[Pancreatic elastase-1 in the stool for the determination of exocrine pancreas function of postoperative patients with early enteral nutrition -- a pilot study]. / Pankreas-Elastase-1 im Stuhl zur Bestimmung der exokrinen Pankreasfunktion unter frühpostoperativer enteraler Ernährung -- Pilotstudie.

BACKGROUND AND OBJECTIVE: There are only incomplete data about exocrine pancreatic function after major gastrointestinal surgery. Early enteral nutrition with high-molecular diets is increasingly administered to these patients. A knowledge of exocrine secretion of the pancreas is crucial, because pancreatic enzymes are needed for the adsorption of the high-molecular diets. To determine the exocrine pancreatic secretion the fecal elastase-1 is a sensitive method for measuring exocrine pancreatic secretion. PATIENTS AND METHODS: In a prospective study fecal elastase-1 was measured in patients on enteral nutrition (n=12) early after major gastrointestinal operations. They were given a high molecular diet via an intraoperatively placed small-needle catheter jejunostomy, starting 12 hours after operation with a continuous infusion of 20 ml/h (1 kcal/ml),increased to 80 ml/h during the next few days. Samples from the first and second stools after beginning the enteral nutrition were taken for measuring the fecal elastase-1. RESULTS: All patients fed enterally had no relevant feeding-associated complications and no diarrhea. The elastase-1 concentrations were normal in both the first and the second stool samples in all patients (normal stool elastase is > 200 g/g). The average elastase concentration in the first stool sample was 361,4 mg/g (median: 317 mg/g) and 454 mg/g in the second (median: 466,6 mg/g). Thus no exocrine pancreatic insufficiency was detected in any of the patients. CONCLUSION: The results of elastase-1 in stool demonstrate that severe exocrine pancreas dysfunction is not generally present in patients on early enteral nutrition after major gastrointestinal surgery.

Laparoscopic needle catheter jejunostomy: modification of the technique and outcome results.

BACKGROUND: We describe a modification of the technique for laparoscopic jejunostomy in patients with stenosis of the upper gastrointestinal tract and assess the patients outcomes with this enteral access. METHODS: In a retrospective study of 80 patients, we evaluated the outcome of a modified technique for the laparoscopic placement of a jejunostomy catheter into the proximal jejunum. Standard laparoscopy equipment and ready-to-use jejunostomy catheters were used. After the creation of a pneumoperitoneum, the proximal jejunal loop was fixed to the parietal peritoneum. The jejunum was then punctured with a split needle, and the catheter (9F) was pushed into the jejunum. Finally, the catheter was secured with an additional purse-string suture. The external fixation was performed with nonabsorbable sutures. Enteral nutritional support with a polymeric enteral diet was initiated after fluoroscopic control on the first postoperative day at a rate of 20 ml/h. The flow rate was increased progressively until the nutritional goal of 60-80 ml/h was reached on the 3rd or 4th postoperative day. RESULTS: In all patients (n = 80), the placement site of the catheter was correct, and all patients were able to receive enteral nutrition on the 1st postoperative day. There were no intraoperative complications. The mean operating time was 51 min. Two patients developed a localized infection at the catheter site; one patient developed an abscess; and three patients had catheter obstructions. CONCLUSIONS: Patients in need of intermediate or long-term enteral nutrition may benefit from laparoscopic catheter jejunostomy. The technique described is safe, effective, and less invasive than alternative techniques of laparoscopic jejunostomy.

Impact of omega-3 fatty acid enriched TPN on leukotriene synthesis by leukocytes after major surgery.

Major surgery leads to post-traumatic immune dysregulation which is driven by the activation of potent proinflammatory mediators including the leukotrienes (LTs). The LTs of the four-series derive from arachidonic acid (an omega-6 fatty acid). In contrast, LTs of the five-series are metabolic products of eicosapentaenoic acid (an omega-3 fatty acid) and exert less biological activities. Therapeutical strategies to attenuate proinflammatory signals include the provision of omega-3 fatty acids. Thirty patients with major elective abdominal surgery and an indication for total parenteral nutrition (TPN) were compared in a prospective, double blind, randomized study of two parallel groups. Group 1 (n=14) received an omega-3 fatty acid enriched 20% lipid emulsion (MCT:LCT:fish oil = 5:4:1, MLF541; Lipoplus) for 5 days postoperatively. Group 2 (n=16) received a standard 20% fat emulsion (LCT; Intralipid). The LT release from whole blood leukocytes stimulated with Ca-ionophore was analyzed preoperatively and on postoperative days 1, 6 and 8 by HPLC. There was a significant increase in the generation of LTB(5) (P=0.0035) and in the ratio of LTB(5)/LTB(4) (P=0.0017) the omega-3 group, but not in the reference group after 5 days infusion of the lipid emulsions. The omega-6/omega-3 fatty acid ratio 3:1 of the newly developed MLF541 lipid emulsion is appropriate to increase the synthesis of the biologically less active leukotrienes of the five-series. Nutritive enrichment with omega-3 fatty acids in a balanced ratio with omega-6 fatty acids is an important step to avoid hyperinflammatory situations in patients after major surgery.

