CXCL5 drives neutrophil recruitment in TH17-mediated GN

Neutrophil trafficking to sites of inflammation is essential for the defense against bacterial and fungal infections, but also contributes to tissue damage in TH17-mediated autoimmunity. This process is regulated by chemokines, which often show an overlapping expression pattern and function in pathogen- and autoimmune-induced inflammatory reactions. Using a murine model of crescentic GN, we show that the pathogenic TH17/IL-17 immune response induces chemokine (C-X-C motif) ligand 5 (CXCL5) expression in kidney tubular cells, which recruits destructive neutrophils that contribute to renal tissue injury. By contrast, CXCL5 was dispensable for neutrophil recruitment and effective bacterial clearance in a murine model of acute bacterial pyelonephritis. In line with these findings, CXCL5 expression was highly upregulated in the kidneys of patients with ANCA-associated crescentic GN as opposed to patients with acute bacterial pyelonephritis. Our data therefore identify CXCL5 as a potential therapeutic target for the restriction of pathogenic neutrophil infiltration in TH17-mediated autoimmune diseases while leaving intact the neutrophil function in protective immunity against invading pathogens.

Shorter postoperative atony after laparoscopic-assisted colonic resection?

BACKGROUND

The duration of the postoperative ileus after laparoscopic surgery remains a controversial topic. The aim of our study was to compare the restoration of intestinal motility after laparoscopically assisted and conventional resection of the distal colon in a canine model.

METHODS

Two weeks after the implantation of three electrodes on the jejunum, the distal colon was resected in a laparoscopic-assisted or conventional procedure in two groups of four dogs each. Gastrointestinal motility was monitored by registration of the electromyograhic activity of the small intestine and by intermittent fluoroscopies of radiopaque markers.

RESULTS

Electrical activity in the early postoperative period was characterized by the basic electrical rhythm and the absence of spike activity. The first postoperative activity front of the migrating motility complex (MMC), indicating the restoration of motility, occurred significantly earlier after laparoscopic-assisted resection (4.5 +/- 1 hr) than after conventional resection (31 +/- 10 h). Radiological observations showed a significantly delayed gastric emptying and a prolonged transit of radiopaque markers to the rectum after open surgery.

CONCLUSION

These results support the hypothesis that laparoscopic-assisted resection of the colon leads to a shortened postoperative atony in comparison to open surgery.

Kidney dendritic cells in acute and chronic renal disease

Dendritic cells are not only the master regulators of adaptive immunity, but also participate profoundly in innate immune responses. Much has been learned about their basic immunological functions and their roles in various diseases. Comparatively little is still known about their role in renal disease, despite their obvious potential to affect immune responses in the kidney, and immune responses that are directed against renal components. Kidney dendritic cells form an abundant network in the renal tubulointerstitium and constantly survey the environment for signs of injury or infection, in order to alert the immune system to the need to initiate defensive action. Recent studies have identified a role for dendritic cells in several murine models of acute renal injury and chronic nephritis. Here we summarize the current knowledge on the role of kidney dendritic cells that has been obtained from the study of murine models of renal disease.

Defecation mechanisms after anterior resection with J-pouch-anal and side-to-end anastomosis in dogs

BACKGROUND

Colonic J-pouch-anal anastomosis or colonic side-to-end anastomosis is the reconstruction of choice after low anterior resection. However, the mechanisms of defecation after both reconstruction forms are still speculative.

METHODS

Low anterior rectal resections were performed in 12 dogs with six colonic J-pouch-anal (pouch) and six coloanal side-to-end (SE) reconstructions. Four months postoperative stool frequency, intestinal transit time, and neorectal compliance were determined by radiography and barostat. Defecation mechanisms were evaluated radiographically during expulsion of artificial stool.

