Lateral Fasciectomy Sparing the Superficial Peroneal Nerve with Simultaneous Mesh Graft in Non-healing Lateral Leg Ulcers of Diverse Vascular Origins: Surgical Technique, Short- and Long-term Results from 44 Legs.

OBJECTIVES: The technique of lateral fasciectomy (LF) sparing the superficial peroneal nerve with mesh graft coverage is a novel treatment of non-healing lateral leg ulcers of various vascular origin affecting the fascia. We report short- and long-term results of LF for recalcitrant lateral leg ulcers. DESIGN: This study is a single center, retrospective case series of consecutive patients treated by LF. MATERIALS: From 827 ulcers treated at our institution, 44 recalcitrant lateral leg ulcers affecting the fascia (41 patients) underwent lateral fasciectomy between 2006 and 2013. METHODS: Preoperative indications, step-by-step surgical procedures, and perioperative care methodologies are presented. Long-term effects of healing and recurrence were clinically investigated or obtained through telephone interviews with relatives and local practitioners. RESULTS: Three discrete etiologies were identified: venous ulcers (n = 24), arterial-venous/mixed ulcers (n = 11), and arteriolar Martorell hypertensive leg ulcers (n = 9). Complete healing was achieved in 40 legs (91%) after 3 months, and in 43 of the affected legs (98%) in total. The median duration to complete healing was 64 days. There was no difference between the healing times of different etiologies. No local recurrence was observed during the follow-up period, which ranged from 1.8 to 8.7 years (median: 5.11, mean: 5.12). Twelve patients (27%) died within this period due to multimorbidity. CONCLUSIONS: Following lateral fasciectomy and mesh graft coverage, 43 legs (98%) healed in previously treatment resistant lateral leg ulcers.

Outcome and complications of long-term self-expanding esophageal stenting.

Esophageal stenting with self-expanding plastic or covered metal stents is believed to be safe and effective. As data on the outcome of patients with long-term stenting are not available, this study was conducted to evaluate the safety and efficacy of long-term esophageal stenting. From 2002 to 2008, 70 patients with long-term esophageal stenting for various indications from a prospective database were included into further analysis. The median stent period was 297 (124-1980) days during a mean follow-up time of 55 ± 52.4 months. Overall complication rate was 30% with a primary success rate of 97.2%. The stent-related total reintervention rate was 17.1%. There were no correlations between stent characteristics and the risk of complication or migration. No stent-related death was observed. Our data provide evidence that long-period esophageal stenting is safe and effective for various indications.

High risk of unilateral recurrent laryngeal nerve paralysis after esophagectomy using cervical anastomosis.

The goal of this study was to estimate the incidence of temporary and permanent unilateral recurrent laryngeal nerve paralysis (URLNP) after esophagectomies with cervical anastomosis and to determine the impact of surgical technique, tumor type, tumor localization and age on the incidence of URLNP. From March 2002 to November 2009, 84 patients underwent a laryngoscopical evaluation before and after esophagectomy with cervical anastomosis prospectively. If the postoperative URLNP recovered within 6 months, the paresis was classified as transient; if not, it was defined as permanent. The results indicate that the overall incidence of postoperative URLNP was 50% (42/84). Twenty-four of the 84 patients (28.6%) showed a transient URLNP. A permanent URLNP was observed in 9 of the 84 patients (10.7%). The remaining 9 of the 84 patients (10.7%) were categorized as paresis with unknown clinical outcome due to missing follow-up. There were significantly more postoperative URLNPs in the group operated by transthoracic esophagectomy than by transhiatal esophagectomy (p < 0.001). Multifocal tumors and those localized suprabifurcational showed a higher incidence of postoperative URLNP than unifocal lesions with infrabifurcational localization (p = 0.046). Histological type of tumor and patients' age had no impact on URLNP. The high incidence of URLNP in our study underlines the high risk of URLNP after esophagectomy with cervical anastomosis, and consequently the importance of routine laryngoscopic pre- and postoperative evaluation of the vocal fold motility.

