Trans-crustal structural control of CO2-rich extensional magmatic systems revealed at Mount Erebus Antarctica.

Erebus volcano, Antarctica, with its persistent phonolite lava lake, is a classic example of an evolved, CO2-rich rift volcano. Seismic studies provide limited images of the magmatic system. Here we show using magnetotelluric data that a steep, melt-related conduit of low electrical resistivity originating in the upper mantle undergoes pronounced lateral re-orientation in the deep crust before reaching shallower magmatic storage and the summit lava lake. The lateral turn represents a structural fault-valve controlling episodic flow of magma and CO2 vapour, which replenish and heat the high level phonolite differentiation zone. This magmatic valve lies within an inferred, east-west structural trend forming part of an accommodation zone across the southern termination of the Terror Rift, providing a dilatant magma pathway. Unlike H2O-rich subduction arc volcanoes, CO2-dominated Erebus geophysically shows continuous magmatic structure to shallow crustal depths of < 1 km, as the melt does not experience decompression-related volatile supersaturation and viscous stalling.

Management of urologic complications in renal transplantation: a single-center experience.

INTRODUCTION: Ureterovesical complications subsequent to renal transplantation are associated with a high morbidity leading to graft loss or even death. In the present study, the management of these complications by using interventional and surgical procedures (native pyeloureterostomy [NPUS]/ureteroureterostomy [NUU] vs ureteroneocystostomy [UNC]) was evaluated retrospectively. PATIENTS AND METHODS: Between 1994 and 2012, a total of 780 kidney transplantations (690 deceased and 90 living donors) were performed at our institution. Demographic, clinical, and laboratory data from patients with urologic complications were analyzed and compared. RESULTS: Fifty patients (6.4%) exhibited ureterovesical complications, and 18 patients (36%) were operated on immediately. In 32 (64%) of 50 patients, an interventional procedure was initially performed, with 21 patients (66%) undergoing operation due to therapy failure. NPUS/NUU and UNC were performed in 26 (66.6%) and 13 (33.3%) patients, respectively. Indications for an operation were ureteral stenosis in 12 patients (30.8%), ureteral necrosis and urine leakage in 19 patients (48.7%), and symptomatic vesicoureteral reflux in 8 patients (20.5%). Long-term results were comparable between all groups. CONCLUSIONS: Surgical revision of ureteral complications should be the standard therapy. NPUS/NUU, UNC, and the successful interventional procedures did not differ significantly in terms of long-term results.

[VATS lobectomy--a standard procedure in the therapy for stage I non-small cell lung cancer?]. / VATS-Lobektomie--Ein Standardverfahren in der Therapie des nicht kleinzelligen Lungenkarzinoms im Stadium I?

Even though VATS lobectomy has been practised since 1991 in stage I of non-small cell lung cancer (NSCLC), it was not being considered equivalent to conventional lobectomy due to considerable doubts in terms of safety and oncological permissibility. This study describes our experience and an evaluation of the systematic establishment of lobectomy by means of video-assisted thoracic surgery (VATS) as standard treatment of NSCLC in stage I, which serves as an alternative to conventional surgery. For this purpose, 42 NSCLC patients in stage I, undergoing a conventional lobectomy in 2010 (group I), were retrospectively compared to 30 patients in the same tumour stage (group II) who were treated in 2011 using VATS lobectomy. The comparison of these two groups was drawn regarding operation time, number of resected lymph nodes, required analgesics, duration of drainage, rate of postoperative complications and length of hospital stay. Although VATS lobectomy requires a longer operation time of approximately 30 minutes, it shows significant advantages in reference to postoperative need of analgesics, duration of drainage and complications after surgery. Furthermore, the amount of resected lymph nodes was comparable in both groups. Therefore, VATS lobectomy constitutes an essential extension for the operative management in a lung cancer centre. Our results show that this new method is not only of equal, but of superior value compared to conventional lobectomy. Our experience and recent data in the literature illustrate that VATS lobectomy will play a decisive role in therapy for NSCLC in stage I, potentially even in stages II and IIIA.

[Pharmaceutical care in a visceral surgical ward]. / Pharmazeutische Betreuung einer viszeralchirurgischen Station.

