Biomedical subjects
Publications and source records attributed to A Hirner.
In the specialty "surgery" women are underrepresented, especially in leading positions. The reason for that is not less motivation, less ability or less capacity of women, but the working conditions. For women in surgery working conditions are so unfavourable that only few women make their career in surgery.
Explore the source record for details and available documents.
BACKGROUND: Measuring serum cytokines, pituitary hormones, or acute phase proteins during or after surgery is not an optimal method for quantifying the impact of surgical procedures. In an effort to assess surgical stress by means of the immune response, we focused on changes in cell-mediated and antibody-mediated immunity as illustrated by the type 1/type 2 T-helper (Th1/Th2) cell balance. The sensitivity of this approach was evaluated by comparing laparoscopic and conventional cholecystectomy (LCE, CCE). METHODS: In a pragmatic prospective study 43 patients with symptomatic cholelithiasis were operated on either by LCE (n = 25) or CCe (n = 18). Blood sampling was done 24 hours before surgery, immediately before incision, and 2, 24, and 48 hours after surgery. Cell surface markers and cytokine production were used to characterize the Th1/Th2 balance and were measured by means of flow cytometry and enzyme-linked immunosorbent assay techniques. RESULTS: Activation of Th2 cells evokes the production and secretion of interleukin-4 (IL-4), which up-regulates the expression of immunoglobulin E receptors (Fo epsilon RII, CD23) on B cells. Phytohemagglutinin-induced IL-4 production in freshly isolated peripheral blood mononuclear cells from patients increased more after CCE than LCE (IL-4, +41% versus +17%; p < 0.05). Also the expression of CD23 on B cells was higher after CCE than LCE (+146% versus +63%; P < 0.01). CD30, a membrane molecule that belongs to the tumor necrosis factor receptor superfamily and probably is an important indicator of Th2 activity, was more evaluated on T cells from patients who underwent CCE. The Th1 response, characterized by phytohemagglutinin-induced IFN-gamma secretion in peripheral blood mononuclear cells and up-regulation of human leukocyte antigen-DR expression on monocytes, was lower after CCE than after LCE. CONCLUSIONS: This study shows that surgical stress induces a shift in the Th1/Th2 balance toward Th2, suggesting that cell-mediated immunity is down-regulated and antibody-mediated immunity is up-regulated after surgery. The evaluation of this shift may be clinically meaningful and help quantify even less invasive surgical procedures. When comparing CCE and LCE in this not strictly randomized study, we found LCE to be the less stressful procedure.
Appendicocutaneous fistula represents a rare form of enterocutaneous fistulas, that can occur following acute appendicitis, drainage of a perityphlitic abscess or an appendectomy. This case report describes the unique occurrence of an appendicocutaneous fistula as complication of abdominal drainage in absence of one of the above mentioned diseases.
Image-DNA-cytometric analysis was performed retrospectively on air-dried touch preparations from gastric carcinoma from 122 patients who underwent surgery from 1989-1994. The results of DNA cytometry were compared with conventional histologic staging and grading. Aneuploidy could be verified in 81 cases (66.3%), and a significant correlation was demonstrated between aneuploidy and a high incidence of lymph node metastases, whereas no correlation with tumor type and histologic grade was detected. Thus DNA ploidy may by useful in predicting prognosis in gastric cancer.
Explore the source record for details and available documents.
The combination of autologous blood donation and rHuEPO therapy is rarely justified for medical and economic reasons. Adequate alternative indications for the use of rHuEPO perioperatively have yet to be studied. Therefore, in addition to the increasing costs of safe homologous blood products and the decreasing costs of recombinant proteins, a reevaluation of the cost-effectivity relationship will be mandatory for rHuEPO in surgery.
From 1989 to 1995, 25 ICU-patients underwent cholecystectomy for acute acalculous cholecystitis (AAC). Preoperative diagnosis remains difficult and ultrasound imaging proved to be the most valid instrument for early diagnosis. Predisposing factors like duration of respiratory failure, extent of surgery, amount of blood loss and mode of analgesia were analyzed. Undelayed surgical treatment was important to avoid further complications such as gangrene or perforation of the gall bladder.
The results of selected elective and emergency operations of patients treated in the surgical department of Bonn University in 1994 and 1995 are presented and compared to the ASA-score. It was possible to show that old age itself is not a contraindication for major surgical interventions but that lethality mainly depends on concurrent diseases, i.e. the biological age. The numeric age is not an important factor. Physiological ageing only leads to diminished functional capacity, which can be partly compensated by more intensive care combined with early medical treatment. An age-specific factor which cannot be measured is the psychosocial age, the mental health. Mental health has an important influence on surgery in the aged patient.