HER-2 status in primary oesophageal cancer, lymph nodes and distant metastases.

BACKGROUND: Some 10-15 per cent of patients with oesophageal cancer overexpress human epidermal growth factor receptor (HER) 2 at the primary tumour site, leading to the hope that specific targeted systemic therapy might favourably influence clinical and subclinical disease at locoregional and distant sites. This approach is based on primary tumour characteristics, without knowledge of expression patterns at metastatic sites. In oesophageal cancer, concordance between HER-2 status at the primary tumour and other sites is unknown. METHODS: The HER-2 status of primary tumours and corresponding metastatic sites (lymph node and distant) and local recurrence were evaluated in a series of patients with oesophageal cancer, using immunohistochemistry and dual colorimetric in situ hybridization. RESULTS: There were 97 adenocarcinomas (ACs) and 79 squamous cell carcinomas (SCCs). Some 14 per cent of primary ACs and 1 per cent of primary SCCs were staged as HER-2-positive. The HER-2 status was identical in the primary tumour and lymph node metastases in 95 per cent of ACs and 99 per cent of SCCs respectively (P = 0·375, sign test). Nineteen of 22 distant metastases from AC and all from SCC had identical HER-2 status to the primary tumour. In two of 22 patients with AC the primary tumour was classed as negative but distant metastases were HER-2-positive. CONCLUSION: With over 85 per cent concordance in HER-2 status between primary tumours and distant metastases in oesophageal cancer, routine HER-2 testing of metastases to confirm HER-2 positivity is not warranted. Assessment of HER-2 status at metastatic sites may be worthwhile in some patients with easily accessible metastases and negative HER-2 status at the primary tumour, or if adequate material cannot be obtained from the primary site.

[Anastomoses in the upper gastrointestinal tract]. / Anastomosen im oberen Gastrointestinaltrakt.

BACKGROUND: Anastomotic leaks are the major postoperative complications mainly due to technical difficulties. The aim was to review anastomotic techniques and risk factors for leak development. METHODS: A Pubmed search was performed using the terms esophagogastric/esophagojejunal anastomosis, gastrojejunostomy, gastric bypass, esophagectomy, anastomotic leak/risk factors, gastrectomy, TEA, fluid management, early enteral feeding and reinforcement. English and German literature sources were included with the accent on recent prospective randomized controlled trials (pRCT) with high numbers of cases as well as meta-analyses. CONCLUSIONS: There is not enough evidence to recommend either hand sewn or mechanical anastomoses. Surgical skills and routine as well as precise work are necessary to reduce complications. Although stapling leads to uniformity of anastomoses it cannot compensate for surgical deficits.

Preoperative chemotherapy with cisplatin and docetaxel followed by surgery and clip-oriented postoperative chemoradiation in patients with localized gastric or gastroesophageal junction adenocarcinoma: results from a phase II feasibility study.

BACKGROUND: We conducted a phase II feasibility study using preoperative chemotherapy with cisplatin and docetaxel followed by surgical resection and postoperative chemoradiation in patients with gastric or gastroesophageal cancer. METHODS: Preoperative chemotherapy (two or three cycles) consisted of 50 mg/m(2) docetaxel and 50 mg/m(2) cisplatin. Surgical resection was planned 4 weeks after the last chemotherapy cycle. Patients underwent postsurgical chemoradiation, receiving a total dose of 39.6 Gy and 5-fluorouracil (5-FU) continuous infusion (350 mg/m(2)/day). The primary end-points were feasibility, overall response rate and R0 resectability rate after preoperative chemotherapy. The secondary end-points were tolerability, treatment-associated complications, disease-free survival and overall survival. RESULTS: Between 2002 and 2004, 15 patients were enrolled in this study. After neoadjuvant treatment, two patients (13%) experienced progressive disease, four patients (27%) showed partial remission and nine patients (60%) showed stable disease. In 11 patients (73%) R0 resectability could be achieved. Six of these patients (54%) were able to undergo postoperative chemoradiation. Notably, five (83%) of these patients were disease free and alive at median follow-up of 72 months. Chemotherapy-associated neutropaenia and neutropaenic fever, anastomotic dehiscence, pulmonary embolism and acute pancreatitis were observed. CONCLUSIONS: The combination of preoperative chemotherapy and postoperative chemoradiation is feasible in a significant subset of gastric cancer patients.

