[Which laparoscopic interventions are currently reliable for various indications?].
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Appendectomy↗
Biomedical subjects
E H Farthmann
Publications and source records attributed to E H Farthmann.
Effect of human bowel wall distension on translocation of indigenous bacteria and endotoxins.
The effect of colonic distension on the translocation of indigenous bacteria and endotoxins was prospectively assessed in 50 consecutive patients undergoing colonoscopy. Semiquantitative bacteriologic cultures, chromogenic LAL testing for endotoxemia, and serial determinations of inflammatory markers were used. At the end of the endoscopic procedure, true bacteremia was found in only two patients with obstructing colorectal cancer. There was no evidence of systemic endotoxemia either being induced or increased during the observation period. The endotoxin detoxifying plasma capacity was elevated in patients with preexisting inflammation and did not change within this period. Levels of TNF-alpha, interleukin-6 (IL-6), and elastase (E alpha 1PI) did not differ from baseline values. C3 alpha levels increased in 20% of the patients, whereas fibrinopeptide A values rose by up to 10(2) during colonoscopy. However, since neither endotoxin, TNF alpha, nor IL-6 levels were found to be elevated in this study, the excessive activation of the coagulation system must be related to the distension of bowel wall vessels rather than to an effect of endotoxins escaping from the lumen.
Bacteremia↗
[Intestine saving surgery in Crohn disease--results of limited resection and stricture-plasty].
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.
Abscess↗
A new operative technique of paratopic positioning of pediatric en bloc kidneys for transplantation.
Technical difficulties and insufficient renal mass have been reasons not to use en bloc-removed kidneys from organ donors under the age of 3 years. We developed a new technique of paratopic positioning of en bloc-removed kidneys with a prolonging interpositional graft of donor aorta and vena cava. With transperitoneal approach, anastomosis directly to the recipient's aorta and vena cava can be performed. Using this technique, 7 patients have been transplanted so far. They were chosen out of a list of possible recipients according to HLA-match, body weight and blood pressure. All patients had primary function. Anastomosis and renal vessels were controlled by color duplex ultrasound imaging and angiography. Patients developed a stable kidney function. There were no surgical complications except a thrombosed kidney in 1 patient. With the new technique described, transplantation of en bloc-removed kidneys from donors under the age of 3 years can be performed with a low rate of technical complications. Donors of this age should be considered not only as potential liver donors but as kidney donors as well.
Adult↗
[Laparoscopic techniques in therapy of choledocholithiasis].
Several methods for therapy of common bile duct stones (CBDS) during laparoscopic cholecystectomy are available. After intraoperative cholangiography laparoscopic removal of CBDS can be achieved via the cystic duct or a choledochotomy using a thin cholangioscope, balloon catheters and Dormia baskets. Lithotripsy (electrohydraulic or laser) is necessary in presence of larger stones. Also combined procedures with intraoperative antegrade or retrograde papillotomy have been described. Published studies show that laparoscopic common bile duct exploration can be performed successfully by experienced surgeons. However, these procedures are demanding and time-consuming. Further evaluation is essential.
Cholangiography↗
Radiation enteropathy.
PURPOSE: Radiation enteropathy presents a complex clinical picture which varies from case to case. Diagnosis and treatment require a thorough knowledge of the natural history of the condition and of the complications which are to be expected. PATIENTS AND METHODS: The pathogenesis, clinical picture, diagnosis and treatment of radiation damage to the gut are described. The progress of 90 patients operated on in the Chirurgische Universitätsklinik Freiburg is retrospectively evaluated. RESULTS: Haemorrhage, vomiting, diarrhoea and, occasionally, perforation are the signs of acute radiation enteropathy, which appears weeks or months after radiotherapy. Except for perforations, these can usually be treated conservatively. Chronic radiation enteropathy does not manifest itself until years after irradiation, with diarrhoea, obstruction and the development of fistulae. The acute ileus can often be relieved with decompression tubes. After localising the stenosis radiologically with a contrast medium, and improvement in the general condition, many cases require operative intervention. This usually consists of resection, the establishment of a bypass anastomosis or enterostomy. In 44% of the patients postoperative complications followed, with a mortality of 22%. The cause of the high complication rate is partly the poor general condition of the patient, and partly the radiation induced impairment in wound healing, which may lead to insufficiency of the anastomosis and the development of fistulae. CONCLUSIONS: The treatment of radiation enteropathy is a demanding task. Because of the high complication rate, it is generally wise to choose the least risky procedure.
