Biomedical subjects
Publications and source records attributed to L Köhler.
A case of a coincidental finding of hepatic carcinoid micrometastases, barely visible to the eye, during routine laparoscopic cholecystectomy is reported. The micrometastases were possibly recognized as a result of a beneficial aspect of laparoscopic surgery, namely the >10x enlargement of tissue/pathologic structures.
This study evaluated whether twice daily isotonic perfusion of the bypassed ileum for six weeks would enhance its motor activity and its absorption of fluids, electrolytes, and vitamin B12. The study also determined if patients undergoing perfusion had improved bowel function and decreased hospital stay after ileostomy closure. Following proctocolectomy, ileal pouch-anal canal anastomosis, and diverting loop ileostomy, six patients self-infused an isotonic solution (sucrose and sodium chloride) into the bypassed ileum twice daily, while seven patients did not (controls). Two months following proctocolectomy, and just prior to ileostomy closure, a manometric catheter assembly was placed into the unused distal ileum via the stoma and the distal ileum perfused with an isotonic sodium chloride solution for 3 hr during fasting and 3 hr after a meal. Absorption was measured, single and clustered pressure waves were identified, and a motility index was calculated. Water absorption, motility index, and cluster parameters did not improve in perfused patients compared to controls during fasting or after a meal, nor did perfused patients have improved vitamin B12 absorption. The perfused patients also did no better clinically following ileostomy takedown; the onset of bowel movements, their frequency, time to tolerate a diet, and hospital stay were similar to controls. We conclude that six weeks of twice daily isotonic perfusion did not improve motor activity or water, electrolyte, and vitamin B12 absorption in the bypassed distal ileum after proctocolectomy, ileal pouch-anal canal anastomosis, and loop ileostomy. The perfusion also did not improve bowel function after ileostomy takedown.
OBJECTIVE: To evaluate the current practice of incisional hernia repair in Germany and analysis of the results of the Mayo duplication technique done in our hospital over a 10-year period. DESIGN: Nationwide survey, retrospective analysis. SETTING: University department, Germany. SUBJECTS: Survey of most surgical departments and of 114 patients with 135 incisional hernias in our unit. INTERVENTION: Mayo duplication repair incisional hernias. MAIN OUTCOME MEASURES: Common practice, recurrence rates, quality of life. RESULTS: The Mayo overlap is the preferred technique in most surgical departments. The estimated failure rates (12% or less) in general practice are grossly underestimated. In our hospital the recurrence rate after Mayo duplication repair was 61/114 (54%) during a follow up time of 5.7 years with a follow-up-rate of 84%. Univariate and multivariate analyses failed to identify any predisposing factors. All patients with incisional hernias had limitations their physical function. CONCLUSIONS: The widely used Mayo procedure leads to unacceptable results for repair of incisional hernias and other techniques should be evaluated and used more often. Repair of an incisional hernia does not improve overall quality of life.
Inoculation of phorbol ester-differentiated U937 cells as a model for human macrophages with Chlamydia trachomatis of the urogenital serovar K resulted in a persistent infection, with maximal growth at day 7, until day 10 post-infection. At these times inclusion bodies were present in 0.5-2% of the cells. Typical inclusion bodies containing elementary bodies and reticulate bodies were observed by electron microscopy. Furthermore, single chlamydial particles resembling atypical elementary or intermediate bodies were identified in the cytoplasm in > 80% of the host cells. IFN-gamma exerts antichlamydial activity in epithelial and fibroblastoid cells, but the infection of U937 cells by C. trachomatis was not affected by IFN-gamma. The activity of the tryptophan-degrading enzyme indoleamine 2,3-dioxygenase (IDO) was not detected in untreated or in IFN-gamma-treated or chlamydiae-infected or mock-infected U937 cells. The presence of atypical persisting chlamydiae and the lack of IDO expression in U937 cells indicates that the development of these atypical bacteria is independent from IFN-gamma-mediated tryptophan deprivation and other IFN-gamma-mediated effects. Evaluation of persistently infected cells revealed that the expression of the chlamydial major outer-membrane protein, heat-shock protein (hsp60) and lipopolysaccharide (LPS) antigens was not significantly altered in the course of the culture. An intense staining of the LPS on the surface of the host cells was demonstrated by immunofluorescence. The data show that phorbol ester-differentiated U937 cells restrict chlamydial growth strongly but not completely through a mechanism distinct from IDO-mediated tryptophan deprivation. The mechanisms of persistence of chlamydiae in monocytes, which differ considerably from those described for other cells, require further investigation.
