Biomedical subjects
Publications and source records attributed to W Pimpl.
The surgical technique used in thyroidectomy is of decisive importance for the rate of recurrent nerve injury. The latter was reduced from 4.9 to 2.2 per cent by surgical treatment without opening of the retrothyroid connective tissue space and without ligature of the inferior thyroid artery.
Prevention of struma recurrence is a major aspect in postoperative management, following struma surgery. Prophylaxis is based on substitution of L-thyroxine, depending on TSH levels. The latter should be somewhere between 0.5 and 2.0 microU/ml. The rate of struma recurrence was below two per cent.
This study was initiated to evaluate the role of serotonin in cholera toxin-induced jejunal secretion of water and electrolytes. Chronic Thiry-Vella loops, constructed in six dogs, were perfused with an isosmotic neutral perfusate containing [14C]polyethylene glycol as the recovery marker. Fluxes of water, sodium, chloride and potassium were calculated and immunoreactive serotonin levels were measured in blood and effluent perfusates. Intraluminal application of 20 micrograms of cholera toxin induced secretion; fluxes of water (basal, 32.3 +/- 11.1; 6 hr, -541 +/- 35 microliter/min), sodium (basal, 9.0 +/- 2.8; 6 hr, -78.3 +/- 5.6 microEq/min), chloride (basal, 3.8 +/- 1.5; 6 hr, -65.7 +/- 4.0 muEq/min) and potassium (basal, 0.10 +/- 0.08; 6 hr, -2.80 +/- 0.18 muEq/min) were all significantly different from basal. Serum electrolytes remained normal, except that potassium fell from 4.9 +/- 0.5 to 3.9 +/- 0.2 mEq/l. Although circulating serotonin levels did not change from base line (180.9 +/- 29.3 ng/ml), effluent concentrations increased significantly from 68.2 +/- 4.6 to 81.1 +/- 5.0 ng/ml (at 3 hr) and jejunal outputs increased from 136.6 +/- 10.2 to 205.1 +/- 10.1 ng/min (at 6 hr). In a separate set of experiments, verapamil was infused i.v. (12.5 micrograms/kg/min) during the 4th hr in four dogs exposed to cholera toxin. The lower dose of toxin (5 micrograms) induced secretion which was unaffected by the calcium channel blocker. In another series of studies, ketanserin (a 5-HT2 receptor blocker) was infused i.v. at 33 micrograms/kg/min during the 4th hr in four additional dogs exposed to the lower dose of cholera toxin. This potent serotonin antagonist failed to inhibit cholera toxin-induced jejunal secretion.(ABSTRACT TRUNCATED AT 250 WORDS)
Combined endoscopic and surgical intervention was undertaken in 728 consecutive patients with primary or secondary gallstone disease. In primary gallstone disease the combined treatment resulted in a residual stone rate of 1.28%, and 1.09% for the total group. Intervention on the lower biliary tract (n = 228) resulted in a morbidity rate of 7.4% and a mortality rate of 1.3%. The corresponding figures with purely endoscopic procedures were 1.2 and 0.0%, respectively. Intraoperatively manometrically tested papillary function after endoscopic papillotomy (EPT) revealed no significant difference from normal. In patients with proven biliary pancreatitis the mortality rate after EPT was 2.9%. These results indicate that routine inclusion of endoscopy into the surgical treatment concept for gallstone disease can improve the overall results.
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Over a 5-year period, 443 patients were treated for primary gallstone disease. There were 333 patients with negative preoperative findings in the common bile ducts (CBD) on sonography and liver enzymes estimation who underwent cholecystectomy without endoscopic retrograde cholangiography (ERC). Thirty-eight surgical explorations of the choledochus were necessary, and in 11 patients a second intervention (endoscopically) had to be performed. There were 110 patients with signs of stone formation in the bile ducts. These patients were submitted to examination of the CBD by ERC. Choledocholithiasis was found in 67 patients; in 47, endoscopic papillotomy and stone extraction were successful. On 7 occasions it was insufficient and in 13 patients it was not attempted due to the size of the stone. One second intervention (endoscopically) had to be performed in this group of patients. The sonographical and laboratory suspicion of bile duct-stones could be disproved in 43 patients. In these cases, the preoperative ERC was negative. We therefore had information on the bile duct system preoperatively and no surgical bile duct exploration was necessary for diagnosis. Thirty-eight of 333 patients (11.4%) had a false-negative and 43 of 110 (39%) a false-positive sonographical or laboratory diagnosis. This shows that there is no other preoperative diagnostic test other than ERC for the precise preoperative evaluation of common bile duct stones. Morbidity, mortality and the rate of choledochus revision (especially negative explorations) can be reduced by preoperative endoscopic bile duct stone removal.(ABSTRACT TRUNCATED AT 250 WORDS)
The widely differing mortality rates of severe gastroduodenal hemorrhage reported in the literature (10-30%), are due to very inhomogeneous patient groups. The purpose of this study was therefore to rank various clinical and endoscopical factors by giving them points from 0 to 6, both to establish comparable groups and to use them as prognostic parameters for a potential fatality rate. One hundred and ninety-three patients with severe gastroduodenal bleeding, verified at emergency gastroscopy immediately after admission, were admitted to this prospective study. The statistical assessment of the prognosis for these 8 factors revealed a linear correlation between increasing score and mortality rate for the following risk factors: patient age, activity and intensity of hemorrhage, type and number of associated illnesses, various therapeutic procedures. Only the type of the source and the site of the hemorrhage did not correlate well. By adding up the points of all risk factors for every patient we calculated the overall score and established a correlation to the mortality rate: A definite statistical correlation was demonstrated between increasing score and fatal outcome. If a patient with a score of less than 20 points did survive in 100%, the mortality rate increased linearly to 83.3% in patients with a score of 40 points. Using this scoring system it is possible to establish comparable groups of patients - which seems indispensable for a critical examination of various therapeutic procedures. Furthermore, this score can serve as a predictor of the probability of a fatal outcome shortly after patient admission.
