[A novel device for treating enteroatmospheric fistulae in the open abdomen]. / Ein neuer Adapter zur Versorgung von entero-atmosphärischen Fisteln beim offenen Abdomen.

The formation of an enteroatmospheric fistula in the open abdomen is a severe complication. In comparison to enterocutaneous fistulae the management remains a challenge. Safety of the surrounding bowel or granulation tissue is a major problem. Suturing of the fistula is rarely successful. Otherwise limited resection and a new anastomosis of the intestine is often not possible. A variety of therapeutic procedures exists to separate the fistula from the surrounding wound. Combinations using vacuum therapy seem to be most effective. But none of the therapies used will match every situation. We present a novel -device for managing enteroatmospheric fistulae in combination with vacuum therapy. In most -cases separation of the fistula from the negative pressure on the surrounding wound is achieved. The fistula adapter allows for a safe build-up of granulation tissue with an effective drainage of fistula secretion. The novel device also supports split thickness skin grafting around the fistula.

[Temporary abdominal closure and early and late pathophysiological consequences of treating an open abdomen]. / Temporärer Bauchdeckenverschluss und pathophysiologische Früh- und Spätfolgen der Behandlung eines offenen Abdomens.

BACKGROUND: The open abdomen (OA) is a severe disease pattern accompanied by high morbidity and mortality. It is either result of a surgical dis-ease or approach. The aim of this review article is to provide a systematic overview on the options of a temporary closure of the abdominal wall including early and late consequences in the treatment of an open abdomen based on the current medical literature. METHODS: Topic-related, selective, PubMed-based literature search of the last decade including historically relevant references combined with own clinical experiences. RESULTS: The initial course is marked by problems in intensive care. The most frequent causes of -death are ventilatory problems, acute renal fail-ure, persisting infections and sepsis as well as multiorgan failure. Intensive care duration ranges from 13 to 65 days. Perioperative mortality is account-ed for 10-52 %. Specific complications can be seen in surviving patients such as enteroatmospheric fistula (1.3-41 %), ventral hernia (32-100 %), intraabdominal abscess formation (2.1-21 %), intestinal adhesions and digestion disturbances, neurological und psychological problems (approximately 20 %) as well as heterotopic ossification (17-25 %). DISCUSSION: Application of a temporary abdominal closure aims to avoid those complications. Furthermore, time and effort for care and treatment are recommended to be reduced as patients comfort should be improved, simultaneously. Primary fascial closure is of utmost importance to reach this goal. Procedures with highest fascial closure rate (Wittmann patch, STAR, 75-93 %; dynamic retention sutures, 61-91 %; V.A.C., 69-84 %) have lowest mortality. CONCLUSION: Type and severity of the various early and late consequences in the treatment of an open abdomen are substantially determined by the complication-inducing causes and the basic disease as well as by the options of an efficient, even in some cases temporary closure of the abdominal wall.

Expression of matrix-metalloproteases in the fluid of chronic diabetic foot wounds treated with a protease absorbent dressing.

UNLABELLED: It is well known, that wound healing in diabetes is impaired. Persistently high levels of matrix-metalloproteases (MMPs) contribute to wound persistence. The topical use of protease-inhibitors might beneficially affect wound healing. RESEARCH DESIGN AND METHODS: 19 patients with chronic diabetic foot lesions (Wagner/Armstrong 2A) were studied. 6 patients received "good standard wound care", 13 patients were treated with a protease-inhibitor-modulating-matrix (ORC/collagen matrix) that was changed daily. At day 1 and 5 biopsies were taken from the wounds; wound fluids were collected daily. Biopsies were analysed using quantitative real-time-PCR and all samples were analysed using ELISA and zymography for MMPs, TIMPs, IL 1-ß and TNFα levels. RESULTS: No differences in mRNA-expression of MMPs, TNFα and for MMP levels in wound tissue were detected between both groups or between the 2 sampling time points. MMP-2 active was significantly reduced in wound fluids of ORC/collagen treated lesions (p=0.043) after 5 days. MMP-2 pro was also reduced by about 25% when compared to increasing levels in the control group (+27%). We observed a significant reduction of the wound area in the ORC/collagen group (p=0.003). CONCLUSIONS: Local treatment with a protease-inhibitor has a beneficial effect on wound healing. In contrast to unchanged mRNA-levels and protein levels of MMPs there was a clear reduction of MMP-2-levels in wound fluids. Our data support the potential role of ORC/collagen as a wound dressing. Modulation of MMPs appears to be beneficial in the treatment of chronic diabetic wounds.

