Einleitung: Der nach Pfortaderthrombosierung als sog. „prähepatischer Block“ auftretende, portale Hypertonus bewirkt häufig eine sekundäre Varizenbildung. Die Patienten mit begleitenden Gerinnungs-oder myeloproliferativen Erkrankungen haben ein hohes Risiko für Varizenblutungen. Der splenorenale Shunt n. Cooley kann eine dauerhafte portale Drucksenkung mit deutlich gesenkter Blutungswahrscheinlichkeit bewirken. Durch hohe Offenheitsraten des Shuntes kann auf wiederholte Endoskopien verzichtet werden, eine deutlich erhöhte Lebensqualität ist die Folge.

Einleitung: Seit Einführung der hochaktiven antiretroviralen Therapie (HAART) hat sich die Lebenserwartung bei HIV+ Patienten (Pts) verbessert, so dass eine orthotope Lebertransplantation (OLTX) in ausgewählten Fällen eine vernünftige Therapieoption darstellt.

Standardized intestinal manipulation (IM) leads to local bowel wall inflammation subsequently spreading over the entire gastrointestinal tract. Previously, we demonstrated that this so-called gastrointestinal field effect (FE) is immune mediated. This study aimed to investigate the role of CCR7 in IM-induced FE. Since CCR7 is expressed on activated dendritic cells and T cells and is well known to control their migration, we hypothesized that lack of CCR7 reduces or abolishes FE. Small bowel muscularis and colonic muscularis from CCR7(-/-) and wild-type (WT) mice were obtained after IM of the jejunum or sham operation. FE was analyzed by measuring gastrointestinal transit time of orally given fluorescent dextran (geometric center), colonic transit time, infiltration of MPO-positive cells, and circular smooth muscle contractility. Furthermore, mRNA levels of the inflammatory cytokine IL-6 were determined by RT-PCR. The number of dendritic cells and CD3+CD25+ T cells separately isolated from jejunum and colon was determined in mice after IM and sham operation. There was no significant difference in IL-6 mRNA upregulation in colonic muscularis between sham-operated WT and CCR7(-/-) mice after IM. Contractility of circular muscularis strips of the colon was significantly improved in CCR7(-/-) animals following IM and did not vary significantly from sham-operated animals. Additionally, inflammation of the colon determined by the number of MPO-positive cells and colonic transit time was significantly reduced in CCR7(-/-) mice. In contrast, jejunal contractility and jejunal inflammation of transgenic mice did not differ significantly from WT mice after IM. These data are supported by a significant increase of CD3+CD25+ T cells in the colonic muscularis of WT mice after IM, which could not be observed in CCR7(-/-) mice. These data demonstrate that CCR7 is required for FE and postoperative ileus. CCR7 indirectly affects FE by inhibiting migration of activated dendritic cells and of T cells from the jejunum to the colon. These findings support the critical role of the adaptive immune system in FE.

The coeliac aneurysm: A rare cause of abdominal pain Visceral artery aneurysms (VAA) represent 0.1-0.2% of all vascular aneurysms. For VAA's etiology, congenital or arteriosclerotic factors, media defects, infections, vasculitis and trauma are discussed. Ultrasound, CT scan and magnetic resonance imaging underline the diagnosis of VAA. The low perioperative morbidity and mortality and the excellent surgical longterm results justify the prophylactic therapy also from asymptomatic VAA because the mortality of ruptured VAA is close to 100%. The radiological interventional treatment is indicated for only selected patients whereas an advantage is not verified yet.

In comparison to the conventional technique of incisional or umbilical hernia repair with sublay mesh augmentation, incisional hernias in obese patients can be surgically treated with minor surgical trauma by laparoscopic intraperitoneal onlay mesh (IPOM) repair. However, although shortened operation time, hospital stay and faster postoperative reconvalescence might be possible with IPOM repair, the economic calculation including mesh costs is significantly higher. In this study the two operation techniques were compared and the perioperative advantages and disadvantages of both methods were analyzed based on the German diagnosis-related groups (DRG) system.

Intrathorakale Nieren sind seltene und meist zufällig erhobene Befunde. Eine Besprechung der Fachliteratur über intrathorakale Nieren bei Kindern und Erwachsenen soll die Schwerpunkte der diagnostischen Vorangehensweise und der Indikation zur operativen Versorgung beleuchten. Ergänzend wird der Fall einer 35-jährigen Frau mit dem Rezidiv einer linksseitigen intrathorakalen Niere nach Schwangerschaft diskutiert.