[Long-term results of benign bile duct strictures after treatment with pedicled jejunal patches]. / Langzeitergebnisse nach Behandlung benigner Gallengangsstrikturen mit gestieltem Jejunumstreifen.

Benign strictures of the common bile duct after surgery or due to gallstones may lead to obstruction and derangement of bile drainage in the extrahepatic biliary system. Although the treatment of choice in these situations is the endoscopic dilatation, in some cases with stenosis of a long segment of the bile duct a partial replacement with a vascularised jejunal patch may be possible and useful. To our knowledge, there are no reports on long-term results of the procedure. We describe the course, the surgical technique and long-term results of four patients with a jejunal patch reconstruction of the common bile duct. Ten years after surgery there were no radiologic or laboratory signs of a restenosis of the common bile duct.

Assessment of the temperature distribution during hyperthermia treatment by isolated extremity perfusion.

A finite-element model of the human leg is developed for the assessment of temperature distribution during hyperthermia treatment by isolated extremity perfusion with a heart-lung-machine. The simulation comprises the true geometry, adequate perfusion models for the different parts of the extremity circulation in normal and tumour tissue, and the numerical procedure for the solution of the partial differential heat balance equation used. The simulation is validated using both experimental physiological and clinical data, and predicts temperature distributions and courses for various modifications of the hyperthermia procedure. It is concluded that the homogeneous temperature required in combination with chemotherapy can be achieved by isolated extremity perfusion, if a good thermal insulation is applied. If temperatures >42 degrees C are required, an additional external heat source (microwaves or ultrasound) is necessary. Although these sources may produce high absorption rates, combination with extremity perfusion is useful in reducing higher temperature gradients and the danger of locally lower temperatures.

[Post-traumatic intrahepatic arterioportal fistula]. / Die posttraumatische intrahepatische arterioportale Fistel.

Traumatic arterioportal fistulas (APF) are very rare. The most common reasons are liver biopsy and liver injuries. They are also caused by liver tumours and vessel anomalies. This is a case-report of a patient who developed an APF after blunt abdominal trauma. The fistula bearing part of the liver was resected in two sessions. In cases of large APFs with a flow from multiple collaterals the therapy of choice is the embolization. If not possible a selective excision of the fistulous sac or the resection of the fistula containing liver segment are recommended.

Outcome and cost-effectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal tract surgery: a prospective randomized study.

HYPOTHESIS: Perioperatively administered enteral immunonutrition will improve early postoperative morbidity and cost-effectiveness after gastrointestinal tract surgery. DESIGN: A prospective, randomized, double-blind, multicenter clinical trial. SETTING: Surgical departments in German university and teaching hospitals. PATIENTS: One hundred fifty-four patients with upper gastrointestinal tract malignant neoplasms who were eligible for analysis. INTERVENTION: Preoperatively, patients received 5 days of oral immunonutrition (an arginine-, RNA-, and omega3 fatty acid-supplemented diet) or an isoenergetic control diet (1 L/d). Early postoperative enteral feeding with immunonutrition or an isoenergetic, isonitrogenous control diet using a catheter jejunostomy was performed for 10 days. MAIN OUTCOME MEASURES: Postoperative infectious complications, their treatment costs, and cost-effectiveness of immunonutrition were analyzed. Plasma levels of the fatty acids eicosapentaenoic acid and docosahexaenoic acid were measured. RESULTS: In the immunonutrition group, significantly fewer infectious complication events occurred (14 vs 27; P = .05). The number of patients with complications was significantly lower in the supplemented diet group after postoperative day 3 (7 vs 16; P = .04). The treatment costs of complications in the supplemented diet group were suggestively lower than in the control diet group (DM 75172 vs DM 204273). Cost-effectiveness was DM 1503 in the experimental group vs DM 3587 in the control group, where DM denotes deutsche mark (German currency). CONCLUSION: The perioperative administration of an enteral immunonutrition significantly (P = .05) decreased the early occurrence of postoperative infections and reduced substantially the treatment costs of the complications after major upper gastrointestinal tract surgery.

