We report a case of a 52 year old small bowel transplant recipient, with a clinical course complicated by CMV disease. Recipient and donor were CMV-IgG positive. Ganciclovir i.v., followed by valganciclovir was used for CMV-prophylaxis for 100 days. An antilymphocytic induction therapy was performed with Alemtuzumab on days 0 and 1. Immunosuppression was continued with tacrolimus, mycophenolat mofetil, prednisolon. Six months posttransplant the patient presented with CMV tissue invasive disease of the esophagus and stomach, without presence of viremia, tested by quantitative PCR. Treatment with ganciclovir resulted in complete viral load suppression and valganciclovir was initiated for secondary prophylaxis, whereas mycophenolat mofetil and prednisolon were discontinued. Shortly afterwards candida and recurrent CMV based esophagitis was diagnosed, still without viremia. Improvement was achieved with ganciclovir and caspofungin. However, during the following course the patient developed CMV tissue invasive disease of the ileal graft, with persistent absence of viremia. Antiviral coverage was extended with foscarnet and CMV immunoglobulin. Viral load declined to undetectable levels, however the patient failed to improve clinically due to occurrence of graft rejection. Despite infliximab and high dose prednisolon, graft rejection was progressive, requiring surgical explantation of the graft. This case highlights the importance of additional diagnostic tools such as endoscopy including PCR analysis of tissue samples. Extension of primary antiviral prophylaxis interval up to 6 months and prolonged retreatment in recurrent CMV disease may be useful to avoid severe CMV-related complications.

Die kausale Therapie des Kurzdarmsyndroms stellt die Dünndarmtransplantation (DDTx) dar. Die geeignete Immunsuppression nach DDTx ist bislang noch nicht gefunden. Im Folgenden berichten wir über unsere Erfahrungen mit Alemtuzumab als Induktionstherapie nach DDTx.

Introduction: Urinary catheters are a risc factor for urinary tract infections after kidney transplantation as bacteria settle on its surface and are released during removal. The present study investigates the efficacy of antimicrobial prophylaxis prior and during catheter removal in kidney transplanted patients. Material and methods: Forty patients after allogen kidney transplantation with triple immunosuppression (Tacrolimus, Prednisolone, Mycophenolate mofetil) underwent removal of their transurethral urinary catheter six days after operation. Twenty patients periinterventionally received an oral antibiotic prophylaxis with Ciprofloxacin 2x250mg on the day before and on the day of catheter removal. Urinary tract infection was defined as a positive urin culture (105 microorganisms). Results: All patients showed instant transplant function. After catheter removal 50% of all patients without antibiotic prophylaxis and 20% of all patients with antibiotic prophylaxis had a positive urine culture with gram negative germs. Bacterial colonisation of the cathetertip revealed in 90% of all patients in the prophylaxis group and in 66,6 % of all patients without antibiotic prophylaxis. Conclusion: Antibiotic prophylaxis with ciprofloxacin during urinary catheter removal is efficient in reduction of pathogenic germs in the urine after kidney transplantation.

Einleitung: In der Entzündung werden nicht nur Leukozyten, sondern auch Thrombozyten aktiviert und interagieren miteinander. Eine Möglichkeit der interzellulären Kommunikation stellen Chemokine dar. Ziel der vorliegenden Untersuchung war die Charakterisierung der Rolle des Thrombozyten assoziierten Chemokinliganden- und Chemokinrezeptorpaares CX3CL1(Fractalkine)/CX3CR1 in den experimentellen Modellen der DSS-induzierten Kolitis und der Lipopolysaccharid- (LPS) induzierten Sepsis der Maus.

Einleitung: Ein Mechanismus in der Pathogenese chronisch entzündlicher Darmerkrankungen ist die Interaktion zwischen Thrombozyten und Leukozyten, die unter anderem über die Expression und Sekretion von Chemokinen stattzufinden scheint. Ziel der vorliegenden Untersuchung ist die Charakterisierung der Rolle der Chemokinliganden- und Chemokinrezeptorpaare SDF-1α/CXCR4 und CX3CL1 (Fractalkine)/CX3CR1 im experimentellen Modell der DSS-Kolitis der Maus.

