Pathophysiological and clinical aspects of the CO2 pneumoperitoneum (CO2-PP).

Experimental studies demonstrated a severe cardiac load of the CO2 pneumoperitoneum caused by an accelerated after- and a decreased preload. Patients displaying cardiovascular risks are therefore often rejected from laparoscopic surgery. Hence, the pathophysiological changes and the intraoperative risk of the CO2 pneumoperitoneum in high-risk cardiopulmonary patients (NYHA II-III, n = 15) undergoing laparoscopic cholecystectomy are described. The changes in cardiac after- and preload seem to be due to the elevated intraabdominal pressure rather than transperitoneally resorbed CO2 and are reversible by desufflation. In one patient conversion to open operation had to be performed because of a severe drop in cardiac output and right ventricle ejection fraction. Mixed oxygen saturation was predicting intraoperative worsening in this case. The described pathophysiological changes may seem to be well tolerated even in high-risk cardiac patients. Monitoring of hemodynamics should include an arterial catheter line and blood gas analyses. Pharmacologic interventions or pressureless laparoscopic procedures might not be necessary as long as laparoscopic cholecystectomy is performed.

[Significant value and therapeutic implications of routine gastroscopy before cholecystectomy]. / Valeur significative et implications thérapeutiques de la gastroscopie de routine avant cholécystectomie.

Endoscopy of the upper digestive tract was performed in 338 consecutive patients undergoing cholecystectomy between January 1991 and December 1992. Pathological findings were seen in 160 (47.3%), 6.8% of the patients had peptic ulcers, 1.8% gastric erosions, 25.7% gastritis, 3.2% polyps, 4.7% hiatal hernias, 3.0% oesophagitis and 0.6% gastric cancer. In most patients the gastroscopic results did not correlate with the clinical symptoms. The therapy concept had to be changed in 8.3% of the patients due to gastroscopic findings, 23 patients with ulcers, 2 with erosions and 1 with oesophagitis had to be treated medically and so the cholecystectomy was postponed. Two patients with gastric cancer underwent gastrectomy. These results underline the importance of a routine gastroscopy before elective cholecystectomy.

Human galanin modulates human colonic motility in vitro. Characterization of structural requirements.

BACKGROUND: Human galanin (hGal) is a 30-residue non-amidated gut-brain peptide that shows considerable sequence divergence compared with galanin (Gal) forms of other species. Conflicting results have been reported with regard to the structural requirements for its modulatory action on gut motility. METHODS: We investigated the effect of human and rat Gal and substituted analogues of Gal on the contractility of longitudinal muscle strips of the human colon in vitro. RESULTS: Both hGal and rGal contracted the preparations in a concentration-dependent and tetrodotoxin-resistant manner without difference in sensitivity. The NH2-terminally truncated peptides hGal (3-30) and rGal (3-29) were inactive, whereas the NH2-terminal fragments, hGal (1-21) and rGal (1-18), remained fully responsive. Single amino acid substitutions at NH2-terminal positions showed divergent results: substitution of Trp2 reduced significantly potency and efficacy, whereas substitutions at positions 1, 3, 4, or 5 did not markedly modify the bioactivity of Gal. Galantide, a high-affinity Gal antagonist in the central nervous system, is a full agonist in human colonic smooth muscle. CONCLUSION: The COOH-terminal part of Gal contributes mainly the receptor-binding affinity of the peptide, whereas the NH2-terminal region is essential for biologic activity.

A novel technique for long-term vascular access in the unrestrained rat.

A new system for long-term vascular access in the unrestrained rat (n = 380) is described that combines low cost with high reliability and free movement. It consists of a polyurethane catheter that is placed in the right atrium via the external jugular vein. A leather harness is applied to the animal and the catheter passed subcutaneously to the neck into the harness. The harness is connected to the outside of a swivel joint via a silicone tube in which the catheter runs. The catheter is connected to the inside of the swivel. The swivel is a modified conventional 5-mL glass syringe and is positioned in ball bearings and a Johnson joint. Swivel, ball bearings, and the Johnson joint are counterbalanced and can move up and down. With this system all catheters functioned well until they were electively removed after 28 days. Four catheter dislocations resulted from harness failure and three from a twisted catheter. Seven cases of septicemia and eight of thrombosis occurred. All animals gained weight (3.53 +- 0.37 [SEM] g/d) during the time the system was in place. The entire apparatus is simple and inexpensive to construct. The rotary portion of the swivel and the Johnson joint avoid twisting of the catheter, and the counterbalance enables the animal to move up and down. The low thrombogenicity of polyurethane further reduced complications. This system reduces stress for the animal during long-term investigations.