Die Reparation von Nabelhernien bei Patienten mit Leberzirrhose und Aszites ist komplikationsträchtig. Wir haben in den letzten Jahren folgendes Konzept zur Versorgung der Nabelhernien bei diesen Patienten angewendet: Reparation der Hernie durch direkte Naht und gleichzeitige Implantation von 2 dicklumigen Robinson-Drainagen zur Aszitesdrainage bis zum Abschluss der Wundheilung ca. 10–14 Tage postoperativ. Dann erst ist die Bauchdeckenrekonstruktion unseres Erachtens so stabil, dass der Aszites kein Risiko mehr darstellt. Voraussetzungen zur Durchführung der Operation waren die bestmögliche konservative Aszitestherapie und die perioperative antibiotische Prophylaxe mit Gyrasehemmern zur Vermeidung einer spontanen bakteriellen Peritonitis. In einem Zehnjahreszeitraum (01.01.1997 bis 31.12.2006) wurden an unserer Klinik 22 Patienten mit Leberzirrhose und Aszites wegen einer komplizierten Nabelhernie (Inkarzeration, Irreponibilität, Hautulzeration, Aszitesleckage) operiert. Dabei wurde eine Gruppe der Patienten nach Hernienreparation mit einer Aszitesdrainage versorgt (n=10), während die andere Gruppe (n=12) keine Drainage erhielt. In der retrospektiven Analyse wurden Morbidität und Mortalität zwischen beiden Gruppen verglichen. Die postoperative Morbidität konnte durch den Drainageneinsatz von 25% auf 10% gesenkt werden. Ebenso gelang eine statistisch signifikante Reduktion des Rezidivrisikos durch Einsatz der Drainagen. Aufgrund dieser Erfahrungen wenden wir dieses Konzept bei dieser Patientenklientel standardmäßig an und können es weiterempfehlen. Allerdings möchten wir eine prospektive randomisierte, bestenfalls Multicenterstudie für eine weitere Validierung initiieren.

Background/Aims: Early revision procedures after pancreatic head resection significantly increase mortality. Due to their complexity, secondary operations at a later stage rank amongst the most demanding surgical procedures. We sought to critically analyze indications and outcome from early revision and subsequent redo procedures following distal pancreatic resection (D PR).Methodology: During a 5-year period 53 subsequent patients undergoing DPR were identified from a pancreatic resection database and analyzed regarding indication for and outcome of early revision and late redo procedures.Results: Six patients (11%) underwent early revision procedures during the same hospital stay. Indications were peritonitis (n=3), intraabdominal hemorrhage (n=2) and oncologic re-resection (n=1). Four patients (7.6%) were readmitted after 192 days (d) on average (range 53-538d) and underwent subsequent redo surgery due to occurrence of metastases in 2 cases, and insufficiency of an ascendo-rectostomy and adhesive ileus. Hospital stay and mortality were significantly increased after early revision surgery (40d vs. 18d; 33% vs. 0%). Splenectomy during DPR was carried out in all patients requiring early operative reintervention, compared to 63% in patients without secondary surgery (p<0.07).Conclusions: Early revision surgery following DPR increases postoperative mortality and length of hospital stay. Risk factors were complex injuries (e.g. gun shot wound), concomitant portal hypertension with collateral circulation and splenectomy. Subsequent redo surgery following DPR was performed on average within 7 month following the index operation without mortality and with comparable morbidity. Indications were recurrent malignant disease and complications of the intestine.

