[Chronic disorders after interventions in the anorectal area--therapeutic possibilities]. / Fortdauernde Störungen nach Eingriffen im anorektalen Bereich--Therapiemöglichkeiten.

Long lasting alterations of anal function and persistent pain in a few patients after ano-rectal operations are a great therapeutic problem. Sometimes more than 6 months after LAR there are complaints about incontinence, disturbance connected to a spastic evacuation--whereas pain is more often connected with the situation after Stapler hemorrhiodectomy or other anal interventions. The therapeutic management has to consider all etiological factors and consists mainly of conservative therapy, including regulation of stool volume, slow-down of colon transit, strengthening of anal and pelvic floor muscles, regulation of co-ordination and ability of relaxation and straining, therapy of pain and--last not least--psychological support.

[Precancerous conditions and neoplasms of the anal area]. / Praeneoplasien und Neoplasien im Analbereich.

Classification of this lesions could be done concerning localisation and histological type. Squamous cell carcinoma of the anal canal are the most often to be found, but overall neoplasias in this region are very seldom. The most important role in pathogenesis seems to play infection with HPV viruses. Symptoms are in the beginning unspecific and similar to other common proctological diseases. Proctological diagnostic procedures are to be combined with cytological methods. Therapeutic management depends on malignant potential of the lesions and contains local excision, total operation and combined radiochemotherapy, which is today considered standard therapy of squamous cell carcinoma of the anal canal.

[Conservative therapy of incontinence]. / Konservative Therapie der Inkontinenz.

Conservative therapy of faecal incontinence includes normalisation of colonic function, restauration of damaged anal skin and exercising methods. The most successful of those seems to be Biofeedback with good short time results up to 92% patients without further complaints, the long time results still being up to 67%. Prognosis depends on neuropathy, age and ability of perception and compliance. Passive electrostimulation replaces the damaged nerve and therefore has to be done lifelong. Increasing anal resting pressure seems to be a possible result.

[Prognostic scores in peritonitis: the Mannheim Peritonitis Index or APACHE II?]. / Prognosescores bei Peritonitis: Mannheimer Peritonitis-Index oder APACHE II?

Scoring systems are mandatory to quantify the severity of abdominal sepsis on the basis of objective criteria. The Mannheim Peritonitis Index (MPI) is a disease-specific score based on easy to handle clinical parameters. APACHE II is a large-scale general scoring system with acute physiological and chronic health parameters. To evaluate the prognostic value of both systems 108 patients with severe abdominal infection managed by open treatment entered a prospective study. 32 patients (29.6%) died, 23 of them due to sepsis and 9 from other causes. Both MPI and APACHE II scores correlated closely with mortality, with three and two significantly different classes, respectively. Statistical validation showed a sensitivity of 93% and a specificity of 16% for MPI, and 89% and 25% for the APACHE II. ROC curves were nearly parallel for both scores. In conclusion there was no significant difference in prognostic value between the scoring systems.

[The value of clinical parameters for determining the prognosis of peritonitis--validation of the Mannheim Peritonitis Index]. / Wertigkeit klinischer Parameter zur Prognosebeurteilung der Peritonitis--Validierung des Mannheimer Peritonitis-Index.

In order to evaluate the prognostic value of simple clinical parameters and the Mannheim Peritonitis-Index (MPI) 438 patients with abdominal infection entered a prospective study. 300 of them were managed by closed treatment with drainage, 138 by open treatment with planned relaparotomy. 63 patients (14.4%) died, 34 of them due to sepsis, 29 due to another cause. Stepwise logistic regression analysis showed only preoperative shock, concomitant disease and sepsis to be significant and independent factors leading to death. MPI had a strong correlation to mortality. Statistical validation showed a sensitivity of 88% and a specificity of 78% at the critical score of 26 points. The MPI is an easily documented prognostic index for peritonitis with high accuracy in individual prognosis.

[Differentiated treatment strategy for peritonitis: single stage closure with drainage or open with programmed reintervention/lavage?]. / Differenzierte Behandlungsstrategie der Peritonitis: Einzeitig geschlossen mit Drainage oder offen mit programmierter Reintervention/Lavage?

