[Tumor of the esophoagocardiac junction]. / Tumor des ösophagokardialen Übergangs.

The presence of heterotopic pancreatic tissue in the gastroesophageal junction is a very rare entity. An exact preoperative diagnosis is only rarely possible despite all available diagnostic procedures. We report on the case of a submucous tumor of the gastroesophageal junction which became symptomatic due to reflux problems and was successfully removed by endoscope-assisted laparoscopic resection.

Neurogenic appendicopathy: a clinical disease entity?

BACKGROUND AND AIMS: This study compared two histopathological examinations for the diagnosis of neurogenic appendicopathy (NA), assessed the frequency of NA, and evaluated whether it is a clinical disease entity distinct from acute appendicitis. PATIENTS AND METHODS: In a prospective observational multicenter study (surgical departments of five hospitals with one reference pathology) we evaluated 282 patients who underwent appendectomy for suspected appendicitis; we examined the frequency of NA in acute appendicitis and in the negative appendectomy group. For the diagnosis two staining methods were compared. We also attempted to determine clinical features of NA. RESULTS: We observed 93% accuracy for hematoxylin-eosin staining compared with S-100 staining (reference standard) in the diagnosis of NA. There was NA in 3.8% of patients with acute appendicitis and in 47% of those with negative appendectomy. We observed significant differences between the three groups (NA without appendicitis, acute appendicitis, and negative appendectomy without neurogenic appendicopathy) only for sex, age, vomiting, similar previous complaints, rebound tenderness, guarding, rigidity, leukocytes (univariate analysis) and sex (multivariate analysis). CONCLUSION: Neurogenic appendicopathy is a histopathological entity that can be identified by hematoxylin-eosin staining. History and clinical examination do not enable us preoperatively to differentiate between acute appendicitis, NA, and negative appendectomy.

[Management of common bile duct stones--Results of a nationwide survey with analysis of 8 433 common bile duct explorations in Germany]. / Management der Choledocholithiasis - Umfrageergebnisse und Analyse von 8 433 Gallengangsrevisionen in Deutschland, Germany.

BACKGROUND: Aim of this study was the evaluation of the management of choledocholithiasis and outcome of laparoscopic as well as open cholecystectomy in Germany. METHODS: A written questionnaire was sent to 449 randomly selected German surgeons annually from 1991 to 1994 and additionally to all German university hospitals until 1998. RESULTS: A total of 98 482 operations for gallstone disease including 86 485 cholecystectomies (non-university hospitals 1991-1993: n = 60 246, university hospitals 1991-1996: n = 26 239) and 8 433 common bile duct (CBD) explorations (non-university hospitals: n = 6 919, university hospitals: n = 1 514) with or without cholecystectomy were reported. The overall complication rate for CBD explorations was 13.2 % (non-university hospitals) and 15.1 % (university hospitals), the overall hospital mortality rate was 0.64 % (non-university hospitals) and 0.58 % (university hospitals, n. s.). When choledocholithiasis was suspected, in 1998 all university hospitals used a two-stage management with preoperative ERC. In case of diagnosed isolated choledocholithiasis 93 % usually chose an endoscopic approach. When simultaneous cholecysto-choledocholithiasis was diagnosed preoperatively 86 % of the university hospitals used a two-stage management with preoperative ERC and stone extraction and secondary cholecystectomy (1991: 45 %). The percentage of CBD explorations decreased continuously from 7.4 % in 1991 to 3.8 % in 1996 (p < 0.01). CONCLUSION: These results allow for the estimation of frequency and overall risks in surgical therapy of CBD stones. At the moment, laparoscopic CBD exploration does not play a significant role in Germany. Data show a trend to the two-stage "therapeutical splitting" with lower complication rates.

Neurogenic appendicopathy in children.