New epidemiological aspects of patients with severe hyperhidrosis presenting for sympathetic surgery.

BACKGROUND: Epidemiological data on individuals suffering from severe primary hyperhidrosis are scarce. OBJECTIVE: This study aims to prospectively assess disease-specific characteristics of patients with severe, mostly therapy-resistant hyperhidrosis presenting for sympathetic surgery. METHODS: We evaluated a total of 227 patients (69.6% women) with a mean age of 30 years (standard deviation, 9.5 years) using a standardized questionnaire. Severity of disease was rated on a visual analogue scale (VAS) graded between 0 (no symptoms) and 10 (worst symptom). Age, sex, previous therapies, hormonal therapies and body mass index were analysed for their possible influence on severity of the disease and on hyperhidrosis sites. In addition, allergies were investigated for the first time in this patient population. RESULTS: There was a positive correlation between age of onset and sites of hyperhidrosis. The most commonly affected areas were palmar-axillary-plantar (51.1%) and palmar-plantar (15.0%), with sex-specific differences. Two hundred and twelve patients (93.4%) had previous conservative therapies; 219 patients (96.5%) reported VAS scores between 8 and 10. Female patients stated higher VAS scores for palmar (P = 0.009) and axillary (P = 0.012) sites. Type IV allergies were found to be much higher than in the general Austrian female population. Hormonal therapies and the body mass index had no influence on severity of hyperhidrosis after analysis of VAS scores. CONCLUSION: Sex-dependent aspects can be found in patients strongly affected by primary upper limb hyperhidrosis.

Inadequate weight loss vs secondary weight regain: laparoscopic conversion from gastric banding to Roux-en-Y gastric bypass.

BACKGROUND: Beside complications like band migration, pouch-enlargement, esophageal dilation, or port-site infections, laparoscopic adjustable gastric banding (LAGB) has shown poor long-term outcome in a growing number of patients, due to primary inadequate weight loss or secondary weight regain. The aim of this study was to assess the safety and efficacy of laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP) in these two indications. METHODS: A total of 25 patients, who underwent laparoscopic conversion to RYGBP due to inadequate weight loss (n = 10) or uncontrollable weight regain (n = 15) following LAGB, were included to this prospective study analyzing weight loss and postoperative complications. RESULTS: All procedures were completed laparoscopically within a mean duration of 219 +/- 52 (135-375) min. Mean body weight was reduced from 131 +/- 22 kg (range 95-194) at time of the RYGBP to 113 +/- 25, 107 +/- 22, and 100 +/- 21 kg at 3, 6, and 12 months, respectively, which results in excess weight losses (EWL) of 28.3 +/- 9.9%, 40.5 +/- 12.3%, and 50.8 +/- 15.2%. No statistically significant differences were found comparing weight loss within these two groups. CONCLUSION: RYGBP was able to achieve EWLs of 37.6 +/- 16.1%, 48.5 +/- 15.1%, and 56.9 +/- 15.0% at 3, 6, and 12 months following conversion, respectively, based on the body weight at LAGB.

Improved quality of life after sympathetic block for upper limb hyperhidrosis.