The study deals with the immunological capacity and perfusion rate of splenic grafts in pigs after autologous transplantation into the omentum majus. 12 months after the operation, the weight and relative perfusion of the regenerated tissue was clearly reduced. Independent of this fact, the splenic grafts could balance out an IgM-deficiency, observed due to splenectomy, 4 months after the transplantation. Furthermore, the number of antibody forming cells in the grafts was only slightly decreased compared to the normal spleen. These results show that regenerated splenic tissue is able to carry out specific immunological functions. One of the limiting factors in preventing postsplenectomy sequelae (i.e., sepsis) seems to be the poor regeneration weight and low perfusion of the grafts.
Emergency operations were performed on 20 patients for perforated sigma diverticulitis with diffuse (n = 15) or locally delimited (n = 5) peritonitis, between 1979 and June 1986. The average age of the patients was 65.7 years. Sigma resection with closure of the rectosigmoid and colostomy, that is Hartmann's operation, was performed on all of them. The postoperative lethality was as high as 45 per cent (nine patients), but this was not attributable to complications for which the surgical method had to be blamed. Only one patient died of anastomosis dehiscence, following additional resection of part of the small intestine. All the other deaths (n = 8) had been caused by internal organic complications. Hence, lethality is believed to be controllable only by close cooperation from the very beginning between surgeon and specialist in intensive therapy. Re-anastomosis (generally three months from primary operation) can be simplified by means of mechanical staplers, with the risk being reduced to nearly nil. These are benefits that support the recommendation of Hartmann's operation as an emergency approach to perforated sigma diverticulitis. It can be performed even by the less experienced surgeon on night duty.
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Recurrent laryngeal nerve injury still remains the major problem in thyroid gland surgery and is influenced both by morphology and function of the goitre and essentially by the resection technique. Between 1982 and 1985 a total of 825 patients was operated on for the first time due to a benign goitre. In period A (Jan. 1982 to Dec. 1983) we always-- preceding the resection of the goitre--performed the ligature of the A.thyreoidea inferior (n = 412) whereas in period B (Jan. 1984 to Dec. 1985) we dispensed with it (n = 413). In neither of the two periods the preparation of the N.laryngeus recurrens--save few exceptional cases--was performed. The immediate postoperative recurrent laryngeal nerve palsy rate decreased from 4.9% in period A to 2.2% in period B, the persistent palsy rate (laryngeal control half a year postoperatively) from 2.18% to 0.48%. Due to the change to smaller, more hyperfunctional goitres in endemic areas we believe it possible to perform the resection of benign goitres without the preliminary ligature of the A.thyreoidea inferior and the preparation of the recurrent laryngeal nerve. On one hand this can lead to the facilitation of the surgical task, on the other hand to the decrease of the injury risk on the recurrent laryngeal nerve.
Preoperative procedures, surgical techniques, and postoperative management are discussed in this paper, against the background of latest developments and with reference to 443 struma patients who received surgical treatment in 1984 and 1985. The technique of surgical removal has been modified by the author, as compared to what it used to be back to 1964. Ligature of the inferior thyroid artery has been abandoned. The postoperative rate of unilateral nerve palsy recurrence has been reduced from 4.47 to 2.20 per cent, whereas other complications remained unchanged, such as postoperative bleeding and thyreotoxicosis. Other topical aspects resulted from modification of the regime of prophylaxis to prevent recurrence. The substitution therapy applied by late 1985 had been based on daily thyroxine doses as low as 50 micrograms, with the postoperative hypothyreosis rate reaching a level of more than 50 per cent, as early as three months after surgery. The hypothyreosis rate was lowered to something below ten per cent, after the daily T4-therapy had been increased to 75 micrograms, on January 1st, 1986. General life-long and individually adjusted prophylaxis against recurrence is ensured by regular postoperative clinical and TSH follow-up with adequately adapted thyroxine medication.