Adult↗
[The value of CEA immunoscintigraphy for diagnosis of colorectal cancer and its metastases: results of a prospective study].
The importance of the CEA-immunoscintigraphy (IS; BW 431/26 Fa Behring) for the diagnosis of colorectal carcinoma and its metastases was determined in a prospective trial including 60 patients. The results were compared with results of the ultrasound, the CT-Scan and the Angio-CT. Patients suffered from a colorectal carcinoma (15), from a local tumor recurrence after bowel resection (10), from hepatic (39) and/or extrahepatic metastases (16). In 40 patients the diagnosis was confirmed by laparotomy. Regarding the detection of hepatic metastases the sensitivity and specificity of the Angio-CT were superior to the IS (0.86 and 0.63 vs. 0.78 and 0.45). Ultrasound and Angio-CT together revealed true positive results in 89.2%. The IS did not improve this rate. Regarding the detection of extrahepatic metastases the sensitivity and the specificity of the CT were slightly superior to the IS (0.59 and 0.87 vs. 0.47 and 0.28). However, the IS increased the rate of true positive results by 18.8% (US + CT 43.7%; +IS 62.5% true positive results). Due to these results the IS is not recommended as the method of choice to detect liver metastases. But in patients unfit for diagnostic laparotomy the IS may give additional information of the extrahepatic tumor stage.
Adult↗
[Abdominal surgery in advanced age. Indications and prognosis exemplified by stomach, bile duct, colon and hernia surgery].
The increased risk of morbidity and mortality associated with abdominal surgery in the aged is determined by the number and severity of accompanying diseases and the emergency situation. Age per se is not a risk factor. Limitation of the risk requires an age-oriented treatment plan, which must take account of the specific problems of the geriatric patient in the pre-, intra-, and postoperative phases. Emergency operations should be avoided as far as possible. The aim of geriatric surgery is not merely to prolong life, but also to secure adequate quality of life. To accomplish this, it may occasionally be necessary to forgo surgical radicality in favor of a palliative procedure. The results of abdominal surgery in the elderly are presented on the basis of exemplary cases of stomach, biliary, colonic and hernial surgery.
Abdomen↗
Indications for surgical treatment of acute pancreatitis.
The clinical spectrum of acute pancreatitis ranges from mild, self-limiting symptoms to fulminant illness that may rapidly lead to multiple organ failure and death. Differentiation between acute interstitial pancreatitis, necrotizing pancreatitis, pancreatic abscess and acute pseudocyst is mandatory for the choice of surgical treatment. If morphological evaluation by dynamic pancreatography reveals pancreatic or peripancreatic necrosis, bacteriological evaluation by CT-guided fine-needle aspiration is the mainstay of further decision-making, and should be performed if general signs of inflammation are not improved by conservative therapy. Basically, operative treatment may be directed against underlying pathology (e.g. cholelithiasis), or may aim to manage complications. Infected necrosis is the only clear indication for surgery. Whether the choice should be debridement and gravity drainage, continuous closed lavage of the lesser sac, staged relaparotomies, or open packing, depends on the extent of the process and the individual situation. Peripancreatic fluid collections and pancreatic pseudocysts without major ductal pathology rarely need operative treatment in the early stages, whereas abscesses resulting from infected necrosis should be dealt with by surgery rather than by percutaneous drainage.
Abscess↗
[Diagnosis and treatment strategy of intra-abdominal abscess].
Intraabdominal abscesses are life-threatening complications of inflammatory processes or major surgery. Ultrasonography, computed tomography, magnetic resonance, and scintigraphy are the diagnostic methods of choice. The sole diagnosis intraabdominal abcess" is insufficient to recommend a specific therapeutic strategy. Therapy depends upon etiology and localization of the process and the individual situation of the patient. An individualizing strategy may include both operative and percutaneous drainage. 100 patients with intraabdominal abscesses were treated in our department from 1987 through 1991. Roughly one third was diagnosed intraoperatively whereas less than one half of the pretherapeutically diagnosed abscesses were treated by percutaneous drainage.