[A rare aneurysm of the popliteal vein]. / Seltenes Aneurysma der V. poplitea.

BACKGROUND: A popliteal venous aneurysm is rare but needs to be considered a silent threat due to the risk of pulmonary embolism. CASE REPORT AND METHOD: Using the report of an exemplary case, the diagnostic and therapeutic management including outcome is described. In particular, the favourable, case-adapted surgical approach of aneurysma resection and direct suture of the vascular wall because of the extraordinary aneurysma of the right popliteal vein is emphasised. RESULTS AND CLINICAL COURSE: A 50-year-old woman underwent duplex ultrasonography because of pain in the right popliteal fossa, which revealed an aneurysm of the popliteal vein. The diagnosis was confirmed by phlebography. During the surgical approach, the popliteal vein was explored and the aneurysm subsequently excised. The defect in the wall of the popliteal vein was directly sutured avoiding a stenotic segment of the vein. The postoperative course was uneventful. Postoperatively, oral anticoagulation with coumarins was initiated for 6 months; follow-up investigations using duplex ultrasonography at 6 and 12 months showed a patent popliteal vein with no thrombotic changes. CONCLUSION: According to the recommendations from the international literature, surgical approach using venorrhaphy or resection is absolutely indicated to prevent pulmonary embolism, especially in the mostly younger patients.

[A rare extra-skeletal myxoid chondrosarcoma of the lower leg - is amputation absolutely necessary]. / Seltenes extraskelettales myxoides Chondrosarkom des Unterschenkels - ist eine Amputation zwingend erforderlich?

INTRODUCTION: Sarcomas represent less than 2 % of all malignancies. Special challenges are bone sarcomas in extra-skeletal localisation. The aim of this case report is to show the management of an extraordinary extra-skeletal myxoid chondrosarcoma based on a case report with references from the literature. CASE REPORT: After a delay in diagnostics for 1.5 years, an MRI scan taken in a 42-year-old male patient with progressive swelling of the left calf showed a soft-tissue tumour in the proximal part of the muscle. Histopathological investigation of a percutaneous biopsy revealed a chondrosarcoma. En-bloc-resection (R 0) of the rear superficial compartment was performed (specimen weight 1 370 g; tumour size 11.5 x 9.5 x 8 cm) leading to the definitive diagnosis of an extra-skeletal myxoid chondrosarcoma. The patient was discharged with a bland wound 8 days after surgery. At 4 weeks postoperatively, the patient received adjuvant radiotherapy with a 56-Gy boost. During the follow-up period of 28 months, there have been neither signs of local tumour recurrence nor distant metastases. DISCUSSION: The myxoid chondrosarcoma is a rare tumour lesion, and according to the literature, only 2 % occur outside of the skeleton. The accurate diagnostic and therapeutic algorithm allowed a precise preparation for surgery and made amputation obsolete. Compartment resection preserving the main neurovascular bundles as well as enabling an early mobilisation resulted in both sufficient radical resection status and adequate postoperative motor function. Intraoperative clip-marking of the former tumour bed is considered a key point for the focused radiotherapy. CONCLUSION: Each persistent soft tissue swelling must be appropriately diagnosed using adequate imaging and even biopsy (in case of a doubtful finding), which should be performed with definitive surgery in mind.

[Differential value of the diagnostic options to determine the level of amputation]. / Aussagekraft der diagnostischen Möglichkeiten zur Bestimmung der Amputationshöhe.

