Biomedical subjects
Publications and source records attributed to M Dürig.
A young man with Weber B fracture had adrenalectomy under the suspicion of pheochromocytoma on the right side. Surprisingly hematoma of the right adrenal gland was found. This case is presented to point out the mechanism of trauma and diagnostic possibilities of the injury.
A prospective, randomized trial has been undertaken to evaluate the prophylactic effects of low molecular weight heparin (LMWH) and dextran-70 in 216 patients with hip fracture during a postoperative period of ten days. Deep vein thrombosis (DVT) was diagnosed using the 125Iodine fibrinogen uptake test, confirmed by ascending venography. 113 patients received LMWH and 103 dextran-70. The frequency of DTV of 14.2% in the LMWH group was significantly lower compared with the 30.1% in the dextran group (p less than 0.003). During the first 10 days postoperative there were no fatal pulmonary embolism (PE). After this period PE occurred in 2 patients (1.8%) in the LMWH group and 1 patient (1.0%) in the dextran group. In each group one patient died from PE. There was no major bleeding in either group. The frequency of local complications was slightly higher in the dextran group (10.7%) compared with the LMWH group (3.5%). The postoperative hemoglobin level was significantly lower in dextran treated patients than in patients receiving LMWH (p less than 0.0001).
The introduction of totally implantable catheter device has provided a simple, permanent and safe access to the vascular system. They have greatly improved the quality of life of the patients involved, whose activities, daily hygiene and bodily attractiveness remain practically unrestricted. To gain the greatest freedom from complications in the use of fully implantable catheter devices, the following requirements are important in to our experience: 1. Experience with only one kind of catheter system, irrespective of whether it is claimed to be the best, the simplest, or the cheapest. Various companies offer a variety of totally implantable catheter devices. Every system has its advantages and its disadvantages. However, each system also requires a considerable degree of surgical experience and experience in postoperative care and management to keep the complication rate as low as possible. Frequent changing to other systems does not enlarge the experience obtained. 2. The experience of the surgical team. In Basel catheter systems are implanted by three surgeons only. We are convinced that this contributes to our relatively low rate of complications. Brothers et al. (1988) also show that the rate of complications is inversely related to the experience of the surgeon involved. 3. The experience, commitment and training of the nursing staff responsible for the care and maintenance of the implanted catheter device. This care and maintenance of the implanted catheter device should start immediately after the surgical procedure.(ABSTRACT TRUNCATED AT 250 WORDS)
A patient with refractory diarrhoea (up to 10 l/d) following colectomy and ileostomy was treated with clonidine, after loperamide, tinctura opii, cholestyramine and somatostatin had failed to reduce stool volume to less than 6 l/d. Under combined treatment with clonidine (1200 micrograms/d) and somatostatin (6 mg/d), which was well tolerated, stool weights were normalised within 24 hours. This case report on the successful anti-diarrhoeic effect of clonidine is completed by experimental data from rat jejunal and duodenal segments. In the presence of the adenylate cyclase-stimulating agent forskolin, clonidine normalised both mucosal cAMP content and cAMP-induced hypersecretion in rat intestine. This suggests that the anti-diarrhoeic effect of clonidine in-vitro results from an alpha 2-receptor mediated inhibition of the stimulated adenylate cyclase. Case report and experimental data therefore support the theory that therapeutical application of clonidine in diarrhoea may be successful.
The extreme lack of renal grafts for transplantation stimulated us to analyze how strict the selection criteria of kidney donors must be. We investigated therefore if preexisting lesions in renal grafts influence initial and late renal function. 147 zero-hour biopsies of 101 donors (mean age 33, from 6-64 years) were examined. By ligh microscopy 38% of biopsies showed no, 44% showed nonspecific and 18% specific lesions. Nonspecific lesions comprised intimal fibrosis of small arteries in 44%, interstitial fibrosis in 8% and an arteriolar hyalinosis in 29%. Out of 102 immunohistologically examined biopsies 74.5% showed nonspecific IgM/C3 deposits in glomeruli and/or arterioles. An age dependent decrease of normal renal biopsies was found which was most evident in donors older than 40 years. Specific findings consisted of glomerulosclerosis (n = 4), glomerulonephritis (n = 11), intravascular coagulation (n = 10) and eclamptic kidney (n = 1). In case of nonspecific immunohistologic findings and in glomerulonephritis rebiopsies showed that antigen deposits usually disappeared within 4 months. Independent of morphologic findings 82% of transplant recipients had a good initial and late renal function. Since donor age, glomerulosclerosis, glomerulonephritis, intravascular coagulation or eclamptic changes seem not to compromise renal function after transplantation a more liberal choice of donors should be considered.
Diagnosis of splenic injury is influenced by both the type of injury and the diagnostic possibilities at the place of evaluation. Noninvasive examination with ultrasonography, computed tomography, or radionuclide scanning detects the injury. If not available diagnostic peritoneal lavage can indicate the necessity of laparotomy. Splenic salvage is the treatment of choice in splenic injury. Selective non-operative treatment of blunt trauma, splenorrhaphy, and partial splenectomy were used successfully to preserve 67% of injured spleens. Clinical and experimental findings indicate that replantation of splenic autologous tissue will not protect the host from septicemia.
In a five-year period (1983-1988) catheters were implanted in 205 patients (118 venous, 31 peritoneal, 29 arterial, 25 epidural and 2 pleural), using the same system (Port-a-Cath). Total implant duration was 88,345 patient days (242 patient years). On average there was one catheter complication per 2000 patients days. The only catheter-system infections occurred with peritoneal catheters. This relatively low complication rate was probably due to the use of only one system, a uniform implantation technique practised by only three surgeons, and strict postoperative supervision by the oncology nursing team.
