[Appendicitis in the elderly. CRP value as decision support for diagnostic laparoscopy]. / Altersappendizitis. CRP-Wert als Entscheidungshilfe für eine diagnostische Laparoskopie.

BACKGROUND: The diagnosis of acute appendicitis in the elderly bears many pitfalls due to a broad range of differential diagnoses and uncommon clinical presentation. This may result in late detection of appendicitis leading to poor outcome. The aim of this study was to examine the characteristics of appendicitis in elderly patients in order to facilitate early diagnosis. MATERIALS AND METHODS: All patients who underwent appendectomy in our institution were prospectively recorded over a 30 month period. Data on patient's age (>60 years versus < or =60 years), clinical findings, the inflammatory parameters leucocytes and C-reactive protein (CRP) and histological-findings (perforated versus non-perforated) were collected. Statistical analysis was carried out by ROC analysis, chi(2) and t-tests. RESULTS: In the examination period 403 patients underwent appendectomy and 11.2% (n=45) were older than 60 years. These patients were characterized by significantly more frequent perforations compared to those patients < or =60 years (35.6% versus 7.0%, p< or =0.05), peritonitis (42.2% versus 9.5%, p< or =0.05), conversion to open surgery (23% versus 5%, p< or =0.005), longer postoperative hospital stay (9.2 days versus 4.3 days, p< or =0.05) and a higher complication rate (28.9% versus 3.6%, p< or =0.005). CRP values in patients >60 years were on average 123.2 mg/l and significantly higher than in patients < or =60 years (35.5 mg/l, p< or =0.005). The ROC analysis resulted in a CRP cut-off value of 101.9 mg/l for patients >60 years for the existence of a perforation with a specificity of 72.4% and a sensitivity of 81.3% (AUC 0.811). CONCLUSIONS: The CRP value showed a strong correlation with respect to the grade of inflammation and perforation. In conclusion, elderly patients with symptoms of appendicitis and a CRP value higher than 102 mg/l should undergo early diagnostic laparoscopy.

[Interdisciplinary ethics consultation on the surgical intensive care unit]. / Das interdisziplinäre Ethikkonsil auf der operativen Intensivstation.

BACKGROUND: An interdisciplinary ethics consultation (EC) on the intensive care unit (ICU) can be requested by the clinical team as a result of a subjective assessment of the patient's situation. The aim of this study was to objectify the initiation of EC by means of the SOFA score and to examine its impact on the clinical course. PATIENTS AND METHODS: Over a two-year period, all patients receiving an EC on the ICU were recorded. Age, hospital stay and mortality were compared with ICU patients who did not receive EC. SOFA score values of EC patients at the time of admission to the ICU and the time of EC were compared. Furthermore, the effect of different EC decisions (maximisation/limitation of treatment) on hospital stay and mortality were defined. RESULTS: EC was carried out in 52 of a total of 764 patients (6.8 %). Age (76.6 years; range: 40-99), hospital stay (20.5 days; range: 5-286) and ICU mortality (92.3 %) were significantly higher in EC patients compared to patients without EC (68.3 years; range: 10-100; p

[Twiddler's syndrome in a left pectoral implanted defibrillator]. / Twiddler-Syndrom bei einem links pektoral implantierten Defibrillator.

Twiddler's syndrome describes a rare complication following implantation of a pacemaker/defibrillator and is characterized by spontaneous, repeated rotation of the generator in the subpectoral pocket. We describe the case of a 78-year-old man who presented with an exit block 7 months after defibrillator implantation. As cause, a 15-fold rotation of the defibrillator's generator around its own axis could be verified, which entailed dislocation of the defibrillator's electrode. Safe fixation of the electrode and generator in the subpectoral pocket is of paramount importance, particularly in patients with loose subcutaneous fatty tissue, to prevent this rare complication.

Synergistic effects in apoptosis induction by taurolidine and TRAIL in HCT-15 colon carcinoma cells.