The study deals with the immunological capacity and perfusion rate of splenic grafts in pigs after autologous transplantation into the omentum majus. 12 months after operation the weight and relative blood flow of the regenerated splenic tissue were clearly reduced. The number of antibody forming cells in the grafts was only slightly decreased compared to the normal spleen, whereas the autotransplants could balance a serum-IgM-deficiency, observed due to splenectomy, 4 months after grafting. Furthermore the mitogenic stimulation of T- and B-lymphocytes showed different proliferation rates for the autotransplants compared to the spleen.
Several clinical and laboratory studies have demonstrated the risk of sepsis in connection with encapsulated bacteria. The importance of clearing these organisms by the spleen is now well accepted. In contrast, the present work deals with the clearance of non-encapsulated gram-negative bacteria (Escherichia coli). The animals used for the experiments (a heterogeneous population of rabbits) were divided into a control group, a splenectomized group, and an autotransplanted group. The histological examination of the splenic transplants revealed typical splenic tissue including lymphatic follicles with germinal activity 42 days after transplantation. For estimation of the clearance capacity different amounts of bacteria were injected i.v. into the rabbits, and colony-forming bacterial cells in the blood were counted at certain intervals. In the control group no bacteria could be detected in the blood after 7 min. All animals of the splenectomized and autotransplanted groups showed a remarkable decrease in clearance efficiency (no bacteria in the blood after 19 min). No difference in the clearance kinetics could be shown between splenectomized and autotransplanted animals. Measuring the uptake of bacterial cells into different organs elicited low incorporation in the spleen as compared to non-immunocompetent organs, but no difference between normal spleen and splenic replants. However, saturation with E. coli cells reached higher limits in the normal spleen than in autotransplants. The immunologic capacity with respect to IgM-producing lymphocytes was measured by the hemolytic plaque assay. The results showed a severe malfunction of the autotransplants as compared to the normal spleen (only 2% of the activity of the control group). Vaccination against E. coli increased the clearance efficiency in all three groups. The data presented in this paper point out that several functions of the spleen cannot be carried out by autotransplants. The reasons, therefore, may be limited transplant mass and/or decreased specific functions.
Intraoperative manometry was performed in 771 patients undergoing cholecystectomy with (n = 158) and without (n = 613) interventions on the common bile duct and papilla. The method measures the resting pressure (RP) and pressure increase (PI) after injection of 1 ml NaCl/s as well as the time (TR) used for return to the initial pressure, using a Statham transducer. All values are recorded and statistically processed by the two-tailed t test. All three manometric parameters (RP, PI and TR) were statistically different (p less than or equal to 0.0001) between patients with and without alterations of the bile duct and papilla respectively. There was also a clear difference (p = 0.0001) of the TR (which is an indirect measure of the bile flow) between patients with stenosis of papilla (n = 55) and those who showed calculi in the bile duct (n = 103). In a further study we could demonstrate that histopathological changes of the papilla (specimen was taken during transduodenal papilloplasty because of isolated papilla stenosis) led to a prolonged TR, whereas TR in patients with negative histology was decreased. The sensitivity and specifity of this manometric method was very high, 92.4 and 98.6% respectively. This method of manometry enables to obtain precise data about pressure and flow in the bile duct uninfluenced by subjective reading errors in a simple and reproducible way. In our opinion it should complete other intraoperative diagnostic methods during cholecystectomy, particularly as manometry was the only method which led to the correct final diagnosis in 2% of 771 patients.
The fibrin sealing was employed in connection with lymph node dissections - on one hand intraoperatively in order to avoid lymph fistulae (n = 26), on the other hand postoperatively in treatment of manifest lymph fistulae (n = 9). Thereby lymph fistulae could be avoided in 96.2% (n = 25) resp. a quick successful treatment of the lymph fistulae could be achieved in 7 of 9 cases (77%). On the average a quantity of 1 ml of fibrin sealant was sufficient; a high concentration of aprotinin (3500 IU) and thrombin (500 IU) was chosen. No side effects on part of the fibrin sealing were noted.
Splenectomy is primarily followed by reduced defence against infection due to encapsulated bacteria, such as pneumococci. Organ preservation, therefore, has been emphasised in the treatment of traumatic rupture of the spleen, especially when it comes to patients in childhood. There are several practicable approaches to orthotopic preservation of the spleen, including conservative treatment of patients for smallest ruptures under stringent clinical control and, even more, fibrin sealing. Growth in accurate knowledge of the segmental structure of the spleen have enabled partial removal of the organ along the poorly vascularised intersegmental regions. Autologous transplantation of splenic pulp into the major omentum should be considered an alternative to splenectomy alone in strictly selected cases of massive splenic rupture.
24 patients (8 female, 16 male) with severe gastroduodenal haemorrhage were treated by vagotomy; in 17 cases highly selective vagotomy was performed, in 3 case truncal vagotomy + pyloroplasty and in 4 patients vagotomy was combined with excision or purse-string suture of the ulcer. Treatment was effective in 23 patients, without recurrence of haemorrhage. In 19 patients vagotomy not only curbed the bleeding but provided definitive therapy (Visick I-II); 4 patients died (mortality rate 16%).