, which has changed the former center-oriented to a patient-oriented allocation weighting waiting time over medical urgency criteria. The more liberal acceptance of so called marginal cadaveric donor livers will probably impair further improvements in the acute and long-term outcome of liver transplantation. This problem can be partially compensated by the use of novel surgical techniques, such as splitting a donor liver to be transplanted into two adult recipients or, more commonly and safe, into an adult and one child. Another alternative to increase the donor pool is living donor liver transplantation, which was first introduced for pediatric recipients but is now increasingly used in adults. In 2001, a constant number of 757 liver transplantations were performed in Germany, including 12.5 % living donor transplantations. Recently, general guidelines for the selection of patients with end-stage liver disease and acute liver failure have been published by the Bundesärztekammer. Additional developments have contributed to improve the results of liver replacement including individualized immunosuppression strategies and novel treatment options to avoid recurrent viral disease following transplantation.

Lipid peroxidation as additional marker in patients with colorectal cancer. Results of a preliminary study.

BACKGROUND AND AIMS: Up to now, various tumor markers have been proposed for the detection of the onset of malignant cell transformation or the better follow-up of cancer patients. The aim of the present study is to investigate the diagnostic value of systemic lipid peroxidation as an additional evaluative tool in the follow-up of surgical patients with colorectal cancer in combination to the clinically routine tumor markers carcinoembryonic antigen (CEA) and carcinoantigen 19-9 (CA 19-9). PATIENTS AND METHODS: 36 patients with a colorectal carcinoma were included in this study. Blood samples were collected 1 day prior to the operation, 10 days and 1 year after the operation. Oxygen free radical mediated lipid peroxidation was determined by measurement of thiobarbituric acid-reactive substances in the same serum that were used for the determination of tumor markers. RESULTS: Compared to control values, a highly significant increase of lipid peroxidation was found in the serum of all colorectal carcinoma patients up to the first 10 postoperative days. Differentiation of the patients, according to the T-stage, showed a marked and more obvious tendency towards higher serum lipid peroxides with increased tumor stage when compared to the conventional tumor markers. One year postoperatively the serum levels of lipid peroxidation returned to nearly normal values. Also the conventional tumor markers CEA and CA 19-9 showed a relative rise in the levels with the respective tumor stage, but differences were only statistically significant in the highest T-categories. CONCLUSION: After curative resection of the tumor, the level of systemic lipid peroxides decreases to normal values. We conclude from these results that the tumor is the primary cause of the increased systemic lipid peroxides.

[Long-term results after surgical therapy of Crohn's disease]. / Langzeitergebnisse nach chirurgischer Therapie des Morbus Crohn.

UNLABELLED: We performed a retrospective analysis in patients after operative therapy of Crohn's disease in our institution. PATIENTS AND METHODS: 81 patients that underwent surgery from 1990-1995 were analysed retrospectively. The follow up period in these patients was 42 months. RESULTS: In 81 patients a total of 88 operations were performed. 56 patients were operated for the first time. The average patient's age was 35 years (range 14-76 years). Crohn's disease was located predominantly in the area of the ileocoecal valve. The most frequent operation was the ileocoecal resection. The prevalent operative indication in patients with small intestine Cohn's disease was the obstruction, in small intestine and colon manifestation the fistula. Complications in the early postoperative course appeared in 14 % of the patients. Postoperative mortality was 1.1 %. In a postoperative observation period of 3.5 years 3 of 57 patients (5 %) had to undergo surgery again, due to recurrence. Altogether 25 of 81 (31 %) patients revealed a recurrence. CONCLUSIONS: The surgical therapy of Crohn's disease can be performed safely and provides long-term recurrence and complaint free periods.

[Visceral artery aneurysms]. / Das Viszeralarterienaneurysma.

