[Show abstract][Hide abstract] ABSTRACT: Purposes:
An abdominal inflammatory focus is the second most often source of sepsis with a high risk of death in surgical intensive care units. By establishing evidence-based bundled strategies the surviving sepsis campaign provided an optimized rapid and continuous treatment of these emergency patients. Hereby the hospital mortality decreased from 35 to 30 %. Sepsis treatment is based on three major therapeutic elements: surgical treatment (source control), antiinfective treatment, and supportive care. The international guidelines of the surviving sepsis campaign were updated recently and recommend rapid diagnosis of the infection and source control within the first 12 h after the diagnosis (grade 1c). Interestingly this recommendation is mainly based on studies on soft tissue infections.
In this retrospective analysis 76 septic patients with an intraabdominal inflammatory focus were included. All patients underwent surgery at different time-points after diagnosis.
With 80 % patients of the early intervention group had an improved overall survival (vs. 73 % in the late intervention group).
Literature on the time dependency of early source control is rare and in part contradicting. Results of this pilot study reveal that immediate surgical intervention might be of advantage for septic emergency patients. Further multi-center approaches will be necessary to evaluate, whether the TTI has any impact on the outcome of septic patients with intestinal perforation.
World Journal of Emergency Surgery 11/2015; 10(1):54. DOI:10.1186/s13017-015-0047-0 · 1.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
If untreated, the abdominal compartment syndrome (ACS) has a mortality of nearly 100 %. Thus, its early recognition is of major importance for daily rounds on surgical intensive care units. Intraabdominal hypertension (IAH) is a poorly recognized entity, which occurs if intraabdominal pressure arises >12 mmHg. Measurement of the intravesical pressure is the gold standard to diagnose IAH, which can be detected in about one fourth of surgical intensive care patients.
The aim of this manuscript is to outline the current diagnostic and therapeutic options for IAH and ACS. While diagnosis of IAH and ACS strongly depends on clinical experience, new diagnostic markers could play an important role in the future. Therapy of IAH/ACS consists of five treatment "columns": intraluminal evacuation, intraabdominal evacuation, improvement of abdominal wall compliance, fluid management, and improved organ perfusion. If conservative therapy fails, emergency laparotomy is the most effective therapeutic approach to achieve abdominal decompression. Thereafter, patients with an open abdomen require intensive care and are permanently threatened by the quadrangle of fluid loss, muscle proteolysis, heat loss, and an impaired immune function. As a consequence, complication rate dramatically increases after 8 days of open abdomen therapy.
Despite many efforts, the mortality of patients with ACS remains unacceptably high. Permanent clinical education and surgical trials will be necessary to improve the outcome of our critically ill surgical patients.
Langenbeck s Archives of Surgery 10/2015; DOI:10.1007/s00423-015-1353-4 · 2.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Necrotizing fasciitis (NF) is an inflammatory disease of the soft tissue, which causes local tissue destruction and can lead to lethal septic shock. The therapy consists of early surgical treatment of the septic focus and an accompanying broad spectrum antibiotic therapy. Recent literature considers the additional use of immunoglobulin therapy in severe soft skin and tissue infections.
In this report, we describe the case of a 33-year-old male patient treated at a university hospital intensive care unit because of an NF of his left leg. The patient rapidly developed a complicated septic disease after a minor superficial trauma. Despite intense microbiological diagnosis, no causative pathogens were identified. After non-responding to established broad anti-infective treatment, the patient received intravenous immunoglobulin, that rapidly improved his clinical condition.
NF represents a disease processes, which is characterized by fulminant, widespread necrosis of soft tissue, systemic toxicity, and high mortality (>30%). Beside the surgical debridement and broad spectrum antibiotic therapy IVIg therapy might be an additional option in the treatment of NF. But the current literature supporting the use of IVIG in NF is largely based on retrospective or case-controlled studies, and only small randomized trials.
The demonstrated case suggests that IVIg treatment of patients with NF can be considered in case of hemodynamic unstable, critically ill patients. Although randomized controlled trials are missing, some patients might benefit from diminishing hyperinflammation by immunoglobins.
Annals of Medicine and Surgery 09/2015; 4(3):260-3. DOI:10.1016/j.amsu.2015.07.017
[Show abstract][Hide abstract] ABSTRACT: Hintergrund
In mehreren klinischen Studien zeigt sich eine Verbesserung der Langzeitprognose für Patienten, die unter perioperativer periduraler Schmerztherapie zusätzlich zur Allgemeinnarkose an einem kolorektalen Karzinom operiert wurden.
Hat eine zusätzlich verwendete perioperative peridurale Analgesie (PDA) einen Effekt auf das Langzeitüberleben von Patienten nach chirurgischer Resektion eines kolorektalen Karzinoms?
