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Necrotizing skin and soft-tissue infections in the intensive care unit. Clin Microbiol Infect 2019; 26:8-17. [PMID: 31284035 DOI: 10.1016/j.cmi.2019.06.031] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 06/19/2019] [Accepted: 06/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission. OBJECTIVES To review all aspects of care for a critically ill individual with NSTI. SOURCES Literature search using Medline and Cochrane library, multidisciplinary panel of experts. CONTENT The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial. IMPLICATIONS Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.
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Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA). World J Emerg Surg 2017; 12:35. [PMID: 28785301 PMCID: PMC5541698 DOI: 10.1186/s13017-017-0147-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 07/27/2017] [Indexed: 02/08/2023] Open
Abstract
[This corrects the article DOI: 10.1186/s13017-016-0089-y.].
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Abstract
Postoperative peritonitis is still a life-threatening complication after abdominal surgery and approximately 10,000 patients annually develop postoperative peritonitis in Germany. Early recognition and diagnosis before the onset of sepsis has remained a clinical challenge as no single specific screening test is available. The aim of therapy is a rapid and effective control of the source of infection and antimicrobial therapy. After diagnosis of diffuse postoperative peritonitis surgical revision is usually inevitable after intestinal interventions. Peritonitis after liver, biliary or pancreatic surgery is managed as a rule by means of differentiated therapy approaches depending on the severity.
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Therapeutic management of peritonitis: a comprehensive guide for intensivists. Intensive Care Med 2016; 42:1234-47. [PMID: 26984317 DOI: 10.1007/s00134-016-4307-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/04/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE The management of peritonitis in critically ill patients is becoming increasingly complex due to their changing characteristics and the growing prevalence of multidrug-resistant (MDR) bacteria. METHODS A multidisciplinary panel summarizes the latest advances in the therapeutic management of these critically ill patients. RESULTS Appendicitis, cholecystitis and bowel perforation represent the majority of all community-acquired infections, while most cases of healthcare-associated infections occur following suture leaks and/or bowel perforation. The micro-organisms involved include a spectrum of Gram-positive and Gram-negative bacteria, as well as anaerobes and fungi. Healthcare-associated infections are associated with an increased likelihood of MDR pathogens. The key elements for success are early and optimal source control and adequate surgery and appropriate antibiotic therapy. Drainage, debridement, abdominal cleansing, irrigation, and control of the source of contamination are the major steps to ensure source control. In life-threatening situations, a "damage control" approach is the safest way to gain time and achieve stability. The initial empirical antiinfective therapy should be prescribed rapidly and must target all of the micro-organisms likely to be involved, including MDR bacteria and fungi, on the basis of the suspected risk factors. Dosage adjustment needs to be based on pharmacokinetic parameters. Supportive care includes pain management, optimization of ventilation, haemodynamic and fluid monitoring, improvement of renal function, nutrition and anticoagulation. CONCLUSIONS The majority of patients with peritonitis develop complications, including worsening of pre-existing organ dysfunction, surgical complications and healthcare-associated infections. The probability of postoperative complications must be taken into account in the decision-making process prior to surgery.
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Pathophysiology and burden of infection in patients with diabetes mellitus and peripheral vascular disease: focus on skin and soft-tissue infections. Clin Microbiol Infect 2015. [PMID: 26198368 DOI: 10.1016/j.cmi.2015.03.024] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diabetes mellitus affects 284 million adults worldwide and is increasing in prevalence. Accelerated atherosclerosis in patients with diabetes mellitus contributes an increased risk of developing cardiovascular diseases including peripheral vascular disease (PVD). Immune dysfunction, diabetic neuropathy and poor circulation in patients with diabetes mellitus, especially those with PVD, place these patients at high risk for many types of typical and atypical infections. Complicated skin and soft-tissue infections (cSSTIs) are of particular concern because skin breakdown in patients with advanced diabetes mellitus and PVD provides a portal of entry for bacteria. Patients with diabetes mellitus are more likely to be hospitalized with cSSTIs and to experience related complications than patients without diabetes mellitus. Patients with PVD requiring lower extremity bypass are also at high risk of surgical site and graft infections. Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent causative pathogen in cSSTIs, and may be a significant contributor to surgical site infections, especially in patients who are colonized with MRSA on hospital admission. Patients with cSSTIs and diabetes mellitus or PVD experience lower clinical success rates than patients without these comorbidities, and may also have a longer length of hospital stay and higher risk of adverse drug events. Clinicians should be vigilant in recognizing the potential for infection with multi-drug-resistant organisms, especially MRSA, in these populations and initiating therapy with appropriate antibiotics.