The purpose of this article is to review the etiology, clinical presentation and treatment options of visceral artery aneurysms (VAA) on the basis of our experiences. Visceral artery aneurysms are uncommon lesions with a frequency of 0,1-0,2 % in autopsy statistics. In fact many visceral artery aneurysms still present first with a rupture (22 %) and despite emergency laparotomies the mortality rate is about 8,5 %. The course of disease often is disastrous due to rupture of the aneurysms or thromboembolic complications, emphasizing the importance to be aware of this differential diagnosis of abdominal pain. This article covers 9 patients with VAA. 3 patients each revealed an a. lienalis aneurysm and a. gastrica aneurysm, resp. In the other 3 patients an aneurysm of the a. gastroepiploica, the a. pancreatico-duodenalis and the a. mesenterica superior resp. was proven. In 8 of 9 patients a surgical therapy of the VAA took place. Only 2 patients (22 %) were interventionally treated. 1 patient deceased due to postoperative hemorrhage. Both the surgical and the radiological intervention therapy are available for treatment of the VAA. The decision on the choice of the therapeutic procedure should be made on an individual basis.

[Experiences in stage-adapted therapy of pleural empyema]. / Erfahrungen in der stadienadaptierten Therapie des Pleuraempyems.

INTRODUCTION: Up till now the phases adapted treatment of a pleural empyema unfortunately is still not obvious, but recently the operative spectrum has been widened in the field of video-assisted thoracoscopic surgery (VATS) of the pleural empyema. PATIENTS AND METHODS: In the present study we examined all our patients with a pleural empyema and we followed them for a postoperative period of 4 years analysing our therapy-efficacy and our treatment concept of pleural empyema. RESULTS: 52 out of 102 patients--who suffered from a pleural empyema in the last 10 years--were reexamined postoperatively. In 96% of the 102 cases we found a phase II-III empyema. Initially all patients were treated with a closed-chest-tube drainage, followed by an operation in 78%. In 6 cases a video-assisted-thoracoscopic evacuation of the cavity with an early decortication was performed. All the 52 patients who were treated in an early phase showed the best functional results 4 years later. CONCLUSION: Especially in phase III the open operative revision of a pleural empyema is the method of choice. In the fibrinopurulent phase the drainage therapy may be sufficient. If the empyema cavity is divided we recommend the early video-assisted-thoracoscopic revision of the thoracic empyema.

[History of surgical esophageal replacement]. / Geschichte des operativen Oesophagusersatzes.

At the beginning of the twentieth century, surgeons often attempted operative esophagus replacement. At first, these operations had a palliative intent to help the patients eat. Setbacks because of lack of experience in thorax surgery, infection problems and technical difficulties led to different approaches to a solution. The first successes occurred when a stomach tube was formed with a abdominocollar high course and collar anastomosis. The history of surgical replacement of the esophagus is given in detail to the present day and the development is discussed.

Evidence for persistence of parvovirus B19 DNA in livers of adults.

Recent studies have suggested a pathogenic role of human parvovirus B19 (B19) in the development of acute fulminant liver failure in children. The hypothesis was based on the detection of B19 DNA in 8 of 10 explanted livers of children requiring liver transplantation. In the present study, explanted livers from 43 adults selected at random undergoing orthotopic liver transplantation for various reasons were examined. Pre-transplant sera were available from 40 patients of whom 35 (88%) were anti-B19 IgG-seropositive. All but one serum were negative for anti-B19 IgM antibody. By polymerase chain reaction, B19 DNA was detected in the livers of 15/35 (43%) anti-B19 IgG-positive patients, in 2/3 livers of patients with unknown anti-B19 antibody status, and in the initial transplant of an anti-B19 IgG-positive patient who underwent liver retransplantation, and whose own liver was negative for B19 DNA. In a second study group, liver and bone marrow samples from 23 autopsied adults selected at random were tested. Serum specimens were available from 22 individuals, of whom 17 (77%) were anti-B19 IgG-seropositive. All sera were negative for anti-B19 IgM antibody. B19 DNA was detected in the livers of 4/17 (24%) anti-B19 IgG-positive individuals, three of whom had also B19 DNA in their bone marrow. This is the first report demonstrating that B19 DNA is frequently present in livers of anti-B19 seropositive adults suggesting persistence of B19 in the liver. Further studies are needed to address whether B19 is an innocent bystander in the liver or whether the presence of B19 in liver is of biological and clinical significance.

[Choledochus revision in the age of endoscopic papillotomy. Indications and outcome]. / Die Choledochusrevision im Zeitalter der endoskopischen Papillotomie. Indikation und Ergebnisse.