Schleicher, C.; Kebschull, L.; Palmes, D.; Bonrath, E.; Anthoni, C.; Schmidt, H.; Senninger, N.; Wolters, H. Author Information

Bonrath, E. M.1; Schleicher, C.2; Anthoni, C.2; Palmes, D.2; Senninger, N.2; Schmidt, H.3; Hoelzen, J. P.4; Hahnenkamp, K.5; Wolters, H.2 Author Information

Schleicher, C.1; Wolters, H.1; Kebschull, L.1; Anthoni, C.1; Suwelack, B.2; Senninger, N.1; Palmes, D.1 Author Information

Prolapse and retraction of an intestinal stoma are postoperative complications which severely decrease the quality of life of patients and in some cases lead to an operative revision. Both entities should be treated with sophisticated care by specialized stoma therapists in the early phase in order to prevent secondary problems such as dermal ulceration. However, in case of additional problems, such as ileus, bleeding, incarceration or impossibility of adequate stoma care, an operative revision is indicated. It remains an individual decision whether a local or a transabdominal revision of the stoma is necessary.At present the level of information and the number of well designed studies dealing with prolapse or retraction of a stoma are unsatisfactory and there are merely studies which report on prolapse and retraction as an incidental finding rather than primarily focusing on these problems. In addition there is a lack of clear cut definitions for both entities which would allow a comparison of data obtained in different studies.There is clearly a demand for a structured scientific clarification as the occurrence of stomal retraction or prolapse may present psychological and medical problems for the patients and therefore needs to be treated, conservatively and/or operatively, by both stoma specialists and surgeons.

The deviation of feces is a very old and still largely applied technique used by general surgeons. Indications divide into elective and emergency operations. Among the elective cases, rectal carcinoma, extensive perianal fistulae and neurogenic disorders of the distal colon are the most common indications. In an emergency situation causes such as extensive peritonitis (e.g. due to anastomotic leakage) and extensive trauma to the pelvis/rectum quite often result in a stoma. All segments of the intestine, from the first loop after the ligament of Treitz down to the sigmoid colon, are feasible for a deviation procedure depending on the indications and the anatomical conditions. The decision whether to create a loop ostomy or a terminal stoma is reached with respect to the underlying indications and the anatomical and pathophysiological situation. The aim of the procedure is a complete and adequate stool deviation as well as a situation where the patient is able to take care of the ostomy in a convenient and reliable fashion while guided and educated by a stoma therapist. The prevention and treatment of complications, such as stoma necrosis or retraction are absolutely crucial in order to have satisfying long-term results and an acceptable quality of life.

BACKGROUND:Anastomotic leaks represent the most common severe postoperative complications after esophagectomy. In this study standard inflammatory laboratory parameters [leukocytes, C-reactive protein (CRP)] were evaluated as indicators for anastomotic leakage after esophagectomy.PATIENTS AND METHODS:Between 1 / 1997 and 12 / 2006 a total of 558 patients with esophageal cancer underwent an Ivor-Lewis esophagectomy. Among these patients, all those (n = 50, 8.9 %) suffering from an anastomotic leak were matched to 50 patients without anastomotic leakage. Leukocytes, CRP level and clinical parameters (body temperature, cardiac / respiratory problems, wound secretion) were retrospectively analysed at short-term intervals in both groups.RESULTS:Patients with anastomotic leaks showed significant continuously increased CRP levels and leukocyte counts from the second or, respectively, 5 (th) postoperative day onwards compared to patients without anastomotic leaks. Using a stepwise regression, an 80 % sensitivity for leakage detection has been calculated by a cut-off value for CRP set at 13.5 mg / dL from day 2 onwards or, respectively, for leukocytes at 10.5 Gpt / L from day 8 onwards. Concomitantly, patients with anastomotic leaks suffered significantly more from respiratory problems and abdominal pain.CONCLUSION:CRP appears to be a reliable and predictable indicator for anastomotic leakage after esophagectomy and should, therefore, be routinely used as a screening marker to provide a reason for extended diagnosis.