The level of amputation after utilizing all possible options of revascularization is considered one of the substantial criteria for sufficient reconvalescence, recovery of mobility, reduction of perioperative mortality and, finally, social reintegration. In case of vascular genesis, the possibilities to reestablish or improve arterial perfusion need to be proven. According to the data from the literature on the various technical methods, only the ptO2 measurement has become widely accepted to determine efficiently the level of amputation. In addition, study results have given evidence for the distal shifting to the genual and infragenual level of amputation. Furthermore, a good prognostic value has been achieved with measures of radionuclide imaging. An alternative but simple procedure including influencing factors and standards of measurement is the determination of the systolic occlusion pressure. Further technical advances can be achieved by a combination of methods but this requires the systematic verification prior to their use. However, their technical potential and options appear to be not fully utilized yet.

[Antegrade aortomesenteric revascularisation originating from the supracoeliac aortic segment--a promising surgical option in chronic ischaemia of the visceral arteries]. / Die antegrade aortomesenteriale Revaskularisation von suprazöliakal--eine vielversprechende operative Option bei chronischer Viszeralarterienischämie.

INTRODUCTION: Ischaemia of the visceral arteries is considered to be an extraordinary challenge in the interdisciplinary therapeutic management. AIM AND METHOD: Using a case series of patients with chronic ischaemia of the visceral arteries, our diagnostic and therapeutic experience was analysed with regard to postoperative quality of life (increase of body weight, frequency in daily diarrhoea), perioperative morbidity and hospital mortality in dependence on the type of surgical reconstruction of the visceral arteries. RESULTS: During a time period of 2 years, 3 patients (male/female=1:2; mean age, 61.7 years) underwent surgical interventions on the visceral arteries from a total of 1118 vascular interventions (main indication revealed by colonoscopy and pathohistology of mucosal biopsy: ischaemic colitis). In all cases, symptomatology was affected by abdominal angina. Duplex sonography, angiography, and multislice CT scan revealed the combination of an occlusion of the coeliac trunk and of the superior mesenteric artery by atherosclerosis in 2 cases. In the remaining case, there was an isolated occlusion at the origin of the superior mesenteric artery. For revascularisation, the aortomesenteric reconstruction was subdivided according to the: i) target vessel: -combination of revascularised common hepatic artery and superior mesenteric artery (n=1) with an autologous Y-vein bypass ("reversed technique"), -exclusive revascularisation of the superior mesenteric artery (n=2)-prosthetic bypass; ii) origin of the bypass: -from the supracoeliac aortic segment (antegrade) n=3 (primarily in patients 1 and 3; as a redo operation in patient 2); -from the infrarenal segment (retrograde) n=1 (initial surgical intervention in patient 2) using an autologous venous bypass. In all cases, a significant improvement of the quality of life was observed as indicated by an increase of body weight (n=3; +no further abdominal angina) and primary wound healing in all 3 cases (hospital mortality, 0). CONCLUSION: Chronic ischaemia of the visceral arteries is characterised by an increasing incidence and a stealthy onset and requires an interdisciplinary approach to find the correct diagnosis using all available diagnostic procedures including sufficient periodic follow-up investigations. We favour the antegrade aortomesenteric revascularisation from the supracoeliac aortic segment as a promising surgical option in chronic ischaemia of visceral arteries.

[The difficult wound]. / Die schwierige Wunde.

Difficult wounds of different origin are a challenge for medical and custodial knowledge and capability. They are often characterised by a complex and protracted course of disease and cause considerable costs. Critical wounds particularly include chronic wounds such as venous stasis ulcers, diabetic foot ulcers or pressure ulcers and often lead to physical and psychosocial strain. Large-scale and deep wounds, wounds in traumatised tissue, wound complications and infections as well as wounds in patients with severe accompanying diseases or in patients of old age are often marked by a severe and unpredictable course and are therefore a threat for patients. Knowledge of characteristic symptoms and particularities of the course of disease are essential for early diagnosis and succsessful treatment. Despite many recent advances in wound care the management is often compounded by a lack of clearly defined, comprehensive wound care standards.