Primary duodenal carcinoma and duodenal adenoma are rare tumours. Duodenal carcinoma makes up about 0.3% of all malignant tumours of the gastrointestinal tract (Alwmark et al. 1980; Spira et al. 1977). The present paper describes a duodenal carcinoma arising in a mixed tubulo-villous non-Vaterian adenoma in a 68 year old male. Immunocytochemical analysis revealed evidence of neuroendocrine differentiation in both adenoma and carcinoma. In a review of the literature a correlation between the size of adenoma and the probability of concomitant carcinoma is demonstrated. Duodenal adenoma measuring more than 4 cm in diameter should be considered potentially malignant.
A prospective, randomized, double-blind and controlled clinical trial of systemic antibiotic prophylaxis with Cefazolin and Ornidazol (CO) versus Cefazolin and Placebo (CP) was carried out consecutively in 100 patients undergoing elective, colorectal surgery. The incidence of wound infection in the CP-group was 20% (n = 10) and in the CO-group 8% (n = 4) (p less than 0.10 ns). The reduction of anaerobic bacterias from 20% (n = 10) in the CP-group to 0% (n = 0) (CO) was significant (a1 = 0.0139; a2 = 0.0277 s, Fischer's exact test). The time of hospitalization was reduced from 20.3 days (CP) to 16.7 days (CO) (p less than 0.05 s). The agent for antibiotic prophylaxis in elective colorectal surgery is to cover the spectrum of anaerobic bacterias.
17 patients with infectious diseases needed a long-term parenteral antibiotic therapy. Therefore a subcutaneous catheter system (Port-a-Cath) was implanted for intravenous application of the antibiotic drugs. With a total dwelling-time of 952 patient/days no catheter super-infection was observed. Due to postoperative hematoma in an anticoagulated patient one catheter system was not functioning temporarily. One had to be removed on suspicion of a fungous colonization which could not be verified after bacterial examination. Quality of life for all patients was unaltered so that ambulant therapy was possible in almost 20%.
Ruptured appendicitis involves a morbidity rate greater than that of negative exploration, and estimations of morbidity as high as 15% for negative laparotomy have been accepted by various investigators. We undertook a prospective analysis of 450 patients admitted to our hospital with suspected acute appendicitis, to identify those aspects in differentiating diseases that required surgery from those permitting observation. A prompt appendectomy was performed in 265 patients (59%). The appendix was normal in 4% of them. 185 patients were observed clinically and by laboratory investigations. None of them had to be operated on during the following 12 months of out-patient observation. We may conclude that clinical observation by an experienced physician may decrease the rate of negative laparotomies.
Ninety-eight patients with documented mesenteric infarction during a 19-year period were reviewed. In 13 patients infarction was due to a mesenteric venous thrombosis (MVT). Patients with MVT distinguished themselves from those having another aetiology by: (1) longer history of pain before admission (median 8 days, P less than 0.0001); (2) typical appearance of the bowel at laparotomy (10/13); (3) a localized segment of ischaemic jejunum or ileum of less than 120 cm in length (12/13) allowing better operability at the first laparotomy (P = 0.006). In hospital the mortality was lower for venous mesenteric infarction (5/13, 38 per cent) than for mesenteric infarction of other aetiologies (70/85, 82 per cent) (P = 0.002). Patients with primary venous mesenteric infarction showed a better survival rate (one death in eight patients) than patients with associated diseases such as liver cirrhosis, sepsis or previous operation who had a poor prognosis with a mortality comparable to other aetiologies of acute bowel ischaemia (four deaths in five patients). Since the high recurrence rate of this disease in the early postoperative period was due to residual venous thrombosis and to a hypercoagulable state, a wide bowel resection is recommended followed by early and long-term anticoagulation. Thrombectomy is probably inefficient since it removes only centrally located thrombi and leaves peripheral occlusion, which is responsible for the recurrence.
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A state of immunosuppression or immunodeficiency has been described after surgical trauma. Cellular immune functions are more heavily affected. At present the relationship between these abnormalities and the increased incidence of infections in surgical patients has not been clarified. The activation of the humoral compartment and the appearance of lymphoblastoid B cells spontaneously secreting IgG and IgA have been observed in surgical patients. These cells are a marker of a recent antigenic exposure. In this study the kinetics of appearance of this B cell subset and the relationship between spontaneous Ig secretion and DNA synthesis have been analysed in six cholecystectomized patients. A peak of spontaneous IgG and IgA secretion is evident 5 and 7 days after the intervention. In some patients (two out of six) the appearance of lymphoblastoid B cells is cyclical. A second wave of spontaneous Ig secretion becomes evident 14 days after surgery. Double immunofluorescent staining of peripheral blood lymphocytes for BrdU and cytoplasmic Ig (cIg) was employed to demonstrate that a fraction of lymphoblastoid B cells is actively proliferating and that other cells negative for cIg but active in DNA synthesis appear in the circulation. These data confirm the signs of activation observed after elective surgery in otherwise healthy subjects.
The controversy about the extent of resection of gastric cancer has been lasting for decennies. The extreme viewpoints may have become less divergent recently although controlled data are still lacking. As gastrectomy has generally become safer, a somewhat broader indication for it is justified. Subtotal resection is still justified for cancer of the antrum of the intestinal type (Laurén-classification) without evidently involved distant nodes and as long as a clear margin can be expected, furthermore in some advanced disease situations and finally in high risk patients, especially with severe cardiopulmonary handicaps.
Indications for splenectomy in malignant hematological diseases are discussed for relief of symptoms (splenomegaly, cytopenias), for staging (M. Hodgkin) or improvement of survival (hairy cell leukemia). The role of splenectomies is also evaluated for Non-Hodgkin lymphomas, chronic lymphatic leukemia, myelofibrosis and for chronic myeloic leukemia.
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