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Clinical efficacy of tigecycline used as monotherapy or in combination regimens for complicated infections with documented involvement of multiresistant bacteria. Infection 2014; 43:37-43. [PMID: 25367409 PMCID: PMC4315528 DOI: 10.1007/s15010-014-0691-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 10/08/2014] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Tigecycline is an established treatment option for infections with multiresistant bacteria (MRB). It retains activity against many strains with limited susceptibility to other antibiotics. Efficacy and safety of tigecycline as monotherapy or in combination regimens were investigated in a prospective noninterventional study involving 1,025 severely ill patients in clinical routine at 137 German hospitals. MATERIALS AND METHODS Data on the full population have been published; our present analysis focuses on infections caused by MRB. The study population included patients with complicated infections, high disease severity (APACHE II > 15: 65 %) and high MRB prevalence. Most patients had comorbidities, including cardiovascular disease, renal insufficiency, and/or diabetes mellitus. Treatment success was defined as cure/improvement without requirement of further antibiotic therapy. RESULTS Pathogens isolated from 215 evaluable patients with documented MRB infections included 132 methicillin-resistant Staphylococcus aureus (MRSA), 42 vancomycin-resistant Enterococci (VRE) and 67 Gram-negative extended beta-lactamase (ESBL) producers. Of the MRB subpopulation, 140 patients received tigecycline monotherapy, 75 were treated with combination regimens. High overall clinical success rates were recorded for MRB infections treated with tigecycline alone (94 %) or in combinations (88 %); in detail intraabdominal infections (monotherapy: 90 %; combinations: 93 %), skin/soft tissue infections (93; 100 %), community-acquired pneumonia (100; 100 %), hospital-acquired pneumonia (94,7; 72,7 %), diabetic foot infections (89; 33 %), blood stream infections (100; 100 %) and multiple-site infections (92; 71 %). CONCLUSIONS Tigecycline achieved high clinical success rates in patients with documented infections involving MRB strains despite high disease severity. These results add to the evidence indicating that tigecycline is a valuable therapeutic option for complicated infections in severely ill patients with a high likelihood of multidrug-resistant pathogen involvement.
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[Therapy of skin and soft tissue infections from surgeon's point of view]. Dtsch Med Wochenschr 2014; 139 Suppl 3:S91-2. [PMID: 25429540 DOI: 10.1055/s-0034-1369846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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[Efficacy of ceftaroline in treating complicated skin and soft tissue infections]. Dtsch Med Wochenschr 2014; 139 Suppl 3:S87-8. [PMID: 25429538 DOI: 10.1055/s-0034-1369826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Pan-European early switch/early discharge opportunities exist for hospitalized patients with methicillin-resistant Staphylococcus aureus complicated skin and soft tissue infections. Clin Microbiol Infect 2014; 20:993-1000. [PMID: 24673973 DOI: 10.1111/1469-0691.12632] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 03/16/2014] [Accepted: 03/22/2014] [Indexed: 11/30/2022]
Abstract
The objective of this study was to document pan-European real-world treatment patterns and healthcare resource use and estimate opportunities for early switch (ES) from intravenous (IV) to oral antibiotics and early discharge (ED) in hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA) complicated skin and soft tissue infections (cSSTIs). This retrospective observational medical chart review study enrolled 342 physicians across 12 European countries who collected data from 1542 patients with documented MRSA cSSTI who were hospitalized (July 2010 to June 2011) and discharged alive (by July 2011). Data included clinical characteristics and outcomes, hospital length of stay (LOS), MRSA-targeted IV and oral antibiotic use, and ES and ED eligibility according to literature-based and expert-validated criteria. The most frequent initial MRSA-active antibiotics were vancomycin (50.2%), linezolid (15.1%), clindamycin (10.8%), and teicoplanin (10.4%). Patients discharged with MRSA-active antibiotics (n = 480) were most frequently prescribed linezolid (42.1%) and clindamycin (19.8%). IV treatment duration (9.3 ± 6.5 vs. 14.6 ± 9.9 days; p <0.001) and hospital LOS (19.1 ± 12.9 vs. 21.0 ± 18.2 days; p 0.162) tended to be shorter for patients switched from IV to oral treatment than for patients who received IV treatment only. Of the patients, 33.6% met ES criteria and could have discontinued IV treatment 6.0 ± 5.5 days earlier, and 37.9% met ED criteria and could have been discharged 6.2 ± 8.2 days earlier. More than one-third of European patients hospitalized for MRSA cSSTI could be eligible for ES and ED, resulting in substantial reductions in IV days and bed-days, with potential savings of €2000 per ED-eligible patient.