[Recurrent calculus ileus of the small bowel. A diagnostic problem]. / Der rezidivierende Steinileus des Dünndarms. Ein diagnostisches Problem.

Occlusion of the lumen by gallstones must be considered a rare cause of small bowel ileus; diagnosis and clinical symptoms have only sporadically been reported. The present paper shows that, in addition to gallstones, coproliths may also cause small bowel ileus, giving rise to identical clinical symptoms. For this reason, pre-operative diagnostic work-up should differentiate concretions in gallbladder and small bowel with respect to size, shape, consistency and X-ray contrast. If the stone proves to be a coprolith, the stenotic segment of bowel should be resected to prevent recurrences, while in the case of a gallstone, its manual manipulation across Bauhin's valve into the colon suffices.

Randomized comparison of endoscopic palliation of malignant esophageal stenoses.

In a randomized study, palliative therapy of malignant esophageal and gastric stenosis was investigated by a comparison of endoscopic laser therapy (ELT) with palliative endoscopic perturbation (PEP). A total of 124 patients exhibiting a malignant stenosis in the esophagus and proximal stomach were referred to our unit between January 1, 1987, and March 31, 1990. Criteria for randomization were: (1) inoperable malignant stenosis, (2) dysphagia enabling the ingestion of semi-solid food, (3) the possibility of performing ELT and PEP, and (4) the absence of fistula formation. Only 40 patients met these criteria; the remaining 84 subjects were assigned to an escape group whose treatment consisted of ELT, PEP, percutaneous endoscopic gastrostomy, transnasal feeding tube, radiotherapy, and endoscopic bougienage. We found no significant difference between ELT and PEP with regard to survival, food passage, or quality of life. We recommend the application of PEP in patients exhibiting advanced tumor disease and a poor general condition and favour the use of ELT combined with afterloading in patients with a life expectancy of greater than or equal to 3 months.

Deep anterior resection with circular stapled anastomosis of congenital megacolon: clinical results.

This report deals with instrumental suture in the deep anterior rectum resection when treating Hirschsprung's disease. The concept includes: ensuring diagnosis, cleaning the intestines, antibiotic prophylaxis, intraoperative testing of the anastomosis and postoperative X-ray by a standardized technique. Our first experience in the use of the stapler was gained with ten patients. One case of anastomosis insufficiency occurred. With the stapler apparatus, safe anastomosis was possible. The stapler facilitates anastomoses in deep resections. Therefore, a deep resection of the pathological segment in Hirschsprung's disease is possible. The practicality of the stapler and the favourable clinical experience justify the continued application of the instrumental suture technique in children's surgery.

[Esophageal tube in inoperable esophageal and cardia cancer: indications and technique]. / Oesophagustubus beim inoperablen Oesophagus- und Cardiacarcinom: Indikation und Technik.

Endoscopic tube implantation remains still one of the alternatives in palliation of inoperable patients with malignant stenosis of the esophagus and cardia. Although LASER-treatment has less complications, patients in poor general condition, patients with tracheo-esophageal fistulas, patients with external compression of the esophageal lumen, are clear indications for tube implantation. The right choice of palliative technique should depend on the individual situation of the patient.

[Endoscopic removal of an ingested foreign body--indications and choice of procedure]. / Die endoskoipische Entfernung ingestierter Fremdkörper--Indikation und Verfahrenswahl.

The majority of ingested foreign bodies does not cause problems for the patients and leaves the gastrointestinal tract spontaneously without complications. However the low risk of modern fiberendoscopy allows a safe approach of endoscopic extraction. In children and all other cases, where general anesthesia is required for the extraction procedure, indication for endoscopic extraction should be limited. From 1980-1986 we followed a concept, which differentiated for emergency, early-elective or elective extraction, depending on localisation and nature of the foreign bodies as well as the necessity for general anesthesia. In 88 endoscopic extractions (22 emergency, 66 elective) no complications were observed.

Direct immunostaining of TSH receptor related autoantibodies in Graves' disease.