Tissue deposits of hydroxyethyl starch (HES): dose-dependent and time-related.

Tissue deposits occur after administration of plasma substitutes. After hydroxyethyl starch (HES), deposits may last for months, causing pruritus and impairment of function. Because elimination of HES deposits has not been demonstrated in humans, we studied 26 patients, for up to 7 yr after HES administration, to assess HES storage. HES dose ranged from 0.34 to 15.00 g kg-1 body weight, and administration intervals from 1 day to 7 yr. Biopsies of the liver, muscle, spleen, intestine or skin were studied using light and electron microscopy and immunohistochemistry. HES storage was dose-dependent, decreased in all organs with time and was greater in patients suffering from pruritus. We conclude that tissue deposition of HES is transitory and dose-dependent, with differences between subjects in severity and duration.

Thyroid nodules in recurrent multinodular goiters are predominantly polyclonal.

Not only thyroid adenomas and carcinomas, but also the majority of single and well delimited goiter nodules, even if morphologically heterogeneous, are of clonal origin. However, it is still unknown whether the nodules of rapidly growing, recurrent goiters are clonal or polyclonal. We investigated by PCR-based analysis of exon 1 of the human androgen receptor gene clonality of nodules grown in recurrent multinodular goiters (MNG) of 14 female patients. The total goiter volume varied widely between 15 ml and 170 ml. The mean age of patients undergoing surgery for recurrent goiter at the time of their first operation was significantly lower with 34.6 +/- 10.9 yr in comparison to 50 consecutive patients who were operated for MNG for the first time (53.7 +/- 13.5 yr). The interval between first and recurrent operation was 18 +/- 8.5 yr. The mean volume of well circumscribed nodules selected for the present investigation was 3.8 +/- 1.4 ml. Assessment of clonality in at least 2 samples of each lesion revealed a polyclonal pattern in 10 out of 14 nodules, whereas only 3 nodules were clonal and in one case the result remained unclear. The unexpected finding that most nodules within MNG, that had re-grown after a first subtotal thyroidectomy, were of polyclonal rather than clonal composition, suggests that these lesions are generated by de novo-proliferation of cohorts of differing thyrocytes sharing the common trait of an exceedingly high intrinsic growth rate or alternatively, by unknown growth stimulating molecular events acting focally on clusters of cells derived from different ancestors. In addition, the relatively young age of patients with recurrent MNG at the time of their first surgery and the comparatively short interval between first and second operation point to a genetic element in the occurrence of growth-prone thyrocytes.

Operative results and outcome of twenty-four totally laparoscopic vascular procedures for aortoiliac occlusive disease.

PURPOSE: The study objective was to apply laparoscopic techniques to conventional bypass procedures for aortoiliac occlusive disease. METHODS: From October 1995 to August 1997, we performed seven iliofemoral (IFB), five unilateral aortofemoral (UAFB), and 11 aortobifemoral (AFB) bypass procedures and one aortic endarterectomy (TEA) totally laparoscopic. A transabdominal approach with pneumoperitoneum was preferred, and only laparoscopic vascular instruments were used. Endoscopic intervention followed principles of vascular surgery. As in open surgery, we used Dacron grafts and polypropylene sutures. RESULTS: Twenty procedures were carried out totally laparoscopic; four conversions to open surgery were necessary. Severe complications included one postoperative respiratory failure requiring ventilatory support for four days, and one iliac vein lesion with subsequent open surgery. Mean operating time was 258 +/- 49 minutes for IFB, 218 +/- 54 minutes for UAFB, 279 +/- 69 minutes for AFB, and 290 minutes for aortic TEA. Mean blood loss was 92 +/- 49 ml for IFB, 390 +/- 316 ml for UAFB, 563 +/- 516 ml for AFB, and 100 ml for aortic TEA. Mean postoperative stay was 7.4 days for IFB, 7.8 days for UAFB, and 10.1 days for AFB. After the aortic TEA, the patient was discharged on day 6. At control examination all grafts were patent; two patients had mild claudication because of one progressive disease and one distal suture stenosis. CONCLUSION: Laparoscopic vascular surgery for aortoiliac occlusive disease is feasible, safe, and effective. At the beginning, a cooperation between experienced laparoscopists and vascular surgeons is needed to overcome procedural challenge, because operating time and conversion rate decrease with growing experience. The advantages observed in the majority of our patients were minimal tissue trauma, decreased blood loss, and faster postoperative recovery when compared with patients who had open aortic surgery at our institution. Further evidence has to be gained by clinical trials to define the role of laparoscopic vascular surgery for aortoiliac occlusive disease.