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[Empirical antibiotic therapy in intra-abdomial infections: cases and evidence-based therapeutic recommendations]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2013; 51:1069-81. [PMID: 24022201 DOI: 10.1055/s-0033-1335043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Intra-abdominal infections (IAI) are a common problem in visceral medicine. In Germany more than 150 000 patients are treated each year for IAI with courses ranging from uncomplicated disease to severe life-threatening manifestations. IAI represent the second most common cause of septic shock and the second most common cause of infection-related mortality in intensive care. Due to increasing antimicrobial resistance, changes in pathogen spectra and increasing patient co-morbidities, recommendations for empirical antibiotic therapy have to be continuously updated: Whereas inadequate empirical treatment is associated with poor prognosis, unselected broad-spectrum therapy may increase antimicrobial resistances. Illustrated by clinical cases of typical intra-abdominal infections, this article reviews recommendations for antibiotic therapy based on national and international guidelines under consideration of local resistance rates and patient-specific factors to provide a basis for improved therapy of this common problem.
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SP35-1 Gram-positive bacteria (MRSA, VRE) in complicated intra-abdominal infections – do they play a role? Int J Antimicrob Agents 2013. [DOI: 10.1016/s0924-8579(13)70239-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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[Infection control in the operating room: preventive measures and isolation precautions in cases of multidrug resistant pathogens]. Zentralbl Chir 2011; 137:284-92. [PMID: 21667444 DOI: 10.1055/s-0031-1271525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Providing surgical treatment for patients colonised or infected with multidrug resistant organisms (MDROs) is daily routine in German hospitals. However, there is uncertainty about the application of adequate infection control measures in the OR. One of the reasons is that specific guidelines are not available. MATERIAL AND METHODS We evaluated current practice in surgical departments of selected German university medical centres using a questionnaire. In addition, centres were asked to provide in-house standard operating procedures (SOP), if available. RESULTS Nineteen questionnaires from 19 departments within 4 centres and 5 in-house SOPs were ana-lysed. The results showed a broad spectrum of applied infection control measures. Wide variations existed both within centres and within departments of the same centre regardless of existing in-house standards. CONCLUSIONS Guidelines addressing perioperative infection control measures for patients harbouring MDROs should be developed with a focus on practicability to reduce both transmission of MDROs and unreasonable measures. Implementation of existing SOPs can be a target for optimisation.
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Diffuse postoperative peritonitis -- value of diagnostic parameters and impact of early indication for relaparotomy. Eur J Med Res 2010; 14:491-6. [PMID: 19948445 PMCID: PMC3352290 DOI: 10.1186/2047-783x-14-11-491] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Objective Current criteria for performing relaparotomy for suspected peritonitis are non explicit and based on non-quantitative, subjective arguments or hospital practice. The aim of this study was to determine the value of routinely used clinical and diagnostic parameters in early detection of postoperative, diffuse peritonitis (PP). Furthermore, the prognosis and outcome after early indication for relaparotomy in patients with PP compared to community-aquired peritonitis (CAP) was evaluated. Methods Between 1999 and 2008, a total of 251 patients with diffuse secondary peritonitis either postoperative (PP) or community acquired (CAP) were analyzed retrospectively. PP (n = 114) and CAP (n = 137) were compared regarding physical examination, MPI-Score, APACHE II-Score, evidence of organ failure, laboratory parameters, diagnostic instruments and clinical course. The treatment regimen comprised surgical source control (with/without programmed lavage), abdominal closure and relaparotomy on demand, broad spectrum antibiotic therapy and intensive care support. Results The APACHE II-Score (20 CAP vs. 22 PP, p = 0.012), MPI-Score (27 CAP vs. 30 PP, p = 0.001) and the number of lavages differed significantly. Positive phyiscal testing and signs of sepsis [abdominal pain (81.6% PP vs. CAP 97.1%, p = 0.03), rebound tenderness (21.9% vs. 35.8%, p = 0.02), fever (35.1% vs. 51.8%, p = 0.03)] occurred significantly less often in the PP patients than in the CAP group. Conventional radiography (66.2%) and ultrasonography (44.3%) had a lower diagnostic sensitivity than did abdominal CT-scan (97.2%). Mortality was higher in the PP group but did not differ significantly between the two groups (47.4% PP vs. 35.8% CAP, p = 0.06). Conclusion The value of physical tests and laboratory parameters in diagnosing abdominal sepsis is limited. CT-scanning revealed the highest diagnostic accuracy. A treatment regimen of early relaprotomy appears to be the most reasonable strategy for as early discovery of postoperative peritonitis as possible.