Induction of apoptosis in tumor cells by TRAIL (tumor necrosis factor [TNF]-related apoptosis-inducing ligand) is a promising therapeutic principle in oncology, although toxicity and resistance against TRAIL are limiting factors. Taurolidine (TRD), an antineoplastic agent with low toxicity, is a potential candidate for combined therapy with TRAIL. The aim of this study was to evaluate the apoptotic effects of a combined treatment with TRD and TRAIL in a human HCT-15 colon carcinoma cell line. HCT-15 cells were incubated with increasing concentrations of recombinant human TRAIL (50 ng/mL to 500 ng/mL) or TRD (50 micromol/L to 1000 micromol/L). In a second experiment, cells were furthermore exposed to a combination of both substances (TRAIL 50 ng/mL and TRD 100 micromol/L). At various time points (3 h to 36 h), cell viability, apoptosis, and necrosis were quantified by FACS analysis (propidium iodide/annexin V-FITC) and confirmed by TUNEL assay. Incubation with TRD resulted in cell death induction with maximum effects observed at 100 micromol/L and 1000 micromol/L after 36 h. TRAIL application led to dose-dependent cell death induction as early as 6 h. Combined treatment of TRD (100 micromol/L) and TRAIL (50 ng/mL) caused a sustained induction of apoptosis that was superior to single-agent application, exceeding a merely additive effect. Combinatory treatment of human colon carcinoma cells with TRD and TRAIL results in a synergistic effect on apoptosis induction with a significant increase of the apoptotic index. Combination of TRAIL with the nontoxic TRD might represent a novel therapeutic strategy in oncological therapy.

Genetic deletion of JNK1 and JNK2 aggravates the DSS-induced colitis in mice.

The c-Jun N-terminal kinases (JNKs) are considered as novel targets for therapy of inflammatory bowel diseases (IBD). However, the relevant JNK isoforms have to be elucidated. Here, we analyze the individual contribution of the JNK1 and JNK2 isoforms in a dextran sulfate sodium (DSS) model of experimental colitis. JNK1 and JNK2 knockout mice (JNK1 ko, JNK2 ko) and their wild-type controls (WT1, WT2) received three cycles of DSS treatment, each consisting of 1.7% DSS for 5 days, followed by 5 days with water. Animals were daily evaluated by a disease activity index (DAI) comprising measurement of body weight, estimation of stool consistency, and test for occult blood/gross rectal bleeding. After 30 days all animals were sacrificed, and the inflamed intestine was histologically evaluated by a crypt damage score. Unexpectedly, neither JNK1 ko nor JNK2 ko prevented mice from developing a chronic colitis when compared to wild-type controls WT1 and WT2, respectively. On the contrary, DAI and mortality were aggravated in JNK2 ko compared to WT2. DAI and mortality did not differ between JNK1 ko and WT1, but the histological crypt damage score was significantly enhanced in the cecum of JNK1 ko mice. Genetic deletion of JNK2 worsens the disease outcome in an experimental model of murine colitis. We hypothesize that the functional deletion of the otherwise proapoptotic JNK2 prolongs the activity of proinflammatory immune cells with deterioration of disease activity.

Ceftriaxone prophylaxis in abdominal, cardiovascular, thoracic, orthopaedic, neurosurgical and general surgery: a review of practice 1996 - 2003.

The microbiology, efficacy and cost-effectiveness of ceftriaxone prophylaxis were compared with those of alternative antimicrobial agents in abdominal, cardiovascular, thoracic, orthopaedic, neurosurgical and general surgical procedures published since 1996. Ceftriaxone was compared with cefazolin +/- metronidazole, cefoxitin, cefuroxime, ceftazidime, cefotaxime, cefepime + metronidazole, penicillins, ticarcillin/clavulanic acid, ampicillin/sulbactam, vancomycin and combined clindamycin/gentamicin. Ceftriaxone, used primarily as 'single shot prophylaxis', was at least as clinically effective if not better than the comparative single- and multiple-dose agents over the broad range of surgical procedures. Furthermore the overall cost of ceftriaxone prophylaxis has often been shown to be markedly less than comparators, despite the relatively high acquisition cost of ceftriaxoe, when factors other than acquisition cost were considered. Advances in surgical techniques, the changes in bacterial ecology in hospitals, the spread of bacterial resistance and the substantial increase in the surgical population at risk suggest that third generation cephalosporins, particularly ceftriaxone, should be taken into consideration for surgical prophylaxis.

[Leiomyosarcoma of the inferior vena cava. Review of a rare disease]. / Leiomyosarkom der Vena cava inferior. Ubersicht zu einem seltenen Krankheitsbild.

Primary sarcomas of the great vessels are rare. Their most common site is the inferior vena cava. We report a primary leiomyosarcoma of a 41 year old female patient localised just below the right renal vein. The resected tumour showed the histological signs of a well differentiated, progesterone positive leiomyosarcoma. The case is discussed on the data of the reviewed literature.

IgM-enriched immunoglobulin (pentaglobin) positively influences the course of post-surgical intra-abdominal infections.