BACKGROUND:Parkinson's disease (PD) is a progressive degenerative disease of the human central nervous system with a demographical increase in surgical patients. Comorbidities are known to increase the perioperative risk profile and therefore amplify treatment expenses.AIM:The aim of this study was to analyse whether the reimbursement of additional costs due to PD in surgical patients was sufficiently considered by diagnosis-related grouping (DRG).PATIENTS AND METHODS:Over a period of 13 years, 50 patients suffering from MP treated in the Department of Surgery were retrospectively compared using matched-pair analysis with controls not affected by PD. Both groups of patients were assessed regarding hospital stay and mortality and morbidity with an emphasis on reimbursement by the National Ordinance on Hospital Rates (Bundespflegesatzverordung, BPflV) from 2004 (last year of employment) compared to DRG in 2007.RESULTS:Extra reimbursement for PD patients in comparison to controls diminished from 20 % according to BPflV (2004) to 2 % according to DRG (2007). Within the DRG System of 2007, total compensation for PD and control patients was significantly lower (47 vs. 35 %) compared to the BPflV of 2004.CONCLUSION:Compensation of surgical therapy in PD patients has significantly decreased within the DRG system, not considering the increased perioperative risk profile of these patients. In times of rising economic pressure, inadequate reimbursement of treatment costs bears the risk of rejection or restriction for patients with concomitant PD in spite of medical indications.

As we have shown in the past, acute rejection-related TNF-α upregulation in resident macrophages in the tunica muscularis after small bowel transplantation (SBTx) results in local amplification of inflammation, decisively contributing to graft dysmotility. Therefore, the aim of this study is to investigate the effectiveness of the chimeric-monoclonal-anti-TNF-α antibody infliximab as perioperative single shot treatment addressing inflammatory processes during acute rejection early after transplantation. Orthotopic, isogenic and allogenic SBTx was performed in rats (BN-Lewis/BN-BN) with infliximab treatment. Vehicle and IV-immunoglobulin-treated animals served as controls. Animals were sacrificed after 24 and 168 h. Leukocyte infiltration was investigated in muscularis whole mounts by immunohistochemistry, mediator mRNA expression by Real-Time-RT-PCR, apoptosis by TUNEL and smooth muscle contractility in a standard organ bath. Both, infliximab and Sandoglobulin® revealed antiinflammatory effects. Infliximab resulted in significantly less leukocyte infiltration compared to allogenic controls and IV-immunoglobulin, which was accompanied by lower gene expression of MCP-1 (24 h), IFN-γ (168 h) and infiltration of CD8-positive cells. Smooth muscle contractility improved significantly after 24 h compared to all controls in infliximab treated animals accompanied by lower iNOS expression. Perioperative treatment with infliximab is a possible pharmaceutical approach to overcome graft dysmotility early after SBTx.

BACKGROUND:The aim of this study was to compare preoperative and postoperative findings, and clinical progress in patients with peripheral arterial occlusive disease undergoing femoropopliteal supragenicular bypass or profundaplasty in a case-control study.METHODS:Between January 2001 and June 2004, 171 patients with occlusion of the superficial femoral artery underwent surgery. A retrospective analysis of 28 matched patient pairs was performed. Endpoints were bypass occlusion, surgical revision, amputation and death. Mean length of follow-up was 36 months.RESULTS:At 3 years after surgery there was no statistically significant difference in outcome between femoropopliteal bypass surgery and profundaplasty. There was a trend towards improved results in patients who had bypass surgery for critical leg ischaemia. Preoperative patency of the crural outflow arteries was an independent prognostic factor in multivariable analysis.CONCLUSION:There were no significant outcome differences between supragenicular bypass surgery or profundaplasty in patients who had surgery for intermittent claudication or ischaemic rest pain. Patients with a single patent tibial artery and gangrene or ulceration appeared to benefit more from bypass surgery.

Introduction: Standardized intestinal manipulation (IM) as a model for intestinal trauma leads to a localized bowel wall inflammation and hypomotility subsequently spreading over the entire nonmanipulated gastrointestinal tract. This phenomenon was defined as gastrointestinal field effect (FE) and is the functional base of the perpetuating paralytic ileus. This study should elucidate the role of mesenteric lymph nodes, of migrating immune cells and their possible blockage by FTY-720. Material and Methods: T cells were isolated and analyzed from the muscularis layer of the small and large bowel and from the blood of C57Bl/6-mice (WT), of lymph node deficient mice and of FTY-720 treated mice 24 hours after IM and sham-operation and after intraoperatively CSFE-labeling of the small bowel muscularis. The FE was determined by measuring the gastrointestinal and colon transit time, in vitro contractility of muscularis strips and by measuring the mRNA levels of proinflammatory cytokines (IL-6, TNF-α, MIP-1α, IL-10) by Taqman®-PCR. T cell surface markers were analyzed by FACS-Calibur (II). Results: We observed a 3fold reduction of T cells in the small bowel and a 4 fold upregulation of T cells in the colon after IM. We found CSFE labeled T cells in the colon after IM combined with CSFE-labeling of the small bowel in WT mice, but not after sham-operation. We did not observe a relocation of CSFE-labeled T cells in FTY-720 treated mice and lymph node deficient mice after IM. T cell analysis was performed. The gastrointestinal and the colon transit time were significantly improved in lymph node deficient mice and FTY-720 treated mice. There was also a contractility comparable to sham-operated mice and a 100fold downregulation of proinflammtory cytokines within the colonic muscularis after IM in the modified mouse strains. Conclusion: The FE is mediated by the migration and relocation of T cell subsets. The blockage of T cell migration such as by FTY-720 abolishes the FE. Teh FE is based on immunological mechanisms. Therefore, the postoperative ileus is obviously immunologically mediated.