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Abstract
BACKGROUND Mucoceles of the appendix are rare. After appendectomy, mucoceles are detected with a frequency of 0.2 to 0.3 %. Both stenosing / obliterating processes and alterations of the epithelium (hyperplasia, mucinous cystadenoma, cystadenoma with uncertain malignant potential (UMP), mucinous cystadenocarcinoma lead to the occurrence of mucoceles. The perforation of a mucocele with possible spread of mucus and cells into the abdominal cavity constitutes a severe complication (pseudomyxoma peritonei). Surgical resection is the curative approach for mucoceles of the appendix. MATERIALS AND METHODS Data of patients who were treated for an appendiceal mucocele between 1995 and 2009 were analysed retrospectively with regard to clinical presentation, diagnostic measures, surgical procedure and histopathological result. Follow-up was evaluated in telephone interviews. RESULTS We extracted 5 cases from our database. Clinical symptoms varied greatly among the individual patients, ranging from peracute abdominal pain in the right lower quadrant to chronic obstipation. Results from abdominal ultrasound and / or abdominal CT scans contributed to the indication for surgical intervention in all cases. In 2 patients surgery was stated as urgent whereas in 3 the operation was scheduled electively. In one patient the diagnosis of an appendiceal mucocele was stated preoperatively and in another intraoperatively. In 3 patients only the histopathological result revealed the underlying mucocele. We performed 1 open and 1 laparoscopic appendectomy, 1 open appendectomy with a partial resection of the coecum and 2 laparoscopic ileocoecal resections. One of the patients had a pseudomyxoma peritonei. The histopathological diagnoses ranged from mere epithelial hyperplasia to an adenoma with uncertain malignant potential and a mucinous cystadenocarcinoma. One patient's long-term follow-up could not be evaluated. All other patients had neither recurrence nor any complications after discharge. CONCLUSIONS Mucoceles of the appendix present with a wide spectrum of clinical symptoms and histopathological alterations. Only an accurate histological analysis reveals the underlying pathological lesion correctly. This study emphasises that a mucocele of the appendix constitutes an important differential diagnosis in patients presenting with pathologies in their right lower abdominal quadrant.
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Risikoabschätzung und Operationsplanung bei zentralen Lungentumoren mittels 3-D Visualisierung. Pneumologie 2008. [DOI: 10.1055/s-2008-1074097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Der thoraxchirurgische Eingriff – Eine vertretbare Therapieoption auch in höherem Lebensalter? Pneumologie 2008. [DOI: 10.1055/s-2008-1074440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Evaluation of homogeneity of alveolar ventilation with electrical impedance tomography during anaesthesia and laparoscopic surgery. Crit Care 2008. [PMCID: PMC4088686 DOI: 10.1186/cc6536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
Skin and soft tissue infections are common diseases. The spectrum ranges from slight furuncles to severe necrotizing soft tissue infections. Grampositive bacteria account for 70-80 % of cases as causative organisms. Diagnostics include rapid evaluation of locally limited or diffuse spreading extent of the disease. In complicated skin and soft tissue infections, surgical intervention with debridement and necronectomy is indicated. Necrotizing skin and soft tissue infections call for programmed redebridement. If systemic signs of inflammation are present (fever > 38 degrees C, leukocytosis, CRP elevation) or significant comorbidity exists, application of antibiotics is indicated. The prognosis in operatively treated patients is dependent on the time of surgical intervention.
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Abstract
The treatment of severe diffuse peritonitis is still associated with a mortality of up to 50 %. Particularly the postoperative peritonitis shows high mortality rates due to septic organ failures. The aim of surgical treatment is the definitive source control followed by removal of fibrin and abdominal lavage of contaminants and infectious fluids. Dependent on the severity of the peritoneal reaction, further treatment consists of primary abdominal closure and relaparotomy on demand, programmed lavage or laparostomy respectively. Septic complications have to be treated by intensive care medicine.
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Das perforierte Jejunaldivertikel – eine seltene Differentialdiagnose des akuten Abdomens. Zentralbl Chir 2006. [DOI: 10.1055/s-2006-944338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Postoperative Prognose von Patienten mit einem infrarenalen Bauchaortenaneurysma – eine Langzeituntersuchung. Zentralbl Chir 2006. [DOI: 10.1055/s-2006-944332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Electrical impedance tomography: changes in distribution of pulmonary ventilation during laparoscopic surgery in a porcine model. Langenbecks Arch Surg 2006; 391:383-9. [PMID: 16555085 DOI: 10.1007/s00423-006-0034-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2005] [Accepted: 01/29/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND Because of the creation of a pneumoperitoneum, impairment of ventilation is a common side-effect during laparoscopic surgery. Electrical impedance tomography (EIT) is a method with the potential for becoming a tool to quantify these alterations during surgery. We have studied the change of regional ventilation during and after laparoscopic surgery with EIT and compared the diagnostic findings with computed tomography (CT) scans in a porcine study. MATERIALS AND METHODS After approval by the local animal ethics committee, six pigs were included in the study. Two laparoscopic operations were performed [colon resection (n=3) and fundoplicatio (n=3)]. The EIT measurements (6th parasternal intercostal space) were continuously recorded by an EIT prototype (EIT Evaluation Kit, Dräger Medical, Lübeck, Germany). To verify ventilatory alterations detected by EIT, a CT scan was performed postoperatively. RESULTS Ventilation with defined tidal volumes was significantly correlated to EIT measurements (r2=0.99). After creation of the pneumoperitoneum, lung compliance typically decreased, which agreed well with an alteration of the distribution of pulmonary ventilation measured by EIT. Elevation of positive end-inspiratory pressure reopened non-aerated lung areas and showed a recovery of the regional ventilation measured by EIT. Additionally, we could detect pulmonary complications by EIT monitoring as verified by CT scans postoperatively. CONCLUSION EIT monitoring can be used as a continuous non-invasive intraoperative monitor of ventilation to detect regional changes of ventilation and pulmonary complications during laparoscopic surgery. These EIT findings indicate that surgeons and anesthetists may eventually be able to optimize ventilation directly in the operating theatre.
