[Long-term results of benign bile duct strictures after treatment with pedicled jejunal patches]. / Langzeitergebnisse nach Behandlung benigner Gallengangsstrikturen mit gestieltem Jejunumstreifen.

Benign strictures of the common bile duct after surgery or due to gallstones may lead to obstruction and derangement of bile drainage in the extrahepatic biliary system. Although the treatment of choice in these situations is the endoscopic dilatation, in some cases with stenosis of a long segment of the bile duct a partial replacement with a vascularised jejunal patch may be possible and useful. To our knowledge, there are no reports on long-term results of the procedure. We describe the course, the surgical technique and long-term results of four patients with a jejunal patch reconstruction of the common bile duct. Ten years after surgery there were no radiologic or laboratory signs of a restenosis of the common bile duct.

[Post-traumatic intrahepatic arterioportal fistula]. / Die posttraumatische intrahepatische arterioportale Fistel.

Traumatic arterioportal fistulas (APF) are very rare. The most common reasons are liver biopsy and liver injuries. They are also caused by liver tumours and vessel anomalies. This is a case-report of a patient who developed an APF after blunt abdominal trauma. The fistula bearing part of the liver was resected in two sessions. In cases of large APFs with a flow from multiple collaterals the therapy of choice is the embolization. If not possible a selective excision of the fistulous sac or the resection of the fistula containing liver segment are recommended.

Outcome and cost-effectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal tract surgery: a prospective randomized study.

HYPOTHESIS: Perioperatively administered enteral immunonutrition will improve early postoperative morbidity and cost-effectiveness after gastrointestinal tract surgery. DESIGN: A prospective, randomized, double-blind, multicenter clinical trial. SETTING: Surgical departments in German university and teaching hospitals. PATIENTS: One hundred fifty-four patients with upper gastrointestinal tract malignant neoplasms who were eligible for analysis. INTERVENTION: Preoperatively, patients received 5 days of oral immunonutrition (an arginine-, RNA-, and omega3 fatty acid-supplemented diet) or an isoenergetic control diet (1 L/d). Early postoperative enteral feeding with immunonutrition or an isoenergetic, isonitrogenous control diet using a catheter jejunostomy was performed for 10 days. MAIN OUTCOME MEASURES: Postoperative infectious complications, their treatment costs, and cost-effectiveness of immunonutrition were analyzed. Plasma levels of the fatty acids eicosapentaenoic acid and docosahexaenoic acid were measured. RESULTS: In the immunonutrition group, significantly fewer infectious complication events occurred (14 vs 27; P = .05). The number of patients with complications was significantly lower in the supplemented diet group after postoperative day 3 (7 vs 16; P = .04). The treatment costs of complications in the supplemented diet group were suggestively lower than in the control diet group (DM 75172 vs DM 204273). Cost-effectiveness was DM 1503 in the experimental group vs DM 3587 in the control group, where DM denotes deutsche mark (German currency). CONCLUSION: The perioperative administration of an enteral immunonutrition significantly (P = .05) decreased the early occurrence of postoperative infections and reduced substantially the treatment costs of the complications after major upper gastrointestinal tract surgery.

Origin of the chromosome 1 HSR of the house mouse detected by CGH.

The polymorphic Sp100-rs repeat cluster in chromosome band 1D of the house mouse, Mus musculus, makes up as much as 0.1-5% of the haploid genome. 'High-copy' versions of this long-range repeat cluster are cytogenetically apparent as DAPI-negative chromomycin-A3-positive homogeneously staining regions (HSRs). The cluster is a relatively recent acquisition in the genus Mus; the related species M. caroli possesses neither the Sp100-rs cluster nor even the Sp100-rs gene. Except for chromosomes with high-copy clusters, no major rearrangements are visible in chromosomes 1 from M. musculus and M. caroli: they have the same order of G-bands, DAPI-bands and chromomycin A3-bands. Comparative genomic hybridization (CGH) visualizes the cluster in M. musculus and detects a single region of sequence homology to the cluster in M. caroli chromosome band 1D. This indicates that the M. musculus cluster has evolved in situ from sequences originally present in the same chromosome band.