OBJECTIVE: In the age of endoscopic papillotomy (EPT) the operative revision of the bile duct needs to be used stringently and interventional therapeutic options have to be considered primarily in the treatment of gallbladder and bile duct stone disease. PATIENTS AND METHODS: 70 patients treated by choledochus revision for cholecysto- and choledocholithiasis in our department between 1988-1999 were analyzed retrospectively for indication and results. RESULTS: ERCPs were performed in only 24 patients. In 17 patients no endoscopic papillotomy could be accomplished due to a former operation (Billroth II or Whipple-OP). 70 patients underwent a surgical bile duct exploration with insertion of a T-drainage. The postoperative surgical complication rate amounted to 36%. The most frequent complications after revision of the common bile duct were edematous pancreatitis as well as bile duct fistula. 37 of 70 patients could be reexamined 4-48 months postoperatively. A pancreatitis or stenosis of papilla Vateri were not seen in these patients. In the sonography the common bile duct was inconspicuous. CONCLUSIONS: In the therapy of bile duct stones the therapeutic splitting has become generally accepted. The patients should be submitted to a ERCP with EPT and subsequent laparoscopic cholecystectomy. Surgical revision of the common bile duct nevertheless remains an important tool in the therapy of choledocholithiasis.

Assessment of HIV transmission risks in clinical situations in health care students from Germany, Lithuania and Namibia.

Due to the increasing global HIV prevalence, comprehensive knowledge about clinical HIV transmission risks in health care professionals is essential. Mainly medical and nursing students are at risk, because they are working close to infected patients. By using an anonymous questionnaire, the study analysed the assessments of German medical/dental students (n = 182), Lithuanian medical students (n = 176) and Namibian student nurses (n = 135) on the risk of getting HIV infected in different clinical situations. It became obvious that the Namibian student nurses overestimated the risk of HIV transmission in several situations (eg changing dirty linen, physical examination). In comparison, the Lithuanian students showed the most realistic assessments, while the German students also tended to overestimate the risks of HIV transmission. The results indicate that assessments on the risk of HIV transmission in clinical situations are influenced by the national prevalence and daily contacts with HIV patients. Education of health care students should consider this and focus more on epidemiological aspects and infection control procedures, to avoid endangering students and patients.

Detection of APC and k-ras mutations in the serum of patients with colorectal cancer.

Detection of tumor DNA in peripheral blood of patients with colorectal cancer (CRC) may allow early diagnosis of tumor disease and be of prognostic value. However, a reliable tumor marker detectable in the serum of patients with this disease is missing. Because k-ras and APC mutations occur frequently and at an early stage in CRCs, these mutations might also be detected in the serum of CRC patients and serve as tumor markers. Hence, tumor tissues of CRC patients were examined for the presence of mutations in the k-ras and APC genes. If a mutation was detected in the tumor, the serum of the patient was screened subsequently for the presence of this mutation. K-ray mutations were detected in 22 of 30 colorectal tumor tissues, but only in six patients was the mutation identified in their serum samples. Mutations of the APC gene were identified in 25 of 65 tumors: 20 of these 25 patients showed the respective mutation in their serum. Given their higher detection rate, APC mutations could be a more informative serum marker than k-ras in CRC patients.

[An uncommon form of gastric rupture in giant scrotal hernia]. / Eine ungewöhnliche Form der Magenruptur bei riesiger Skrotalhernie.

The spontaneous gastric rupture without a preexisting gastric ulcer is an extremely rare event. In the case presented we report the occurrence of a gastric rupture in context with a giant left scrotal hernia. The entire intestine was transposed into the hernial sack and this obviously led to a chronic distension of the stomach and finally to the spontaneous gastric rupture. Other reasons of a spontaneous gastric rupture as well as the surgical therapy are discussed. Important are a fast diagnosis and surgical revision in order to prevent patients from a massive diffuse peritonitis.

[Plastic surgery of the anorectal area. Indications, technique and outcome]. / Plastische Chirurgie im Anorektalbereich. Indikation, Technik und Ergebnisse.