BACKGROUND: In a prospective multicenter study, we could show that neurogenic appendicopathy is a histological entity. This study compares the general and the pediatric population with respect to clinical presentation and incidence of neurogenic appendicopathy (NA). METHODS: Included were patients that underwent appendectomy for suspected appendicitis, excluded were patients younger than 6 years and patients with missing data. Neurogenic appendicopathy was diagnosed by S-100 immunochemistry and/or haematoxylineosin (H.E.) staining. Two age groups (< or = 14 y and > 14 y) were compared with respect to the frequency of NA. RESULTS: In only four cases out of 84 children (4.8%) did we find neurogenic appendicopathy compared to 48 patients (24.2 %) out of 198 adolescents and adults. In the subgroup with negative appendectomy, the frequency of NA was 16.7% (< or = 14 years) and 56.6% (> 14 years). A clinical differentiation between neurogenic appendicopathy and acute appendicitis was not possible because of the small sample size. CONCLUSION: Neurogenic appendicopathy is a very rare histopathological entity in children. History and clinical examination do not make it possible for us to differentiate preoperatively between acute appendicitis and neurogenic appendicopathy.

Gallstone surgery in German university hospitals. Development, complications and changing strategies.

A representative anonymous questionnaire was sent to all German university hospitals ( n=45) to address the development and outcome of laparoscopic gallstone surgery between 1991 and 1998. The response rate was 64%, and 28,753 operations for gallstone disease were analysed. Two-thirds of the procedures (67%) were performed laparoscopically. While a significant decrease of surgical complications (1991 vs 1998: 5.4% vs 3.4%; P<0.001) and re-laparotomy rate (1.0% vs 0.5%, P<0.05) was observed, no significant changes were detected with regard to the mortality rate. A learning curve regarding common bile duct (CBD) injuries was detected, showing a significant increase between 1991 and 1994 (0.3% and 0.7%, respectively, P<0.05) and a decrease to 0.2% in 1995 and 1996 ( P<0.05). The use of intraoperative cholangiography is compulsory in 10%, selective in 52%, while 38% of the university hospitals never use it. Most institutions use the Veress needle for pneumoperitoneum installation, and 93% use hook cautery for dissection. Since 1998, 45% of all institutions have also used the harmonic scalpel. The spectrum of indications for laparoscopic procedures has increased with time since acute cholecystitis, CBD stones and adhesions are not considered a general reason for a primary open approach. Our findings confirm a learning curve with regard to postoperative morbidity after laparoscopic cholecystectomy. This observation may be due to better training as well as surgical experience.

[Intraoperative cholangiography in laparoscopic cholecystectomy for acute cholecystitis]. / Das intraoperative Cholangiogramm bei der laparoskopischen Cholezystektomie wegen akuter Cholezystitis.

In our prospective study we wanted to prove whether the safety of laparoscopic treatment of acute cholecystitis could be improved by intraoperative cholangiography. From July 1993 to June 1998 210 patients with acute cholecystitis underwent a laparoscopic cholecystectomy. In 23 cases (10.9%) a conversion was necessary. 189 patients underwent a laparoscopic cholangiography. In 2 cases (1.1%) an incision of the common bile duct was detected which had been mistaken for the cystic duct. So the cutting of the common bile duct could be prevented. In 12 patients (6.3%) unknown common bile duct stones were found. The complication rate was 9.5% without any mortality or major injury of the common bile duct.

Expression of adhesion molecules on circulating polymorphonuclear leukocytes during orthotopic liver transplantation.