BACKGROUND: The aim of the study was to assess two disease-specific quality of life (QoL) instruments after limited endoscopic thoracic sympathetic block (TS) at T4 for upper limb hyperhidrosis. METHODS: : Between 2001 and 2005, 112 patients underwent 223 TS procedures in a prospective study. Some 103 patients (92.0 per cent) had palmar, 87 (77.7 per cent) had axillary and 75 (67.0 per cent) had combined hyperhidrosis. QoL questionnaires devised by Keller et al. and Milanez de Campos et al. were employed before and after treatment. Mean(s.d.) follow-up was 21.9(10.1) months. RESULTS: A total of 106 patients (94.6 per cent) were evaluated. All patients with palmar hyperhidrosis were completely or almost dry after surgery. Side-effects of compensatory sweating and gustatory sweating were observed in 17.0 and 28.3 per cent of patients respectively. QoL improved after TS in 100 per cent (Keller) and 97.3 per cent (Milanez de Campos) of patients illustrated by ameliorated scores of 78.7 and 67.8 per cent, respectively (both P < 0.001). Both questionnaires showed that compensatory sweating resulted in reduced postoperative QoL (P = 0.011, Keller; P = 0.032, Milanez de Campos). CONCLUSION: Endoscopic sympathetic block at T4 leads to improved QoL. Both current questionnaires fulfilled validation criteria for disease-specific QoL instruments in upper limb hyperhidrosis.

Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels.

BACKGROUND: Different changes of plasma ghrelin levels have been reported following gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion. METHODS: This prospective study compares plasma ghrelin levels and weight loss following laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) in 20 patients. RESULTS: Patients who underwent LSG (n=10) showed a significant decrease of plasma ghrelin at day 1 compared to preoperative values (35.8 +/- 12.3 fmol/ml vs 109.6 +/- 32.6 fmol/ml, P=0.005). Plasma ghrelin remained low and stable at 1 and 6 months postoperatively. In contrast, no change of plasma ghrelin at day 1 (71.8 +/- 35.3 fmol/ml vs 73.7 +/- 24.8 fmol/ml, P=0.441) was found in patients after LAGB (n=10). Increased plasma ghrelin levels compared with the preoperative levels at 1 (101.9 +/- 30.3 fmol/ml vs 73.7 +/- 24.8 fmol/ml, P=0.028) and 6 months (104.9 +/- 51.1 fmol/ml vs 73.7 +/- 24.8 fmol/ml, P=0.012) after surgery were observed. Mean excess weight loss was higher in the LSG group at 1 (30 +/- 13% vs 17 +/- 7%, P=0.005) and 6 months (61 +/- 16% vs 29 +/- 11%, P=0.001) compared with the LAGB group. CONCLUSIONS: As a consequence of resection of the gastric fundus, the predominant area of human ghrelin production, ghrelin is significantly reduced after LSG but not after LAGB. This reduction remains stable at follow-up 6 months postoperatively, which may contribute to the superior weight loss when compared with LAGB.

Periarterial application of papaverine during laparoscopic donor nephrectomy improves early graft function after kidney transplantation in pigs.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) increases incentives to donation by subjects who might refuse an open operation. However, the incidence of delayed graft function is higher after LDN than after open operation. This may be caused by the reduction of renal perfusion as a result of the raised intraabdominal pressure and mechanically induced renal angiospasm during the operation. We conducted experiments to find out whether the application of papaverine around the renal artery during LDN could improve early graft function after transplantation. METHODS: Renal function was studied in 10 male pigs (weight approximately 25 kg). The left kidney was harvested laparoscopically (intraabdominal pressure 8 mmHg). Five animals were randomly selected to have perivascular application of 50 mg papaverine (treatment group) before preparation of the vessels. In controls no papaverine was used. After LDN and open right nephrectomy the left kidney was autotransplanted. The main outcome measures were volume of urine produced and creatinine clearance during the first 20 h after the transplant. RESULTS: The groups were comparable in respect of body weight, hemodynamic values, amount of infusions, warm and cold ischemia time, and duration of anastomosis. Urine output and creatinine clearance were significantly higher in pigs treated with papaverine than in controls. CONCLUSIONS: Papaverine substantially improved early graft function in pigs when applied around the renal artery during LDN. Whether this is applicable to procurement of human kidneys remains to be evaluated.

Limited endoscopic thoracic sympathetic block for hyperhidrosis of the upper limb: reduction of compensatory sweating by clipping T4.