RESULTS

One dog with pouch reconstruction could not be evaluated due to an anastomotic leak, while the others had uncomplicated course. Spontaneous stool frequency was significantly increased with both reconstruction methods (control 2.0+/-0.9, pouch 2.7+/-1.2, SE 3.3+/-0.9 day; p<0.05). Intestinal transit time was significantly higher with pouch reconstruction due to storage of stool in the pouch and the descending colon compared to SE (control 760+/-82, pouch 592+/-97, SE 550+/-87 min; p<0.05). Compliance and functional capacity were higher in pouch than in side-to-end reconstructions (pouch 5.0+/-0.7 ml/mmHg, 124+/-23 ml; SE 2.7+/-0.3 ml/mmHg, 92+/-24 ml; p<0.05). During defecation, there were no contractions of the pouch detectable.

CONCLUSIONS

The colonic J-pouch reconstruction results in better functional outcome than side-to-end coloanal anastomosis. Our results show that pouch evacuation is passive and independent from pouch motility. The functional principle of the colonic J-pouch is not its reservoir function but a delay of colonic motility.

Tumor necrosis factor alpha- and inducible nitric oxide synthase-producing dendritic cells are rapidly recruited to the bladder in urinary tract infection but are dispensable for bacterial clearance

The role of dendritic cells (DC) in urinary tract infections (UTI) is unknown. These cells contribute directly to the innate defense against various viral and bacterial infections. Here, we studied their role in UTI using an experimental model induced by transurethral instillation of the uropathogenic Escherichia coli (UPEC) strain 536 into C57BL/6 mice. While few DC were found in the uninfected bladder, many had been recruited after 24 h, mostly to the submucosa and uroepithelium. They expressed markers of activation and maturation and exhibited the CD11b+ F4/80+ CD8- Gr-1- myeloid subtype. Also, tumor necrosis factor alpha (TNF-alpha)- and inducible nitric oxide synthase (iNOS)-producing CD11bINT DC (Tip-DC) were detected, which recently were proposed to be critical in the defense against bacterial infections. However, Tip-DC-deficient CCR2-/- mice did not show reduced clearance of UPEC from the infected bladder. Moreover, clearance was also unimpaired in CD11c-DTR mice depleted of all DC by injection of diphtheria toxin. This may be explained by the abundance of granulocytes and of iNOS- and TNF-alpha-producing non-DC that were able to replace Tip-DC functionality. These findings demonstrate that some of the abundant DC recruited in UTI contributed innate immune effector functions, which were, however, dispensable in the microenvironment of the bladder.

Evaluation of anastomotic microcirculation after low anterior rectal resection: an experimental study with different reconstruction forms in dogs

BACKGROUND

Data on anastomotic microcirculation of coloanal anastomoses are contradictory. Therefore, it was the aim of the present study to investigate perianastomotic blood perfusion in a standardized experimental setting comparing three forms of reconstruction using laser fluorescence videography, a new method for the evaluation of microcirculation.

METHODS

After a standardised rectal resection in dogs, reconstruction was performed as straight end-to-end (n = 6), side-to-end (n = 6), or J-pouch (n = 6) coloanal anastomosis. Bowel perfusion was evaluated using IC-View laser fluorescence videography.

RESULTS

The perfusion index was significantly reduced in all three groups compared to the reference regions: endto-end anastomosis, median, 93% (range, 63%-136%); side-to-end-anastomosis, 65% (35%-138%); colonic-J-pouch anal anastomosis, 52% (32%-72%); p < 0.001).

CONCLUSIONS

Straight coloanal anastomoses provide better anastomotic microcirculation after rectal resections than colonic-J-pouch anal anastomoses or side-to-end anastomoses. However this effect does not seem to be decisive for the prevention of anastomotic leaks.

[Assisted death in daily surgical practice--an interdisciplinary discussion with examples]

New laws for assisted patient death in The Netherlands and Belgium have resulted in animated discussion about the permissibility of the practice in Germany. Physicians here are being confronted more and more by patients and their relatives with the wish for assisted death. Polls confirm that the majority of this population supports active death assistance, whereas doctors reject it. At a symposium in October 2002 (Clinically Assisted Death and Human Dignity-A Dutch-German Dialogue), case studies illustrating this question were presented. The present study compiles viewpoints of physicians, ethicists, theologians, jurist, politicians, and journalists.