[Lipoma: a rare differential gastrointestinal tumor diagnosis]. / Lipom: seltene Differentialdiagnose gastrointestinaler Tumore.

This is a case report of a female patient who during a routine follow-up after a gastrectomy showed a tumor of the ileo-cecal valve, which--according to all radiologic diagnostic procedures--was highly suspected to be a malignant tumor. However, the histologic diagnosis was benign lipoma. The incidence and the characteristics of gastrointestinal lipomas in the actual literature will be reviewed.

Early postoperative enteral immunonutrition: clinical outcome and cost-comparison analysis in surgical patients.

OBJECTIVE: To determine if early postoperative feeding of patients with upper gastrointestinal malignancy, using an enteral diet supplemented with arginine, dietary nucleotides, and omega-3 fatty acids (IMPACT, Sandoz Nutrition, Bern, Switzerland) results in an improved clinical outcome, i.e., reduced infectious and wound complications and decreased treatment costs when compared with an isocaloric, isonitrogenous control diet. DESIGN: A prospective, randomized, placebo-controlled, double-blind, multicenter trial of the clinical outcome and a retrospective cost-comparison analysis. SETTING: Surgical intensive care units in three different German university hospitals. PATIENTS: Of 164 patients enrolled in the study, 154 patients were eligible for analysis. They were admitted to the intensive care unit after upper gastrointestinal surgery for cancer and they received an enteral diet via needle catheter jejunostomy. Infectious complications were defined as sepsis or systemic inflammatory response syndrome, pneumonia, urinary tract infection, central venous catheter sepsis, wound infection, and anastomotic leakage. The complication events were prospectively divided into two groups: early (postoperative days 1 to 5) and late (after the fifth postoperative day) postoperative complications. The treatment costs of each complication were analyzed and compared in both groups. INTERVENTIONS: Patients were randomized to receive either the immunonutritional diet (n = 77) or an isocaloric and isonitrogenous placebo diet (n = 77). Enteral feeding was initiated 12 to 24 hrs after surgery, starting with 20 mL/hr and advanced to a target volume of 80 mL/hr by postoperative day 5. MEASUREMENTS AND MAIN RESULTS: Clinical examination and adverse gastrointestinal symptoms were recorded on a daily basis. Both groups tolerated early enteral feeding well, and the rate of tube feeding-related complications was low. Postoperative complications occurred in 17 patients in the immunonutrition group vs. 24 patients in the control group (NS). Further, in the early phase (postoperative day 1 to 5), complications occurred to a similar extent in both groups (12 patients in the immunonutritional group vs. 11 patients in the control group). However, in the late phase (after postoperative day 5), considerably fewer patients in the experimental diet group experienced complications compared with the control group (5 vs. 13, p < .05). In addition, the frequency rate of complicating events were recorded in each group. In the experimental diet group, a total of 22 complicating events were recorded vs. a total of 32 events in the placebo diet group (NS). However, the occurrence of late complicating events, i.e., complicating events after the fifth postoperative day, was significantly reduced in the immunonutrition group when compared with the control group (8 vs. 17 events, p < .05). The total costs for the treatment of the complications were 83,563 German marks in the experimental diet group vs. 122,430 German marks in the control group, resulting in a cost-reduction of 38,867 German marks. (At the end of December 1995, the conversion rate from German marks to U.S. dollars was 1.4365 German marks to $1.00.) CONCLUSIONS: Early enteral feeding with an arginine, dietary nucleotides, and omega-3 fatty acids supplemented diet, as well as an isonitrogenous, isocaloric control diet (placebo) were well tolerated in patients who underwent upper gastrointestinal surgery. In patients who received the supplemented diet, a significant reduction in the frequency rate of late postoperative infectious and wound complications was observed. Thereby, the treatment costs were substantially reduced in the immunonutrition group as compared with the control group.

Mitoxantrone-induced DNA strand breaks in cell-cultures of malignant human astrocytoma and glioblastoma tumors.

