Pericentral hepatocytes translocate hydrophilic bile acids more rapidly than hydrophobic ones.

The aim of this study was to analyze whether velocity of periportal and pericentral translocation is different for bile acids differing in their physicochemical properties. Isolated livers of male Sprague-Dawley rats were perfused antegradely or retrogradely, in single pass arrangement with labeled taurodehydrocholate, cholate, taurocholate, glycocholate, or taurodeoxycholate (inflow rate: 32 nmol/min/g liver). Bile was collected at 2-min intervals; aliquots were counted in a liquid scintillation spectrophotometer to trace uptake rate and biliary excretion profile. Biliary excretion patterns of all bile acids tested were almost identical in periportal cells; in contrast, it differed greatly in pericentral cells. Pericentral cells excreted taurodehydrocholate as fast as periportal cells, while periportal cells eliminated taurodeoxycholate about four times as fast and cholate, taurocholate and cholate about two times as fast as pericentral cells. It is concluded that, in contrast to periportal translocation, the velocity of pericentral translocation depends upon the hydrophilicity of the respective bile acid. Therefore, different or additional translocation pathways for bile acids may be involved in periportal versus pericentral cells.

[Sclerosing, coagulating, ligating... Managing hemorrhoids!]. / Sklerosieren, koagulieren, ligieren... So packen Sie H"amorrhoiden!

Hemorrhoids are a pathophysiological consequence of hyperplasia of the corpus cavernosum recti, and can be classified into three grades of severity. Clinically, they usually manifest in the form of peri-anal bleeding, a diffuse sensation of discomfort, itching and secretion of mucus. The diagnosis is established on the basis of the dinical presentation. Treatment is mainly conservative, but is likely to be successful only in the early stages. Already second degree symptomatic hemorrhoids require definitive treatment. Although peri-anal thrombosis is sometimes a very painful condition, it is usually harmless. If pain is severe, surgical incision is indicated.

[An end to smearing! Detecting and treating rectal rectal and anal prolapse]. / Schluss mit der Schmiererei! Rektum- und Analprolaps erkennen und therapieren.

Rectal prolapse is defined as the invagination of the entire wall of the rectum into or through the lumen of the anal canal. In the main it is a disorder of elderly women. The leading symptom is a sensation of incomplete defecation. Patients commonly complain of incontinence of varying severity, tenesmus, unsuccessful straining, and the passage of blood and mucus in the stools. The diagnosis is based on the history and physical examination. Equipment-based diagnostic procedures serve treatment planning. For therapy, a range of possibilities are available. Anal prolapse is categorized as third-degree hemorrhoidal disease, and the diagnosis can be made by simple inspection. Reduction may be attempted during digital examination of the rectum. Treatment is determined by the clinical presentation.

[Are there still surgical indications in therapy of anal carcinoma?]. / Gibt es noch chirurgische Indikationen in der Therapie des Anal-Karzinoms?

The development of combined radio-chemotherapy according to Nigro has had a big influence on the therapy concept of the anal canal carcinoma. Due to the successful oncological treatment combined with a possible continence preservation, a rectum extirpation is rarely indicated. Surgical indications in the therapy concept of anal canal carcinoma are large, sphincter destroying tumors, treatment complications, therapy resistant progression and the therapy of lymph node- and organ metastases. In the therapy concept of the cancer of the anal margin, the local excision as a primary therapy is of central interest in the current literature. The introduction of plastic surgery in the treatment of even vast tumors leads to adequate results of the oncological and functional treatment. The abdomino-perineal rectum extirpation is exceptionally indicated for large, sphincter destroying tumors.

[Indications for restorative rectal resection in carcinoma--complete vs. partial and local resection]. / Indikation zur restorativen Rektumentfernung beim Karzinom--komplette vs. partielle und lokale Resektion.

Rectal continence preservation became feasible in treatment of cancer of the lower third of the rectum based upon technical evolutions and better understanding of tumor biology. Absolutely necessary precondition is correct preoperative staging. Operative strategy is determined by tumor stage, localization, grade and continence function. In most cases the total mesorectal excision leads to tumor-free circumferential resection margins. Distal safety margins are assured by intraoperative frozen sections. Restorative approaches are contraindicated in case of sphincter infiltration. If continence function is impaired preoperatively, restorative procedures lead to a worse functional result. The local recurrence remains the most important problem in rectal cancer surgery. Safety in resection is achieved by total mesorectal excision. The presence of distal satellite metastasis or lymph node metastasis bear a certain risk for local recurrence after partial resections of middle or upper third rectal cancer. Local resection in T1-Tumors with G1- or G2-Grading may produce comparable results.