In small bowel transplantation (SBTx), graft manipulation, ischemia/reperfusion injury and acute rejection initiate a severe cellular and molecular inflammatory response in the muscularis propria leading to impaired motility of the graft. This study examined and compared the effect of tacrolimus and sirolimus on inflammation in graft muscularis. After allogeneic orthotopic SBTx, recipient rats were treated with tacrolimus or sirolimus. Tacrolimus and sirolimus attenuated neutrophilic, macrophage and T-cell infiltration in graft muscularis, which was associated with reduced apoptotic cell death. Nonspecific inflammatory mediators (IL-6, MCP-1) and T-cell activation markers (IL-2, IFN-gamma) were highly upregulated in allogeneic control graft muscularis 24 h and 7 days after SBTx, and tacrolimus and sirolimus significantly suppressed upregulation of these mediators. In vitro organ bath method demonstrated a severe decrease in graft smooth muscle contractility in allogeneic control (22% of normal control). Correlating with attenuated upregulation of iNOS, tacrolimus and sirolimus treatment significantly improved contractility (64% and 72%, respectively). Although sirolimus reduced cellular and molecular inflammatory response more efficiently after 24 h, contrary tacrolimus prevented acute rejection more efficiently. In conclusion, tacrolimus and sirolimus attenuate cellular and molecular inflammatory response in graft muscularis and subsequent dysmotility of the graft after allogeneic SBTx.

Introduction: Abdominal surgery results in the inflammation of the tunica muscularis (ME), subsequently leading to postoperative ileus (POI) [1]. Previously, we demonstrated that inhibition of macrophage function and cytokine production prevents rodents from POI [2]. Omega-3 and omega-6 polyunsaturated fatty acids (PUFA) are known to exert anti- or proinflammatory effects, respectively. The aim of this study was to analyze the effect of omega-3 and omega-6 PUFA on POI in rodents. Methods: Male rats and mice underwent intestinal manipulation (IM) after 5 days preoperative enteral or parenteral application of vehicle, omega-3 (Omegaven®) or omega-6 (Lipovenos®-MCT) PUFA-enriched emulsions (1 ml/100 g bodyweight, once daily). Erythrocyte membranes were analyzed by gas chromatography for fatty acid composition. Inflammatory activity was determined by detection of neutrophils 24 h after IM. Production of nitric oxide (NO) from ME specimen was determined by Griess reaction. Contractility of jejunal ME strips was measured in vitro in an organ bath setup. Gastrointestinal and colonic transits were determined in vivo. Results: Omegaven treatment significantly increased omega-3 to omega-6 PUFA rates in erythrocytes (1 : 9), compared to untreated controls (1 : 15). Furthermore, Omegaven reduced neutrophil levels (–35 %) and NO production (–38 %) after IM and improved contractility and gastrointestinal and colonic transit time. Interestingly, enteral Omegaven treatment showed increased NO production and tended toward increased neutrophils levels. In all experiments, Lipovenös-MCT treatment solely showed a trend to reduced inflammation and improved motility. Conclusion: Perioperative parenteral omega-3 PUFA enriched nutrition reduces intestinal inflammation and prevents postoperative ileus.