Anal canal stenosis with alteration of the sensoric continence or mucosal ectropion may occur after anorectal operations. Island flaps with perianal skin or the VY-anoplasty are simple plastic methods to reconstruct the anorectal region and cure patients--who often have suffered for a long time--from anal strictures or mucosal ectropion. In the period from 1994-1998 we reconstructed the anodermal region of seven patients using one of the above mentioned anorectal plastic procedures. Three patients complained of an anal stenosis and one patient suffered from an ectropion of the rectal mucosa after an improperly performed Whitehead hemorrhoidectomy. Three patients had a sensomotoric incontinence twice due to a congenital anal atresia and in one case caused by an accident. All patients were highly pleased after the operation--no complication occurred.

[The parathyrotoxic crisis - a surgical emergency]. / Die parathyreotoxische Krise - ein chirurgischer Notfall.

INTRODUCTION: The extremely rare but life-threatening hypercalcemic crisis is caused by an exacerbation of a chronic hyperparathyroidism. The etiologic reasons for this exacerbation are conditions which increase the serum calcium level in addition to the hyperparathyroidism with a complete breakdown of the calcium homeostasis, e. g. malignant tumors, primary and tertiary hyperparathyroidism, vitamin D poisoning or overdoses of calcium, vitamin D and calcium-containing ionizer in patients with renal insufficiency. METHODS: We present the clinical course of five patients with an acute hypercalcemic crisis and discuss the diagnostic procedure and the principles of surgical treatment with regard to the current literature. RESULTS: A hypercalcemic crisis develops if the total serum calcium concentration is over 4 mmol/l and parathormone over 90 pmol/l. The resulting syndrome is manifested by nausea and vomiting, polyuria and consecutive dehydration and hypotonia culminating in lethargy, hallucinations and coma. Hypercalcemia is the single most important diagnostic finding. CONCLUSION: The emergency therapy predominantly consists on the one hand in rehydration and parallel stimulation of diuresis. Urgent surgery is required if conservative therapy is not successful.

[Littré's hernia--clinical aspects and review of the history]. / Geschichte und Klinik der Littré-Hernie.

In 1700, the French surgeon Alexandre de Littré described for the first time a new form of inguinal hernia. This hernia varied from the known forms of hernias in its clinical course and in the postmortem examination results performed by Littrè himself. The characteristic feature of this hernia was the fact that the entire circumference of the bowel wall was not part of the hernial sac, but only the antimesenteric part of the intestinal wall. The underlying pathomechanism was explained 100 years later by Meckel. In a scientific paper about hernias some years earlier, Richter described the intestinal wall hernia, and this initiated the confusing use of the clinical entity known as the Richter-Littré hernia in Germany. In this case report we describe the historic development of this entity.

[Experiences in surgery of proctologic diseases in patients with HIV infection]. / Erfahrungen in der Chirurgie proktologischer Erkrankungen HIV-Infizierter.

Individuals who are seropositive for the human immunodeficiency virus (HIV) often suffer from disorders affecting the anorectum, but unfortunately the best kind of treatment frequently seems questionable. In a retrospective investigation we reviewed 29 HIV-positive patients with anorectal lesions who had experienced a proctologic operation. Our impression correlates with other findings according to which HIV-positive patients in advanced stages have a poorer post-operative outcome in terms of morbidity and survival than patients in an early CDC disease stage. This implies that the indication for a proctologic operation in an immunocompromised state has to be considered carefully.

[Gastric teratoma]. / Das Magenteratom.

Gastric teratomas are rare and mostly benign. They frequently become evident as a palpable abdominal mass. A malignant, aggressive solid tumor must be excluded. We present a 6-month-old male infant with a history of bleeding of the upper gastrointestinal tract. After in toto excision the histopathology was that of a benign gastric teratoma. Our method of reading the diagnosis and the subsequent therapy are described.

[Surgery in the elderly--extent and status in surgery]. / Chirurgie beim alten Menschen--Umfang und Stellenwert in der Chirurgie.

The results of selected elective and emergency operations of patients treated in the surgical department of Bonn University in 1994 and 1995 are presented and compared to the ASA-score. It was possible to show that old age itself is not a contraindication for major surgical interventions but that lethality mainly depends on concurrent diseases, i.e. the biological age. The numeric age is not an important factor. Physiological ageing only leads to diminished functional capacity, which can be partly compensated by more intensive care combined with early medical treatment. An age-specific factor which cannot be measured is the psychosocial age, the mental health. Mental health has an important influence on surgery in the aged patient.