BACKGROUND: Endoscopic thoracic sympathicotomy of T2 to T4 (ETS 2-4) has evolved into an effective treatment for severe hyperhidrosis of the upper limb. Complications such as bleeding or Horner's syndrome are rare, but side effects such as compensatory and gustatory sweating occur in 30-50% of patients. Following the Lin-Telaranta classification, we aimed to reduce these side-effects by clipping T4 solely [endoscopic thoracic sympathetic block (ESB 4)]. We present our experience and clinical results using this method, with emphasis on patients' quality of life. METHODS: A total of 176 procedures (91 patients) were carried out in the ETS 2-4 group and 103 procedures (53 patients) in the ESB 4 group: 60.4 and 43.4% had palmar hyperhidrosis, 8.8 and 5.7% had isolated axillary, and 30.8 and 50.9% had combined manifestations, respectively. Follow-up was 22.1 months (obtained from 79.1% of patients) for the ETS 2-4 group and 7.5 months for the ESB 4 group (obtained from 88.7%). RESULTS: The success rate was similar for both groups: 87.9 and 64.5% had completely dry limbs, 9.9 and 35.5% ( p < 0.0002) were nearly dry, and 2.1 and 0% remained wet. (ETS 2-4 vs ESB 4). Although the armpits remained slightly humid in more patients in the ESB 4 group, 100% stated full satisfaction. Complications did not differ significantly. However, compensatory sweating (55.6 vs 8.5%, p = 0.0002) and gustatory sweating (33.3 vs 2.1%, p = 0.0019) were markedly reduced (ETS 2-4 vs ESB 4). Quality of life was assessed by a hyperhidrosis index, which significantly improved in most patients. CONCLUSIONS: ETS 2-4 and ESB 4 have similar success rates in the treatment of upper limb hyperhidrosis. The major side effects of compensatory and gustatory sweating were effectively reduced by the limited method of clipping T4, and patients' satisfaction and improvement in quality of life were remarkable.

The influence of periarterial papaverine application on intraoperative renal function and blood flow during laparoscopic donor nephrectomy in a pig model.

BACKGROUND: The transplantation of live donor kidneys harvested laparoscopically is associated with a higher incidence of delayed graft function than the transplantation of grafts harvested via the open technique. The delay is believed to be due to a decrease in renal blood flow during laparoscopic donor nephrectomy (LDN). The aim of this study was to evaluate whether renal function and blood perfusion can be enhanced by the periarterial application of papaverine during LDN. METHODS: Renal function and blood flow were studied in a porcine model that included a total of 24 pigs (20-30 kg). In 12 of the pigs, urine output and creatinine clearance were determined as measures of renal function. In the other 12 pigs, renal blood flow was determined using fluorescent-labeled microspheres. In each group, the pigs were randomized into two subgroups, one with and one without a perivascular injection of 50 mg papaverine. RESULTS: As compared to the controls, the animals receiving papaverine had a significantly higher urine output (3.1 +/- 1.6 vs 0.9 +/- 0.45 ml/h/kg; p = 0.02), superior creatinine clearance (2.22 +/- 0.5 vs 0.95 +/- 0.1 ml/min/kg; p = 0.038), and enhanced renal blood flow (4.9 +/- 2.2 vs 2.1 +/- 0.8 ml/min/g; p = 0.008). CONCLUSIONS: When applied to the tissue surrounding the renal artery, papaverine substantially improves renal function and blood flow during laparoscopic live kidney donation. Whether graft optimization during kidney procurement also translates into improved posttransplantation function remains to be established.

Teaching laparoscopic cholecystectomy: do beginners adversely affect the outcome of the operation?