BACKGROUND: Medication errors and subsequent drug-related problems (DRPs) result from lack of sufficient information during the prescribing step. The objectives of this study were to evaluate the contribution of having a pharmacist participate in clinical routine on a surgical unit by studying DRPs, and the classification of DRPs in the Pharmaceutical Care Network Europe (PCNE) system. MATERIALS AND METHODS: The pharmacotherapy of all patients of a visceral surgical ward was evaluated by a pharmacist in a prospective study design over a six-month period. The identified DRPs were classified using the PCNE system. RESULTS: In 29 131 prescription lines, 697 DRPs were registered. This corresponds to a mean intervention rate of 2.4 %. All DRPs were classified into the modified PCNE system with 910 causes and 1 148 interventions. The most frequent DRPs were "lack of home medication" (35.6 %), drug dosing problems (18.6 %), the inappropriate duplication of drugs of the same therapeutic group (6.7 %) and drug interactions (6.5 %). 78.6 % vs. 3.7 % of all registered DRPs were completely vs. near completely resolved by pharmacist. CONCLUSIONS: We consider the PCNE system with the four-level of classification to be a practical and easy-to-use tool in the daily hospital setting. Although we did not notice clinically relevant impairments of patient safety, a pharmacist may support the drug therapy and improve patient safety in clinics supporting the free choice of the drug therapy by the physician.

Liver transplantation to treat suspected hepatocellular carcinoma in iron-free foci in congenital hemochromatosis: case report.

Hepatocellular carcinoma (HCC) commonly develops in cirrhotic or noncirrhotic livers affected by congenital hemochromatosis. In patients with congenital hemochromatosis and HCC, liver transplantation is a therapeutic option with a 5-year posttransplantation survival rate as high as 80%. Herein is reported congenital hemochromatosis in a 37-year-old man. During a routine checkup, 2 liver nodules were detected. Signal characteristics at magnetic resonance imaging indicated the presence of iron-free foci (IFF). The serum α-fetoprotein concentration was within the range of normal, and repeated liver biopsy did not show histomorphologic signs of malignancy but confirmed the presence of IFF in surrounding siderosis. The patient was listed for liver transplantation with match MELD (Model of End-Stage Liver Disease including exceptions) because of suspected HCC. After 173 days on the waiting list, liver transplantation was performed successfully. Histologic examination of the explanted liver confirmed 2 HCC lesions with a diameter of 0.9 cm in the exact projection as the IFF detected at magnetic resonance imaging. At 20 months of rapamycin-based immunosuppression therapy, there were no signs of HCC recurrence. This is, to our knowledge, the first report of liver transplantation performed to treat suspected HCC based on the finding of IFF in congenital hemochromatosis, with histopathologic confirmation of the diagnosis of HCC after transplantation. According to this case and the current literature, IFF in patients with congenital hemochromatosis should be considered preneoplastic lesions vulnerable to possible development of HCC.

Effect of FTY720 treatment on postischemic pancreatic microhemodynamics.

CD4+ T cells contribute to disturbances of pancreatic microcirculation after cold and even after warm ischemia/reperfusion (I/R). The aim of this study was to investigate a possible protective role of FTY720 (fingolimod) in this setting. In an in vivo model (42 Wistar rats), ischemia of the pancreas was induced for 60 minutes under anesthesia with xylazin/ketanest. Sham-operated (SO) (I), untreated ischemic (II), and treatment group with FTY720 pre-treatment (1 mg/kg body weight i.v.) (III) were investigated. The effect of FTY720 on I/R injury was assessed by in vivo microscopy 30-90 minutes after reperfusion and by measurement of serum lipase. In the untreated ischemic group (II), capillary constriction to 85.3 ± 6.3% of SO diameters and a reduction of functional capillary density to 67% was found. After 30 minutes of reperfusion, the number of T cells in capillaries was increased (165.7%; P < .05 vs I). FTY720 pretreatment reduced this number to 54.2% of SO (P < .05 vs II). Likewise, the number of adherent leukocytes in capillaries (145.4 ± 11.2% of SO) was reduced in group III (109.3 ± 11.4%; P < .05 vs II), leading to an improvement in functional capillary density in the treatment group (98.2 ± 2% of SO; P < .05 vs II). According to improved microcirculation, lipase values were reduced in the therapy group (P < .05). In conclusion, FTY720 ameliorates the microcirculatory and biochemical manifestations of pancreatic I/R injury by preventing T-cell infiltration.