In this study mitoxantrone (Mtx) induced DNA strand breaks were measured with the alkaline elution technique in short term cell cultures derived from human gliomas. Glioblastomas or astrocytomas from 5 patients who underwent intracranial surgery were cultured and incubated i h with different concentrations of Mtx (0, 0.01, 0.1 and 1.0 microgram/ml). The alkaline elution method was modified to measure DNA lesions in human gliomas. Mtx induced DNA strand breaks in a dose dependent manner in all cell cultures tested. There was a linear increase of DNA strand break frequency induced by Mtx between 0.01-1.0 microgram/ml. concerning these in vitro data, Mtx might be potentially useful for the treatment of patients with malignant brain tumors.

Verification of the position of pedicle screws in lumbar spinal fusion.

Medial or lateral pedicle screw penetration with the potential to affect neural structures in a wellknown and frequent problem associated with posterior spinal fusion. We evaluated the placement of pedicle screws (n = 141) in 36 patients following posterior lumbar spinal fusion with Socon or Kluger instrumentation via a lateral transpedicular approach. The examination was based on CT and MR images performed after removal of the instrumentation, on average 1 year after implantation. We found seven pedicle screws with lateral cortical penetration of the pedicle and five screws with medial cortical penetration of the pedicle (8.5% pedicle penetration overall). No severe radicular complications accompanied these pedicle penetrations. The mean insertion angles of the pedicle screws at the L4 level were 22.6 degrees and 23.1 degrees for the left and the right side, respectively. At the L5 level the mean insertion angle was 20.5 degrees on the left side and 21.5 degrees on the right, and at the S1 level the mean angle was 16.2 degrees on the left and 15.2 degrees on the right. The results of this study indicate that the lateral transpedicular approach is a safe procedure for pedicle screw insertion.

Rapid normalization of epidermal integrin expression after allografting of human keratinocytes.

Allogeneic keratinocyte grafts have beneficial effects on skin wounds, but the underlying interactions between graft and woundbed remain to be explored in detail. The epidermal integrins play a pivotal role in mediating cell-to-cell and cell-to-matrix interactions. In unwounded epidermis, alpha 2 beta 1-, alpha 3 beta 1-, alpha 6 beta 4-, alpha 5 beta 1-, and alpha v beta 5-integrins are confined to basal cells. During healing of incisional wounds, these integrins are also expressed in suprabasal cells, where they remain detectable even after epidermal integrity is fully reestablished. We examined the integrin subunits alpha 2, alpha 3, alpha 6, alpha 5, and alpha v in partial thickness burn wounds grafted with allogeneic keratinocytes and asked whether the effect of allogeneic keratinocyte grafts, i.e., fast reepithelialization, is reflected by an accelerated reversion to a normal integrin pattern. Biopsies were taken after wound debridement before grafting and 10 d after transplantation. After 10 d, a stratified epidermis had developed in all cases and integrins were mainly restricted to the basal cell layer of the neo-epidermis. alpha 2-, alpha 3-, alpha 6-, and alpha v-subunits were present at basal and/or lateral cell borders, duplicating the integrin pattern in normal epidermis. The findings indicate that grafting accelerates the shift of the epidermis from an inflammatory to a regenerative state, as reflected by the reversion of the integrin pattern from a "spread-and-migrate" to the "steady-state" phenotype.

alpha 2-Antiplasmin and plasminogen activator inhibitors in healing human skin wounds.