BACKGROUND: Polyvalent IgM-enriched intravenous human immunoglobulin (IVIG) preparations are discussed to be beneficial regarding sepsis outcome. MATERIALS AND METHODS: Sixty-four patients with abdominal infection were treated with Pentaglobin or Albumin. Serum levels of endotoxin and chemokines were determined. RESULTS: Incidence of fever was 19/28 in the pentaglobin and 18/26 in the albumin group, the percentage of days with fever was 34 +/- 26 for pentaglobin and 43 +/- 25 for albumin (mean +/-SD). Procalcitonin levels of the pentaglobin treated patients fell under the upper limit of normal on day six whereas levels of albumin patients remained elevated. CONCLUSION: Pentaglobin has a positive influence on the course of post-surgery intra-abdominal infection.

[Intra-abdominal fibromatosis after appendectomy as cause for ileus]. / Intraabdominale Fibromatose nach Appendektomie als Ursache rezidivierender Ileuszustände.

Aggressive intraabdominal fibromatosis is a rare response to surgical trauma. Characteristic is the local destroying growth. Only an operation in the purpose of R0-resection ends in cure. We report on a 29-year-old man, who developed intraabdominal fibromatosis as reaction to surgical trauma 19 years after appendectomy and subsequent to several relaparotomies due to adhesions. A huge conglomeratumor which included the ileum and the colon acsendens resulted in bowel obstruction and ileus. Complete surgical removal of the tumor lead after a primary complicated course to recovery.

[Prospective comparative observational study on the antibiotic treatment of secondary peritonitis in Germany -- efficacy and cost analysis]. / Antibiotische Behandlung der sekundären Peritonitis in Deutschland. Prospektive vergleichende Beobachtungsstudie zur Wirksamkeit und den Behandlungskosten.

AIMS: Cephalosporins and broad-spectrum penicillins in combination with metronidazole are suitable for treatment of secondary peritonitis. The aim of this study was to compare the clinical and bacteriological efficacy, length of hospital stay (LOS), treatment costs of ceftriaxone (CRO) in combination with metronidazole vs standard regimens (SR) 1 and 2. METHODS: Patient data were subjected to matched-pairs analysis according to four different categories of the Mannheim peritonitis index. RESULTS. From January 1998 to March 2000, a total of 365 patients from 59 surgical wards in German hospitals were included. Clinical efficacy was 90.2% vs 70.4% ( P=0.004) for CRO/SR 1 and 78.3% vs 82.6% for CRO/SR 2. Bacteriological efficacy was comparable. Antibiotic treatment costs were 593/539 Euros for CRO/SR 1 and 466/750 Euros for CRO/SR 2, i.e., costs for CRO were 37.9% lower than with SR 2. CONCLUSION: Based on clinical, bacteriological, and pharmacoeconomic results, ceftriaxone in combination with metronidazole can be regarded as a first-line antimicrobial treatment of secondary peritonitis.

[Which imaging in case of sigmoid diverticulitis? The value of ultrasound (Conventional B-mode in combination with hydrocolonsonography and colour flow Doppler) in comparison to the well-established modalities like contrast enema and helical computertomography]. / Welche bildgebende Diagnostik bei Verdacht auf eine Sigmadivertikulitis? - Wertigkeit der sonographischen Untersuchungsverfahren (konventionelle B-Bild-Diagnostik in Kombination mit der Hydrokolonsonographie und der farbkodierten Duplexsonographie) im Vergleich mit den etablierten Verfahren wie dem Kolon-Kontrasteinlauf und der Spiral-Computertomographie -

Sigmoid diverticulitis is in case of complications like perforation, abscess and peritonitis a life-threatening disease. A diagnostic work up with high sensitivity is mandatory. In a prospective study upon 247 patients with the possible diagnosis of acute diverticulitis ultrasound is a screening method with a high specificity (97 %) and leads in combination with the hydrocolonsonography and the colour flow doppler to a high sensitivity (76 %). Without any typical findings in ultrasound, helical CT scan is the best method in the evaluation of the acute diverticulitis (sensitivity and specificity 100 %), because contrast enema is inferior to CT in the evaluation of abscesses (6 %) and perforation (53 %). CT has in case of perforation and of abscesses a sensitivity of 90 % and 100 %, while ultrasound has a sensitivity of 12 % to perforation and of 39 % to abscesses.