We present the results of a study based on an animal model concurring whether captopril can improve microcirculation in the small intestine in nonocclusive mesenteric ischemia dependent on when therapy is begun. Cardiogenic shock was produced by pericardial tamponade with starch solution. The flow in the carotid artery could be reduced to 43% of the preshock value. In four therapy groups and a control group the intestinal microcirculation was examined by laser Doppler flowmetry in the serosa and mucosa. The measurements were taken at regular intervals during the 4 h of the experiments. Captopril was either given systemically or locoregionally through the upper mesenteric artery. Therapy was given at the beginning of the shock or 1 h after induction of shock at a dosage of 0.25 mg/kg body weight as a bolus and continuous application of 10 micrograms/kg body wt. Concerning the hemodynamic changes during shock the group receiving captopril systemically at the beginning of shock showed a significant (P = 0.05) improvement in microcirculation compared to the controls and other therapy groups. Flow reduction was seen in the controls (156-32 relative flow units = RFU) in group Ia (systemic therapy 1 h after shock), as well as the controls (129 to 12 RFU) and, in group Ib (systemic therapy beginning with shock) a flow rise could be seen (307 to 481 RFU). In group IIa (local therapy 1 h after shock) (a steady flow was seen (168-170 RFU) and in group IIb (local therapy beginning with shock) and group Ib an increase in flow was also measured (226-303 RFU). This positive effect of captopril on the intestinal perfusion was observed when applied 1 h after the induction of shock.
PURPOSE: To study the diagnostic value of radiological imaging modalities in patients undergoing endoscopic cholecystectomy. PATIENTS AND METHODS: In 286 patients with endoscopic cholecystectomy ultrasound and intravenous cholecystography was performed for preoperative work-up. Postoperatively all patients were examined with ultrasound. RESULTS: ERCP showed a stone in the common bile duct in 12 patients with suspected stones on ultrasound, cholecystography or laboratory values. All 12 patients were treated with papillotomy. Postoperative ultrasound detected increasing fluid in the peritoneal cavity in three patients. Laparotomy of one patient showed bleeding from the cystic artery, in the second patient, injury of the right bile duct. One patient showed an accessory hepatic duct, another patient demonstrated pancreatitis. CONCLUSION: Ultrasound and intravenous cholecystography are suitable for preoperative imaging. Postoperative ultrasound is useful in detecting complications.
AIM OF THE STUDY: Fifteen patients with phaeochromocytoma who underwent surgery were studied consecutively. METHODS: They received either (10) a balanced anaesthesia technique with isoflurane and fentanyl or (5) a combination of propofol and alfentanil for total intravenous anaesthesia. EEG processing was performed in order to guarantee adequate anaesthetic depth. Antihypertensive therapy was performed with sodium nitropusside. Continuous blood sampling was performed with a roller pump and an autosampler system in order to get high resolution measured of plasma catecholamines. Their concentration was measured by HPLC with electrochemical detection. RESULTS: There were 100fold differences in the maximal catecholamine concentrations during phaeochromocytoma resection between patients. In some cases adrenaline and noradrenaline levels exceeded normal values by a factor of 1000 to 1500. Secretion rates were calculated on a pharmacokinetic basis an revealed secretion rates of 0.3 to 97.3 micrograms/min for adrenalin and 6.7 und 402.8 micrograms/min for noradrenaline. If systolic blood pressures were greater than 160 mmHg sodium nitroprusside was given by infusion with a rate of 300 +/- 315 micrograms/min. Over a period of 69.2 +/- 39.8 min during resection of the tumor the total dose was 7017 +/- 12433 micrograms. CONCLUSIONS: There were positive correlations between plasma catecholamine concentrations, systolic blood pressure values, and infusion rates of sodium nitroprusside. The comparison of the two anaesthetic techniques resulted in a significant reduction of antihypertensive therapy and more stable haemodynamics in patients with total intravenous anaesthesia. However, the beneficial effect of this anaesthesia regimen has to be proven on a larger basis of patients in a randomized manner.