Mechanical injury of tissues is followed by the formation of a provisional fibrin matrix, which is later replaced by granulation tissue. The fibrinolytic proteinase, plasmin, is thought to contribute to the displacement of the primary matrix. Plasmin is generated from the ubiquitous proenzyme plasminogen by plasminogen activators. The system of plasminogen activation is controlled at several levels: plasminogen activator inhibitors (PAI-1 and PAI-2) counteract the activity of plasminogen activators and alpha 2-antiplasmin inhibits the activity of plasmin. In order to elucidate the mechanisms that regulate the plasminogen activator system in healing human skin wounds, we performed the immunohistological study reported here. The plasmin inhibitor alpha 2-antiplasmin and PAI-2 were found in the primary fibrin-rich matrix and in the granulation tissue. alpha 2-Antiplasmin was diffusely distributed in the tissue and its distribution correlated with the presence and localization of plasmin(ogen) except that, in contrast to plasmin(ogen), the alpha 2-antiplasmin was apparently not cell-associated. The stainings for PAI-2 increased with time and paralleled the development of the cellular infiltrate. PAI-2 was found in association with cells, which were identified by double immunofluorescence stainings as monocytes/macrophages and fibroblasts. In line with the immunohistological data, polymerase chain reaction after reverse transcription revealed mRNA for PAI-2 in healing human skin wounds. Taken together, our findings indicate that in healing human skin wounds, PAI-2 is the primary regulator of plasminogen activators, whereas alpha 2-antiplasmin may serve to control plasmin activity.

External fixation of open femoral shaft fractures.

OBJECTIVE: To determine whether external fixation proves to be a sensible technique for definitive stabilization in open femoral fractures. DESIGN: Retrospective clinical study. MATERIALS AND METHODS: From 1985 to 1989, 18 patients (mean ISS 25.4) with open femoral fractures (type II 11%, type III 89%) were treated by primary and definitive external fixation. After failure of closed reduction procedures, open reduction via debrided soft tissue wounds was employed in 72%. Supplemental internal fixation of large wedge fragments was required in 66%. External fixators were removed after a mean of 166 days. Early deep infections developed in 11%. Additional cast, brace, or traction were not required. MEASUREMENTS AND MAIN RESULTS: After a mean follow-up period of 58 months, 88% of the surviving 17 patients were clinically and radiologically evaluated and 12% were interviewed by telephone. Eleven percent developed late deep infection of the femur concerned. Eighty percent have had full or slightly restricted knee motion. The mean knee flexion amounted to 130 degrees. Relevant shortening of the femur was diagnosed in 7%. Nonunions or relevant malunions were not observed in our series. CONCLUSIONS: These morphologic and functional results compare with those published for alternative stabilization techniques of femoral fractures. For special indications, external fixation is considered to be a sensible technique for primary and definitive treatment of open femoral fractures.

Modulation of postoperative immune response by enteral nutrition with a diet enriched with arginine, RNA, and omega-3 fatty acids in patients with upper gastrointestinal cancer.

OBJECTIVE: To find out whether an enteral diet supplemented with arginine, RNA, and omega-3 fatty acids modulated the production of interleukin-1 (IL-1), interleukin-2 (IL-2), IL-2 receptor, interleukin-6 (IL-6), and tumour necrosis factor alpha (TNF-alpha) after operations for upper gastrointestinal cancer. DESIGN: Prospective double blind clinical study. SETTING: University hospital, Germany. SUBJECTS: 42 patients randomised into two groups (n = 21 each), one of which was given an isocaloric and isonitrogenous placebo diet and one of which was fed the same diet supplemented with arginine, RNA, and omega-3 fatty acids. INTERVENTIONS: The cytokines were measured before operation and on postoperative days 1, 3, 7, 10, and 16. MAIN OUTCOME MEASURES: Comparison of concentrations of cytokines in the two groups. RESULTS: Among those receiving the placebo diet (after spontaneous stimulation) IL-6 concentrations were significantly higher on days 3 and 7 (p < 0.05) and TNF-alpha concentrations on day 7. In contrast (after stimulation with phytohaemagglutinin) mean concentrations of IL-2 receptor were significantly higher on days 3 and 7, and of IL-1 beta and IL-2 on day 16 (p < 0.05) in the group receiving the supplemented diet. CONCLUSION: Supplementation of an enteral diet with arginine, RNA and omega-3 fatty acids can modulate the acute phase reaction as indicated by the reduction in concentrations of TNF-alpha and IL-6 in the group fed the supplemented diet. Patients receiving the supplemented diet also showed accelerated recovery in the concentrations of IL-1 beta and IL-2 receptor.

[Comparative study of surgically treated shoulder injuries with or without metal implants]. / Vergleichende Untersuchung operativ versorgter Schultereckgelenksverletzungen mit und ohne metallische Implantate.