Abscess↗
[Sequelae of cholecystectomy--a prospective study].
In a prospective study designed to assess the situation following cholecystectomy carried out at the Department of Surgery of the University of Freiburg, 105 patients were examined between August, 1988 and December, 1989. Out of 80 patients who were followed up, 64 had undergone cholecystectomy alone and the remaining 16 had been additionally subjected to exploration of the common bile duct. 80% of the patients reported that their preoperative symptoms had disappeared altogether, 8% admitted some improvement and 10% complained that their condition was unchanged. Specific questioning resulted in the reporting of persistent symptoms in 54%, and these consisted mostly of general complaints such as dyspepsia, flatulence, food intolerance and dull upper abdominal pain. These complaints were vanished or appeared with equal frequency following operation. Objective clinical findings could not be confirmed. Comparison between the pre- and postoperative signs in these patients established a statistically significant correlation (p < 0.05) between the patient's age and the severity of the preoperative symptoms on the one hand and a satisfactory postoperative outcome on the other. This also applied to patients for whom an examination of the bile duct was necessary.
Adult↗
[Perioperative risk factors in esophageal cancer: a retrospective study of independent variables].
The postoperative outcome of 127 patients with an esophageal carcinoma was investigated retrospectively, to identify independent factors for the perioperative mortality (hospital mortality). Chi-square single factor analysis was employed to test 35 independent variables, in a second analysis stepwise logistic regression was used to determine the factors correlating with the morality. In 41 patients the esophagus was resected by a thoraco-abdominal approach, in 86 by blunt dissection. The hospital mortality was 17.3%, the 30-day mortality 12.6%. Single factor analysis revealed a significant correlation with the variable smoking (p < 0.003), post-operative morbidity (p < 0.008), CEA (p < 0.02), time of operation (p < 0.02) and surgical procedures (p < 0.02). The influence of the surgeon's experience was significant. In the stepwise logistic regression the duration of operation (p < 0.0039), the surgical procedures (p < 0.016), and the units of blood (p < 0.03) were correlated with mortality. The logistic regression showed a significant increase of mortality for the thoracoabdominal approach with increasing duration of the operation. The estimation of survival time according to Kaplan and Meier revealed a significant correlation with the stage of the tumor, but not with the surgical procedure.
Adenocarcinoma↗
[Stomach carcinoma: surgical strategy and therapy results 1992].
Surgical strategy for gastric carcinoma consists in total gastrectomy as a rule combined with extended lymphadenectomy. In small tumors of the intestinal type located in the distal stomach distal gastric resection can be taken into consideration. In case of high risk patients endoscopic polypectomy of a polypoid early gastric carcinoma can be sufficient. If the operation is done for cure we perform intraoperative radiotherapy within a prospective trial. For palliative situations procedures including removal of the tumor have better results with regard to quality of life and survival than bypass methods.
Gastrectomy↗
[Therapeutic possibilities in therapy-resistant ulcers--surgical aspects].
Indications for surgery and choice of procedure in complicated or chronic gastroduodenal ulcer refractory to conservative treatment are presented. Operations in emergency states are undisputed although they carry a tenfold higher mortality rate than elective procedures. Therefore in spite of effective pharmacotherapy groups at risk have to be identified by interdisciplinary therapeutic concepts in order to enable elective operation on time. Next to patient and ulcer data the efficacy of various procedures has to be considered. The standardized operative techniques and their associated respective rates of complications and recurrence are compared with those of pharmacotherapy.
Algorithms↗
Cholestasis, metabolism and biliary lipid secretion during perfusion of rat liver with different bile salts.
