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Background: Recent clinical trials failed to demonstrate beneficial effects of anti-inflammatory sepsis therapy. The present study therefore asked the following questions: Is there evidence for immunosuppression during postoperative sepsis? When, during the septic course, may immunosuppression develop? Can defective cellular functions be restored by in vitro treatment with interferon-gamma (IFN-gamma)?, Methods: The study included 35 patients with sepsis after major visceral surgery and 85 control patients. Monocyte secretion of interleukin (IL)-1 beta, IL-12 p40 and p70, IL-18, tumor necrosing factor, and IL-10 with or without IFN-gamma treatment and its correlation with the course and outcome of postoperative sepsis were determined., Results: Postoperative sepsis was associated with an immediate defect of endotoxin-stimulated monocyte production of IL-12 p40, IL-1 beta, and IL-10 in both surviving and nonsurviving patients. During the final phase of postoperative sepsis, a significant recovery of IL-12 p40 and IL-1 beta secretion, but not of IL-10 production, correlated with survival. Despite the exposure of monocytes in vitro to IFN-gamma for 16 hours, the production of the biologically active IL-12 p70 heterodimer was severely suppressed both in survivors and nonsurvivors, although the secretion of the p40 subunit was restored. In contrast, IFN-gamma treatment resulted in a significant suppression of monocyte IL-1 beta production in all patient subgroups. Alterations of monocyte tumor necrosing factor secretion were not observed. The production of IL-18 was below the limits of detection in all samples., Conclusions: Postoperative sepsis was associated with immediate monocyte defects that affected both pro- and anti-inflammatory cytokine secretion, which suggests that immunosuppression is a primary rather than a compensatory response to a septic challenge. Sepsis survival correlated with the recovery of the proinflammatory, but not the anti-inflammatory, response. The treatment of monocytes with IFN-gamma did not reconstitute defective proinflammatory cytokine production.

Background and Aims: In about 10% of patients with carcinoma of the colorectum, the tumour has already invaded contiguous organs or else inflammatory tumorous adhesions involving neighbouring structures are found. In such a situation, the question arises whether one should perform a multivisceral resection, the usefulness of which in terms of surgical risk and late oncological results have been investigated in the present study., Patients and Methods: A total of 173 patients with colorectal carcinoma who underwent a multivisceral resection during the period between 1984 and 1995 are reported. Excluded from the study were patients with recurrent tumour or distant metastases., Results: In the majority of cases (63%), the primary tumour originated in the sigmoid colon or rectum. In 102 patients, only a single neighbouring organ was additionally involved, while the remaining patients had involvement of two or more contiguous organs. In 140 patients, the resection was curative, while in the remaining patients an R1/2 situation presented. In the curative group, tumour infiltration was confirmed histologically in 55% of the cases, while in the remaining patients a peritumourous adhesion had mimicked tumour invasion. Postoperative surgical complications occurred in only 1.4% of the interventions, a figure identical to the incidence of complications seen with conventional limited operations. The same applied to the postoperative 30-day mortality rate of 3.6%. The 5-year survival rate of the overall group of patients undergoing multivisceral resection was 42%, that of the subgroup undergoing curative surgery was 51%, and that of the subgroup receiving only palliative resection was 0%. Calculation of the stage-related 5-year survival rates for Union Internationale Contra la Cancrum stage-II and stage-III tumours revealed figures of 58% and 43%, respectively. After non-extended resection, the respective survival rates were identical (60% and 41%)., Conclusion: An identical surgical risk and survival rates for curative resection, equally as good as those seen with conventional, non-extended procedures, justify the liberal use of multivisceral resection in the surgical treatment of colorectal carcinomas directly invading neighbouring organs.

A nationwide limitation of the total health care budget requires the shutdown of certain departments or complete hospitals in order to increase the budget for the surviving hospitals. This development involves surgical departments as well, which have to be re-designed for an economic future.

Purpose: We report the results of 30 patients who underwent en bloc resection of the pelvic peritoneum and all intraperitoneal pelvic viscera in the management of advanced epithelial ovarian cancer., Materials and Methods: Between 1989 and 1993, 30 consecutive patients with advanced epithelial ovarian cancer underwent en bloc resection of the pelvic peritoneum and all pelvic viscera, except for the bladder, with a rectosigmoid reanastomosis below the peritoneal reflection. All 30 patients were managed with gastrostomy and hyperalimentation. All patients received six cycles of platinum-based combination chemotherapy; the first cycle was administered prior to discharge., Results: All patients underwent cytoreduction to the largest residual mass less than 1 cm. No major complications were attributed to the gastrointestinal surgery itself. The median hospital stay was 11 days (range, 7-23). We found 26 recurrences (87%) and 14 deaths (47%). The median times to recurrence and death were 12.5 months (range, 8-24) and 23 months (range, 8-63), respectively. Sixteen of the 26 relapses (62%) were found in extraperitoneal locations and 10 (38%) in intraperitoneal locations. Only 3 (12%) of the 26 relapses presented with bowel obstruction., Conclusions: En bloc resection of the uterus, ovaries, pelvic peritoneum, and rectosigmoid followed by low anterior anastomosis is a safe operation that facilitates complete cytoreductive surgery in poor prognosis patients with advanced epithelial ovarian cancer.