OBJECTIVE: To evaluate the safety of elective laparoscopic cholecystectomy (LC) as a supervised teaching procedure. DESIGN: Prospectively documented series, retrospective analysis. SETTING: University teaching hospital, Austria. SUBJECTS: 581 consecutive patients who underwent elective LC for symptomatic cholelithiasis between January 1993 and December 1997. INTERVENTIONS: LC were allocated to three groups: the first (n = 91) were done by supervised beginners (who had done fewer than 11 LC), the second (n = 249) by supervised trainees who had a little experience (they had done more than 10 but fewer than 51 LC), and the third group (n = 241) who were experienced surgeons (they had done more than 50 LC). MAIN OUTCOME MEASURES: Minor and major complications, conversion and reoperation rate, length of operation and postoperative hospital stay. RESULTS: The minor intraoperative complication rates were 36/91 (40%), 115/249 (46%) and 49/241 (20%), respectively (p < 0.001 when experienced surgeons were compared with the 2 trainees' groups). There were no significant differences between the three groups regarding major complications (1/91, 4/249 and 4/241), conversions (5/91, 21/249, and 17/241) and reoperation rate (1/91, 3/249 and 3/241), median (range) length of operation 82 (24-159), 84 (25-249) and 82 (21-234) minutes and hospital stay 4 (3-19), 4 (3-11) and 4 (2-15) days. CONCLUSION: Elective LC for symptomatic cholelithiasis done by trainees under supervision does not increase surgical morbidity.

Adrenal hemorrhage after orthotopic liver transplantation: MR appearance.

The purpose of this paper is to describe the MR imaging findings of right adrenal hemorrhage after orthotopic liver transplantation. Twenty-seven orthotopic liver transplantation patients underwent MR studies of the liver and/or biliary system. Patients were referred to MR examination because of suspected biliary complications ( n=22) or for evaluation of mass lesions ( n=5). The standard MR protocol included T1-weighted spin-echo (SE) or gradient-recalled echo (GRE) images and T2-weighted turbo SE (TSE) images with fat suppression. In addition, cholangiography pulse sequences and/or contrast-enhanced T1-weighted images were obtained according to specific indications. In 2 patients a right adrenal mass was detected at MR imaging. Three to 4 weeks after transplantation, the lesions were markedly hyperintense on T2-weighted images and showed a hypointense capsule. Follow-up MR examinations revealed a slight decrease in size and a change in morphology. Computed tomography examinations of these 2 patients, obtained 10 weeks after transplantation, showed resolution of the hemorrhage and transformation into a cystic lesion in one case and a complete resolution of the hemorrhage and a normal right adrenal gland in the other case. Adrenal hemorrhage after liver transplantation shows typical MR features and should not be mistaken for an adrenal tumor or a postoperative abscess.

Efficacy and safety of thoracoscopic sympathicotomy for hyperhidrosis of the upper limb. Results of 734 sympathicotomies.

BACKGROUND: Thoracoscopic sympathicotomy (TS) evolved as treatment of choice in severe hyperhidrosis. The aim of this study was to assess the role of video-assistance in TS (VATS) versus conventional TS (CTS) for primary hyperhidrosis of the upper limb with regard to safety, side-effects and long-term outcome. METHODS: 734 TS were performed from below T1 to T4 in 406 patients. In the CTS and in the VATS group 558 and 176 procedures were performed, respectively. Follow-up was completed in 82% of all patients after a median observation period of 16 years. RESULTS: Dry limbs were immediately achieved in 92% (CTS) and 97% (VATS, p = 0.98). Only one patient (CTS) underwent conversion due to bleeding. In the CTS group Horner's syndrome occurred in 2.2% and rhinitis in 9.9% of procedures. No patient of the VATS group experienced Horner's syndrome (p = 0.025), 3 patients developed rhinitis (p = 0.11). At follow-up compensatory sweating was observed in 67.6% vs. 55.6% (p = 0.051) and gustatory sweating in 50.4% and 33.3% (p = 0.01). There were 5 failures or recurrences (1.9%) in the CTS group and 2 (2.8; p > 0.05) in the VATS group at reevaluation. Overall 6.5% (CTS) and 5.6% (VATS) of patients regret the operation (p = 0.7). CONCLUSIONS: We observed a significant decrease of the incidence of complete or incomplete Horner's syndrome and gustatory sweating when the procedure was guided by video-imaging while success rate was similar when compared with CTS.