[Perioperative antimicrobial prophylaxis for colonic surgery: Present status in Germany. A prospective multicenter study with and without Metronidazole]. / Perioperative Infektionsprophylaxe in der elektiven Kolonchirurgie: Klinischer Alltag in Deutschland - Eine multizentrische prospektive Studie mit versus ohne Metronidazol -

INTRODUCTION: The objective of a multicentric observational study, that was performed in Germany between 1(st) September 1996 and 30(th) September 1997, was to assess postoperative infections as a function of risk factors and antibiotic prophylaxis under everyday clinical conditions. 2 481 patients from 114 centres who received infection prophylaxis prior to elective colonic resection were included. In the descriptive analysis of the study it was noted that 36.1 % of the patients had received no prophylaxis with metronidazole despite the fact that the study protocol recommended the use of this drug in preoperative antibiotic combinations. The present analysis therefore considers the influence of metronidazole on the postoperative infection rate. METHODS: In order to exclude any bias due to intergroup differences in risk profile, the groups with and without metronidazole were subjected to a matched-pair analysis. Matching parameters were: duration of operation, blood loss, age, diabetes mellitus, hepatic, renal, or chronic airways disease, immunosuppressive therapy, and rectal resection. This led to the formation of 800 pairs that were matched with respect to these parameters. The 800 pairs were then stratified into the following treatment groups: Group 1 a and b: long-acting cephalosporine (ceftriaxone) with or without metronidazole (n = 2 x 491); Group 2 a and b: short-acting cephalosporines with or without metronidazole (n = 2 x 133); Group 3 a and b: broad-spectrum penicillines with or without metronidazole (n = 2 x 176). RESULTS: In all three treatment groups combination therapy with metronidazole was found to be significantly superior. Postoperative infection rates were 9.4 % and 18.7 % (p = 0.000) respectively in Group 1 a and b, 12.0 % and 25.6 % (p = 0.008) respectively in Group 2 a and b, and 19.9 % and 29.0 % (p = 0.009) respectively in Group 3 a and b. CONCLUSION: Preoperative administration of metronidazole in addition to an effective beta-lactam antibiotic is strongly advised in elective colonic surgery, as absence of antibiotic cover against anaerobic colonic flora leads to a significantly higher postoperative infection rate.

Antimicrobial prophylaxis for abdominal surgery: is there a need for metronidazole?

The objective of the present multicenter observational study was to assess postoperative infections as a function of risk factors and antibiotic prophylaxis under everyday clinical conditions. 2513 patients from 114 centers in Germany who received infection prophylaxis prior to elective colonic resection were included in the study between 1st September 1996 and 30th September 1997. In the descriptive analysis of the study it was noted that 36.1% of the patients had received no prophylaxis with metronidazole despite the fact that the study protocol recommended the use of this drug in preoperative antibiotic combinations. The present analysis therefore considers the influence of metronidazole on the postoperative infection rate. To exclude any bias due to intergroup differences in risk profile, the groups with and without metronidazole were subjected to a matched-pair analysis. Matching parameters were: duration of operation, blood loss, age, diabetes mellitus, hepatic, renal, or chronic airways disease, immunosuppressive therapy, and rectal resection. This led to the formation of 800 pairs that were matched with respect to these parameters. The 800 pairs were then stratified into the following treatment groups: Group 1: long-acting cephalosporin (ceftriaxone) with or without metronidazole (n = 2 x 491); Group 2: short-acting cephalosporins with or without metronidazole (n = 2 x 133); Group 3: broad-spectrum penicillins with or without metronidazole (n = 2 x 176). In all three treatment groups combination therapy with metronidazole was found to be significantly superior. Postoperative infection rates with and without metronidazole were 9.4% and 18.7% respectively in Group 1, 12.0% and 25.6% respectively in Group 2, and 19.9% and 29.0% respectively in Group 3. The lowest infection rate was thus achieved by means of preoperative infection prophylaxis with ceftriaxone plus metronidazole. Thus, preoperative administration of metronidazole in addition to a long-acting beta-lactam antibiotic is strongly advised in elective colon surgery, as absence of antibiotic cover against anaerobic colonic flora leads to a significantly higher postoperative infection rate.

Perioperative infection prophylaxis and risk factor impact in colon surgery.