[10 years results after repair of recurrent problem inguinal hernia with prolene mesh]. / Zehn-Jahres-Ergebnisse nach Reparation der Problemrezidivleistenhernie mit Prolenenetz.

The repair of multiple recurrences of inguinal hernias remains a surgical challenge. In 38 patients with a problematic recurrent inguinal hernia we implanted a polypropylene mesh (Prolene) in order to reinforce the transversalis fascia and to repair the inguinal hernia. 20 of these were medial and 14 lateral hernias; 4 patients had a combination of both types. All patients were prospectively included into this study and were seen in median follow-up periods of 3 and 6 months, as well as 4 and 9 years. As early complications hematoma of the wound (n = 3), scrotal edema (n = 1), temporary pain at the wound site (n = 12) and paresthesia (n = 13) occurred. Two patients (n = 2) developed a femoral hernia and one patient suffered from a persisting nerve injury of the ilioinguinal nerve. Due to the low complication and recurrency rate the tension free repair with polypropylene mesh is a effective method for treatment of problematic recurrent hernias.

[Lipoma: a rare differential gastrointestinal tumor diagnosis]. / Lipom: seltene Differentialdiagnose gastrointestinaler Tumore.

This is a case report of a female patient who during a routine follow-up after a gastrectomy showed a tumor of the ileo-cecal valve, which--according to all radiologic diagnostic procedures--was highly suspected to be a malignant tumor. However, the histologic diagnosis was benign lipoma. The incidence and the characteristics of gastrointestinal lipomas in the actual literature will be reviewed.

The clonality of nodules in recurrent goiters at second surgery.

INTRODUCTION: Some studies showed that in multinodular goiters clonal and polyclonal nodules coexist. The clonality of nodules in recurrent goiters is, however, still unknown and may contribute to help explain the pathogenesis of this thyroid disease. METHODS AND RESULTS: The clonality of 14 nodules derived from recurrent goiters was assessed by means of an X-chromosome-inactivation method. Of 14 nodules, 10 showed a polyclonal pattern, 3 were clonal and, in 1 case, the result remained unclear. The mean age of the patients with recurrent goiter at the time of their first operation was significantly lower than the mean age of 50 patients who underwent thyroid surgery for the first time over the same period of time (34.6+/-10.9 years vs 53.7+/-13.5 years; P<0.05). The mean interval between first and second operation was 18 years. CONCLUSION: The finding that nodules in recurrent goiters are predominantly polyclonal suggests that these lesions have their origin in a de novo proliferation of different cohorts of thyrocytes due to unknown growth stimulating molecular events.

[Laparoscopic fine needle catheter jejunostomy]. / Laparoskopische Feinnadelkatheterjejunostomie.

Gastrostomy or jejunostomy allow a safe and effective long-term enteral nutritional support. In patients with stenosis of the upper gastrointestinal tract the percutaneous endoscopic route is frequently not feasible. In these cases a laparoscopic approach is proposed. In 18 patients (n = 18) mostly with recurrent tumors of the upper gastrointestinal tract a laparoscopic catheter was placed into the jejunum without complications. Enteral feeding was started on the first day after catheter placement. One patient experienced a cathetersite infection. We describe a modified technique of laparoscopic jejunostomy the placement which is easy, effective and less invasive.

[Results of 31 laparoscopic interventions of the aorto-iliac vessels for arterial occlusive disease]. / Ergebnisse nach 31 laparoskopischen Eingriffen an dem aorto-iliakalen Gefässabschnitt wegen arterieller Verschlusskrankheit.

OBJECTIVE: To report our clinical experience with laparoscopic vascular surgery. MATERIALS AND METHODS: Since October 1995 we have performed 31 procedures for aortoiliac occlusive disease. A transperitoneal approach with pneumoperitoneum is preferred. RESULTS: Seven iliofemoral (IFB), 5 aortofemoral (uAFB), 16 aortobifemoral (AFB) bypasses, two thrombendarterectomies (TEA) of the infrarenal aorta, and one obturator bypass were performed totally by laparoscopy. Patients experienced a very comfortable postoperative course; all grafts were patent. Five conversions to open surgery were necessary because of a severe calcified aorta (n = 2), bleeding (n = 1), suture stenosis (n = 1), and fatty retroperitoneum (n = 1). CONCLUSIONS: Laparoscopic vascular surgery for occlusive disease is feasible, safe, and effective. However, further technical and instrumental improvement is necessary before the new surgical technique can be recommended.