Temporary closure of the abdominal wall (laparostomy)

The definitive closure of the abdominal wall, i.e., a closure of the fascial layer and skin may not be favorable in the treatment of numerous surgical conditions, e.g., peritonitis, trauma, or mesenteric ischemia. In these cases, the abdominal wall is temporarily closed, and a laparostomy is created to facilitate re-exploration or to prevent abdominal compartment syndrome. Regarding the technique and material used for the temporary closure, no prospective randomized data exists, but mesh materials are commonly used. They provide drainage of infectious material, permit visual control of the underlying viscera, facilitate access to the abdominal wall, preserve the fascial margin, enable healing by secondary intention, and allow mobilization of the patient. In the case of decreasing intra-abdominal pressure, meshes can be trimmed to centralize the rectus muscle and to facilitate definitive closure. Non-absorbable meshes have been frequently reported to cause enteric fistulae and persistent infection necessitating mesh explantation. While these infectious complications appear to occur less frequently with the use of absorbable materials, these meshes will finally lead to an incisional hernia, requiring repair with non-absorbable mesh after a period of 6-12 months. Nevertheless, in the complex situation requiring a temporary abdominal wall closure, use of absorbable mesh material is common and represents the state of the art.

Is laparoscopic cholecystectomy a mature operative technique?

BACKGROUND

More than 10 years after its introduction, laparoscopic cholecystectomy has become the method of choice for the treatment of cholecystolithiasis. However intraoperative difficulties with dramatic postoperative consequences have been reported. The aim of this study was to identify what role the two-dimensional view, the surgeon's experience, the instruments, technical tools and their (time) influence exercised on the operation course in daily laparoscopic operations.

METHODS

The operative times for 30 laparoscopic cholecystectomies were investigated by ergonomic sequence analysis and analyzed statistically with the use of the Wilcoxon test.

RESULTS

Comparing experienced and less experienced surgeons, a significant difference in the duration of the operation was observed (56 +/- 24 min compared to 75 +/- 13 min p = 0,025), especially in the laparoscopic intra-abdominal phase of the operation. The prolonged duration of the operation (15-20%) was mainly due to problems with the technical tools (40%) and the use of instruments (23.5%). Visualization had a minor influence (14.4%) on the duration of the operation, and the negative effect of the two-dimensional view (0.5%) was negligible. The last two factors did not cause any complications.

CONCLUSIONS

The recognized difficulties still cause a loss of time and in some cases complications, which can only partly be compensated by the surgeon's experience. This leads to reluctance in the application of laparoscopic cholecystectomy in more complicated stages of the disease. Two-dimensional view satisfies the surgeon's demands for a safe procedure.

Comparison of adhesion reformation after laparoscopic and conventional adhesiolysis in an animal model

This study set out to compare adhesion reformation after conventional and laparoscopic adhesiolysis using two different laparoscopic dissection techniques. In a first operation, 36 rabbits underwent fixation of 6 cm2 of the cecum with the serosa removed to the lateral abdominal wall to induce standardized adhesions. After 4 weeks, adhesiolysis was performed laparoscopically (n = 12) or via laparotomy (n = 12) using sharp and blunt dissection. In a third group (n = 12), laparoscopic adhesiolysis was performed using monopolar electrocautery. Outcome was assessed by incidence, extent, and localization of adhesion reformation. After conventional adhesiolysis, all rabbits developed new adhesions relative to 79% after laparoscopic adhesiolysis. The extent of reformed adhesions (median) was greater after conventional adhesiolysis than laparoscopic adhesiolysis (2725 mm2 vs 230 mm2, P < 0.001). The latter did not differ significantly from laparoscopic adhesiolysis by electrocautery (310 mm2). There were small adhesions to 3 of 72 trocar wounds, but extensive adhesions to 33% of the abdominal incisions were found in the conventional group. In this standardized experimental setting, laparoscopic adhesiolysis is associated with a significantly reduced reformation of adhesions. Different laparoscopic dissection techniques have no significant influence on the extent of adhesion reformation.