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Eckmann C. Ann Anat 2005; 187:520. [DOI: 10.1016/j.aanat.2005.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Monitoring pulmonaler Ventilationsstörungen mit der funktionellen Elektro-Impedanztomographie (fEIT). Eine tierexperimentelle Studie. ROFO-FORTSCHR RONTG 2005. [DOI: 10.1055/s-2005-867653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Therapeutische Strategie bei Anastomoseninsuffizienz nach tiefer anteriorer Rektumresektion. ACTA ACUST UNITED AC 2005. [DOI: 10.1055/s-2005-836313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Anastomotic leakage following low anterior resection: results of a standardized diagnostic and therapeutic approach. Int J Colorectal Dis 2004; 19:128-33. [PMID: 14752675 DOI: 10.1007/s00384-003-0498-8] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2003] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS This study analyzed the results of a standardized approach in anastomotic leakage following low anterior resection for rectal cancer without performance of a protective ileostomy during the primary operation. PATIENTS AND METHODS The study included all 306 patients with rectal cancer electively undergoing low anterior resection with retroperitonealization of the anastomosis over 9 years. The diagnostic procedure for anastomotic leakage included serum laboratory investigations and abdominal CT together with contrast enema. Minor leakages, i.e., small leakages and pelvic abscess, were treated with rectoscopic lavage and/or CT-guided drainage of the abscess, respectively. Major leakage was defined as broad insufficiency with or without septicemia. Nonseptic patients were treated by ileostomy and rectoscopic treatment. In septic patients a revision of the anastomosis with loop ileostomy was performed. RESULTS Anastomotic leakage was diagnosed in 30 patients (overall 9.8%; 12 major, 18 minor leakages). Common clinical signs were pelvic pain and fever. No patient developed a peritonitis. The most accurate diagnostic instrument was CT (96.7%). CONCLUSION Retroperitonealization appears to prevent peritonitis in patients with anastomotic leakage following low anterior resection. A differential treatment leads to good results in terms of mortality and anorectal function.
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Laparoscopic colectomy for recurrent and complicated diverticulitis: a prospective study of 396 patients. Langenbecks Arch Surg 2004; 389:97-103. [PMID: 14985985 DOI: 10.1007/s00423-003-0454-7] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2003] [Accepted: 12/10/2003] [Indexed: 02/07/2023]
Abstract
BACKGROUND It was the aim of this prospective study to evaluate the outcome of laparoscopic surgery for diverticular disease. METHODS All patients who underwent elective laparoscopic colectomy for diverticular disease within a 10-year period were prospectively entered into a PC database registry. Indications for laparoscopic surgery were acute complicated diverticulitis (Hinchey stages I and IIa), chronically recurrent diverticulitis, sigmoid stenosis or outlet obstruction caused by chronic diverticulitis. Surgical procedures (sigmoid and anterior resection, left colectomy and resection rectopexy) included intracorporeal dissection and colorectal anastomosis. Parameters studied included age, gender, stage of disease, procedure, duration of surgery, intraoperative technical variables, transfusion requirements, conversion rate, total complication rate including major (requiring re-operation), minor (conservative treatment) and late-onset (post-discharge) complication rates, stay on ICU, hospitalisation, mortality, and recurrence. For objective evaluation, only laparoscopically completed procedures were analysed. Comparative outcome analysis was performed with respect to stage of disease and experience. RESULTS A total of 396 patients underwent laparoscopic colectomy. Conversion rate was 6.8% ( n=27), so that laparoscopic completion rate was 93.2% ( n=369). Most common reasons for conversion were directly related to the inflammatory process, abscess or fistulas. The most common procedure was sigmoid resection ( n=279), followed by anterior resection ( n=36) and left colectomy ( n=29). Total complication rate was 18.4% ( n=68). Major complication rate was 7.6% ( n=28), whereas the most common complication requiring re-operation was haemorrhage in 3.3% ( n=12). Anastomotic leakage occurred in 1.6% ( n=6). Minor complications were noted in 10.7% ( n=40), late-onset complications occurred in 2.7% ( n=10). Mortality was 0.5% ( n=2). Mean duration of surgery was 193 (range 75-400) min, return to normal diet was completed after 6.8 (range 3-19) days. Mean hospital stay was 11.8 (range 4-71) days. No recurrence of diverticulitis occurred. CONCLUSION Laparoscopic surgery for diverticular disease is safe, feasible and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.
