Fibrotic entrapment of the small bowel in congenital intestinal lymphangiectasia.

Congenital intestinal lymphangiectasia is a rare protein-losing enteropathy that is characterized by diarrhea and peripheral edema. This report presents a 37-yr-old woman who had suffered from recurrent diarrhea and peripheral edema since her early childhood and who was admitted for severe attacks of abdominal pain. A diagnosis of intestinal lymphangiectasia was made endoscopically, histologically, and radiographically. Laparotomy revealed complete fibrotic entrapment of the small bowel, which caused partial mechanical bowel obstruction. Surgical decortication led to recovery. To the best of our knowledge, this is the first report on fibrotic entrapment of the small bowel in a patient with long lasting intestinal lymphangiectasia.

[The effects of aprotinin. Blood loss and coagulation parameters in orthotopic liver transplantation: A clinical-experimental, prospective and randomized double-blind study]. / Die Wirkung von Aprotinin. Blutverlust und Gerinnungsparameter bei orthotoper Lebertransplantation: Eine klinisch-experimentelle, prospektive und randomisierte Doppelblindstudie.

The effect of aprotinin (2,000,000 IU as a bolus +500,000 JU/h until the end of the operation) on transfusion requirements and coagulation parameters in orthotopic liver transplantation (study group: n = 9; placebo group: n = 9) was investigated in a randomised, double-blind study. Coagulation parameters were monitored intraoperatively using a mobile laboratory. In contrast to the published results, no effect on transfusion requirements could be demonstrated. However, aprotinin showed a positive effect on some coagulation parameters in the reperfusion phase. The mechanism appeared to be inhibition of the contact activation of the intrinsic system with less thrombin generation in the study group.

Perioperative mucosal pH and splanchnic endotoxin concentration in orthotopic liver transplantation.

Although impairment of splanchnic perfusion may induce mucosal hypoxia and endotoxaemia during orthotopic liver transplantation (OLT), little is known about the changes in mucosal oxygenation during and after the procedure. To study the effects of liver surgery itself on mucosal pH (pHi) and the response of pHi to acute changes in portal flow, we measured gastric pHi during six liver resections using tonometry: in two patients, after clamping of the hepatoduodenal ligament, pHi decreased within 30 min and recovered promptly after reperfusion. We then investigated gastric and sigmoid pHi (pHig, pHis) during the perioperative phase in 18 OLT. Median pHi values were low before surgery (pHig 7.28 (first/third quartiles 7.22/7.34); pHis 7.27 (7.12/7.36)). Although global oxygen delivery and haemodynamic variables remained constant and veno-venous bypass (VVB) was used to maintain portal flow, pHi declined during the anhepatic phase (pHig 7.19 (7.13/7.23), P < 0.01; pHis 7.13 (7.06/7.24), P < 0.05). After reperfusion of the graft, pHi recovered and did not differ from baseline values by the end of OLT. After operation pHig increased further, reaching the highest values 30 h after ICU admission (7.34 (7.26/7.38)). In the intraoperative period, no significant endotoxaemia was observed either in portal or systemic blood. The maximum reduction in pHi was related neither to the duration of VVB and OLT nor to the number of red cell units transfused. pHi after reperfusion did not correlate with graft viability or dysfunction of the lung or kidney. We conclude that pHi indicates mucosal ischaemia during OLT which is not necessarily associated with endotoxaemia, and intraoperative pHi monitoring does not appear to be a valuable predictor of postoperative graft failure and organ dysfunction.

The predictive value of four scoring systems in liver transplant recipients.

OBJECTIVE: To compare 4 general severity classification scoring systems concerning prognosis of outcome in 123 liver transplant recipients. The compared scoring systems were: the mortality prediction model (admission model and 24 h model); the simplified acute physiology score; the acute physiology and chronic health evaluation (Apache II) and the acute organ systems failure score. DESIGN: Retrospective, consecutive sample. SETTING: Adult intensive care unit in a university hospital. PATIENTS: 123 adult liver allograft recipients after admission to the intensive care unit. MEASUREMENTS AND MAIN RESULTS: The scoring systems were calculated as described by the authors to classify the severity of illness after admission of the allograft recipients to the intensive care unit. The mean and median values of survivors and the group of patients, that died during hospital stay were compared. Receiver-operating characteristics were plotted for all scoring systems and the areas under the curves of receiver-operating characteristics were calculated. The predictive value of the 4 scoring systems was tested using a variety of sensitivity analyses. The mortality prediction model (24 h model) was found to have a high significance (p < 0.001) in predicting mortality and showed the greatest area under the curve (0.829). Simplified acute physiology score (p < 0.001) and acute physiology and chronic health evaluation (Apache II) (p < 0.01) had a high significance as well, but did not hit the level of prognosis of mortality prediction model, as shown in the area under the curves. Accordingly, sensitivity was highest in MPM-24 h (83%), followed by SAPS (72%) and Apache II (71%). MPM-24 h had a total misclassification rate of 22% (SAPS = 32%, Apache II = 33%). MPM-admission failed in predicting mortality (sensitivity = 52%). Organ systems failure score seemed not to be useful in liver transplant recipients. CONCLUSION: General disease classification systems, such as the mortality prediction model, simplified acute physiology score or acute physiology and chronic health evaluation are good mortality prediction models in patients after liver transplantation. We suggest that there is no need for improvement of a special scoring system.

[The results of a long-term follow-up of patients with a percutaneous cholecystostomy]. / Ergebnisse einer Langzeitkontrolle von Patienten mit perkutaner Cholezystostomie.