The surgical trauma of abdominal wall incision. A comparison of laparoscopic vs open surgery with three-dimensional stereography

BACKGROUND

Laparoscopic operations seem to respect the integrity of the abdominal wall better than conventional laparotomy, but the effects of surgical trauma are not well understood. The new technique of three-dimensional stereography makes it possible to describe and calculate the mobility of the abdominal wall and the nature of the underlying disturbances.

METHODS

Three-dimensional stereography is a noninvasive optical method of measuring surface areas. Abdominal wall mobility can be assessed by comparing changes to the abdominal surface in its minimum and maximum excursions. Different parameters, such as height difference and curvature, are calculated. We studied patients undergoing different types of surgical procedures (laparoscopy and open surgery) by measuring their abdominal wall mobility before and after the procedure. We also compared these patients to a control group. Each group consisted of 30 patients, who were evaluated prospectively.

RESULTS

We found a significant difference in abdominal wall mobility between patients treated via a laparoscopic approach, and those who had conventional surgery. At 7 days after laparoscopy, abdominal movement was always the same in the laparoscopic group as in the controls. By contrast, the open surgery group still showed a significant lack of mobility 12 days after the procedure.

CONCLUSION

The new method of three-dimensional stereography makes it possible to compare the trauma associated with different surgical approaches as it affects the integrity of the abdominal wall. As compared with open surgery, laparoscopy has a significant positive effect on abdominal wall integrity.

[Laparoscopic surgery: expectations and reality]

Despite the rapid development and widespread application of laparoscopic operation techniques, only laparoscopic cholecystectomy and laparoscopic fundoplication have replaced the open operations as standard techniques. Nowadays only about 10% of appendectomies and 25% inguinal hernias are performed by the laparoscopic approach. Colorectal operations are rarely performed laparoscopically. Demanding operative skills and uncertainty about the oncological quality have hindered the spread of laparoscopic colorectal resections. Studies at specialized centers have shown that it is possible to follow the principles of oncological surgery. First results of small series promise similar long-term results, but large prospective randomized trials are still unpublished. Depending on the extent of the operative procedure, laparoscopic operations result in reduced postoperative pain, fewer adhesions, shortened postoperative atonia and improved convalescence in comparison with open surgery. The direct costs of laparoscopic procedures are higher than open operations as a result of longer operation times and expensive equipment. As a result of shorter hospitalisation and quicker return to work, the overall health care costs may be reduced, but strong unbiased evidence is still lacking.

New adhesion formation after laparoscopic and conventional adhesiolysis: a comparative study in the rabbit

This study aimed to compare new adhesion formation after laparoscopic and conventional adhesiolysis. In a first operation, 24 rabbits underwent fixation of deserosated cecum (6 cm2) to the lateral abdominal wall to induce standardized adhesions. After 4 weeks, adhesiolysis was performed by laparoscopy (n = 12) or laparotomy (n = 12). Outcome was assessed by the incidence, extent, and location of adhesion reformation. After conventional adhesiolysis, new adhesions developed in all the rabbits, as compared with 75% after laparoscopic adhesiolysis. The extent of newly formed adhesions was significantly reduced (p < 0.001) after laparoscopic adhesiolysis (368+/-115 mm2) as compared with conventional adhesiolysis (2434+/-245 mm2). There were no adhesions to trocar wounds, but adhesions to the abdominal incision were found in 33% of the conventional group. In a rabbit model comparing laparoscopic and conventional adhesiolysis in a standardized experimental setting, laparoscopic adhesiolysis is associated with a significantly reduced formation of new postoperative adhesions.

Laparoscopy versus laparotomy: comparison of adhesion-formation after bowel resection in a canine model

AIM

The purpose of the study was to compare adhesions following laparoscopic and conventional operations.