Ten thyroid specimens from patients with Graves' disease were investigated immunohistologically with respect to the localisation of thyrotropin (TSH) receptor related autoantibodies. After conventional preparation of formalin-fixed and paraffin-embedded thyroid slices for immunostaining, 3-5 micron tissue sections were incubated with a porcine thyrotropin receptor containing membrane preparation (pTSH-R). The TSH receptor containing membrane fragments bound to the thyroid tissue were revealed with a slightly modified unlabelled PAP technique according to Sternberger, using an antiserum to pTSH-R obtained from immunized rabbits. This technique resulted in a staining of a considerable portion of plasma cells within the lymphoplasmacellular infiltrates of all the Graves thyroids. No staining occurred if for negative control either pTSH-R or its antiserum from rabbit was omitted. In addition, the staining reaction was markedly reduced by pretreatment of pTSH-R with serum from patients with Graves' disease in order to occupy its binding sites for autoantibodies prior to the staining procedure. It is concluded that the staining of the intrathyroidal plasma cells is due to their synthesis of autoantibodies directed against TSH receptor related structures of thyroid epithelia. The results are in keeping with the concept that the thyroid as the target organ itself is the site of autoantibody synthesis in Graves' disease.

Evidence of autoimmune pathogenesis in autonomous thyroid adenoma.

Using an immunohistochemical attempt to immunostain thyroid related autoantibodies, 30 specimens of autonomous adenomas of the thyroid were investigated. Twelve out of 23 inflammatory infiltrates surrounding the 'hot' nodules contained plasma cells, which gave a positive staining reaction for thyroid related autoantibodies. Seven adenomas showed no significant lymphoplasmacellular infiltration. It is concluded that this phenomenon might be due to an autoimmune pathogenesis in a part of patients with autonomous adenomas, indicating that there is no sharp line between autoimmune and non autoimmune thyroid disorder.

[Ulceration of large leiomyoma of the stomach]. / Ulzerationen auf grossen Leiomyomen des Magens.

Two case reports are given of patients harboring big gastric leiomyoma with central ulceration. X-ray, endoscopic and intraoperative findings are described; the surgical procedure is discussed.

[Hemorrhage of esophageal varices in child B and C patients. Results of sclerosing therapy]. / Osophagusvarizenblutung bei Child-B- und -C-Patienten. Ergebnisse der Sklerosierungstherapie.

In a 3-years period 51 patients with acute bleeding oesophageal varices with Child-stadium B and C were admitted to our department. Endoscopic sclerosing therapy was performed during emergency endoscopy. --The analysis of these patients indicates, that unsuccessful conservative treatment before endoscopic sclerosing therapy has a negative influence on the outcome of our patients. This fact should be kept in mind when results of this study are compared with other studies. Fatal prognostic criteria are early recurrent bleeding within the first 24 h after emergency endoscopy, thrombocytopenia and a deficiency of fibrinogen. The latter is an indication for ballon tamponade of the varices in the distal oesophagus even after successful endoscopic hemostasis.

[The injection method for hemostasis in gastroduodenal lesions. Indications and possibilities]. / Die Injektionsmethode zur Blutstillung bei gastroduodenalen Läsionen. Indikationen und Möglichkeiten.

Endoscopic injection of polidocanol was used in a prospective study of 88 patients with gastroduodenal bleeding. Active bleeding by injecting polidocanol (1%) in 54 patients achieved initial haemostasis in 51 (94%); lasting arrest of bleeding was achieved in 39 (72%). This injection treatment was also used to prevent recurrence of bleeding where there had been signs of previous bleeding: this proved successful in 25 of 34 patients (74%). The endoscopic injection method thus gave results equivalent to other endoscopic methods of achieving haemostasis.

[The concept of endoscopy-related therapy in gastroduodenal ulcer hemorrhage]. / Endoskopie-abhängiges Therapiekonzept bei der gastroduodenalen Ulkusblutung.

In a prospective study a new therapeutic concept was tested on 76 patients with bleeding gastroduodenal ulcers. During emergency endoscopic an exact inspection of the ulcercrater helped to determine the possibility of recurrent bleeding of the ulcer. This possibility was expressed in a modified Forrest-classification. Endoscopic hemostasis has been performed in all cases of active bleeding. Ulcers with a big visible vessel stump should be operated early elective after an intervall of intensive care, because definitive endoscopic hemostasis seemed not to be sufficient with this bleeding type. The new concept decreased the operation frequency of bleeding gastroduodenal ulcers from 51% in 1981/82 to 34% in 1983. Mortality of bleeding duodenal ulcers decreased from 18% to 8,6%, in bleeding stomach ulcers from 24% to 18%. Endoscopic hemostasis with injection therapy has proved to be most successfull in the F1b bleeding type.