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Abstract
HISTORY AND CLINICAL FINDINGS Case 1: Following an influenza a 40-year-old patient was treated by intramuscular injections for backache. 24 hours later he was admitted to a hospital with massive pain in both lower extremities and a markedly reduced general condition. Case 2: Two days after a knee joint arthroscopy a 57-year-old man developed strong pain in the extremity treated by application of diclofenac. On the following day the patient was admitted to a university hospital in a septic state with a swollen, cold and blurry changed extremity. INVESTIGATIONS The myoglobin concentration was dramatically increased in both cases (> 15 000 mg/l). CRP values were elevated. The progressive septic state with acute renal failure was verified by elevation of creatinine concentration and decrease of leukocyte values in the second case (from 10/nl to 2,5/nl) shortly after admission. DIAGNOSIS, TREATMENT AND COURSE Both the patients died for septic shock. Case 1 died shortly after admission before surgical intervention. The second patient developed rapid progression of the myositis including the trunk despite radical surgical treatment (hip joint exarticulation). CONCLUSION In cases of sudden and painful swelling of an extremity of unknown origin or following intramuscular injection streptococcal myositis has to be taken into account. Only an immediate surgical intervention up to amputation of the affected extremity can stop the fatal course.
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[Anticoagulation in the treatment of sepsis. Correction of microcirculation: a new approach manipulating endothelial cell function]. Chirurg 2002; 73:1093-9. [PMID: 12430059 DOI: 10.1007/s00104-002-0553-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The correction of coagulation disorders is only one aspect in the treatment of severe sepsis. The metabolic changes caused by sepsis are complex. They include the interactions of hundreds of plasma proteins. The system works in balanced patterns of agonists and antagonists, not allowing a preference for single substances. The endothelial cell plays a key role in multiple defence functions in sepsis. Thus, future research in sepsis has to focus on the manipulation of endothelial cell function.
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[Surgical management of peritonitis and sepsis]. Zentralbl Chir 1999; 124:176-80. [PMID: 10327571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The intraabdominal sepsis is one of the major surgical problems today. The Systemic Inflammatory Response Syndrome in peritonitis often leads to multiple organ failure. The surgical eradication of the infectious focus is the most important prerequisite for a successful treatment. Dependent on the form and severity of the local inflammation, different forms of abdominal lavage can be applied. Using surgical and physiological as well as organ failure scores like the Mannheimer-Peritonitis-Index (MPI), the APACHE-II and the Septic-Severity-Score (SSS), the prognosis can be objectively assessed and different clinical studies can be compared. However, in 88 own patients suffering from diffuse purulent peritonitis with sepsis (May 1990 to December 1996), all the above mentioned scores significantly allowed to discriminate surviving (mean MPI: 25, APACHE-II day 1: 19, SSS day 1: 28) from non surviving patients (mean MPI: 31, APACHE-II day 1: 26, SSS day 1: 45). Furthermore, mortality increased significantly with increasing score ranges (< 20, 20 to 30, and > 30 points) for MPI from 0% to 28% to 81%, for APACHE-II day 1 from 20% to 46% to 100%, and for SSS day 1 from 10% to 37% to 71%.
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Abstract
Since the mid-1980s increasing numbers of severe group A streptococcal infections (Streptococcus pyogenes) have been reported worldwide. Younger, healthy patients after minor local trauma are most commonly afflicted. The infection is characterized by a rapid course with shock, sepsis, multiorgan failure, soft-tissue infection and a high mortality rate. This special disease has been termed "streptococcal toxic shock-like syndrome". The M-proteins, especially types 1 and 3, and the streptococcal pyrogenic exotoxin A (speA) might play an important role in the pathogenesis of the infection. High dose therapy with antibiotics, monitoring in the intensive care unit and early, aggressive and often multiple debridement of necrotic soft tissue are necessary to save the patient's life.