[Late complications of open abdomen]. / Spätfolgen des offenen Abdomens.

Open abdomen is the final result of a variety of diseases and their treatment strategies. The aim of this article is to present systematically late complications after open abdominal therapy and our own treatment results from 2003 to 2005. The main diagnoses for open abdomen are persistent peritonitis, abdominal compartment syndrome, and abdominal injuries. A perioperative mortality rate of 10-56%, long stays at the ICU, and a mean of 3-5 reoperations are characteristic for the severity of such diseases. Late complications may include incisional hernia (47-78%), gastrointestinal and pancreatic fistulas (8-41%), postoperative delayed abscess (10-21%), polyneuropathy (21%), psychic disorders (24%), indigestion (12%), and ossification (17%). These postoperative disorders may range in severity from clinically less significant to therapy-relevant with surgical consequences. Despite the high morbidity, approximately 75% of surviving patients achieve good quality of life. In our opinion, this justifies the extensive treatment concepts and associated high costs.

[V.A.C. (Vacuum Assisted Closure) therapy as a treatment option in complications following lymphadenectomy in patients with penile cancer]. / Die V.A.C. (Vacuum Assisted Closure) Therapie als Behandlungsalternative bei Komplikationen nach Durchführung einer Lymphadenektomie bei fortgeschrittenen Peniskarzinomen.

INTRODUCTION: Penile cancer is a rare tumor entity. Primary therapy consists of tumor excision (laser therapy, circumcision, partial or complete penectomy). Therapy of advanced or metastasized penile cancer is still challenging due to high morbidity with postoperative lymph edema, fistula, wound infection and resulting secondary wound healing. METHODS: In this series we retrospectively investigated clinical and diagnostic data from 28 patients (1995-2005) with penile cancer regarding their follow-up, especially in respect to morbidity after lymphadenectomy and the resulting therapy. We evaluated the efficacy of V.A.C. therapy as an alternative in this setting regarding costs and duration of hospital stay. RESULTS: 11/28 pats. underwent lymphadenectomy (LA) because of tumor stage or suspicious lymph node status. Eight of those pats. developed complications, as there were: lymph edema, and/or secondary wound healing with fistula. 4/8 pats. were treated with V.A.C. therapy. In this group a significant advantage regarding cost and time of hospitalization was observed. DISCUSSION: Despite higher primary introduction costs an early V.A.C. therapy in patients with secondary wound healing and lymph obstruction is advisable and resulted in a shortened hospitalization and reduced overall costs per patient.

[Multimodal treatment of colon cancer?]. / Multimodale Therapie beim Kolonkarzinom?

Surgical therapy is still the basis of therapy of patients with colon carcinoma. Multimodal therapeutical concepts are presently applied as a therapeutical standard in the adjuvant therapy and increasingly in the systemic therapy of patients with primarily inoperable metastases of the liver to reach a secondary operability. Interdisciplinary multimodal therapeutical concepts are even accepted within the therapy of metastasized colon carcinomas. There are still unanswered questions regarding sequences of palliative systemic therapies and their combinations with local ablative methods.

Effects of the angiogenesis inhibitor angiostatin on the growth of CC531 colon carcinoma cells in vitro and in a laparoscopic animal model of peritoneal carcinomatosis.