Out of 234 elective patients 162 (69%) with colorectal disease were resected by laparoscope. The conversion rate was 8.5%. Mortality and morbidity were low. Patients' recovery was quick. A total of 96 patients were operated because of colorectal cancer. The number of resected lymph nodes and resection margins was sufficient. No port metastases were observed. Six patients developed either perineal or hepatic tumor recurrence.
Nonsteroidal antiinflammatory drugs (NSAIDs) are among the most frequently prescribed drugs in western countries. The high incidence of adverse gastrointestinal effects which are potentially life-threatening require steps for prevention. The use of NSAIDs should be restricted to patients with inflammatory rheumatic diseases. If NSAIDs are indicated it is important to identify patients who are at high risk to develop serious gastrointestinal side effects. These patients should receive Misoprostol at a dose of 2 to 3 x 200 micrograms per day. Up to date Misoprostol is the only drug with proven efficacy with respect to the prevention of gastroduodenal ulcer and its complications. NSAIDs inhibit the key enzyme of prostaglandin synthesis, the cyclooxygenase. Recently published data show that 2 isoenzymes of the cyclooxygenase exists. Cyclooxygenase-1 is primarily involved in the maintenance of organ function whereas cyclooxygenase-2 is expressed in inflamed tissue. Specific cyclooxygease-2 inhibitors have been developed. Clinical trials have to prove if the concept of a selective cyclooxygenase-2 inhibition with high antiinflammatory potency but lack of gastrointestinal side effects holds true in humans.
The aim of this study was to access the importance of the laparoscopic colorectal resection. Of 131 patients 80 were operated on laparoscopically. The conversion rate was 14% (13/93). A total of 47 patients suffered from cancer. Curative resection was performed in 41 patients (87%). For comparison, 48 patients who underwent open resection were used. The complication rate was lower after laparoscopy and no reoperation was performed. Patients recovered quicker and their first oral food intake and bowel movement were earlier. Hospital stay was shorter (15.3 vs. 8.1 days), and pain at rest and in motion was significantly reduced. Equal numbers of mesenteric lymph nodes were retrieved; adequate margins of resection could be obtained and the length of resected bowel did not differ. No port metastases were observed. Reduced morbidity, reduced hospital stay, reduced abdominal pain, quicker reconvalescence, and reduced overall health care costs are strong arguments in favor of laparoscopic colectomy.
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Viscerosyntheses represent an unrenouncable component of several endoscopic procedures. The extra cost for a laparoscopic viscerosynthesis of approximately 2000 DM in the year 1994 are economically well invested with regard to a reduced postoperative pain, a reduced amount of postoperative analgesics, a faster recovery, and most of all drastically reduced morbidity of the abdominal wall. The unfortunate structure of the healthcare system burdens the hospital with additional financial expenditures, thus shifting the profits to the insurance companies. A change in this profit structure would allow for a faster spread of efficient and promising therapies. Economical studies including patients, physicians, hospital administrations and insurance companies are considered to be imperative in order to promote the development of efficient therapies.
The results of a nationwide survey regarding the treatment of incisional hernias following open laparotomy revealed that the Mayo-duplication is the surgical technique preferred by the majority of surgeons. However, in exceptional situations alloplastic material is implanted by up to 50% of the surgeons asked. More than one forth of the departments performed more than 30 incisional hernia repairs per year. Even for complicated cases the surgeons' own estimation of their recurrence rates was 11.7%. Compared with the data (recurrence rate of the Mayo-duplication of 30%-50%) published in the literature there seems to be a quantitative and qualitative underestimation of the treatment of incisional hernias.