19 out of 37 patients with percutaneous cholecystostomy were followed up for assessment of gallbladder function after percutaneous drainage. 17 out of 19 of the patients remained free from symptoms of gallbladder disease during a mean follow-up period of 25.8 months. Contractility of the gallbladder calculated by measurement of the sonographic diameter of the gallbladder with provocation tests was 62%. One patient was operated upon for choledocholithiasis three years after percutaneous cholecystostomy. Histology showed signs of chronic cholecystitis. It can be concluded that cholecystectomy is not routinely necessary after percutaneous cholecystostomy provided biliary excretion is normal.

Balloon dilatation and stent placement of suprahepatic caval anastomotic stenosis following liver transplantation.

We present an unusual case of suprahepatic caval anastomotic stenosis after adult liver transplantation in the early postoperative period. Color flow Doppler sonography and cavography were used to confirm the clinical diagnosis. Successful nonoperative treatment of the obstruction was achieved by balloon dilatation and subsequent implantation of a vascular stent.

[Acute cholecystitis: percutaneous transhepatic drainage]. / Akute Cholezystitis: Perkutane transhepatische Drainage.

Despite emerging endoscopic techniques for treatment of gallbladder diseases the operative cholecystectomy is the treatment of choice in acute cholecystitis. Percutaneous cholecystostomy is an alternative treatment modality in poor surgical risk patients. In 19 out of 36 patients with percutaneous cholecystostomy no subsequent cholecystectomy was performed. A long-term observation of these 19 patients showed normal function of the gallbladder in ultrasound studies, thus percutaneous drainage can be a definitive treatment for acute cholecystitis in selected cases.

[Obesity and surgery]. / Adipositas und Chirurgie.

UNLABELLED: BASICS AND AIMS: Obesity is generally considered to be a surgical risk factor, although its influence cannot be accurately defined. The risks of surgery in the obese patient are discussed on the basis of a review of the literature. MAIN TOPICS: In itself, obesity does not increase the surgical risk, but it is often associated with cardio-respiratory, metabolic or coagulation disorders that increase morbidity and mortality in obese patients. The only statistically significant difference between obese and non-obese patients is the higher rate of secondary healing in the former. CONCLUSIONS: Guidelines aimed at reducing perioperative risk in these patients are suggested.

Disorders of bile acid metabolism in cholesterol gallstone disease.

The aim of the study was to evaluate the metabolism of individual bile acids in patients with cholesterol gallstone disease. Therefore, we determined pool size and turnover of deoxycholic (DCA), cholic (CA), and chenodeoxycholic acid (CDCA) in 23 female gallstone patients classified according to their gallbladder function and in 15 healthy female controls. Gallstone patients had normal hepatic bile acid synthesis, but, depending on gallbladder function, differed with respect to turnover and size of the bile acid pools: Patients with well-emptying gallbladder (group A, n = 9) had enhanced turnover and reduced pools of CA (-46%; P less than 0.01 vs. controls) and CDCA (-24%; P less than 0.05), but normal input and size of the DCA pool. With reduced gallbladder emptying (less than 50% of volume; group B, n = 6), turnover and pools of CA, CDCA, and DCA were similar as in controls. Patients with loss of gallbladder reservoir (group C, n = 8) had increased input (+100%; P less than 0.01) and pool size of DCA (+45%; P = 0.07) caused by rapid conversion of CA to DCA, while the pools of CA (-71%; P less than 0.001 vs. controls) and CDCA (-36%; P less than 0.05) were reduced by enhanced turnover. Thus, in patients with cholesterol gallstones, the pools of primary bile acids are diminished, unless gallbladder emptying is reduced. Furthermore, in a subgroup of gallstone patients, who had completely lost gallbladder function, the CA pool is largely replaced by DCA owing to rapid transfer of CA to the DCA pool. This probably contributes to supersaturation of bile with cholesterol.

Cholesterol nucleation time in gallbladder bile of patients with solitary or multiple cholesterol gallstones.

Patients with multiple cholesterol gallbladder stones have been found to be at a higher risk for the recurrence of gallstones after successful nonsurgical treatment than those with a solitary stone. Cholesterol gallstone recurrence, like primary gallstone formation, probably involves a triple defect with supersaturation, abnormally rapid nucleation of cholesterol in bile and altered gallbladder motor function. We investigated whether the increased recurrence rate of patients with multiple stones might be caused by more rapid nucleation. Therefore the time required for cholesterol monohydrate crystals to appear in ultracentrifuged bile of patients with solitary (n = 71) or multiple (n = 42) cholesterol gallstones was determined. The cholesterol nucleation time was significantly (p less than 0.01) longer in the bile from patients with solitary stones (less than 1 to 16 days, median = 2.0 days) than in the bile from patients with multiple stones (less than 1 to 8 days, median = 1.0 days). Moreover, 15 of 71 (21.1%) patients with solitary cholesterol stones but only 1 of 42 (2.4%) patients with multiple cholesterol stones showed a normal (greater than 4 days) nucleation time. However, no difference in the cholesterol saturation index was found between the bile samples from patients with solitary stones and the bile samples from patients with multiple stones (1.55 +/- 0.65 vs. 1.54 +/- 0.59, mean +/- S.D., respectively). The more rapid cholesterol nucleation in gallbladder bile may, therefore, be the major risk factor causing the higher percentage of stone recurrence in patients with multiple cholesterol stones as compared with patients with solitary cholesterol stones.