307 Patients with intraabdominal infections were operated between 8/1988 to 8/1991. Simple clinical parameters (according to the Mannheimer Peritonitis-Index) were evaluated before treatment. The classical therapeutic concept of one-stage laparotomy with drainage of the abdomen was performed in 223 patients initially. Because of recurrent infection and other complications in 19% of them 1 - 2 relaparotomies had to be done, and in 8% change to open treatment was necessary. Open treatment with planned relaparotomy was necessary in alltogether 101 patients, 93 abdominal complications due to primary disease or sepsis were detected in 43 of them. Abdominal treatment was successful (eradication of source of infection, no recurrence of infection) in 98% of the patients after closed and in 84% after open treatment. Mortality was 6.8% vs. 32.7% and on the whole 15.3%.

Recipient P wave synchronized pacing of the donor atrium in a heart-transplanted patient: a case study.

We present the case of a 23-year-old patient who underwent orthotopic heart implantation and subsequent implantation of an atrial dual chamber pacemaker. The stimulation rate in the donor atrium is controlled by the recipient's sinus node activity, thereby maintaining AV synchrony and allowing appropriate rate increase during exercise.

New methods for noninvasive monitoring of rejection after heart transplantation.

Between August 1981 and February 1987, 67 orthotopic heart transplants and three heart-lung transplants were performed in 69 patients at the University of Munich Hospital. The immunosuppressive regimen consisted of cyclosporine A, azathioprine, and prednisone. The diagnosis of acute rejection was based on cytoimmunologic monitoring, frequency analysis of fast Fourier transformed surface electrocardiograms (FFT-ECGs), and two-dimensional echocardiography. The results of these diagnostic methods were compared to the findings provided by endomyocardial biopsies, which were performed simultaneously with the noninvasive studies. Seventy patients underwent cytoimmunologic monitoring. In 88% of all rejection episodes, this technique revealed activated lymphocytes and lymphoblasts in the mononuclear concentrate of the peripheral blood samples; the presence of such cells is known to be an extremely early sign of acute rejection. Twenty-six patients were monitored by means of FFT-ECG. In 20 of the 21 cases of rejection, this method disclosed significant changes in the frequency spectrum of the QRS complex in the 70- to 110-Hz range; in 12 cases, these changes were the earliest sign of acute rejection. Therefore, FFT-ECG had a sensitivity of 95%. All of the QRS changes were reversible with rejection therapy. Forty-five patients were subjected to two-dimensional echocardiography. In 31 of the 35 cases of rejection, the echocardiogram showed a significant increase in the left ventricular wall thickness and a decrease in the left ventricular cross-sectional area during mild rejection. Moderate or severe rejection was characterized by an increase in the diastolic area, as well as a decrease in the systolic area change and in the diastolic maximum velocity of area change. Thus, two-dimensional echocardiography had a sensitivity of 89%. In the recent cases, the diagnosis of rejection was based on noninvasive methods alone. After rejection therapy had been instituted, endomyocardial biopsies were performed to assess the effectiveness of the treatment. With noninvasive rejection monitoring, the number of endomyocardial biopsies performed during the first three postoperative months was only 2.8 per patient; in comparison with invasive rejection monitoring, noninvasive follow-up was associated with a 75% reduction in the need for biopsy.

Frequency analysis of the surface electrocardiogram for recognition of acute rejection after orthotopic cardiac transplantation in man.

Recognition of acute rejection after heart transplantation has been based mainly on invasive methods until now. In this study we analyzed two well-defined surface electrocardiographic recordings by fast Fourier transform (FFT) (Blackman Harris window, 512 points) after low-noise, high-gain amplification (filter setting 0.5 to 300 Hz) each day for 4 weeks after cardiac transplantation in 27 patients. Twenty acute rejection crises requiring treatment were diagnosed by cytoimmunologic monitoring and endomyocardial biopsy. Single-beat analysis of the QRS complex by FFT revealed a progressive change of the spectral morphology (increase of the frequency content between 70 and 110 Hz) on the days of rejection in 19 of 20 patients. At that time there were no visible changes on the electrocardiogram in the time domain in most patients. At the same time, the frequency content of the ST segment decreased between 10 and 30 Hz in 16 of 20 patients. After successful treatment, the frequency spectra of the QRS complex and ST segment returned to control within 1 to 2 weeks in most patients. One false-positive result was seen in a patient with mediastinitis and large pericardial effusion. A drop in QRS amplitude (greater than 20%) occurred in 10 of 20 rejection crises and in 10 patients without rejection. Nine patients after cardiac transplantation without rejection and seven control patients after cardiac surgery (not transplantation) showed stable frequency plots from one day to the other after the first postoperative day, but with considerable changes in QRS amplitude.(ABSTRACT TRUNCATED AT 250 WORDS)

Particularities of dual chamber pacemaker therapy in patients after orthotopic heart transplantation.