The evaluation of injured children with suspected blunt abdominal trauma (BAT) is clinically challenging. Computed tomography (CT) requires that patients be sedated, stable, and transportable, and even so, it is considered the diagnostic modality of choice for children with BAT. The authors questioned whether abdominal ultrasonography (US) performed during the initial assessment of the injured child is accurate enough to replace CT in the detection of intraabdominal injury. One hundred twenty-four children with BAT aged 2 to 14 years; (average, 8.3) were admitted to the authors' institution during 1992 and 1993. Some had associated injuries (head, 60; chest, 25; extremities, 15; pelvis, 5). The indications for US were pelvic, abdominal, or lower chest trauma, tenderness, or guarding; altered consciousness; microhematuria; and/or low hemoglobin/hematocrit values. Three patients underwent abdominal CT at the time of admission. For 121 children, an emergency US examination was performed using a 3.5-MHz transducer and a portable machine. The examination evaluated the kidneys, liver, and spleen for parenchymal injuries, and the subhepatic, subphrenic, and paracolic spaces and the pelvis for evidence of free peritoneal fluid. The presence of fluid and/or parenchymal injury was interpreted as a positive US result. Twenty-eight patients had positive US findings. Ten of these had a subsequent positive CT result, eight had a normal CT result, and 10 had a negative second US result. Eleven patients (with a total of 17 visceral injuries) were treated conservatively. One patient underwent emergency surgery for liver and caval injuries. Four patients required blood transfusions. Ninety-three of the 121(78%) had a negative US result. For one of these patients, a subsequent CT scan showed a minor subcapsular splenic hematoma, which resolved spontaneously. The authors conclude that US is sensitive in detecting free peritoneal fluid or visceral injuries and is an effective screening modality. It has replaced abdominal CT in 76% of our patients with suspected BAT. In view of the reliability, simplicity, low cost, and bedside availability of US, the authors suggest that this modality be used in the initial assessment and diagnosis of children with suspected intraabdominal injury from blunt trauma.

Liver transplantation is one of the most extensive operations in visceral surgery. Preexisting cardiopulmonary abnormalities, disturbances of glucose, hormone, and electrolyte metabolism and cirrhosis-associated diseases, including hypersplenism with thrombopenia and severe coagulopathy, require advanced surgical skills. Optimal perioperative intensive care management is necessary because of the patient's immunosuppressed condition. In principle, patient management after liver transplantation is similar to that performed after major visceral surgery. However, special attention should be paid to initial liver perfusion and function. Like for sepsis in visceral surgery, in liver transplantation monitoring of cytokines and other mediators is important. New approaches for bioartificial liver support in patients with acute liver failure have primarily been developed as a bridging system to liver transplantation, but they may also be of value for patients with septic liver failure or liver failure after major liver resections.

Twenty-nine patients who incurred a transperitoneal low-velocity gunshot wound to their spine were evaluated for the occurrence of spinal infectious complications. All patients underwent an exploratory laparotomy to determine the extent of viscera involvement. No attempt was made to debride the involved spinal area, and the bullet was not removed unless it was easily accessible. Of the 21 patients with a parenchymal and/or noncolonic viscous injury, 17 (77%) were treated with intravenous (i.v.) antibiotics for a minimum of 5 days the remainder received treatment for a maximum of 48 h. All 8 patients with colonic injuries received a minimum of > or = 5 days of antibiotic treatment. Follow-up averaged 44.9 months (range 3-144 months). Only 1 (4.7%) patient with either a noncolonic or parenchymal perforation developed an infectious complication (subdiaphragmatic abscess); two patients (25%) with colonic perforations developed a psoas abscess. No patient developed a spinal infection. This study suggests that patients who sustain a transperitoneal low-velocity gunshot wound to their spine do not need to undergo spinal debridement and may be treated with parenteral antibiotics. Any course of broad-spectrum antibiotics for 5 days appears to minimize infectious complications. Bullet removal and missile tract debridement of the spine is not routinely necessary.