BACKGROUND: As angiogenesis is one of the key steps in tumor growth, invasion, and metastasis, antiangiogenic therapy is supposed to be an attractive approach for antitumor treatment. We investigated the cytotoxic, anti-adhesive, and anti-invasive effects of angiostatin in vitro and on intraperitoneal tumor growth in a laparoscopic rat model of peritoneal carcinomatosis using CC531 colon adenocarcinoma cells. METHODS: The in vitro adhesion and cytotoxicity assays were performed with microtiter plates, and the invasion assay with Transwell dual chambers. Normal saline was used as control. In in vivo experiments, CC531 adenocarcinoma cells were intraperitoneally given to Wistar Albino Glaxo rats after the establishment of a pneumoperitoneum. The animals received angiostatin in different doses intraperitoneally, and in some, angiostatin was additionally administered subcutaneously. Saline was used as control. After 21 days, the animals were euthanized to determine the intra-abdominal tumor weight. RESULTS: In in vitro experiments, there was no effect of angiostatin on the viability of tumor cells in the cytotoxicity assay, but there was a significant inhibition of tumor cell adhesion and invasion (p<0.05 and p<0.01) in all angiostatin concentrations. In in vivo experiments, an intraperitoneal application of 20 microg angiostatin, but not 10 microg, significantly (p<0.005) decreased the intraperitoneal tumor weight compared with controls. This effect was most pronounced after the combined intraperitoneal and subcutaneous applications. CONCLUSION: Angiostatin given intraperitoneally at a dose of 20 microg alone or in combination with subcutaneous application significantly diminishes intraperitoneal tumor growth in rats undergoing laparoscopy. This may offer additional therapeutic options for patients undergoing laparoscopic surgery for colorectal cancer.

[Vena cava filter -- is there an indication for implantation?]. / Kavafilter -- gibt es eine Indikation zur Implantation?

The indication of vena cava filter implantation is controversially discussed. On the basis of the available literature and our own results a critical analysis of this issue is given. Between 1994 and 2003, we inserted a total of 29 vena cava filters; 24 temporary and 5 permanent filters. In twelve patients, the placement of the filter was indicated due to pulmonary embolism and a contra-indication to dose adjusted heparin therapy. Seven additional patients experienced a recurrent pulmonary embolism despite adequate heparin therapy. An additional prophylactic filter insertion was carried out in ten patients. The temporary vena cava filters were left in place between 7 to 38 days with an average of 17 days. Total implantation time of temporary filters was scheduled until complete mobilisation of the patients, generally in conjunction with an effective dosage of oral anticoagulants. No patient died in connection with the insertion of the filter and no further pulmonary embolisms occurred. One case of inferior vena cava thrombosis occurred in each group of temporary and permanent filters. In one third of the removed filter systems, thrombi in the filter were found. Local infections of the catheter and introducer sets were observed in two patients. Moreover, in one case the strut of a temporary filter broke and subsequently dislocated 17 days after insertion. However, there is little evidence concerning vena cava filters, and further investigations are necessary. Until additional data are available, filters should generally be restricted to patients with deep venous thrombosis and pulmonary embolism who cannot receive anticoagulation, and highly selected cases.

[Management of postoperative compartment syndrome -- case report]. / Management des postoperativen lagerungsbedingten Kompartmentsyndroms -- Kasuistik.

AIM: Differential diagnosis and management of the lower extremity compartment syndrome as a potentially devastating complication of prolonged surgery in the lithotomy position. CASE REPORT: A 55-year-old patient underwent radical cystoprostatovesiculourethrectomy including reconstruction of an ileal conduit because of a multifocal recurrent tumor of the urinary bladder (operating time > 8 hours). On the first postoperative day, the patient complained about swelling within the right calf leading to the suspicion of a deep vein thrombosis. Phlebography of the right leg revealed: i) thrombosis-untypical occlusion of the distal popliteal vein and ii) no detection of the deep vein within the right calf (femoral and iliac veins were with no pathological finding). Tissue pressure was as follows: right, 55 mmHg/left, 11 mmHg, underlining clinical suspicion of compartment syndrome. The patient underwent a fasciotomy of the right calf. Over the following 5 days, muscle edema decreased, allowing subsequent mobilization of the patient. On the 8 (th) postoperative day, the patient died unexpectedly due to an acute myocardial infarction. CONCLUSION: In case of a swelling of the lower extremity after long-lasting surgical interventions performed in lithotomy position, a compartment syndrome is one of the possible differential diagnoses, the consequences of which can be avoided by an early diagnostic and adequate treatment.