Background. The mechanical trauma of the gut is an unavoidable consequence of abdominal surgery leading to postoperative ileus (POI). Former studies revealed that activation of resident macrophages in the muscularis externa (ME) is an initial step in the inflammatory cascade resulting in massive inflammation of the bowel wall with intestinal dysmotility [1, 2]. The aim of this study was to investigate the efficacy of the macrophage-specific c-Raf-pathway inhibitor CPSI 2364 in preventing POI in swine. Additionally, we investigated disturbances of intestinal wound repair, as macrophage-function is essential in this process [3]. Materials and Methods. Swine were treated orally with placebo or 1mg/kg CPSI 2364 before standardized intestinal manipulation. 24 h later swine were sacrificed and the whole digestive tract was removed for further investigation. Inflammation within the ME of the small bowel was quantified using RT-PCR (MCP-1) and a myeloperoxidase-assay. To examine smooth muscle function, jejunal muscularis strips were exposed to an increasing concentration of a muscarinic agonist in an in vitro organ bath and contractility was analyzed. Furthermore intestinal transit time was measured in vivo. In a second experiment swine received an anastomosis of the colon to examine intestinal wound repair. On postoperative day 6 mRNA levels of wound healing parameters (VEGF, Collagen 1 and 3) and perianastomotic hydroxyproline concentration were examined. To assess mechanical strength bursting pressure was measured. Results. After treatment with CPSI 2364 a significant inflammatory reduction within the ME on mRNA- and cell-level could be demonstrated. Furthermore, smooth muscle function was improved, resulting in an accelerated intestinal transit time and an elevated contractility. Clinical course and perianastomotic mRNA-levels, hydroxyproline concentration or bursting pressure showed no evidence of impaired intestinal wound healing. Conclusion. Preoperative application of CPSI 2364 reduces postoperative inflammation within the ME subsequently preventing POI. A detrimental influence of CPSI 2364 on intestinal wound repair could not be demonstrated.

Background: Distal pancreatectomy is performed less frequently than pancreatic head resection. Secondary operations due to postoperative complications are surgically complex and demanding, hence often interdisciplinary approaches are pursued. We have analysed the indications and outcome of revision surgery and interventional procedures subsequent to pancreatic left resection.Patients and Methods: Between 2001 and 2009 we prospectively evaluated 61 patients regarding demographic factors, hospital stay, diagnosis, closure technique, redo operations and interventions, morbidity and mortality.Results: Major complications without redo procedures were observed in 4(9%) of 44 patients. 8 (13%) patients underwent early (7 +/- 8 days) postoperative revision procedures. A significant increase in hospital stay and mortality appeared in this group. Interventional procedures (7 x CT-guided abscess drains, 1 x haemorrhage with angiographic coiling, 1 x transgastral stenting of a pseudocyst) were performed significantly later (22 +/- 11 days p.o., p < 0,01) in 9(15%) patients.Conclusions: Pancreatic fistulas and related complications represent the most common indications for revisions, but can usually be controlled by interventional procedures. In contrast to secondary surgery, interventional revisions do not significantly increase the length of hospital stay or mortality. There was no benefit of any certain closure technique of the pancreatic remnant.

Umbilical hernia repair is often accompanied by complications in patients with liver cirrhosis and ascites. In recent years we have been using the following concept for treating umbilical hernias in such patients: repair of the hernia by direct sutures and concomitant implantation of two large bore Robinson drainage tubes until the wound healing was completed within the next postoperative 10-14 days. During this time the reconstruction of the abdominal wall is in our opinion as robust that the ascites no longer represents a risk. Preconditions to perform this procedure were the best medicamentous treatment of ascites as ever possible and the perioperative administration of prophylactic antibiotics like gyrase inhibitors to avoid spontaneous bacterial peritonitis. Over a period of 10 years (01.01.1997-31.12.2006) we operated on 22 patients suffering from liver cirrhosis and ascites because of a complicated umbilical hernia (incarceration, irreponibility, skin ulceration, leackage of ascites). One group of patients (n=10) was treated by umbilical hernia repair with the concomitant implantation of two drainage tubes and the other group (n=12) by umbilical hernia repair without draining off the ascites. Morbidity and mortality were compared in both groups in a retrospective analysis. The postoperative morbidity could be reduced from 25% to 10% by using the drainage tubes as well as the rate of recurrent hernias in the drainage group. Due to these experiences we use the concept as standard in such patients and would like to recommend it further. However, we would like to initiate a prospective, randomized, at best multicenter trial for further validation.