Visceral outpatient operations are well established in Dresden. Since 1978, 13,948 cases have been operated on in general surgery. Most patients (57.8%) had local anesthesia; only 9.2% needed general anesthesia. A total of 9,175 patients (65.8%) had visceral outpatient surgery. The conditions for these operations in outpatients are: the patient's compliance, the cooperation of the family, an operating theater with complete equipment and, last but not least, a qualified surgical team. The pre- and postoperative management must be perfectly organized. Even today there are special limitation for one-day surgery. We have not yet introduced laparoscopy into our outpatient program. Oncological surgery can be performed, provided the general standards for radical tumor surgery can be realized. With careful selection of patients and the right indication, complications are rare in outpatient surgery. In only 0.7% of all cases did wound infections occur postoperatively. None of the patients died.

From April 1986 to June 1994 a total of 284 patients with gastric carcinoma were admitted to the authors' department. Mainly advanced tumour stages were seen: stage I = = 23%, II = 13%, III = 22% and IV = 42%. In 256 tumour resections (resection rate = 90%) multivisceral surgery (mvs) was necessary in 146 patients (mvs = 57%). Long-term survival of stage IV gastric cancer patients cannot be prolonged by mvs, and RD-resection can be achieved in few patients (9/120 = 7.5% in stage IV). Perioperative morbidity, postoperative complications and the mean postoperative hospital stay were increased after extensive surgery. Major complications were anastomotic leakage, local infections and pulmonary diseases. Even when resection seems to be an acceptable palliation for stage IV gastric cancer patients, mvs in only justified where RD-resection seems achievable.

In chloralose-anesthetized cats, rapid distension of the urinary bladder with warm (37 degrees C) normal saline (50-60 ml) causes an increase in blood pressure and contraction of the spleen. This response is due to peripheral vasoconstriction. In this experiment, the evidence of direct involvement of the spleen, as well as splenic and splanchnic sympathetic efferent activity on the viscerovascular reflexes, was investigated by pharmacological and electrophysiological (single unit preparation) means and analysis. The viscerovascular reflexes induced by urinary bladder distension remained unaffected by propranolol, but phentolamine, guanethidine sulfate, and hexamethonium completely antagonized the reflex vasopressor response. All these results with these blocking agents show that sympathetic nerves are actively involved in the reflex responses to distension of the urinary bladder with activation at the postganglionic level involving alpha-adrenoceptors and thereby the release of catecholamines. It is thus evident that the same mechanisms operate in the case of reflex elevation of blood pressure and contraction of the spleen. After bilateral denervation of the splanchnic sympathetic nerves, bladder distension failed to produce a reflex response. The efferent activity from the splanchnic and splenic sympathetic nerves in producing a reflex rise in blood pressure was recorded for direct evidence. The significant increase of asynchronous spontaneous discharge rate in the splanchnic and splenic sympathetic nerves was found along with a rise in blood pressure during bladder distension. On the basis of this study, it may be suggested that the spleen as well as splenic and splanchnic sympathetic nerves play an important role in the control of viscerovascular reflexes.

Aim of the Study: Since 1988 all our patients undergoing elective general surgery entered a prospective study, with the aim of identifying risk factors, responsible for a fatal postoperative outcome., Methods: From 1988-1992 a total of 3250 patients (mean age 52.0 years [SD +/- 16.8]), 1750 male and 1500 female have been registered., Results: General complications occurred in 10.4% of patients and local complications have been registered in 10.8% of cases. 29 patients (0,89%) died within 30 days following the operative procedure. The operation per se, the ASA-classification, a history of respiratory disease and an operation for a malignant disease could be identified as risk factors for general postoperative complications., Conclusions: The study design allows us to determine risk factors in elective general surgery. These risk factors can easy be used in clinical practice to evaluate the operative risk of a planned operative procedure.

Visceral involvement was investigated in 168 patients with general peritonitis. Toxic hepatitis, toxic nephropathy, myocardia dystrophy, pulmonary impairment were determined in 85.7%, 83.3%, 69.6% and 19% of them, respectively. 44 (26.2%) patients with terminal peritonitis developed polyorganic insufficiency. Principal approaches to management of visceral pathology in peritonitis are analyzed.