METHODS

In 14 dogs cecal resection and a deserosation of the abdominal wall were performed laparoscopically (n = 7) or by laparotomy (n = 7). After 8 days all dogs were reexamined and the adhesions were quantified by computer-aided measurements. The significance of any differences were tested using Student's t test.

RESULTS

The extent of adhesions after laparoscopy (630 +/- 360 mm2) and after laparotomy (3,300 +/- 1,007 mm2) differed significantly (p < 0.0001). Extensive adhesions to the abdominal incision and interenteric adhesions were found after conventional operations. Identical manipulations, such as cecal resection or deserosation of the lateral wall, led to the same frequency and extent of adhesions in both operation groups.

CONCLUSION

Laparoscopic procedures are associated with significantly less adhesions in comparison to conventional operations. Therefore the risk of adhesion-related complications should be reduced after laparoscopic operations.

Memory deficits in subsyndromes of chronic schizophrenia

Recent psychopathological studies consistently identified a delusional, a negative, and a disorganized subsyndrome in chronic schizophrenia. The aim of the present study was to investigate these subsyndromes with respect to declarative, procedural and working memory deficits. While the delusional subsyndrome was associated with an impaired delayed recognition, the negative subsyndrome showed a marked deficit in delayed recall. In addition, the delusional and the negative subsyndrome shared procedural memory changes. The disorganized subsyndrome was associated with neurological soft signs and a poor working memory performance. These results do not seem to be effected by severity of illness, degree of chronicity, nor attentional deficits. Our findings support the differentiation of three subsyndromes in chronic schizophrenia and suggest that memory impairment in schizophrenia may reflect the involvement of different memory systems rather than an unspecific, global deficit.

[Gastroesophageal reflux--surgical indications, laparoscopic surgical technique, results]

OBJECTIVE

To investigate criteria for indication to surgery and results of laparoscopic fundoplication.

BACKGROUND

Gastroesophageal reflux is a common problem in well developed countries. Beside clinical symptoms of heartburn and regurgitation complications may occur like esophagitis, bleeding, ulceration, mucosal metaplasia and loss of motility. A connection of reflux disease, Barrett's esophagus and adenocarcinoma of motility. A connection of reflux disease, Barrett's esophagus and adenocarcinoma of the esophagogastric junction is discussed. In some patients medical treatment is complicated by relapse, persistent or progressive disease. For these patients laparoscopic antireflux surgery may be an effective alternative.

PATIENTS

22 patients with chronic gastroesophageal reflux disease.

METHODS

Since 9-2-1922 patients with gastroesophageal reflux disease were prospectively evaluated and treated by laparoscopic Nissen fundoplication.

RESULTS

11 patients had frequent recurrent disease, 9 persistent reflux and 2 a stricture while on medical treatment. All had pathologic reflux on 24 hour pH monitoring and defective sphincter on standard manometry. Beside an intraoperative pneumothorax there was no intraoperative complication. Postoperative 2 patients had a temporary and 1 mild persisted dysphagia. None had recurrent reflux. 10 patients were reevaluated one year after surgery. None had an esophagitis, abnormal reflux or an insufficient or hypercontinent sphincter.

CONCLUSIONS

Patients with recurrent or persistent reflux while on medical treatment with abnormal reflux on pH monitoring and defective sphincter on manometry can be treated by laparoscopic Nissen fundoplication with good results.

Intraabdominal humidity and electromyographic activity of the gastrointestinal tract. Laparoscopy versus laparotomy

The purpose of this study was to observe electromyographic activity of stomach, small bowel, and colon during and early after identical laparoscopic and conventional operations to compare the operative trauma. In nine dogs a cholecystectomy was performed laparoscopically (n = 5) or by laparotomy (n = 4). Analysis of electromyographic activity focused on rhythm, frequency, and amplitudes of slow waves. Furthermore, oxygenation of blood and tissue, intestinal impedance, intraabdominal humidity, and temperature were documented to investigate their influence on slow waves. Open cholecystectomy caused an evident decrease of frequency and amplitude of colonic slow waves in comparison to laparoscopic cholecystectomy. Arrhythmic slow waves were observed only in the stomach during conventional cholecystectomy. Stomach and small intestine showed no significant difference of frequency and amplitude of slow waves in both operation groups. Intraabdominal humidity and intestinal impedance differed significantly in laparoscopy and laparotomy. Laparoscopic cholecystectomy proceeded with a minor abdominal trauma documented by smaller alterations of slow waves. This may be caused by reduced peritoneal desiccation.