Material und Methoden
Es erfolgten eine systematische Literaturrecherche (bis 5/2014) in Medline sowie eine Metaanalyse des Einflusses einer PDA auf das Langzeitüberleben von Patienten nach Resektion eines kolorektalen Karzinoms in den UICC-Stadien I bis IV. Die korrigierten Hazard Ratios (HR) mit einem 95 %-Konfidenzintervall (KI) wurden als Maß für den statistischen Effekt auf das Langzeitüberleben zugrunde gelegt. Für die Analyse wurde ein Modell mit zufälligen Effekten verwendet und auf einen potenziell publikationsbezogenen Fehler überprüft (Forest-/Funnel-Plot).
Von 608 identifizierten Publikationen wurden 5 Studien eingeschlossen. Im Modell mit zufälligen Effekten zeigte sich ein verbessertes Langzeitüberleben für Patienten, die perioperativ zusätzlich zur Allgemeinnarkose eine PDA erhielten (HR = 0,81, 95 %-KI 0,68–0,97, p = 0,055). Die Analyse der Einflussfaktoren zeigte einen statistisch robusten Effekt. Damit verminderte sich das Sterblichkeitsrisiko in den analysierten Studien durch die Verwendung einer PDA im Mittel um 19 % gegenüber einer alleinigen Allgemeinanästhesie.
Diese Metaanalyse zeigt trotz eines Publikationsbias, dass eine zusätzliche perioperative peridurale Analgesie das Langzeitüberleben von Patienten mit einem nicht fernmetastisierten kolorektalen Karzinom nach chirurgischer Resektion verbessern kann.
Der Chirurg 07/2015; 86(7):655-661. DOI:10.1007/s00104-014-2891-y · 0.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess pancreatic fistula rate and secondary endpoints after pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) for reconstruction in pancreatoduodenectomy in the setting of a multicenter randomized controlled trial.
PJ and PG are established methods for reconstruction in pancreatoduodenectomy. Recent prospective trials suggest superiority of the PG regarding perioperative complications.
A multicenter prospective randomized controlled trial comparing PG with PJ was conducted involving 14 German high-volume academic centers for pancreatic surgery. The primary endpoint was clinically relevant postoperative pancreatic fistula. Secondary endpoints comprised perioperative outcome and pancreatic function and quality of life measured at 6 and 12 months of follow-up.
From May 2011 to December 2012, 440 patients were randomized, and 320 were included in the intention-to-treat analysis. There was no significant difference in the rate of grade B/C fistula after PG versus PJ (20% vs 22%, P = 0.617). The overall incidence of grade B/C fistula was 21%, and the in-hospital mortality was 6%. Multivariate analysis of the primary endpoint disclosed soft pancreatic texture (odds ratio: 2.1, P = 0.016) as the only independent risk factor. Compared with PJ, PG was associated with an increased rate of grade A/B bleeding events, perioperative stroke, less enzyme supplementation at 6 months, and improved results in some quality of life parameters.
The rate of grade B/C fistula after PG versus PJ was not different. There were more postoperative bleeding events with PG. Perioperative morbidity and mortality of pancreatoduodenectomy seem to be underestimated, even in the high-volume center setting.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
Annals of surgery 07/2015; DOI:10.1097/SLA.0000000000001240 · 8.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Acute rejection is a major risk factor for chronic allograft injury (CAI). Blood leukocytes interacting with allograft endothelial cells during acute rejection were suggested to contribute to the still enigmatic pathogenesis of CAI. We hypothesize that tissue transglutaminase (Tgm2), a multifunctional protein and established marker of M2 macrophages, is involved in acute and chronic graft rejection. We focus on leukocytes accumulating in blood vessels of rat renal allografts (Fischer-344 to Lewis), an established model for reversible acute rejection and CAI. Monocytes in graft blood vessels overexpress Tgm2 when acute rejection peaks on day 9 after transplantation. Concomitantly, caspase-3 is activated, suggesting that Tgm2 expression is linked to apoptosis. After resolution of acute rejection on day 42, leukocytic Tgm2 levels are lower and activated caspase-3 does not differ among isografts and allografts. Cystamine was applied for 4 weeks after transplantation to inhibit extracellular transglutaminase activity, which did, however, not reduce CAI in the long run. In conclusion, this is the first report on Tgm2 expression by monocytes in vivo. Tgm2 may be involved in leukocytic apoptosis and thus in reversion of acute rejection. However, our data do not support a role of extracellular transglutaminase activity as a factor triggering CAI during self-limiting acute rejection.
Mediators of Inflammation 06/2015; 2015:1-13. DOI:10.1155/2015/429653 · 3.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In addition to its well-described role in lipid metabolism, apolipoprotein E (ApoE) exerts immunomodulatory functions. A protective role of ApoE and ApoE-mimetic peptide (ApoE(133-149)) application was documented in several inflammatory disorders. In this study, we test the hypothesis that ApoE(133-149) promotes renal allograft survival.