OBJECTIVE: To assess the effect of six different enteral diets on the gut barrier. DESIGN: Laboratory study. SETTING: University hospital, Germany. MATERIAL: 70 Specific pathogen free female Crl:CDR BR rats. INTERVENTIONS: For 7 days, 6 groups of rats were fed orally with standard chow (n = 15); total parenteral nutrition solution (oral TPN, n = 15); elemental diet (ED, n = 10); nutrient-defined diet (NDD, n = 10); or the NDD supplemented with uracil (NDD+uracil, n = 10), or fibre (NDD+fibre, n = 10). MAIN OUTCOME MEASURES: Bacterial translocation to mesenteric lymph nodes, numbers of Gram negative enterobacteria and total aerobic bacteria in the caecum, and intestinal concentrations of secretory IgA. RESULTS: The incidence of bacterial translocation was significantly increased in the groups given oral TPN, ED, NDD, and NDD+uracil compared with the group given chow. Only NDD+fibre resulted in a similar degree of translocation to that in the chow group. All groups in which there was increased translocation had a highly significant overgrowth of aerobic bacteria in the caecum, mainly by Gram negative enteric organisms. The secretory IgA concentration was reduced in the group that had been given oral TPN, and that in the ED and NDD+uracil groups was similar to that in the chow group. NDD and NDD+fibre were associated with higher intestinal concentrations of secretory IgA than chow. CONCLUSION: Fibre-free enteral diets do not protect the gut antimicrobial barrier whatever else is in them. The superiority of early enteral as opposed to parenteral nutrition after injury may, therefore, not be the result of a specific protective effect on the gut barrier. The supplementation of commercial enteral diets with bulk fibre should be tested in clinical trials.
Injuries to the extrahepatic bile duct present a severe complication in laparoscopic cholecystectomy occurring in 0-2.6%. From June 1991 to September 1994 four patients were treated to the Department of Surgery at Bonn University with bile duct injuries after laparoscopic cholecystectomy. All had complete sections of the common bile duct. They were treated twice with a biliodigestive anastomosis and once by direct suturing of the d choledochus. One of our own patients suffered an injury of the right hepatic duct, most probably due to a thermic lesion. In all cases anatomy was irregular or unclear. To avoid these complications an intraoperative cholangiography should be performed in these situations. The reconstruction after inadvertent injuries of the bile duct depends on the localisation and the age of the lesion.
The emergency treatment of the enterothorax is problematic due to weak lung functions and unstable hemodynamics, and because it does not influence the stage of maturity of the lungs. By delayed operation children with a critical starting position have a greater chance to survive, after their condition has been stabilised by intensive care treatment. During the stabilising period we managed to decrease the FiO2 level below 50% and to decrease the pCO2 level to 43 +/- 13 mm Hg in our patients (n = 10). Furthermore we succeeded to raise the O2 degree of saturation from 72 +/- 13 to 89 +/- 9%. The pH level went up from 7,238 +/- 0,181 to 7,394 +/- 0,060. If the condition of the patients worsens during the stabilising period--in our patients the stabilising period was between 12 and 24 hours--immediate operation is indicated. We have no experience so far in using ECMO in such situations.
Spontaneous splenic rupture as a complication of infectious mononucleosis was diagnosed in a 19-year-old woman. Sonographic and MRI investigations revealed subcapsular hematoma of the spleen without overt rupture. The patient was managed conservatively. Somatostatin treatment was initiated in order to reduce splanchnic blood flow. Further clinical course of the patient was favourable. Seven days after the diagnosis of splenic rupture the patient was discharged from hospital. Non-operative management should be considered in patients with subcapsular splenic rupture to avoid complications of splenectomy (e.g. post-splenectomy sepsis).
In recent years the implantation of self-expanding metal-stents has been recommended as a palliative kind of therapy for dysphagia caused by esophageal carcinoma. The metal-stent has a high flexibility, so that it can fit according to the preformed angel of the esophagocardial transition and does not cause a feeling of pressure when placed in the cervical position. From July 1992 to February 1995 in the surgical department of the University of Bonn 21 patients have got a self-expanding Nitinol stent. No dislocation, bleeding or perforation occurred. The dysphagia improved in all patients. The lethality rate was 9.5%, the mean survival rate 4,6 month. The growth of the tumor through the mesh of the stent was a problem which occurred from the tenth week onwards after implantation. Even when the self-expanding metal-stent does not solve all problems, it enlarges the spectrum of palliative kinds of therapy.
Isolated mesenteric fibromatosis is a rare form from the group of intraabdominal fibromatoses which often accompany Gardner's syndrome. It consists in a benign proliferation of fibroblasts with infiltration of muscles and fat tissue. It is diagnosed by ultrasound and CT-scans. The treatment of choice is the total surgical extirpation of the tumor. We report about a 19 year old patient with an isolated mesenteric fibromatosis following a normal pregnancy without previous surgical interventions.