[Papillary thyroid gland carcinoma in childhood]. / Das papilläre Schilddrüsenkarzinom im Kindesalter.

We report on nine children, 9 to 17 years of age, with papillary carcinoma of the thyroid, whereby eight of them had lymph node metastases, and four had diffuse pulmonary metastases. After total thyroidectomy and up to four cycles of radioiodine treatment, as well as surgical resection of metastases negative to radioactive iodine uptake, there was no evidence of relapsing disease in any of the children. Hence, taking into consideration and optimal tumor patient follow-up and the improvement of the long-term prognosis, we recommended total thyroidectomy, also for encapsulated, well-differentiated thyroid carcinomas.

Elemental diet and IV-TPN-induced bacterial translocation is associated with loss of intestinal mucosal barrier function against bacteria.

OBJECTIVE: The goal of the current study was to directly assess the role of loss of mucosal barrier function in nutritionally induced bacterial translocation. BACKGROUND: Parenteral and certain elemental enteral diets have been shown to promote bacterial translocation. The mechanisms underlying this observation, especially the question of whether nutritionally induced bacterial translocation is primarily related to loss of intestinal barrier function, versus an impaired immune system, remain to be fully elucidated. METHODS: Bacterial translocation was measured in vivo, ileal mucosal membranes were harvested, and their electrophysiologic properties and barrier function were measured ex vivo in the Ussing chamber system 7 days after receiving total parenteral nutrition solution parenterally (IV-TPN) or enterally (elemental diet). Chow-fed rats served as control subjects. RESULTS: The incidence of bacterial translocation was significantly increased both to the mesenteric lymph nodes in vivo and across the in vitro Ussing chamber-mounted ileal mucosal membranes of the elemental diet-fed and IV-TPN-fed rats. The magnitude of Escherichia coli and phenol red transmucosal passage in the Ussing chamber was significantly higher in the IV-TPN-fed rats than in the elemental diet-fed or chow-fed animals. The potential differences across the ileal membrane were similar between the three groups at all time points. However, the specific resistances of the ileal membranes of the IV-TPN and elemental diet groups were significantly less than the chow-fed animals, indicating increased membrane permeability. CONCLUSIONS: Loss of intestinal barrier function plays a major role in nutritionally induced bacterial translocation, and the loss of mucosal barrier function to both E. coli and phenol red appeared greater in the IV-TPN than the elemental diet-fed rats.

Direct endoscopic percutaneous jejunostomy (EPJ). Clinical results.

Direct puncture of the small bowel under endoscopic guidance (direct EPJ) is possible in patients whose stomach has been removed or whose small bowel cannot be punctured by other methods. From January 1990 to June 1992 a total of 39 patients underwent successful direct EPJ at our institution. The indications were malnutrition after partial or total gastrectomy (n = 19), insufficient anastomosis or a stenosis after esophageal resection and esophagojejunostomy (n = 13), esophageal perforation (n = 3), fistulas (n = 2), or severe trauma (n = 2). The tubes were inserted at the bedside under local anesthesia using the string pull-through technique. The procedure was attempted in five other patients but it was technically impossible to insert the tubes in these patients. Postoperative enteral feeding was possible in all 39 patients whose direct EPJ was successful. Complications included tube dysfunction due to plugging and fracture in five patients, pressure-induced enteric ulcers in two, and local infections in three patients. The ulcers and infections were managed conservatively. We conclude that direct EPJ is a safe, effective alternative to surgical catheter-jejunostomy.

[Liver resection in hepatocellular carcinoma]. / Leberresektion beim Hepatozellulären Karzinom.

Hepatic resection offers the only chance of cure for patients with hepatocellular carcinoma. Preoperative tumor staging is based on radiologic procedures (ultrasound, CT- and MR-imaging). Compromised hepatic function will limit resectability, leaving only palliative procedures. Unfavorable prognostic tumor factors (diameter > 5 cm, multifocal, nonencapsulated, vascular invasion) should lead to a combination of adjuvant chemotherapy/chemoembolization and surgical intervention. In irresectable situations multimodality treatment protocols (combined i.v. chemotherapy, radio-immuno-therapy) play an increasing role.

[Treatment of symptomatic non-parasitic liver cysts using percutaneous drainage and irrigation with hypertonic saline solution]. / Behandlung der symptomatischen nichtparasitären Lebercysten mittels percutaner Drainage und Spülung mit hypertoner Kochsalzlösung.