After ischemia-reperfusion, polymorphonuclear leukocytes (PMNLs) become activated by inflammatory mediators, adhere to the vascular endothelium via the interaction of specific adhesion molecules, and cause tissue injury by the release of cytotoxic oxygen radicals and enzymes. Results obtained in animal experiments suggest a key role for PMNLs in ischemia-reperfusion injury of transplanted livers; therefore, we studied the expression of adhesion molecules on circulating PMNLs (beta2-integrins [CD18] and L-selectin [CD62L]) in 20 patients undergoing orthotopic liver transplantation (study group). To determine the effects of surgical trauma to the liver in the absence of ischemia and reperfusion, the expression of PMNL adhesion molecules was measured in 10 patients scheduled for elective partial liver resection without hepatic vascular exclusion (control group). Patients were classified as responders or nonresponders based on changes in the expression of adhesion molecules elicited by reperfusion. In the control group, all patients remained nonresponders, showing that surgical trauma of the liver alone does not cause activation of circulating PMNLs. In contrast, 8 of 20 patients in the study group were classified as responders. In responders, postoperative serum liver enzyme activities were significantly higher than in nonresponders, indicating that activation of PMNL was associated with damage to hepatocellular integrity. Because expression of adhesion molecules was already changed during surgery, monitoring of the expression of beta2-integrins and L-selectin on circulating PMNLs during orthotopic liver transplantation might be useful in prediction of early graft dysfunction.

[Risk factors and pathogenic microorganisms in patients with insufficient esophagojejunostomy after gastrectomy]. / Risikofaktoren und pathogene Mikroorganismen bei Patienten mit insuffizienter Osophago-Jejunostomie nach Gastrektomie.

UNLABELLED: It was the aim of the study to find by retrospective analysis of data from totally gastrectomized patients risk factors for the development of esophago-jejunal anastomotic leakage, that may be avoidable or influenced therapeutically. PATIENTS AND METHODS: The study design was retrospective involving 838 patients with total gastrectomy for gastric cancer from the years 1973-1993. In 134 cases leakage of the esophago-jejunostomy occurred. The relative risk for the development of leakage associated with individual parameters was determined by comparing the data from 704 patients without leakage to the data from 134 patients presenting with this complication. For a subgroup of 86 patients with anastomotic leakage microbiological data of swabs taken from the anastomoses were available, which were evaluated with respect to potentially pathogenic bacilli. RESULTS: The overall leakage rate of esophago-jejunal anastomoses was 15.9% (n = 134). The mortality rate during this time period amounted to 14.3%. Leakage was a most highly significant factor for mortality (p = 0.0001). Significant risk factors for leakage of the esophago-jejunostomy were tumors of the cardia, splenectomy, a duration of operating time of more than 5 hours and manual suture technique compared to stapler anastomoses. Tumor unrelated associated disease, tumor stage and a history of other preexisting gastric diseases were not associated with an increased relative risk. At the time of the initial clinical manifestation of leakage the following pathogenic bacilli could be isolated from leaking anastomoses with decreasing incidence: E. coli, S. aureus, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella pneumoniae a.o. The bacterial spectrum has not changed during the observation period of 20 years. SUMMARY: With the exception of the choice of suture techniques the identified clinical risk factors cannot be avoided or influenced therapeutically due to a lack of potentially curative treatment alternatives. In contrast potentially pathogenic bacilli associated with leakage can be prevented from coming in contact with anastomoses thereby preventing infection and leakage.

[Prognostic significance of apoptosis inducers/inhibitors in stomach carcinoma with/without adjuvant intraoperative radiotherapy (IORT)]. / Prognostische Bedeutung von Apoptose-Induktoren/Inhibitoren in Magenkarzinom mit/ohne adjuvanter intraoperativer Radiotherapie (IORT).

Several studies have tried to improve the surgical results after resection for gastric cancer by different adjuvant therapy protocols, including intraoperative radiotherapy (IORT). Since 1990 we have performed a randomized, prospective trial comparing surgery alone and surgery plus adjuvant IORT to evaluate the role of adjuvant intraoperative radiotherapy in the treatment of curative resected gastric carcinomas. In the present study, p53, bcl-2 immunoreactivity and DNA fragmentation as a typical marker of apoptosis were determined to investigate the predictive value of apoptosis-related factors and the observed response to radiotherapy. Preliminary data indicate that patients with tumors containing increased numbers of apoptotic tumor cells might derive benefit from adjuvant IORT.

Primary shunt perfusion detected by colour flow Doppler imaging and its impact on liver allograft survival.