Results of resection and transplantation for hepatocellular carcinoma in cirrhosis and noncirrhosis.

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Both liver resection (LR) and orthotopic liver transplantation (OLT) are surgical treatment options depending on the size of the tumor and the presence of cirrhosis. Liver cirrhosis is the main reason for the high early postoperative mortality after resection. Even in the Child A stage, extensive resections are not recommended. This study presented the results of surgical treatment (LR or OLT) for HCC in cirrhotic and noncirrhotic livers. We analyzed the data of 76 patients who underwent LR or OLT for HCC from January 2001 to December 2006. In noncirrhotic livers the following resections were performed: 30 right and extended right hemihepatectomies (54.5%); 11 left hemihepatectomies (20%); and 14 mono- or bisegmentectomies (25.5%). In cirrhotic livers the following procedures were performed: in Child A stage 1 right hemihepatectomy, 1 extended right hemihepatectomy, 1 extended left hemihepatectomy, and 4 mono- or bisegmentectomies; and in Child B stage, 3 mono- or bisegmentectomies. Among 11 patients who underwent transplantation, tumors in 2 patients exceeded the Milan criteria. Five patients in the LR group were treated with transarterial chemoembolization before transplantation. LR for HCC in cirrhosis should be performed with caution; there were no long-term survivors in our data. Our study confirmed that OLT shows good long-term survival in early HCC stages. However, this may also be true for stages above the Milan criteria. For HCC in noncirrhotic livers, LR remains the treatment of choice, justifying an extensive surgical approach. Such an approach achieved favorable long term survivals.

Five-year follow-up of a prospective non-randomised study comparing duodenum-preserving pancreatic head resection with classic Whipple procedure in the treatment of chronic pancreatitis.

BACKGROUND: Three prospective randomised studies were conducted to compare pancreatoduodenectomy (PD) with duodenum-preserving pancreatic head resection (DPPHR) in patients suffering from chronic pancreatitis (cP). In these three series, the superiority of the duodenum-preserving technique with regard to quality of life (QOL) and pain relief has been demonstrated. Long-term follow-up investigations have not been published so far. The present paper reports on a 5-year follow-up study of a prospective, non-randomised trial comparing classic Whipple procedure (PD) with Beger DPPHR. MATERIALS AND METHODS: Seventy patients were initially enrolled in this study. Fifty-one patients were left for the present long-term outcome analysis (PD, n = 24; DPPHR, n = 27). The follow-up included the following parameters: QOL, pain intensity, endocrine and exocrine function, and body mass index (BMI). RESULTS: The median follow-up was 63.5 (range 56-67) months. Two patients in the DPPHR group and none in the PD group underwent a re-operation. The QOL scores of the relevant symptom scales (nausea, pain, diarrhoea) and functional parameters (physical status, working ability, global QOL) were significantly better in the DPPHR group than in the PD group. Pain intensity as self-assessed by the patients was less pronounced in the DPPHR group (P < 0.001), whereas the frequency of acute episodes and analgesic medication did not differ between the two groups. No difference was observed between the two groups with regard to endocrine and exocrine function. The values of the median body mass index (BMI) in the PD group [23.4 (range 18.5-25.0) kg/m(2)] and in the DPPHR group [24.2 (range 17.9-27.8) kg/m(2)] were comparable. The 5-year outcome remained stable compared to the early post-operative data published elsewhere. CONCLUSION: This 5-year long-term outcome analysis documents the superiority of the Beger duodenum-preserving technique over the classic Whipple procedure in terms of QOL and pain intensity as self-assessed by the patients.

Sirolimus improves early microcirculation, but impairs regeneration after pancreatic ischemia-reperfusion injury.