Since August 1981, 33 orthotopic heart transplantations were performed in our hospital. Three of these patients (9%) had sinus bradycardias with rates as low as 30 beats/min; they were treated by implantation of a dual chamber pacemaker. These patients had two atria as a result of orthotopic heart transplantation, but only the donor atrium was suitable for positioning the atrial lead. In the postoperative period, some nonsurgical complications were observed in one patient who developed atrial fibrillation which we treated with drugs. A cyclosporin-evoked tremor produced several asystoles due to false inhibition by myopotential interference in the VVI mode. During an episode of acute rejection combined with renal insufficiency, loss of atrial and ventricular sensing occurred. The other patients showed no pacemaker-related complications. Our findings in this unique population of pacemaker patients are discussed.

Special control of infection and rejection episodes after four years of cardiac transplantation at the University of Munich.

During the past 4 years, 36 orthotopic heart transplantations and two heart-lung transplantations were performed at Munich University Hospital. Immunosuppressive regimen consisted of cyclosporine A and low dose prednisone. The rejection diagnosis was based on daily cyto-immunological monitoring (CIM) and high frequency electrocardiography. In addition, viral, bacterial, and fungal infections were examined by CIM. The CIM is based on an evaluation of activated lymphocytes, lymphoblasts, and lymphocyte subsets in the mononuclear concentrate isolated from the peripheral blood by Ficoll Hypaque separation. Of the 38 patients, 24 are currently alive from 1 month to 4 years later (including one heart-lung recipient 1.5 years postoperatively). Altogether, 40 rejection episodes occurred among the patients. The diagnosis was based on CIM (sensitivity = 95%) and on endomyocardial biopsies (sensitivity = 95%). Control of rejection therapy was also done by using these methods. When the biopsies showed ongoing acute rejection, additional antithymocyte globulin or antilymphocyte globulin therapy was administered, relative to the CIM results. When using the endomyocardial biopsies for rejection control only, results showed a very low rate of two to three biopsies per patient in the first 3 months postoperatively. In addition, 16 infection periods were detected: five viral, six bacterial, four fungal, and one case of toxoplasmosis. The CIM showed typical hints of these inflammations in 12 cases (sensitivity = 75%) before clinical signs were visible. This immediately led to further diagnostic examinations and specific anti-infectious therapies, which were initiated early.

Cytoimmunological monitoring in acute rejection and viral, bacterial or fungal infection following transplantation.

This study assessed the ability of immunomonitoring to differentiate between acute cardiac rejection and viral, bacterial or fungal infections, using data of thirty-five cyclosporine treated heart and heart-lung transplant recipients. Peripheral blood samples were analyzed daily for 20 days, then three times weekly until the patient's discharge. Later, peripheral blood was examined every fourteen days on an outpatient basis. White blood cells were counted and differentiated. A mononuclear concentrate was obtained by the Ficoll-Hypaque gradient and centrifugation method, and cytocentrifuged onto slides. The cells were stained by a five minute method. Percentages of lymphocytes, prelymphoblasts, lymphoblasts, large granular lymphocytes and monocytes were calculated. When activated cells were detected, aliquots of the mononuclear concentrate were labeled using monoclonal antibodies. In these thirty-five patients, more than 60 acute rejection episodes were diagnosed by the cytoimmunological method. Acute rejection was characterized by a significant rise of the number of leukocytes, lymphocytes, prelymphoblasts and lymphoblasts. The T-lymphocyte population increased while the B-cells remained normal. Ninety-five percent of all acute rejection episodes were diagnosed using cytoimmunological parameters. During viral infection more than 20% of the mononuclear cells were large granular lymphocytes and the OKT4/OKT8 ratio was less than one. During bacterial and fungal infections the B-lymphocytes increased to 40% of the mononuclear cells. In addition, juvenile polymorphs appeared in the mononuclear concentrate and the OKT4/OKT8 ratio was within normal limits (1.5 to 2.5).(ABSTRACT TRUNCATED AT 250 WORDS)