[Surgery for non-colorectal and non-neuroendocrine liver metastases]. / Die chirurgische Therapie von nicht-kolorektalen und nicht-neuroendokrinen Lebermetastasen.

INTRODUCTION: Hepatic resection has been shown to prolong survival in selected patients with colorectal liver metastases. Due to slow tumor growth patients with neuroendocrine liver metastases tend to have a good prognosis and benefit from chemo-embolisation and symptomatic treatment. The role of surgery in treating non-neuroendocrine and non-colorectal liver metastases is discussed controversially, due to the limited knowledge on this subject. The aim of our study was, therefore, to evaluate our own experiences with hepatic surgery for non-neuroendocrine, non-colorectal liver metastases. METHODS: A retrospective review of 72 patients (median age 60.9 years) who underwent 73 hepatic resections for non-neuroendocrine, non-colorectal liver metastases between 1980 and 2000 at a single tertial referral center was carried out. RESULTS: Hepatic resection was combined with surgery for the primary tumor in 30 cases (41.1%). Hospital mortality was 4.2%. 35 patients (47.9%) developed complications. The mean hospital stay was 17.5 days. In 64.4% of the cases a potentially curative resection was reached. Overall actuarial survival was 52.1% at 1 year, 25.3% at 3 years and 9.9% at 5 years. The respective median overall survival times were 7.1 months (gastric cancer metastases; n = 15), 4.9 months (cholangiocellular cancer metastases; n = 9), 5.6 months (gall bladder, bile duct cancer metastases; n = 8), 35.4 months (kidney cancer metastases; n = 8), 14.4 months (breast cancer metastases; n = 4), 15.3 months (pancreas and other adenocarcinoma metastases; n = 11), 49.9 months (sarcoma metastases; n = 10) and 32.9 months (other metastases; n = 7). CONCLUSIONS: In isolated hepatic metastases originating from sarcoma and hypernephroma radical resection can prolong survival. However, surgery cannot improve the prognosis in patients with liver metastases originating from the pancreas, gallbladder and the biliary tract. In selected patients with liver metastases from gastric and breast cancer long term survival seems possible after resection.

Multiorgan donation from a donor with unrecognized ornithine transcarbamylase deficiency.

Ornithine transcarbamylase (OTC) deficiency, the most common inherited urea cycle disorder, shows a spectrum of severity ranging from severe neonatal hyperammonemic coma to no symptoms among adults. We report on the multiorgan procurement from a donor who died of cerebral edema due to unrecognized late-onset OTC deficiency. The donor's OTC deficiency was diagnosed retrospectively since the liver graft recipient developed cerebral edema postoperatively due to hyperammonemia. Plasma ammonia was extremely elevated (3793 micromol/l), but was not accompanied by general liver dysfunction. Post mortem, the diagnosis of OTC deficiency was established by enzyme and molecular analysis in a biopsy of the transplanted liver. In contrast to the fatal course of the liver graft recipient, the kidney, lung, and heart transplantations were successful. Ten months after transplantation these recipients were alive and showed good graft function. This case demonstrates the importance of careful donor evaluation, particularly if the donor's cause of death is obscure.

[Status of surgical studies in oncology. I]. / Stand der chirurgischen Studien in der Onkologie, Teil 1.

Advances in surgery, anesthesiology and in critical care remarkably elevated safety of surgical therapy of cancer. However, prognosis of most cancer types as esophageal and gastric carcinoma--as discussed in this part of the survey--did not improve, even not after adjuvant therapy. To enhance curative resection rate chemotherapy and radiation or a combination of both have been performed preoperatively. The weakness of radiotherapy is control of distant metastases, chemotherapy failed in local tumor control. Multimodal preoperative strategies offered enhanced survival in responders, but overall there was no significant survival advantage. Until now neither in esophageal nor in gastric cancer randomised studies could demonstrate a substantial overall survival benefit after extended lymphadenectomy.