[Tension-free suture of incisional hernia]. / Der spannungsfreie Verschluss der Narbenhernie.

Incisional hernias are a common complication following abdominal surgery. However, when performed correctly, the techniques utilized for direct hernia repair, Mayo's closure and plastic covering of the defect appear to be effective in the management of primary hernia closure. The recurrence rates of 30-50% continue to represent a significant challenge in the initial management of incisional hernia repair. Fortunately, there is evidence that, with correct preparation of the patient and with correct anatomical reconstruction, better results can be achieved. Also, the use of strictly applied technical skills in combination with standardized operative techniques may help to eliminate further complications and recurrences. In addition, the application of mesh or cutis transplantation to reinforce the attenuated tissue has also been shown to reduce the recurrence rate. With the diligent application of the above measures, as well as of new concepts, which at present include a promising technique called tension-adapted closure, there may be positive developments in the treatment and management of incisional hernias.

[Harmonizing European medical education, continuing and postgraduate education]. / Europäische Harmonisierung von Aus-, Weiter- und Fortbildung.

The harmonization of medical education, specialist training and continuing medical education (CME) in Europe progresses at different levels. University exchange programmes like ERASMUS and SOKRATES try to realize the European idea on the student and academic level. Specialist training is complicated by differences in responsibilities. The UEMS, based on various agreements, coordinates the harmonization process. Surgical training is represented by the European Board of Surgery (EBS). Its basic care and subspecialties have been described and European qualifications are being prepared. The content of education as well as log books, trainee qualification and training centers are regulated by position papers. Continued medical education is described in the Charter of Continued Medical Education of Specialists in which the content of training and requirements are defined.

Aminoterminal propeptide of type III procollagen: a marker of hepatic fibrosis after bile duct obstruction in the monkey.

BACKGROUND/AIMS: In an experimental study in monkeys, liver fibrosis development after segmental bile duct obstruction was investigated and correlated with the aminoterminal propeptide of type III procollagen (PIIINP). MATERIALS AND METHODS: Segmental bile duct obstruction was produced by ligation and section of the left hepatic bile duct in all monkeys. Fibrosis induction was examined by intravenous leukotriene C4 (LTC4, 5 nmol/kg) application, endogenous LT-production stimulated by endotoxin (LPS,salmonella abortus equi, 50 ng/kg), fibrosis inhibition by dexamethasone (1 mg/kg) intramuscularly and subsequent endogenous LT-production stimulation by LPS (50 ng/kg). Ligated and unligated liver lobe biopsies were taken 3, 7 and 12 weeks after ligation. All portal areas were measured morphometrically. PIIINP was measured by a specific radioimmunoassay each week and correlated with the morphometric results. RESULTS: Bile duct obstruction leads to secondary sclerosing cholangitis with bile duct vanishing and subsequent biliary cirrhosis combined with perivenous sclerosis and cavernous transformation of the terminal vein. The collagen concentration increased in the nonligated lobe from mean +/-SEM 1.05 +/- 0.03% to 1.53 +/- 0.19% only after LTC4 and with no difference in the other groups. In the ligated lobe collagen concentration increased significantly in all groups continuously from 1.05 +/- 0.03% up to: controls 6.1 +/- 0.9%, dexamethasone 5.9 +/- 0.8%, LPS 8.2 +/- 0.8%, LTC4 9.075 +/- 1.4%. PIIINP concentration rose within 6 weeks in the controls with hepatic bile duct obstruction from 34.43 +/- 15 ng/ml up to 57 +/- 13.27 ng/ml, after dexamethasone to 48.5 +/- 18.23 ng/ml, after LPS to 57 +/- 13.27 ng/ml, after LTC4 to 80.25 +/- 16.04 ng/ml. After 12 weeks, PIIINP decreased in the controls resp. after dexamethasone to 41.25 +/- 6.94 ng/ml resp. 33.5 +/- 7.72 ng/ml and increased after LPS resp. LTC4 up to 64.25 +/- 17.07 ng/ml resp.104 +/- 22.46 ng/ ml. The correlation of collagen deposition and PIIINP was in the controls r = 0.83, after dexamethasone r = 0.71, after LPS r = 0.83 after LTC4 r = 0.91. CONCLUSION: PIIINP determination after segmental bile duct obstruction correlates with collagen deposition and allows evaluation of hepatic fibrosis activity.