The biological effects of bile acids depend largely upon their molecular structure. When bile acid uptake exceeds the maximal biliary secretory rate (SRm) cholestasis occurs. In order to characterize the influence of bile acid structure on its cholestatic potency we systematically studied SRm, maximal bile flow, maximal and cumulative phospholipid and cholesterol secretion with different taurine-conjugated tri-, di- and keto bile acids (Table I) in the isolated perfused rat liver. Bile acids with a high critical micellar concentration (CMC) promoted the greatest bile flow; a positive non-linear correlation between CMC and maximal bile flow was found. 3 alpha-Hydroxylated bile acids with a hydroxyl group in 6 alpha and/or 7 beta position and lacking a 12 alpha hydroxy group had a high SRm. SRm was not related to CMC or maximal bile flow, respectively. Phospholipids and cholesterol were secreted in a nearly fixed ratio of 12:1; a strong linear relationship could be observed. Cumulative phospholipid secretion over 48 min was significantly lower for non and poor micelle forming bile acids (TDHC and TUC) than for those with comparatively low CMC values (TUDC, TC, THC, THDC, TCDC) (70-140 vs. 210-450 nmol/g liver). At SRm all bile acids with good micelle forming properties showed a similar cumulative biliary lipid output. However, when biliary lipid output was related to 1 mumol bile acid secreted bile acids with a low SRm induced the highest lipid secretion (TCDC, TC). These data (1) demonstrate that a 6 alpha and/or a 7 beta hydroxy group on the steroid nucleus reduce cholestatic potency if the 12 alpha hydroxy group is absent, (2) suggest that in the case of micelle forming bile acids the total amount of phospholipids secreted in bile (depletion of cellular phospholipids) is associated with the occurrence of cholestasis whereby bile acids with a low SRm deplete the cellular phospholipid content at much lower bile acid concentrations than those with a higher SRm and (3) imply that bile acids with non and poor micelle forming properties (TDHC, TUC) presumably do not cause cholestasis (solely) by depletion of cellular phospholipids.
Animals↗
Influence of the distance between interrupted sutures and the tension of sutures on the healing of experimental colonic anastomoses.
Certain technical factors determine the success of the creation of intestinal anastomoses. The influence of the distance between interrupted sutures and the suture tension on wound healing was investigated in an experimental study using a specially designed suture model. The combination of a long suture distance (group A, 2.5 mm) and a short suture distance (group B, 1.5 mm) with three different suture tensions, i.e., (1) no tension; (2) moderate tension; and (3) high tension, resulted in six different techniques. Tension was created by means of a spring balance. The anastomoses were examined macroscopically, histologically by microangiography, and by bursting pressure. Apposition of the bowel wall between the interrupted sutures was inappropriate due to prolapse of the mucosa in 7.9% of the patients in group A but did not occur in groups B2 and B3. The leakage rate was 4.6% in group A and 1.3% in group B. Early healing of the mucosa was noted in group B2. Bursting pressure was significantly higher on day 2 and 4 in groups B2 and B3. The results demonstrate the influence of suture technique on the wound healing of intestinal anastomoses. The best healing pattern was achieved by a small distance between the sutures and a moderate suture tension.
Anastomosis, Surgical↗
Lectin histochemical investigations of fetal cultivated pancreatic tissue.
The terminal glycoproteins of fetal, cultivated (7-12 days), and adult nondiabetic and diabetic pancreatic tissues (Balb c, C3h mice) were investigated by lectin histology (peanut-, phytohemagglutinin, wheat germ agglutinin, Ulex europeus I, concanavalin A and Ricinus communis agglutinin, PaP method +/- neuraminidase). Anti-insulin and -glucagon were used to identify islet cells. S-100 antibody showed dendritic reticulum cells, anti-IAK proved MHC II antigens (C3h). Cultured tissue was partly incubated with anti-IAK and complement for lysis of MHC II antigens. On the 19th gestational day fetal pancreatic tissue did not bind peanut agglutinin, Phytohemagglutinin, or wheat germ agglutinin, whereas concanavalin A and Ricinus communis were weakly bound. Terminal fucose residues were not expressed by C3h fetal islet cells in contrast to Balb c. Following neuraminidase digestion peanut agglutinin and phytohemagglutinin were strongly bound, indicating sialic acid-substituted terminal glycoproteins. Cultivated tissue (Day 7) bound all investigated lectins (except Ulex europeus I in C3h mice), indicating maturation of islet cells. In spite of the peak of insulin concentration in the medium we observed a faint binding of anti-insulin and investigated lectins following 12 days of cultivation. This indicates a disorder of terminal glycoprotein synthesis at this point. There was no difference in lectin binding patterns of adult nondiabetic islet cells compared to the cultivated tissue (7 days), but no Ulex europaeus I binding of the adult Balb c mice was observed. S-100 binding decreased during the cultivation period as dendritic reticulum cells became destroyed by cultivation.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