In 36 patients with acromioclavicular fracture type III, IV and V following the Rockwood classification, different surgical procedures without using metal implants were compared. Augmentation of both, the coracoclavicular and acromioclavicular ligaments was done by Vicryl-threads (5 mm) in 26 cases (group I). Solitary augmentation of coracoclavicular ligaments were done in 6 cases (group II), of acromioclavicular ligaments in 4 cases (group III). Twenty-four patients underwent follow-up regarding clinical, ultrasonic and radiological results after 30 month in average. Dislocations of more than 10 mm we found once in group I and II, three times in group III. Using the Taft score, regarding clinical, ultrasonic and radiological findings, five patients had an excellent, 15 a good five patients a satisfying result and the remaining patient had a poor reconstruction of the acromioclavicular joint. Comparing these results with previous 75 patients who underwent surgical reconstruction of acromioclavicular joint, using metal implants between 1980 and 1985, the results were nearly equal. Although severe complications like migration or fracture of the implant and the necessity for another surgical intervention for explantation were not given in patients who were treated without using metal implants. Solitary augmentation of acromioclavicular ligament showed insufficient results, therefore this therapy should not be recommended anymore.

Plasminogen activation in healing human wounds.

Tissue injury is followed by formation of a provisional, fibrin-containing matrix. It is later on replaced by granulation tissue. Replacement involves extracellular proteolysis by fibrinolytic enzymes. Plasmin is a fibrinolytic proteinase and is generated from ubiquitous plasminogen by cell-derived urokinase-type (uPA) or tissue-type (tPA) plasminogen activator. To explore the cells and components involved in plasminogen activation, we have performed a combined immunohistological and zymographic study on human skin wounds produced iatrogenically by debridement. The fibrin(ogen)-specific staining indicated the progressive removal of a fibrin-containing provisional matrix. Plasmin(ogen) was present over the entire observation period. It was diffusely distributed and also displayed a conspicuous association with cells of the granulation tissue, in particular with monocytes/macrophages and fibroblasts. Also, uPA was associated with monocytes/macrophages and fibroblasts, whereas the uPA-receptor (uPA-R) was stained in monocytes/macrophages only. The uPA was potentially active as indicated by zymography. No tPA-specific staining was found. The findings point at the importance of monocytes/macrophages and fibroblasts in uPA-mediated plasminogen activation in healing human skin wounds.

[Subcutaneous struma recurrence as a sequela of autologous thyreocyte implantation]. / Subcutanes Strumarezidiv als Folge autologer Thyreocytenimplantation.

Goiter recurrence is a well known fact in the surgical therapy of thyroid diseases. Extremely rare the goiter recurrence is localized in the subcutis or the muscle of the neck. We report on two patients with this type of recurrence. The reason may be an autologous implantation of thyroid follicle cells intraoperatively. It can be avoided by removing all particles of the thyroid gland from the operation area.

Intraarticular autogenous bone grafting in recurrent shoulder dislocations.

In a reexamination, 24 young soldiers who had been operated on using a new method of screwing an autogenous bone graft into the glenoid rim in cases of recurrent dislocation of the shoulder joint were investigated. A major functional problem is the reduced lateral rotation, even by using other procedures for operative treatment like Eden-Hybinette or Putti-Platt. This reduction of shoulder movement results in problems using the affected arm during sporting activities or military duties. There has been an excellent result without any redislocation in a follow through of 6 to 42 months and more than 90% satisfied patients, with only a very low rate of reduction of lateral rotations about 10 degrees using this procedure. The X-rays of all the patients, reinvestigated, showed a complete healing of the bone grafts into the glenoid rim and correct position of AO-screws.

[Radiological-densitographic examinations of the skull injuries of the pharoah Seqenenre (author's trasl)]. / Radiologish-äquidensitographische Untersuchungen der Kalottenverletzungen des Pharao Seqenenre.

Skull radiographs of the pharaoh Seqenenre-Ta'a II with special densitographic techniques have shown that he survived a perforating skull injury. The technique is described and its use in medical history and archaeology is discussed.