About 10% of patients undergoing conventional laparotomy will develop incisional hernias. Traditionally these hernias are in this country most often repaired by a Mayo-duplication. In this retrospective analysis we investigated a consecutive series of 114 patients (mean age: 53 (11-87) years, gender ratio m:f 1.2:1.97% electively operated) with 135 hernias, operated between 1/1985 and 12/1992 by a standard Mayo-procedure. Recurrence-rates and quality of life were evaluated by clinical examination. The mean follow-up time was 5.7 (2.5-10.2) years with a follow-up rate of 84.4%. The overall recurrence rate was 53.5%. Further uni- and multi-variate analysis was unable to find any clinically relevant risk factors for hernia development. Health related quality of life was evaluated with a validated index at the time of their follow-up visit. There were no differences in patients without a hernia recurrence (n = 52) when compared to those with an actually present recurrence (n = 36). However, physical function of all patients was significantly impaired when compared to healthy individuals. According to our results and those reported by others the Mayo-duplication when applied to all patients leads to non-acceptable results and implantation of auto- or alloplastic material should be considered more frequently.
The recurrence rates following the "simple" incisional hernia repair procedures (Mayo-procedure or direct adaptation) are unacceptably high, in literature up to 50%. In order to reduce the recurrence rates alternative procedures are necessary, e.g. the additional support of the anterior abdominal wall by implantation of a non resorbable mesh or autodermal plasty. Our national inquiry of 669 hospitals showed that the technique of autodermal hernioplasty is almost unknown among the German surgeons. In this article a comparison of the history, morphology, healing process and possibilities of cutis implantation as well as technical aspects of different types of autodermal hernioplasty (cutis lacing plasty, onlay and sublay corium mesh plasty) are described. By literature analysis the results of autodermal hernioplasty are compared with the results of mesh implantation. The autodermal hernioplasty is discussed as an alternative operative procedure to the implantation of artificial meshs.
Parastomal hernias are a frequent long-term complication after stomal construction. Operative therapy is only indicated in 10% of the cases. Indication for operation are symptomatic hernias. Local fascial repair has due to the high recurrence rate (80%) no longer any indication. After stomal relocation recurrent parastomal hernias are observed in 40% and incisional hernias in 20-30% of the cases. Prosthetic mesh repair has a low recurrence rate (8%) and an acceptable infection rate (9%). Thus, mesh repair is nowadays the procedure of choice for the treatment of parastomal hernias.
The importance of so-called oncological standards is stressed every time an innovation is introduced in surgical practice. It has been stated that for colorectal cancer surgery the following oncological rules must be followed: wide tumor resection with gentle tumour removal, en bloc resection of the tumour without tumour cell spillage, no-touch isolation technique, primary ligation of the vessels and systematic lymph node dissection. Most of these oncological standards and rules are imprecise and unproven. Prognosis of the patients is not improved. Operative trauma has been shown to be associated with reproducible alterations in host immune function. This weakening of the immune system may increase risk of distant recurrence arising from exfoliated malignant cells during the operation. Up to now it is not known if laparoscopic technique diminishes these adverse effects on the immune response.
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It was the aim of our study to investigate the role of laparoscopic colorectal cancer resection for cure. Postoperative morbidity, pain and hospital stay (n = 21) was reduced and patients' recovery accelerated compared to conventionally operated patients (n = 54). The number of resected lymph nodes and tumor distances were comparable; however, portal recurrences remain the main problem.
This review assesses whether the risk of ileoanal pouch construction in patients with ulcerative colitis, compared with that of 'less dangerous' operations, is compensated by a better postoperative outcome. Even though the mortality rate is not greater for pouch construction, the risk of pelvic sepsis and pouchitis increase morbidity. Bowel function after construction of the ileal pouch, although better than that before operation, is not as good as that of normal controls and does not, in itself, justify increased morbidity. Quality of life measurements suggest that the benefit of the ileal pouch procedure is not much greater than that of ileostomy, even though some dimensions of quality of life are improved. However, most patients wish to avoid an ileostomy and surgeons should respect this wish, remembering that the pouch procedure has some risks and that the gain for the patient may be small.