Ischemia and reperfusion injury remains a relevant problem in clinical pancreas transplantation. We investigated the effect of sirolimus (SRL) in a rodent model of 90-min warm pancreatic ischemia. Four groups were studied: (1) sham surgery and vehicle; (2) sham surgery and SRL; (3) warm ischemia and vehicle; (4) warm ischemia and SRL. SRL (1.5 mg/kg/day) and vehicle were administered intraperitoneally for 3 days prior to surgery until the animals were killed. Microcirculation was assessed immediately after reperfusion by means of intravital fluorescence microscopy. Histopathological injury, apoptosis, proliferation and biochemical parameters were analyzed at 2 h, 1 day and 5 days after surgery. Ninety minutes after ischemia, intravital microscopy revealed an improved functional capillary density (p < 0.05) and reduction of adherent leucocytes (p < 0.01) and platelets (p < 0.05) in the SRL-treated group compared to the vehicle-treated controls. In contrast, on day 5 after ischemia, the pancreatic tissue of SRL-treated animals showed a higher grade of histological injury (p < 0.05) and higher rate of apoptotic cells (p < 0.05) than the vehicle controls. In summary, our data indicate that administration of SRL improves microcirculation at a very early stage, but results in an impairment of the recovery phase after pancreatic ischemia-reperfusion injury.

[The influence of normobaric hyperoxia on hepatic oxygenation--experience with an animal model]. / Der Einfluss von normobarer Hyperoxie auf die lebervenöse Oxygenierung--Erfahrungen mit einem Tiermodell.

We investigated the effect of a ventilation with an FiO2 of 1.0 on arterial and hepatic venous oxygenation in 23 Göttingen minipigs. Under balanced anaesthesia (isoflurane/fentanyl), a fibreoptic catheter was placed into a hepatic vein. The correct position of the tip of the catheter was controlled manually after laparotomy. After measurement of baseline values (arterial and hepatic blood gases, ShvO2), in 13 minipigs normoventilation with an FiO2 of 1.0 was performed for 15 minutes. Thereafter, ventilation was continued with an FiO2 of 0.4. In the control group (n = 10), the animals were oxygenated with an FiO2 of 0.4 permanently. The changes due to hyperoxia were measured in hepatic venous oxygen saturation (ShvbgaO2: from 81.2 +/- 1.43% to 87.5 +/- 1.77%, ShvoximO2: from 82.6 +/- 1.14% to 90.5 +/- 0.90%), arterial (from 217.5 +/- 5.0 mmHg to 467.2 +/- 22.0 mmHg) and hepatic venous (from 51.8 +/- 2.0 mmHg) oxygen partial pressure. We found a correlation between hepatic venous oxygen partial pressure und ShvbgaO2 in the blood (r = 0.84, p < 0.001) and between ShvO2 (ShvbgaO2/ShvoximO2), which was either measured directly in the blood or by a fibreoptic catheter (r = 0.6, p < 0.001). Whereas the increase in ShvO2 during hyperoxia may be a result of increased arterial supply, the decrease in ShvO2 after the end of hyperoxia below baseline values needs further investigations. The continuous fibreoptic measurement of ShvoximO2, also under hyperoxic conditions is a valuable parameter for the monitoring of hepatic venous oxygenation.

Mutations of the BRAF gene in cholangiocarcinoma but not in hepatocellular carcinoma.

BACKGROUND: The Raf/MEK/ERK (mitogen activated protein kinase-MAPK) signal transduction cascade is an important mediator of a number of cellular fates, including growth, proliferation, and survival. The BRAF gene, one of the human isoforms of RAF, is activated by oncogenic Ras, leading to cooperative effects in cells responding to growth factor signals. AIMS: The aim of this study was to elucidate a possible function of BRAF in liver tumours. METHODS: Mutations of BRAF and KRAS were evaluated in 25 hepatocellular carcinomas (HCC) and in 69 cholangiocarcinomas (CC) by direct DNA sequencing analyses after microdissection. The presence of active intermediates of the MAPK pathway was assessed immunohistochemically. The results obtained were correlated with histopathological variables and patient survival. RESULTS: Activating BRAF missense mutations were identified in 15/69 CC (22%) and in one case of tumour surrounding liver. KRAS mutations were found in 31 of 69 (45%) CC examined and in two cases of tumour surrounding non-neoplastic liver tissue. In HCC, neither BRAF nor KRAS mutations were detected. All 31 CC with KRAS mutations had an intact BRAF gene. We failed to observe a correlation between BRAF or KRAS mutations and histopathological factors or prognosis of patients. CONCLUSIONS: Our data indicate that BRAF gene mutations are a relatively common event in CC but not in HCC. Disruption of the Raf/MEK/ERK (MAPK) kinase pathway, either by RAS or BRAF mutation, was detected in approximately 62% of all CC and is therefore one of the most frequent defects in cholangiocellular carcinogenesis.