[Diagnosis and therapy of diaphragmatic rupture after blunt thoracic and abdominal trauma]. / Diagnostik und Therapie der Zwerchfellruptur nach stumpfem Thorax- und Bauchtrauma.

Diagnosis of diaphragmatic rupture is often missed after blunt thoracic and abdominal injuries because diaphragmatic injury does not play an important role beside severe injuries of intrabdominal and/or thoracic organs. Between 1976 and 1993, 141 patients were treated for traumatic injury of the diaphragm. In 42 patients with penetrating injuries following stab or shot wounds diaphragmatic lesions were diagnosed by the emergent surgical therapy. 99 had diaphragmatic tears from blunt thoracic or abdominal trauma by accidents. 14 of 99 patients sustained isolated diaphragmatic rupture, in 85 the rupture was combined with other injuries, 24 had fractures of the pelvic ring. Preoperatively the following diagnostic procedures were performed: chest radiograph in 99 patients, abdomen radiograph in 75, contrast radiographs in 34, angiography in 9, sonography in 74 and computed tomography in 48. Sensitivity and specificity of these diagnostic methods depend on the dimension of intrathoracic prolaps of abdominal organs. The sensitivity of contrast radiographs ranged from 72-78%. With the additional experience of ultrasonography since 1985 the sensitivity came up to 82%. In 11 patients additional diaphragmatic rupture was diagnosed by laparotomy indicated by liver and/or splenic rupture. Therapy of diaphragmatic injury was performed in 83 patients within 4 days, in 9 within 4 months and in 7 later than one year. For diaphragmatic repair 87 patients underwent laparotomy and 12 thoracotomy. Local complications were found in 13 patients (13.1%). 19 patients (19.2%) died postoperatively due to accompanying injuries.

[Intestine saving surgery in Crohn disease--results of limited resection and stricture-plasty]. / Darmerhaltende Chirurgie bei M. Crohn--Ergebnisse der limitierten Resektion und Strikturenplastik.

In order to evaluate functional results and outcome of "limited surgery" in Crohn's disease we reviewed the data of 161 operations performed in 65 patients. In our series most of the patients had repeated operations. Nevertheless we saw no short bowel syndrome, no death occurred. Correlation was high between number of operations and length of resected bowel (r = 0.8) whereas no correlation was found between resected bowel and duration of disease nor between duration and number of operations. In conclusion strictly admitted principles of limited surgery seem to preserve good functional results. Risk of complications or short bowel syndrome seems not to be increased.

[The value of colon contrast enema in ileus diagnosis]. / Bedeutung des Kolonkontrasteinlaufs in der Ileusdiagnostik.

In 115 patients with clinical and radiological signs of small and/or large bowel obstruction the contrast enema of the colon was evaluated prospectively to localize the site of occlusion in the colon. Contrast enema was performed in 76 patients with Gastrografin and in 39 with barium. In 22 of 24 patients with large bowel obstruction, in 7 of 11 with combined small and large bowel obstruction, in 4 of 14 with small bowel obstruction and in 19 of 66 with partial obstruction the site of obstruction was identified in the colon. In 107 of 115 patients the site of intestinal obstruction in the colon was either confirmed or excluded (sensitivity 89.2%, specificity 96.6%). In 6 patients the contrast enema failed due to incontinence, missing cooperation or insufficient preparation. In two cases with coprostasis the occlusion was missinterpreted as a carcinoma. Electrolytes and serum fluid concentration before and after the enema were not significantly influenced using the different contrast media. Contrast enema is indicated in patients with intestinal obstruction of unknown site, malignancies, after radiation therapy and recurrent partial obstruction.