[Video thoracoscopic therapy of spontaneous pneumothorax. Technique and initial results]

The acceptance of operative therapy of spontaneous pneumothorax (SPT) has been tempered by the serious trauma of thoracotomy access. Development of videoequipment and miniaturized instruments allows now a thoracoscopic resection of bulla with minimal access. 25 patients with recurrent SPT (n = 15), primary resistant SPT (n = 5), and first SPT (n = 5) were treated from January 1991 thoracoscopically. Bullae resection was performed with an Roeder ligature or an Endo-GIA. Pleurodeses was induced by mechanical irritation or coagulation of the upper thoracic aperture with the argon beamer. Postoperative lung reinflation was rapid and without patchy collapse. The analgetic drug demand was dramatically reduced and patients were mobilised on the 1st postoperative day. Patients were discharged on the 4th postoperative day. Major complication were one hematothorax and one recurrence of SPT. The advantages of the thoracoscopic surgical treatment are rapid full expansion of the lung, decreased postoperative pain, short postoperative hospital stay and early return to normal activity.

[Laparoscopy versus laparotomy. An animal experiment study comparing adhesion formation in the dog]

We performed laparoscopy (n = 7) or laparotomy (n = 7) for exploration of the small intestine, cecal resection with Endo-GIA or TA-30, deserosation of 2 cm2 of the abdominal wall and resection of the omentum majus in dogs. After 8 days all dogs were re-examined and the adhesions were quantified by computer-aided measurement. Laparoscopic operations were followed by significantly (P < 0.001) fewer adhesions. After conventional operations extensive adhesions to the abdominal incision and interenteric adhesions were found, together with frequent conglomerates of adhesions, intestinal kinkings or adhesive bands. Identical manipulations, such as cecal resection or deserosation of the lateral abdominal wall, led to the same frequency and severity of adhesions in both groups. Based on our results, the risk of adhesion-related complications may be reduced by the laparoscopic approach.

[Value of sonography in routine diagnosis of acute appendicitis. A retrospective analysis]

Our retrospective study of ultrasound examinations in 261 consecutively appendectomized patients shows a lower sensitivity in sonographic diagnosis of acute appendicitis compared to our former prospective study. One reason seems to be the different experience of the participating surgeons in ultrasound examination of acute appendicitis. Conditions of a prospective study might be another reason for our former better results. In conclusion recognition of appendicitis during ultrasound must lead to early operation, but a negative ultrasound alone is not safe enough to avoid surgical intervention in clinically supposed appendicitis. In every-day surgery clinical experience combined with additionally performed ultrasound leads to an early and safe indication for appendectomy.

[Jejunogastric invagination--a rare complication of stomach surgery]

The jejunogastric intussusception is a rare complication of gastric surgery. An acute and a chronic form of intussusception can be distinguished. Three anatomical types of jejunogastric invagination have been classified. Endoscopy is the diagnostic procedure of choice, early operative desinvagination the therapy of choice. The effectiveness of different operative procedures to prevent reinvagination is contested.

[Common channel syndrome--2 case reports]

The common channel syndrome is a disease mostly of young girls. To demonstrate the problems of diagnosis and therapy we report on 2 cases operated on in 1987 and 1989. The long delay of several years between the onset of symptoms and the diagnosis might be shortened by improved diagnostic possibilities (Ultrasound, ERCP). In any case of hyperamylasemia or chronic pancreatitis in childhood an obstruction of the biliary tract should be excluded. The common channel syndrome can be treated by means of sphincteroplasty or a bilidigestive anastomosis.