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[Quality assurance in surgical education]. LANGENBECKS ARCHIV FUR CHIRURGIE. SUPPLEMENT. KONGRESSBAND. DEUTSCHE GESELLSCHAFT FUR CHIRURGIE. KONGRESS 1998; 114:694-6. [PMID: 9574243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
UNLABELLED The authors determine the reliability, validity and usefulness of the "QuaSi"-test, a test for the evaluation of surgical residents. METHODS A test with multiple-choice (MC) answers was given to 47 surgeons, residents and interns of our surgery clinic. The reliability and validity of the tests were determined using statistical methods. RESULTS The reliability of the test was very high. Performance varied significantly according to the level of training (postgraduate year). Surgeons performed best, then the senior residents; students and interns performed worst. CONCLUSION The QuaSi-test is a highly reliable and valid examination that provides unique information about the performance of individual residents and the quality of postgraduate-training programs.
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[Clostridium myonecrosis as a sequelae of intramuscular injections--description of 3 fatal outcomes]. LANGENBECKS ARCHIV FUR CHIRURGIE. SUPPLEMENT. KONGRESSBAND. DEUTSCHE GESELLSCHAFT FUR CHIRURGIE. KONGRESS 1998; 114:553-5. [PMID: 9574205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In three fatal cases of clostridial myonecrosis, the following criteria were found: repeated intramuscular injections over several years with anti-inflammatory substances, delay in diagnosis in outpatient care, and following uncontrollable systemic septic complications, despite radical surgical treatment. Only early, aggressive surgical interventions can stop the rapid course of necrotizing soft-tissue infections.
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[Laparoscopic staged lavage in CAPD catheter peritonitis--an alternative to open treatment?]. LANGENBECKS ARCHIV FUR CHIRURGIE. SUPPLEMENT. KONGRESSBAND. DEUTSCHE GESELLSCHAFT FUR CHIRURGIE. KONGRESS 1998; 114:1188-90. [PMID: 9574373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Three patients suffering from severe CAPD peritonitis underwent laparoscopically programmed lavage after removal of the catheter. After an average of four laparoscopic lavage operations all patients had to be treated using conventional open procedures; a mean of ten programmed lavage procedures were carried out because of increasing peritoneal inflammation and worsening of the clinical situation during minimal invasive therapy. One patient did not survive. Laparoscopic treatment is thus not recommended for diffuse peritonitis.
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[Antibiotic prophylaxis in visceral surgery]. Chirurg 1997; 68:951-5. [PMID: 9410689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Invasive group A streptococcal infections. N Engl J Med 1997; 336:513-4; author reply 514. [PMID: 9019656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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41
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Die nekrotisierende Fasziitis der Vulva. Geburtshilfe Frauenheilkd 1997. [DOI: 10.1055/s-2007-1023033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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[Indications for emergency surgery]. Anasthesiol Intensivmed Notfallmed Schmerzther 1996; 31:255-6. [PMID: 8704087 DOI: 10.1055/s-2007-995912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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[Carcinoma of the gastric stump. Diagnosis, surgical procedure and prognosis]. LANGENBECKS ARCHIV FUR CHIRURGIE 1995; 380:108-14. [PMID: 7760648 DOI: 10.1007/bf00186417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The results of a retrospective analysis of cases of gastric stump cancer are reported. Among 298 gastric carcinomas treated between 1. 1. 1986 and 1. 3. 1994, we found 28 (9.5%) cases of gastric stump cancer. Gastric carcinoma showed a male preponderance, with a male:female ratio of ca. 4:1. Two thirds of the patients were older than 70 years at the time of diagnosis. In 27 of 28 patients the original operation performed was a Billroth II resection without Braun's enteroanastomosis. The mean time lag before the development of gastric stump cancer was significantly shorter in the group of patients older than 45 years at the time of first operation (n = 16) than in patients 45 years or younger (n = 12, P = 0.03). Endoscopy with biopsy and endosonography were highly reliable diagnostic instruments. The capability of CT for recognizing lymphatic metastasis is poor (42.1% sensitivity). The main risk factors for the development of gastric stump cancer, according to our data, are male sex, Billroth II resection for first reconstruction, age over 45 years at first operation, and gastric ulcer as reason for the original gastric resection. The cost benefit ratio and timing of endoscopic screening of partially gastrectomized patients are discussed.
