Late results of heterotopic autotransplantation of splenic tissue into the greater omentum.

There is still controversy about the beneficial effects of splenic autotransplantation. As a result, replantation of the spleen has almost been abandoned for surgical treatment of splenic injuries. To learn more about the long-term effects we have analyzed eight patients 9.2 +/- 1.2 years after autotransplantation of the spleen into the greater omentum. Splenic replants could be detected by scintigraphy in seven patients (87.5%). Splenic size, measured by single-photon emission computed tomography, varied between 19.344 and 471.705 units of volume (Uov). Two patients with the smallest replants had pathologic changes of leukocytes and lymphocyte subsets in 12 of 16 measurements (75%). These changes closely resembled a spleenless state and were similar to those in the patient with no detectable splenic autograft. In contrast, five patients with large splenic replants (49.192-471.705 UoV) revealed pathologic findings in only 2 of 40 measurements (5%). Based on an extensive review of the literature and our own results, it can be concluded that splenic autotransplantation into the greater omentum is superior to splenectomy but undoubtedly less effective than in situ preservation of the spleen. Therefore splenic replantation should still be considered, particularly in pediatric surgery, when in situ preservation of the spleen is not possible by other techniques.

Quantitative and functional restorations and alterations of peripheral lymphocytes in patients with autologous spleen implantation.

To reduce the risk of severe infections in splenectomized patients, new methods for splenic preservation or heterotopic autologous spleen implantation have been established. In the latter case, the immunological and functional benefits are still under discussion. In this study we compared immunological parameters in 16 splenectomized patients with and without heterotopic autologous spleen implantation with a nonsplenectomized control group. The total lymphocyte counts--T-cells, CD4+ -, as well as CD8+ - lymphocytes, CD16+ - and B-cells--were highly elevated in both groups, whereby the B-cells were relatively and absolutely higher in the implanted group than in the nonimplanted group. Splenectomized patients had a significantly reduced serum IgM level. The serum IgM of patients with splenic autotransplantation was not significantly lower than that of the controls. In contrast to the impaired in vitro immunoglobulin synthesis in the splenectomized group, the autotransplanted patients showed a normal PWM-induced IgG and IgM synthesis and an increased IgA production compared with the controls. The latter results support the findings of elevated serum IgA levels in this group. The mitogenic-induced proliferation with PHA, ConA, PWM, and OKT3 was not clearly different within the tested groups. The results may indicate a benefit of autologous spleen implantation in regard to the humoral immune response.

Total gastrectomy and oesophagojejunostomy--a prospective randomized trial of hand-sutured versus mechanically stapled anastomoses.

Eighty patients undergoing total gastrectomy for malignant disease were entered into a prospective randomized study, comparing anastomoses constructed mechanically (staples) with hand-sewn (single layer Maxon) anastomoses. The groups were matched with respect to clinical features, medical risk factors and were staged for tumour. Only one anastomotic leak was observed after operation and this was in the group of stapled anastomoses. One patient died in each group (owing to cardiac infarction and multiorgan failure). Operating time, morbidity and hospital stay showed no significant differences between groups. These results indicate that hand-sewn and mechanically stapled oesophagojejunostomy anastomoses allow the same high standard of performance.

[Cellular immunologic parameters in thyroid diseases]. / Zelluläre immunologische Parameter bei Schilddrüsenerkrankungen.

Between October 1984 and June 1987 in 45 patients (9 males, 36 females) pre- and postoperatively the immunocompetent cells in the peripheral blood were measured using OKT- and LEU-11-antigens. 20 patients suffered from malignant and 25 patients from benign diseases. For statistical analysis, H-test according to Kruskal and Wallis was used. Preoperatively, the total account of T-lymphocytes was decreased in patients with thyroid carcinomas, but showed no differences compound to patients with benign diseases postoperatively. No differences were observed in lymphocytic subpopulations in all groups. Parallely, in 50 patients (14 males, 36 females) immunocompetent cells were counted in the resected specimens. There were investigated 29 carcinomas and 21 benign thyroid lesions using the LEU-antigens. Between the group with malignant diseases and that with benigne lesions of the thyroid, no statistically significant differences were observed.

[A totally implantable permanent central venous access, long-term experience with subcutaneous infusion chambers]. / Total implantierbarer dauerhafter zentralvenöser Zugang, Langzeiterfahrung mit subcutanen Infusionskammern.