[Interventional and vascular surgical management for inflammatory arrosion hemorrhage from visceral arteries following pancreatic surgery]. / Entzündliche Arrosionsblutungen aus ViszeralarterienInterventionelles und gefässchirurgisches Management nach vorwiegend pankreaschirurgischen Eingriffen.

Spontaneous or postoperative hemorrhage into the abdominal cavity due to inflammatory vessel arrosion represents an uncommon but menacing situation. According to the literature, such hemorrhage is associated with a lethality of nearly 2%. Therapeutical options include reoperation and interventional radiological techniques such as endovascular catheter techniques with stent graft implantation or the embolization of vessels. We report on the management of seven cases with hemorrhage either from the gastroduodenal artery ( n=5) following pancreatic surgery for pancreatic carcinoma, liposarcoma, and chronic pancreatitis or from the common hepatic artery ( n=1) and the superior mesenteric artery ( n=1) following chronic pancreatitis. The present article describes our experiences with stent graft implantation (hemobahn prosthesis) in four cases. Based on these experiences, we see the advantages of stent grafts in primary hemostasis without any contact to infected tissue and the preservation of regular perfusion. However, further clinical data are required focussing on indication, technical success rates, stent-related complications, and long-term outcome.

[The use of v.a.C.-system in wound management for borderline indications]. / Der Einsatz des V.A.C(R)-Systems im Wundmanagement bei Grenzindikationen.

Vacuum sealing has increasingly become established as a method adapted to treat acute and chronic wounds. Temporary sealing of the open abdomen represents an alternative therapeutic approach. The principle of inverse tissue expansion prevents ventral herniae from developing in the course of delayed abdominal-wall closure. In patients undergoing vascular surgery, the method can be uneventfully adopted in treating chronic ulcer following revascularisation. The accelerated healing process, while reducing the duration of therapy, turns out to be cost-efficient.

[The present state of vacuum sealing]. / Der Stand der Vakuumversiegelung.

In cases of extended post-traumatic soft-tissue and bone loss as well as with mutilating infection or radical tumor resection, multidisciplinary options are required to salvage extremities and functional rehabilitation. A surgical team approach allows for reduction of amputation rates, wound healing complications, and secondary procedures in limb oncology and trauma. The goals and limitations of cooperative surgical concepts are described. In the future, continuing medical education will focus not only on indications and techniques but also on complication management, medicolegal problems, and economic deficits due to maladapted legal structures. Provided clear clinical pathways are introduced to guide indications, surgical procedures, and postoperative treatment, marked financial deficits may be avoided. While, in the past, responsibility for the patient and ethical considerations resulted in the development of voluntary interdisciplinary treatment programs, economic strategies and an increasing number of malpractice suits in the future will inevitably produce new imperatives for interdisciplinary cooperation.

Ultrastructural analysis of an infected collagen-coated vascular graft.

The incidence of infection following arterial reconstruction using synthetic graft materials varies from less than 1 to 5%. One of three mechanisms is thought to be responsible: 1. intraoperative contamination, 2. extension from adjacent infected or colonized tissue, or 3. hematogenous or lymphogenous seeding. We present ultrastructural data of a patient with a polymicrobial graft infection due to a prostheto-enteric fistula 16 years after reconstruction of an aortobifemoral graft. The polymer surface showed signs of biodegradation and was completely covered with a layer of plasma proteins. Disrupted fibroblasts on the intersegmental graft surface were surrounded by bundles of collagen. Gram-negative rods and grampositive cocci were embedded in an extracellular EPS matrix. Bacterial culture confirmed growth of Eikenella corrodens, Fusobacterium nucleatum and Peptostreptococcus species. Fibrin and granulation tissue from the neoadventitia started to mark off the inflammatory process. Transmission electron microscopy is a valuable tool for the investigation of alloplastic arterial devices. After 16 years of implantation the graft shows different signs of biodegradation.