Dark Agouti, Brown Norway, and Fischer 344 kidneys were transplanted to Lewis rats to investigate fatal and reversible acute rejection. Apolipoprotein E expression was assessed in intravascular leukocytes of renal grafts, in graft tissue and in recipient blood plasma. Recipients of Brown Norway kidneys were treated with ApoE(133-149), and graft survival was monitored until day 100. Graft infiltration, cytokine, and chemokine production were analyzed.
Intravascular graft leukocytes and renal tissue obtained from animals undergoing reversible acute rejection expressed increased levels of ApoE mRNA, whereas during fatal rejection, ApoE expression was reduced or remained unchanged. Animals treated with ApoE(133-149) showed prolonged allograft survival, which was associated with a reduced infiltration of CD8 and α/β T-cell receptor-expressing cells, diminished Granzyme B mRNA expression, and decreased caspase-3 activation.
Endogenous ApoE overexpression and exogenous application of ApoE(133-149) seem to protect renal allografts from fatal acute rejection. This effect was associated with a reduced influx of cytotoxic T cells.
[Show abstract][Hide abstract] ABSTRACT: Die akute Mesenterialischämie stellt auch heutzutage aufgrund ihrer hohen Letalität den behandelnden Mediziner vor eine große Herausforderung. Unspezifische Symptome in der frühen Phase der Erkrankung erschweren eine rasche Diagnose der Mesenterialischämie und nur eine frühzeitige Diagnose und Therapie kann den Patienten vor irreversibler Darmischämie, ausgedehnten Darmresektionen, Sepsis und Tod bewahren. Im Gegensatz zu beispielsweise Troponin als frühem Marker für die kardiale Ischämie ist ein zuverlässiger Marker für die Mesenterialischämie bisher nicht im klinischen Alltag etabliert. Dieser würde eine Früherkennung der Patienten in der frühen, reversiblen Phase ermöglichen.
Diese Übersichtsarbeit fasst die Pathophysiologie, Epidemiologie und klinische Symptomatik der akuten Mesenterialischämie zusammen und soll einen Überblick über mögliche Biomarker, allen voran das Serumlaktat, geben. Nur Serumlaktat wird bisher als Routineparameter zur Diagnostik der mesenterialen Ischämie verwendet.
Der Chirurg 10/2014; 86(1). DOI:10.1007/s00104-014-2887-7 · 0.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Adrenomedullin-2/intermedin stabilizes the pulmonary microvascular barrier challenged by application of thrombin ex vivo and by experimental ventilation in vivo. Here, we test the hypothesis that adrenomedullin-2/intermedin(8-47) protects mouse lungs from ischemia/reperfusion injury in vivo. C57BL/6 mice were anesthetized, intubated, ventilated, and heparinized. Blood vessels and the main bronchus of the left lung were clamped for 90 min. Thereafter, lungs were reperfused for 120 min. Five min before clamping and before reperfusion, mice obtained intravenous injections of adrenomedullin-2/intermedin(8-47). After reperfusion, mice were sacrificed and bronchoalveolar lavage of the left and the right lung was performed separately. The integrity of the blood-air barrier was investigated by electron microscopy using stereological methods. In response to ischemia/reperfusion injury, intraalveolar leukocytes accumulated in the ischemic lung. Two applications of 10 ng/kg body weight adrenomedullin-2/intermedin(8-47) dramatically reduced leukocyte infiltration to about 15% (p ≤ 0.001). Also the proportion of the subpopulation of neutrophil granulocytes decreased (12% vs 5%, p = 0.013). Electron microscopy revealed a protection of the blood-air barrier by adrenomedullin-2/intermedin(8-47). Adrenomedullin-2/intermedin(8-47) ameliorates early ischemia/reperfusion injury in mouse lungs by protecting the integrity of the blood-air barrier and by potently reducing leukocyte influx into the alveolar space. Adrenomedullin-2/intermedin(8-47) might be of therapeutic interest in lung transplantation and cardiopulmonary bypass.
“Take home” message: Adrenomedullin-2/intermedin(8-47) ameliorates ischemia/reperfusion injury in mouse lungs and reduces leukocyte influx.
[Show abstract][Hide abstract] ABSTRACT: Rectovaginal fistulas (RVF) are rare but represent a challenge for both patients and surgeons. The most common cause of RVF is obstetric trauma, and treatment is based on fistula classification and localization of the fistula in relation to the vagina and rectum. Conventional therapy frequently fails, making surgery the most viable approach for fistula repair. One surgical procedure which offers adequate repair of lower and middle rectovaginal fistulas consists of interposition of a bulbocavernosus fat flap also called modified Martius flap. First described by Heinrich Martius in 1928, this approach has been continuously modified and adjusted over time and is used in the repair of various pelvic floor disorders. Overall success rates reported in the literature of the interposition of a Martius flap as an adjunct procedure in the surgical management of RVF are 65-100 %. We present a detailed description of the operation technique together with a discussion of the use of a dorsal-flapped modified Martius flap in the treatment of RVF.
Geburtshilfe und Frauenheilkunde 10/2014; 74(10):923-927. DOI:10.1055/s-0034-1383149 · 0.94 Impact Factor