[Surgical techniques in Crohn disease and ulcerative colitis]. / Operative Techniken bei Morbus Crohn und Colitis ulcerosa.

The usefulness of surgical treatment of inflammatory bowel disease is determined by the results that can be achieved. In Crohn's disease, in addition to minimal resections, non-resective procedures such as stricturoplasty, are also available for the treatment of acute and chronic complications. The operative treatment of peri-anal Crohn's lesions is determined by the acute or chronic complications that develop. Ulcerative colitis can be cured by complete removal of the colorectal mucosa, and malignant degeneration thus avoided. Continence-preserving colectomy with proctomucosectomy and ileo-anal pouch anastomosis obviates the need for a permanent ileostomy.

[Postoperative hemorrhage]. / Postoperative Nachblutung.

Postoperative hemorrhage is the second most frequent indication for early relaparotomy. The incidence depends on the level of care in a given hospital. It is highest, therefore, in institutions delivering maximal care with many trauma cases. We performed 3443 laparotomies from January 1988 to March 1991. 214 (5.9%) patients had to be reoperated, 48 of them because of postoperative bleeding. This amounts to 1.3% of the total number of laparotomies. Bleeding was identified through drains, ultrasonography or endoscopy, ultrasonography having the highest sensitivity and specificity. Total mortality was 30%. Analysis of the literature shows that mortality is lowest when relaparotomies are performed on 3%-6% of patients.

[Aggressive abdominal fibromatosis: the place of diagnostic imaging]. / Abdominale aggressive Fibromatose: Stellenwert der bildgebenden Diagnostik.

Aggressive fibromatoses are locally invasive, non-metastasising, fibroblastic soft-tissue tumours. On the basis of examinations made in 6 patients with histologically confirmed diagnosis, the reliability of different imaging modalities in preoperative diagnosis and in follow-up is discussed. The inhomogeneous tumour composition was evident in all imaging procedures. Computed tomography offered the highest sensitivity for tumour detection and proved accurate in demonstrating the characteristic radial tumour spreading of mesenteric aggressive fibromatosis; the attenuation values ranged from 18 to 58 HU. in pre-contrast CT scans. In magnetic resonance imaging the tumours mostly produced a low signal in T1- and T2-weighted sequences; the calculated T2-relaxation times ranged from 97 to 186 ms.

[The pathomorphology of the liver after unilateral hepatic duct obstruction with laboratory-chemical observations of the course in the dog]. / Untersuchungen zur Pathomorphologie der Leber nach unilateralem Hepatikusverschluss mit laborchemischer Verlaufsbeobachtung beim Hund.

UNLABELLED: In an experimental study the morphological and functional changes of the liver with unilateral hepatic duct obstruction were investigated over a period of 13 months. In 4 series different parts of the liver were excluded of the bile drainage by hepatic duct ligation after cholecystectomy (group I = 25%, group II = 50%, group III 75%, group IV = 100% of the liver, series V = control group was cholecystectomy only. The clinical outcome, biochemical parameters, liver biopsy were examined regularly. Bacteriologic investigation of the bile and hepatic flow measurement were performed at the beginning and at the end of the study. RESULTS: The clinical symptoms were discrete and the biochemical parameters showed a typical course. After 6 weeks, atrophy of the excluded liver with contralateral compensatoric hypertrophy was found. The microscopic correlation was the secondary sclerosing cholangitis (SSC). After 6 weeks, a concentric periductal fibrosis was to be observed in the periportal area. After 12 weeks, bile duct vanishing with persistence of the arteries and veins was found. After 36-48 weeks, biliary cirrhosis and total destruction of the liver parenchyma was found respectively. Simultaneously a chronic disturbance of the hepatic perfusion was seen. It was caused by a perivenous fibrosis of the terminal vein with obliteration of the lumen by endangiitic proliferations and cavernous transformation. The genesis of SSC seemed not be be influenced by bile contamination. The ligated as well as the unligated bile ducts were infected in 20-50% only. There was no difference in the liver specimens with sterile or contaminated bile. The hepatic flow measurement showed a reduction of the portal blood flow and a rise of the arterial flow depending on the amount of the excluded liver. A better understanding of the pathophysiological sequelae of the unilateral hepatic duct obstruction suggests that the drainage by surgical or radiological methods may not invariably be necessary.