In 7 patients with a total of 20 symptomatic larger liver cysts an instillation therapy with 20% saline solution was performed via a sonographically placed sump drainage. No clinically relevant complications were observed. After a median follow-up period of 18 months in two patients with cystic livers asymptomatic residual cysts measuring less than 4 cm were found only. In comparison to the instillation therapy using a sclerosing agent the presented technique seems to be equally effective but less traumatizing. Surgical procedures are restricted to a few, otherwise not treatable patients.

[Training program for minimally invasive surgery]. / Trainingsprogramm für die Minimal-invasive Chirurgie.

Currently 'Minimally Invasive Surgery' (MIS) is rapidly finding a widening range of applications and increasing numbers of surgical departments start with new MIS techniques. Surgical work under endoscopic control requires an intensive readjustment to operation technique bringing about new problems in training. We believe that intensive training of MIS procedures on suitable training phantoms should be a prerequisite for clinical application of MIS and therefore have established a training center for MIS in Tübingen, FRG, offering weekly hands on training courses for different procedures.

Diagnosis of liver metastases from malignant gastrointestinal neoplasms: results of pre- and intraoperative ultrasound examinations.

In this prospective study, 108 patients presenting with gastrointestinal cancer were examined for liver metastasis before and during surgery. The investigations emphasized a comparison of pre- and intraoperative ultrasound (US) examinations. The results of intraoperative liver inspection and palpation served as control parameters. In addition, an exact description and characterization of the liver metastases was attempted. Liver metastases were found in 30 of the 108 patients (28%). They could be identified in 17 subjects by preoperative US (57% sensitivity), in 21 patients by intraoperative palpation and inspection (70% sensitivity), and in 27 cases by intraoperative US (90% sensitivity). We concluded that 7%-34% of patients with liver metastases can be identified with 95% reliability using intraoperative US alone or in combination with palpation and inspection.

Intraoperative echo-contrast ultrasound examination of malignant liver neoplasms--initial clinical experience.

The value of intraoperative echo-contrast ultrasound (US) as compared with plain US was studied in 19 patients presenting with malignant liver tumors. The contrast medium SHU 454 was intraoperatively injected via the portal venous system or the biliary tract. Using intraoperative echo-contrast US, extremely small liver tumors could be sought in a limited area of the liver. In comparison with plain US, the former technique resulted in better demarcation of especially small tumors, which were seen as echo-poor areas in relation to the surrounding liver tissue.

Endoscopic microsurgical dissection of the esophagus. Results in an animal model.

Blunt dissection of the esophagus is considered the least invasive technique in the treatment of either benign or malignant diseases of the esophagus. Its disadvantage is that it has to be carried out blindly. The results may be uncontrollable hemorrhage, unrecognized injuries to the trachea, and damage to the recurrent laryngeal nerve. In order to reduce the degree of invasiveness a new endoscopic microsurgical technique for the dissection of the esophagus has been developed and tried out in animals. This paper presents the operative technique. Our new endoscopic microsurgical technique obviates a thoracotomy, while direct endoscopic vision results in improved dissection. The magnified endoscopic view permits selective exposure of blood vessels and prevents injury to the adjacent organs.

Training program for transanal endoscopic microsurgery.

Televised endoscopy and the concept of the "assisted" endoscopic operation is of great help in teaching surgical endoscopic techniques. The use of training dummies provides a new method of training manual dexterity and surgical skills in special courses or in surgical skill laboratories. We have developed a training system for transanal endoscopic microsurgery. Operations with our technique were performed on 116 patients. Like other microsurgical techniques, our method requires a special introduction and intensive training. This paper presents our multistage, video-supported training course for teaching transanal endoscopic microsurgery. The one-day training session is divided into four steps: (1) becoming acquainted with the technology; (2) training on cloth phantom; (3) training on opened bowel; (4) training on closed bovine bowel distended by gas insufflation. Each step is introduced by a short videotape didactically demonstrating the particular aspects of the method.

Endoscopic microsurgery of rectal tumors.

Seventy-five patients with sessile adenomas or early carcinomas of the rectum or rectosigmoid were operated on with the new technique "transanal endoscopic microsurgery" Employing a newly developed complex endoscopic operating system, complete removal of sessile adenomas can be accomplished up to a distance of 25 cm from the anal verge, accurately and non-invasively. Complications occurred in three cases, with no resulting mortality. In the follow-up period we discovered only one adenomatous recurrence that required operative treatment. The superior accuracy of preparation, a short average stay in hospital, and low recurrence and complication rates are the advantages of this transanal endoscopic operative technique.