Primary dysfunction (PDF) and eventual primary nonfunction (PNF) of liver allografts have been characterized by various clinical and laboratory parameters reflecting graft function, cellular integrity and extrahepatic influence following orthotopic liver transplantation (OLT). During the past 6 yr we have been able to demonstrate that this potentially devastating condition is routinely accompanied by a pathological initial perfusion pattern detected by colour flow doppler imaging (CFDI) within hours following OLT. In the majority of PDF cases (n = 30) CFDI revealed increased vascular resistance in regard to arterial blood flow to the malfunctioning graft, with a resulting 1-yr graft survival rate of 80% following the institution of early prostaglandin therapy in this group of patients. A completely different perfusion pattern was noticed by CFDI in a total of 13 cases with grossly decreased arterial resistance, resulting in an apparently supranormal arterial blood supply together with a reduced portal inflow in comparison to primarily functioning grafts. The presence of this pathologic graft perfusion was explained by the formation of arterio-portal shunts within the graft during conservation and reperfusion, leading to a 1-yr graft survival of merely 46.1%.

Gastric antigen challenge releases gastrin and eicosanoids and protects against ethanol.

Various gastrointestinal functions such as mucosal blood flow and mucus secretion can be influenced immunologically. Rats were systemically sensitized with 4-hydroxy-3-iodo-5-nitro-phenylacetic acid (NIP), a synthetic antigen. Mucosal release of gastrin, prostaglandin F2 alpha, 6-keto-prostaglandin F1 alpha, and leukotriene C4 was measured after intragastric or in vitro antigen challenge. Gastric protection from ethanol was determined. In sensitized rats, intragastric antigen challenge increased release of gastrin from the antral mucosa ex vivo and tended to increase release of prostaglandin F2 alpha. Likewise, antral mucosa of sensitized rats released significantly more gastrin and prostaglandin F2 alpha during in vitro antigen challenge than during incubation in the absence of antigen. Release of 6-keto-prostaglandin F1 alpha and leukotriene C4 was not affected by the immunologic reaction. Topical antigen challenge in sensitized rats reduced gastric mucosal damage caused by ethanol by 50%. The immunologically induced gastroprotection was significantly attenuated by pretreatment with indomethacin. The findings show that specific antigen challenge renders the gastric mucosa more resistant against the injurious effect of ethanol indicating that the stomach is a target organ of immunological reactions. As gastrin and prostaglandins exert potent protective effects, release of these mediators may contribute to the protective response to gastric mucosal immune activation.

[Interventional radiologic procedures in postoperative complications after liver transplantation]. / Interventionelle radiologische Verfahren bei postoperativen Komplikationen nach Lebertransplantation.

PURPOSE: Postoperative complications contribute significantly to the morbidity and mortality of liver transplant patients. The management of these complications requires a multidisciplinary approach in which interventional radiology plays an integral role. Indications, techniques, and results of radiological interventions in the management of the liver transplant patient are presented. MATERIAL AND METHODS: During a 10-year period, 52 out of 420 liver transplant recipients underwent radiological interventions, including angioplasty (n = 20), embolization (n = 2), percutaneous drainage (n = 11), and biliary interventions (n = 19). RESULTS: Nine out of ten arterial stenoses located at the anastomoses (n = 8), within the liver (n = 1) and in the coeliac trunk (n = 1) were successfully treated by balloon dilatation. Angioplasty of supra- or infrahepatic anastomotic stenoses of the i.c.v. (n = 5) provided long-term success only in combination with stent implantation. Portal vein stenoses and chronic thrombosis were treated by balloon dilatation and stent insertion via transhepatic catheterization of the portal vein. Late strictures of bile-duct anastomoses can be managed by ante- or retrograde interventions. If biliary complications are related to inflammatory or septic problems, the prognosis of graft survival is poor. CONCLUSION: Interventional radiological procedures are very useful in the management of vascular and biliary complications after liver transplantation. These techniques provide a cure in many situations, and thus, surgical interventions may be avoided in selected cases.