Background: The hazards of operative treatment for variceal hemorrhage and intractable ascites in patients with cirrhosis are well known. Much less information is available on the morbidity and mortality in these patients after abdominal operations not directly related to the sequelae of portal hypertension., Study Design: We reviewed the records of 77 consecutive histologically proved cases of cirrhosis in patients undergoing 85 general surgical, abdominal procedures during a ten year period. Logistic regression analysis was done on 32 preoperative and intraoperative variables with relation to postoperative outcome., Results: There were 47 men and 30 women, with a mean age of 61 years (range of 28 to 86 years). The 30-day mortality rate was 18 percent (15 of 77 patients). Emergent operation was associated with a mortality rate of 32 percent (11 of 35 patients) compared with 8 percent (four of 50 patients) after elective procedures (p < 0.05). Extensive complications occurred in 28 percent of patients (24 patients; 14 percent after elective operative treatment and 49 percent after emergent procedures). The mortality rate was greatest after gastric procedures (38 percent). Other factors of statistical significance (p < 0.05) associated with poor postoperative outcome included cachexia, preoperative transfusion of fresh frozen plasma, and intraoperative platelet transfusion. Surprisingly, operative blood loss, presence of ascites, and operative time were not associated with increased complications or death., Conclusions: We conclude that elective, nonshunt abdominal operations can be performed with acceptable morbidity and mortality rates in selected patients with cirrhosis.

Viscera slide is the normal, longitudinal movement of the intraabdominal viscera caused by respiratory excursions of the diaphragm. By detecting areas of restricted viscera slide, ultrasonic imaging was used to identify anterior abdominal wall adhesions prior to laparotomy or laparoscopy. Transcutaneous ultrasound examination was performed on 110 patients. A prediction of adhesions was made for each patient and then compared to the findings during subsequent laparotomy or laparoscopy. Only patients with previous abdominal surgery or history of peritonitis demonstrated adhesions. Sensitivity and specificity of viscera slide ultrasound in predicting adhesions were 90% and 92%. Nine out of 10 false results involved misinterpretation of ultrasound images of the lower one-third of the abdomen. Ultrasonic imaging of viscera slide is highly accurate in detecting abdominal wall adhesions. This technique is most useful in guiding the insertion of trocar in laparoscopic surgery, and as a noninvasive method in studying the formation of adhesions.

Analysis of 88 repeated surgical interventions after 4,017 operations on the abdominal organs showed the obvious advantages of early relaparotomy with the performance of laparostomy, according to indications, in patients with postoperative pyoinflammatory complications in the abdominal cavity. The mortality rate was 19.3% in early and 80.7% in delayed relaparotomy. A complex of symptoms was determined providing evidence of the development of postoperative pyoinlammatory complications and allowing substantiated indications for a repeated operation to be set.

Since 1988 we have been analysing all our patients undergoing elective general surgery with general or spinal anaesthesia in a prospective study, with the aim of identifying and weighing up risk factors. The risk factors have been divided into the following groups: environment, surgeon, anaesthesia, operative intervention, disease and patient, regardless of the current illness. In 1990 a total of 682 patients (mean age 51.6 years, range 14-90), 365 male and 317 female, entered on study. General complications have been recorded in 63 patients (9.2%), whereas local complications occurred in 73 patients (10.7%). The following parameters were identified as risk factors for general complications: age > or = 70 years, hypertensive blood pressure level, haematocrit < 40% (male patients), operative procedure for malignancies, reduced physical capacity, pathologic cardiac or lung history, pathologic ECG, excessive alcohol consumption, hepatosplenomegaly, foreign origin, carotid artery bruit. Five patients died within 30 days following surgery for a malignant disease. This ongoing prospective study is a valuable instrument for the definition of preoperative risk factors in elective general surgery with the objective of eliminating mortality by the end of the century.

Trauma is a major health and social problem. It is the leading cause of death for those under age 45, and is a major expense to society, in terms of direct medical expense and lost wages. Visceral injury continues to be a major cause of morbidity and mortality in the overall trauma picture. This article reviews the significant developments in the diagnosis and management in specific areas of visceral injury.

The use of the linear stapling device (LSD) is well-established in hollow-organ gastro-intestinal surgery. Its use in operations performed on parenchymatous viscera is less common. We present our experiences with the LSD in partial resection of the spleen (2 cases), pancreas (5 cases), liver (2 cases) and kidney (2 cases). To the best of our knowledge the use of the LSD for partial nephrectomy and resectional debridement of the liver has not been previously described. We suggest that LSDs are useful aids in the resection of parenchymatous organs, and allow rapid resection if applied to healthy tissues and in regions with an intact capsule.