Subcutaneously implanted infusion chambers represent a new method of central venous access. In 57 evaluable out of 70 patients, four different models of infusion chambers with an accumulative observation time of 57 years were implanted. In 72% of the patients, up to 12 cycles of polychemotherapy were administered. Parenteral nutrition and blood drawing were also performed. After 4,970 punctions of the system and 12.2 years of use 46 complications in 38 patients were observed, however, most were minor ones, such as temporary occlusions (12) and extravasations (14). Septum luxation (1), septum perforation (1), catheter fracture (1) and catheter migration (2) as well as 7 cases of septicemia or port-pocket-infection required explanation. Infusion chambers seem to be particularly suitable for intermittent and long-term chemotherapy and emergency bolus injections with a significant advantage (10 complications per one thousand days of use) compared to externally placed venous catheters. However, follow-up and care must be performed by a skilled team.

[Controlled study comparing mechanical and manual esophago-jejunostomy following gastrectomy]. / Kontrollierte Studie zum Vergleich maschineller und manueller Oesophago-Jejunostomie nach Gastrektomie.

40 patients with gastric malignancies were entered into a prospective randomised study of mechanical stapling (EEA) vs. manual single layer suturing of the esophago-jejunostomy following total gastrectomy. The groups were well matched with respect to clinical features, medical risk factors and tumor stage. Following manual technique, no anastomotic leak was observed. In the group with automatic mechanical suturing one technical failure and one insufficiency was seen. This difference, however, is not statistically significant. One patient died (cardiac infarction). The analysis of operating time, morbidity and hospital stay showed no significant differences. These results indicate that by use of a precise standardized conventional suture technique the same security performing an esophago-jejunostomy can be achieved as with mechanical staplers.

[Continuous intravenous or intra-arterial administration via a subcutaneous implantable infusion chamber. Preliminary clinical experiences with particular reference to intra-arterial chemotherapy]. / Dauerhafter intravenöser oder intraarterieller Zugang mit einer subkutan liegenden implantierbaren Infusionskammer. Erste klinische Erfahrungen unter besonderer Berücksichtigung der intraarteriellen Chemotherapie.

An infusion chamber was implanted subcutaneously in 18 patients for intravenous systemic treatment and in 20 for intra-arterial treatment of the liver. Intravenous catheters were introduced via the cephalic vein, intra-arterial ones via the gastroduodenal artery, after exclusion of extrahepatic metastases. Six manageable complications were observed during a total implantation time of 102 months for i.v. treatment and usage over 500 days: three temporary occlusions; one infection; two extravasations. The intra-arterial chemotherapy, largely for hepatic metastases of breast carcinoma, was undertaken according to a modified FAM schema (fluorouracil, adriamycin, mitomycin C): It achieved a high response rate with two full and eleven partial remissions. Complications were rare, except for 4 temporary occlusions. Systemic side effects were almost completely absent, local toxicity was low. One problem was the fixation of the needle which connects to the infusion chamber. This was true for both intravenous and intra-arterial treatment.

[Complications following splenectomy]. / Komplikationen nach Splenektomie.

In a retrospective (n = 570) and prospective study (n = 86) early complications following splenectomy were registered in 127/570 (22.3%) resp. 33/86 (38.4%). The mortality rate was 6.6% resp. 6.9%. Recurrent hemorrhage was the most dangerous, infections (pleuropulmonary, wound healing, subphrenic abscess) were the most frequent complications. Their rate is related only to the underlying disease or operative indication (elective splenectomy with hematological diseases; ruptured spleen; incidental splenectomy).

[Autotransplantation of the spleen]. / Autotransplantation der Milz.

No clinical parameter can prove that the autotransplantation of splenic tissue will restore all splenic functions especially in the immune reaction. Therefore this method is not an alternative to other methods of preservation of the ruptured spleen. Autotransplantation should be used only, when splenic rupture makes splenectomy necessary.

[Perioperative antibiotic prophylaxis in elective splenectomy. A randomized prospective study]. / Perioperative Antibioticaprophylaxe bei der elektiven Splenektomie. Eine randomisierte, prospektive Studie.

After elective splenectomy septic complications in the early postoperative period occur up to 45%. In a prospective, randomised, controlled study of 61 patients the incidence of postoperative infections with and without prophylactic use of an antibiotic was compared. 61 patients undergoing elective splenectomy were divided into two groups. 28 patients were operated without any antibiotic, 33 patients were given 3 X 1500 mg Cefuroxim (Zinazef) for three days, starting 1 h prior to the operation. Infections of the urinary tract and the lung were excluded preoperatively. With a standardized program we searched for intraabdominal abscesses, infections of the lung, the urinary system and the abdominal incision postoperatively. No fatal complication occurred. A significant reduction in total septic complication rate (p less than 0.01) and in pneumonia was found as well in benign as in malignant disease. The study shows, that the apparently disturbed immunological defense following splenectomy can be improved by the prophylactic use of antibiotics.