BACKGROUND: A prospective observational study was undertaken in 2, 481 patients undergoing elective colon resection in 114 German centers to identify optimal drug and dosing modalities and risk factors for postoperative infection. METHODS: Patients were pair matched using six risk factors and divided into 672 pairs (ceftriaxone vs. other cephalosporins, group A) and 400 pairs (ceftriaxone vs. penicillins, group B). End points were local and systemic postoperative infection and cost effectiveness. RESULTS: Local infection rates were 6.0 versus 6.5% (group A) and 4.0 versus 10.5% (group B); systemic infection rates in groups A and B were 4.9 versus 6.3% and 3.3 versus 10.5%, respectively. Ceftriaxone was more effective than penicillins overall (6.8 vs. 17.8%, p < 0.001). Length of postoperative hospital stay was 16.2 versus 16.9 days (group A) and 15.8 versus 17.6 days (group B). Of the six risk factors, age and concomitant disease were significant for systemic infection, and blood loss, rectum resection and immunosuppressive therapy were significant for local infection. Penicillin was a risk factor compared to ceftriaxone (p < 0.0001). Ceftriaxone saved 160.7 EUR versus other cephalosporins and 416.2 EUR versus penicillins. CONCLUSION: Clinical and microbiological efficacy are responsible for the cost effectiveness of ceftriaxone for perioperative prophylaxis in colorectal surgery.

Procalcitonin (PCT) in patients with abdominal sepsis.

BACKGROUND: To assess the accuracy of procalcitonin as a measure of severity in patients with septic abdominal illnesses and the sepsis syndrome, to compare measurements with those of other inflammatory mediators, and to predict outcome. METHODS: We carried out a prospective clinical study from 246 patients with infective or septic episodes confirmed at laparotomy and 66 patients undergoing elective operations who acted as controls. Specimens of blood for measurement of cytokine concentrations determination were obtained daily from septic patients. In the control group specimens were obtained before operation, at the end of operation, and on each of the following days until normal recovery (day 10). Every two weeks up to 3 months for patients with metastases, who were being followed up. RESULTS: Compared with other cytokines such as tumor necrosis factor alphaa and interleukin 6 procalcitonin was closely related to the development of infective and septic complications. 59 of 246 patients (24%) with sepsis died. Procalcitonin concentrations preoperatively [median 2.05 compared with 4.2 ng/ml (p=0.08)] (Mann-Whitney U-test) did not differ, but those on the days 1,4 and at the end differed significantly [day 1: 4.9 compared with 13.8 ng/ml (p<0.01); day 4: 4.8 compared with 13.0 ng/ml (p<0.01) and 0.4 compared with 13.25 ng/ml (p<0.01) at the end of the study]. In the control group only 7 (1.6%) of all blood samples, were detected outside the normal range (up to 0.8 ng/ml). CONCLUSIONS: Procalcitonin is a new indicator of infection and sepsis. TNF and IL-6 concentrations always rise after major operations and fall in the absence of infection, indicating operative trauma. Procalcitonin is sensitive in detecting infective complications. Under routine conditions the procalcitonin concentrations seems to be valid, reproducible and detectable.

Procalcitonin in early detection of postoperative complications.

BACKGROUND: A prospective clinical study was performed to assess the accuracy of procalcitonin in 70 patients with elective colorectal or aortal surgery and to compare it with inflammatory mediators. Also the early prediction of complications and the outcome of these patients was taken into account. METHODS: Laboratory variables and cytokine determination were obtained preoperatively, on the day of operation and postoperatively on a daily basis from day 1 to 5, and on days 7 and 10 in the colorectal group and in the aortal surgery group at different times on the operation day after aortal clamping. The main outcome criteria were early recognition of complications and alterations in the production of procalcitonin and cytokines in order to detect severe infective complications. RESULTS: Procalcitonin was closely related to postoperative complications with significantly elevated levels at day 1 after surgery. The plasma concentrations of IL-6 increase on days 1-3 without a difference in the groups, also C-reactive protein demonstrates no differences. CONCLUSION: Procalcitonin presents itself as a new parameter of infection and sepsis. In the postoperative period PCT seems to be an interesting marker of early prediction of infective complications when high postoperative levels are found. Under routine conditions procalcitonin is a valid reproducible and detectable parameter.

[Monstrous recurrence of serous cystadenocarcinoma of the pancreas]. / Monströses seröses Zystadenomrezidiv des Pankreas.

Serous cystadenoma of the pancreas is a rare benign tumor. The diagnostical management is easy, preoperative histological finding is difficult. The surgical relevance is revealed by the fact, that this tumor shows a high recurrence rate, especially if a complete resection is not feasible because of a difficult tumor localisation. The whole problematic nature of this disease is underlined by the following case report, which illustrates that in 5 years 4 surgical interventions because of recurrent symptoms were necessary. Each single operation improved quality of life for a different time period. First aim must be the radical resection of the tumor during primary operation, but this is not always possible because of unfavorable tumor localisation.