Abdominal visceral injuries are encountered by every surgeon who deals with trauma. It is simple and useful to divide abdominal visceral injuries into those caused by penetrating mechanisms of injury and those due to blunt mechanisms. Determination of the need for operative intervention is generally easier after penetrating trauma. Gunshot wounds to the abdomen should be explored, as should stab wounds to the anterior abdomen that penetrate the fascia. A midline incision is the standard approach to abdominal visceral injuries because of its ease and versatility. Abdominal exploration should be consistent and systemic so as not to miss significant injuries. Hollow viscus injury is most common after penetrating injury, while blunt injury most often results in injury to solid viscera. Diagnostic and operative aspects of the treatment of specific visceral injuries are reviewed.

The paper provides technical characteristics of ESB biocompatible polymer connective elements (of polymethacrylate butyl) for internal organs. Problems of the changes of their physico-mechanical properties during experiments in model environments were discussed. Also results of medical and experimental studies of connective elements on animals, and of their biodestruction, were analyzed. Findings which could be used in clinical use of the connective elements in operating parenchymatous organs and in stomatology and traumatology are shown. On the basis of results obtained after 128 operations it was found that use of ESB connective elements ensures high reliability of haemostasis, and prevents unsealing, both physical and biological, of internal sutures and rules out any adhesion. Moreover it diminishes, in some cases even rules out, the possibility of post-operative complications.

Necrotizing infection of the arterial wall causes rupture and false ("mycotic") aneurysm formation, with a very poor prognosis if untreated. Cure can be achieved by surgical drainage and debridement, with restoration of arterial continuity through uncontaminated tissues. The dilemma of applying these principles to the treatment of mycotic aneurysms of the suprarenal aorta is that no remote or extraanatomic routes are available to maintain perfusion to the viscera. We report the first case of Klebsiella suprarenal mycotic aortic aneurysm successfully treated with in situ prosthetic reconstruction of the aorta and visceral arteries, and we have reviewed the 21 other suprarenal mycotic aortic aneurysms reported in the English-language literature. Repair was performed in 20 of the 22 cases, with in situ prosthetic reconstruction performed in 18. Prolonged survival has been achieved in 16 patients after in situ repair. No long-term survival has been reported after extraanatomic reconstruction of the aorta and visceral arteries in patients with such aneurysms. We conclude that in situ prosthetic reconstruction, accompanied by thorough drainage and debridement, prolonged parenteral antibiotic therapy, and permanent suppressive oral antibiotics, offers the best chance for survival in these patients.

Today, in every child in situation of organs donor, a multiple organ harvesting is performed which requires surgical techniques more precise, in order to improve the results. Heart, heart-lungs and liver transplantation represent in children, for volume reasons, situations where harvesting must be performed in a child matched for height with the recipient. Today a technique of unique harvesting took place of the initial techniques which required careful dissection of all organs, the preparation of organs being made secondarily, after refrigeration and harvesting. The first step is abdominal and sets up a device of abdominal spraying. The second step is the thoracic dissection, heart or cardio-pulmonary block harvesting being performed by the cardiac surgery team. Finally, the third step consists of the harvesting of the abdominal viscera. It is preceded by a precooling, begun during the period before thoracic dissection. It supposes a global cooling of the liver, kidneys, duodeno-pancreatic block and small bowel. Monoblock dissection then begins with the liberation of the liver and eventually of the duodeno-pancreatic block. After hepatectomy, both kidneys are harvested in monoblock. The intestine, itself, is harvested in last position. Progresses should occur, due to the improvement of the performances of the cooling solutions.

A useful approach of the study of nutrient absorption and metabolism is in vivo measurement of blood flow across portal-drained viscera and liver, and flux of bloodborne metabolites, successful application of the approach requires correct placement of chronic catheters in appropriate blood vessels. Additionally, catheters must stay patent long enough to allow the animal to recover from surgery and to complete an experimental protocol. This paper describes surgical techniques to install chronic catheters in mesenteric veins, the hepatic portal vein, and an hepatic vein of cattle. Techniques for access to arterial blood are described also. Materials, equipment, and supplies required for surgery, blood sampling, and blood flow determination are described. Commercial sources of supplies are suggested. Blood flow is measured by downstream dilution of para-aminohippurate, which is infused into a mesenteric vein. Examples of blood flow data for three types of cattle are provided.

Seventy-six (30.6%) out of 248 cases of diffuse infiltrating cancer of the stomach according to Kajitani's classification of gross appearance were surgically treated by LUAE. The survival rate of LUAE cases was better among both relative non-curative cases and Stage IV cases than that among cases treated by other forms of surgery. The survival rate of for LUAE cases was slightly better for cancer located mainly in the upper and mid-portion of the stomach than for cases of diffuse infiltrating cancer not treated by LUAE used as historical controls.