Laboratory markers of veno-occlusive disease in the course of bone marrow and subsequent liver transplantation.

Plasminogen activator inhibitor 1 (PAI-1) and amino-propeptide of type III procollagen (PIIINP) have been described as markers of hepatic veno-occlusive disease (VOD) after bone marrow transplantation (BMT). We determined these parameters in two patients undergoing BMT and subsequent liver transplantation due to VOD. Previously normal PAI-1 levels (maximum 30.0 ng/ml in patient 1, 23.7 ng/ml in patient 2) were elevated for the first time in both patients at the time of clinically diagnosed VOD on days 40 and 20, respectively (patient 1: 317.5 ng/ml; patient 2: 317.2 ng/ml). Levels remained elevated until liver transplantation was performed on days 79 and 41, respectively. Baseline levels (day -8) of aminopropeptide of type III collagen (patient 1: 4.44 microg/l; patient 2: 8.1 microg/l) peaked at the time of BMT in both patients (155.0 microg/l and 108.3 microg/l). After an intermittent decrease at the time of discharge on day 32, a second elevation was observed in patient 1 when she was readmitted and presented with typical signs of VOD on day 40. In patient 2, PIIINP levels remained high until VOD was diagnosed (day 20) and liver transplantation was performed. After liver transplantation, PAI-1 levels normalized in both patients and PIIINP levels declined. Both patients died due to infectious complications and multiorgan failure on days 141 and 101, respectively. Whereas the early rise of PIIINP did not correlate with the clinical onset of VOD, the results emphasise the relevance of PAI-1 for diagnosing VOD.

Mediators of antigen-induced gastrin release: role of antigen-antibody complexes and the complement system.

That orally administered antigen was shown to induce gastrin release in immunized animals was a new aspect of gastrointestinal physiology. The mediators responsible for this immunological effect are still unclear. In an attempt to discover more about the mechanisms regarding antigen-induced gastrin release, we developed an in vitro system where fragments of rat antral mucosa were challenged. This makes it possible to determine the role of antigen-antibody complexes and the complement system in the mechanism of antigen-induced gastrin release. Wistar rats were immunized in vivo with NIP-OVA and mucosal fragments were challenge, in vitro with NIP-HGG. Gastrin was determined after a preincubation and a challenged incubation period without supernatants. After antigenic challenge, supernatants were used for in vitro challenge in order to rule out the presence of a soluble mediator and activation of complement. In a second group of experiments Wistar rats were used to study in vitro the release of specific antibodies after antigenic challenge. With this experimental design we were able to show increased gastrin secretion after antigenic challenge in vitro in the presence of intact tissue. It is shown that the increased gastrin release is most probably mediated by activation of the complement system in the presence of antigen-antibody complexes. These are built up by specific anti-NIP antibodies and NIP-HGG used for the challenge. The complement system might be the final pathway of the observed increased gastrin release.

[Changes in surgical cases]. / Veränderungen des operative Krankenguts.

The shift of age distribution within the population of industrialized societies has led to an increased need of treating diseases in elderly patients and at the same time bearing an increased operative risk. Today, the development of surgical techniques and intensive care treatment enables us to carry out numerous procedures in geriatric patients. Innovative surgical techniques like minimal invasive surgery with minor trauma due to the surgical approach changed patient's categories, also. Taken together with other procedures causing less operative stress indications for patients who were not operable previously have changed. New developments such as organ transplantation and immunosuppression also generated totally new groups of patients with very distinct conditions for the operative procedure. Vanishing indications or selection of patients as in peptic ulcer disease changed the surgical approach completely: Negative selection has shifted elective operative interventions in ulcer disease to emergency procedures. Contrasting experiences made in most other countries and especially in the third world, in Germany economic restrictions have not been encountered as of yet. Economical conditions, an increase in surgical procedures in elderly patients and advances in medical science will continue to change the surgical patient's characteristics profoundly. From the physicians viewpoint we have actively participate in this development by personal interaction with the patient, by interdisciplinary cooperation and prompt social and political action.