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Diagnostik und Management der pränatal therapiebedürftigen Rhesus-Inkompatibilität. Arch Gynecol Obstet 1993. [DOI: 10.1007/bf02266456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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[Myeloperoxidase, lactoferrin and elastase in bronchoalveolar lavage and plasma in pneumonia]. Pneumologie 1992; 46:141-7. [PMID: 1315965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Neutrophilic granulocytes in the lower respiratory tract are of decisive importance for the elimination of pathogenic germs in bacterial pneumonia. On the other hand, the liberation of phagocyte products (e.g. elastase) can result in tissue damage in the parenchyma of the lungs. For this reason, we determined in patients suffering from acute pneumonia (n = 21), in patients with acute pneumonia associated with immunosuppression (n = 12), in patients who had overcome their pneumonia (n = 9) and in controls (n = 17) in bronchoalveolar lavage (BALF) and in plasma, the concentration of the locally produced granulocyte products myeloperoxidase (MPO), lactoferrin (LF) and elastase-alpha 1 proteinase complex (ELA) as well as of the alpha 1 proteinase inhibitor (alpha 1 Pi) and alpha 2 proteinase inhibitor (alpha 2 Pi) via chemoluminescence immunoassay, and compared the same with the differential cell count in the BALF. The protein concentrations were referred to the albumin concentration (Alb) for standardisation. This concentration did not differ significantly between the various patients and control groups. The BALF concentration of ELA in the group with pneumonia (median: 86.3 micrograms/l or 8.5 micrograms/mg Alb) was about eight times higher than in the group of patients suffering from pneumonia with immunosuppression (median: 16 micrograms/l or 1.0 micrograms/l Alb, p less than 0.001) or in whom the pneumonia was no longer present (17.6 micrograms/l or 0.5 micrograms/mg), and approximately 40 times higher than in the control group (3 micrograms/l or 0.2 micrograms/mg, respectively). Similar results were obtained for LF (61 micrograms/mg Alb vs. 11.3; 16.8 and 5.9 micrograms/mg; p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
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Abstract
At 24 weeks of gestation, an intracranial cystic lesion of 3 cm diameter, without further associated foetal malformations, was detected by ultrasound in a 25-year old nullipara prima gravida, during routine prenatal care. Within 5 weeks, the cystic mass developed into a predominantly solid tumour located at the 3rd ventricle, showing patterns of a rapidly growing malignant intracerebral process. At 29 weeks of gestation, pregnancy was terminated by sectio parva because of a progressive hydrocephalus with a biparietal diameter of 10.2 cm. Autopsy confirmed a malignant teratoma. Foetal intracranial teratomas are rare. Diagnosis and therapy should be carried out in perinatal centres.
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Atrial natriuretic peptide and cyclic guanosine-3',5'-monophosphate in normal and pathological pregnancies. Gynecol Obstet Invest 1990; 29:101-3. [PMID: 2159430 DOI: 10.1159/000293311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The concentrations of atrial natriuretic peptide (ANP) and its presumed second messenger, cyclic guanosine-3',5'-monophosphate (cGMP) were determined in maternal plasma and amniotic fluid. Samples were obtained from normal and pathological pregnancies revealing hydramnios or severe Rh incompatibility between week 16 of gestation and delivery. For analysis of ANP and cGMP, radioimmunoassays were used. ANP and cGMP concentrations in maternal plasma did not differ in normal and pathological pregnancies. In amniotic fluid, we found ANP levels of about 120 pg/ml at 16 weeks of gestation which then decreased below the detection limit of 15.6 pg/ml. In contrast, cGMP levels were low at the beginning of pregnancy (4 pmol/ml) and rose significantly (14 pmol/ml), at the end of pregnancy. Pregnancies revealing severe Rh incompatibility exhibited the same levels as normal pregnancies when regular prenatal transfusions resulted in sufficient blood volume substitution. ANP, a volume-homeostasis-regulating hormone, is already produced in early pregnancy. The meaning of the presumed second messenger, cGMP, requires further investigation.
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Abstract
Megalospermatocytes are degenerating primary spermatocytes which do not develop any further than to leptotene stage of the prophase of meiosis. In histological sections they are prominent because of their size (approximately 24 microns in diameter). The nucleus of a megalospermatocyte presents single strands of chromosomes only. The cytoplasm contains extremely widened vesicles and cisternae of the ER which are filled with a finely granular electron dense material. Megalospermatocytes may appear singular in small groups in the testis tissue of young men with varying fertility disturbances. They are relatively frequent in testis tissue of men older than 65 years. Here they represent a special form of a rest of spermatogenetic activity in the germinal epithelium.
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Abstract
The cytology of multinucleated spermatocytes and spermatid giant cells in the seminiferous tubules of men with oligozoospermia and of men older than 65 years has been investigated electron microscopically. Two different processes which are responsible for the origin of multinucleated germ cells have been analysed: Defects of the intercellular bridges (IB): they move apart and thus allow the confluence of one clone's cells to symplasms. The confluence of membranes: within one clone the membranes of neighbouring germ cells are dissolved and thus intercellular bridges are found in the cytoplasm of the resulting giant cells. The spermatid giant cells reveal a new organization of the cell nuclei and the cell organelles. Yet they disintegrate in the lumen of the seminiferous tubules. The appearance of giant cells therefore is an expression of the germ cell degeneration.
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