[Relevance of preoperative nutritional therapy for postoperative outcome]. / Relevanz präoperativer Ernährungstherapie für postoperative Ergebnisse.

Several studies on preoperative artificial nutrition have shown beneficial effects only in severely malnourished patients (weight loss > 15% within short time, serum albumin < 2.8 g/dl). In this group of patients undergoing major gastrointestinal surgery, the postoperative complication rate was reduced to 40-60%. The medical care costs saved per complication avoided were 11,000-14,000 US dollars. A 5-day period of preoperative oral application of immunonutrition containing omega 3-fatty acids, arginine and nucleotides at home may prevent the risks of preoperative hospitalization and may lead to immunomodulating effects, which in addition to the improvement of nutritional status, will be able to decrease postoperative complication rates by a further 50-60%.

[A new model for economic studies of therapies exemplified by postoperative parenteral nutrition]. / Ein neues Modell zur Wirtschaftlichkeitsuntersuchung von Therapien am Beispiel der postoperativen parenteralen Ernährung.

In this economic evaluation we compared the costs of a new therapeutic system (two-chamber bag) in total parenteral nutrition (TPN) with the comparative standard therapeutic systems (multiple-bottle system in intensive care patients followed by a combination solution (glass bottles) on the ward). In the model, standard treatment algorithms of a 10-day course TPN for patients after major gastric surgery were specified for both application systems, the two-chamber bag and the comparative system. Based on the standard treatment pattern, the resource utilisation (manpower services, medical needs, material) was assessed. In a base case analysis the types and amounts of resources were valued using salaries, prices and tariffs to assess the costs. The costs per day and per case of the therapeutic systems were compared. Sensitivity analyses were carried out to validate the cost-estimates. The total costs per patient of the two-chamber bag amounted to DM 2324.41, which was substantially less than the DM 2728.99 cost of the comparative system. The average daily costs for the two-chamber bag system were 12% to 23% lower than for the comparative system. The results were shown to be valid for the whole range of tested parameters. This model makes it possible to obtain an economic evaluation of various therapeutic modalities without undertaking a prospective randomized study with the attendant high time and cost requirements.

[Local effects and changes in wound drainage in the free peritoneal cavity]. / Lokale Auswirkungen und Veränderungen von Wunddrainagen in der freien Bauchhöhle.

In a prospective randomised study 30 mongrel rabbits received two standard colon-resections. Three types of drains were tested: (latex-rubber-) Penrose-drains, rubbertube- and silicontube-drains, which were placed in the lower abdomen. As a closed drainage-system the extraperitoneal tip of the drain was placed in a closed subcutis-pocket. One of the two colon-anastomoses also was drained. The findings were recorded on the 7th postoperative day. A single mechanic alteration was found, an ulcer caused by a silicon-drain, that pushed against the abdominal wall. The other signs of mechanic irritation were microscopically unspecified inflammatory reactions to the foreign body drain. There was no ascending infection caused by the drain. All infections came from complications of the colon resections. In contrast to common opinions the drains in the lower abdomen showed no adhesions to the abdominal wall or organs. Only the entrance of the drain into the peritoneum and the cotton-gaze of Penrose-drains showed in nearly all cases adhesions. The large amount of adhesions to the anastomosis-drains came from complications of the colon-anastomoses. As a cause of material, rubber- and latex-rubber-drains showed large fibrin-clots on their surfaces. 7 days after the operation only about 20% of the drains had sufficient function. The rest was occluded by fibrin-clots in the lumen of the drain or the cotton-gaze. Over all there is no difference in changes and effects of the three different types of drains, but silicon as material showed advantages.

[Optimal and computer-assisted hospital cost control by the surgeon]. / Optimiertes und computergestütztes Erlöscontrolling durch den Chirurgen.

Considering the legal conditions there is no question that with the health reform law (GSG) changes in hospital infrastructure have to be made by the surgeon and the administration cojointly. From our experience an efficient budget control needs a complete and correct data recording--employing an efficient software--as well as strict medical control of profits along with continuous communication between the surgeons themselves and with the administration.

[Postoperative complications in abdominal surgery--what do they cost?]. / Postoperative Komplikationen in der Abdominalchirurgie--was kosten sie?

In this study of 154 patients with major abdominal cancer surgery, 41 postoperative complications occurred and caused additional total costs of DM 205.993,-, DM 5.024,- per case, respectively, where the special personnel costs were not accounted for. There was a significant difference between single and multiple complications as well as for early and late complication costs. Economic analyses are necessary to determine budgets of medical departments with extended and cost-intensive treatment, such as cancer surgery, to maintain optimal care for the patients.