Laparoscopic resection rectopexy (RRP) combined with mesh sacrocolpopexy (SCP) for obstructed defecation syndrome with pelvic organ prolapse in an interdisciplinary approach.

Background: Obstructive defecation syndrome (ODS) is frequently associated with pelvic organ prolapse (POP) and compromises the quality of life in affected patients. In cases conservative treatment fails surgical therapy is required. Objectives: The video case study combines a laparoscopic resection rectopexy (RRP) with a mesh sacrocolpopexy (SCP) in an interdisciplinary surgical approach. Materials and Methods: In this video an 86-year-old woman with ODS and POP, suffering from a dolichocolon with rectal intussusception, an apical prolapse after total hysterectomy 1990, and occasional stress urinary incontinence underwent interdisciplinary laparoscopic surgery. A tubular anterior rectal and sigmoid resection with suture rectopexy as in a resection rectopexy (RRP) was combined with a sacrocolpopexy (SCP) using a synthetic mesh. Main outcome measures: Surgical outcome including postoperative morbidity, functional bowel evacuation, and POP reconstitution as in POP-Q score after surgery were documented. Results: No intra- or postoperative complications occurred. At 6 months follow-up clinical outcomes for ODS, bowel dysfunction, and faecal control were improved. Anatomical outcome for POP and stress urinary incontinence symptoms were corrected. Conclusions: We report a promising interdisciplinary surgical approach as a single treatment option for the complex medical condition of women suffering from ODS and POP combining laparoscopic RRP with SCP. This surgical approach proved to be feasible, safe, and effective.

Laparoscopic incisional hernia repair: evaluation of effectiveness and experiences.

INTRODUCTION: Incisional hernia is the most frequent postoperative complication following abdominal surgery and is a common and costly source of morbidity. Conventional mesh repair is the standard treatment today, but the use of laparoscopic incisional hernia repair (LIHR) seems to be a good alternative. We performed a retrospective analysis comparing open incisional hernia repair with the laparoscopic approach. METHODS: Between June 2004 and June 2006, 123 patients with incisional hernia were included. Open repair (37 men and 45 women; mean age 62.6 years) was performed in 82 cases, whereas 41 patients underwent laparoscopic repair (29 men and 12 women; mean age 64.3 years). Patient- and procedure-associated characteristics, clinical outcome, and recurrence rate were determined after a median follow-up period of 23 months for the laparoscopic group and 24 months for the open group. RESULTS: Hernia sizes were comparable between the groups. Conversion to open repair was required in two cases. Postoperative pain scores did not differ significantly. In the long-term follow-up, however, the pain score was less (P = 0.001) and the satisfaction rate was higher (P = 0.003) in the laparoscopic group. Complications occurred in 23% of patients in the open group and 20% in the LIHR group. The recurrence rate was lower in the laparoscopic group, with 9% (3/35) compared to 23% (18/77) in the open group (P = 0.089). CONCLUSIONS: Our results show the tendency that LIHR is associated with less postoperative pain and comparable postoperative complications. The low recurrence rate proves the safety and the good long-term results of this procedure. Laparoscopic hernia repair is an alternative to open procedures in cases of feasibility. Further studies, especially randomized controlled trials, are required to confirm these findings and provide the basis for future treatment guidelines.

[The quality of patient care under the German DRG system using as example the inguinal hernia repair]. / Die Qualität unseres Abrechnungssystems am Beispiel der Leistenhernien.

The DRG system in Germany was introduced to improve and at the same time simplify the reimbursement of costs in German hospitals. Cost effectiveness and economic efficiency were the declared goals. Structural changes and increased competition among different hospitals were the consequences. The effect on the qualitiy of patient care has been discussed with some concern. Furthermore, doubts have been expressed about the correct representation of the various diagnoses and treatments in the coding system and the financial revenue. Inguinal hernia repair serves as an example to illustrate some common problems with the reimbursement in the DRG system. Virtual patients were grouped using a "Web Grouper" and analysed using the cost accounting from the G-DRG-Browser of the InEK. Additionally, the reimbursement for ambulant hernia repair was estimated. The DRG coding did not differentiate the various operative procedures for inguinal hernia repair. They all generated the same revenues. For example, the increased costs for bilateral inguinal hernia repair are not represented in the payment. Furthermore, no difference is made between primary and recurrent inguinal hernia. In the case of a short-term hospital stay, part of the revenue is retained. In the case of ambulatory treatment of inguinal hernia, the reimbursement is by far not a real compensation for the actual costs. The ideal patient in the DRG system suffers from a primary inguinal hernia, undergoes an open hernia repair without mesh, and remains for 2-3 days in hospital. Minimally invasive procedures, repair of bilateral inguinal hernia and ambulant operation are by far less profitable--if at all. The current revenues for inguinal hernia repair require improvement and adjustment to reality in order to accomplish the goals which the DRG system in Germany aims at.

Nitric oxide mediates histamine induced down-regulation of H2 receptor mRNA and internalization of the receptor protein (R1).

During agonist-dependent long-term stimulation of cells, histamine receptor subtypes are frequently down-regulated. However, the mechanisms underlying the modulation of receptor expression during long-term histamine stimulation have yet to be resolved. Based on our recently reported results showing an H1-mediated down-regulation of histamine H2 receptor mRNA in endothelial cells, our aim was to characterize the mechanism controlling rapid and long-term histamine-mediated modulation of H2 receptor expression in more detail. We were able to show that the histamine-induced down-regulation of H2 receptor mRNA and cell surface expression lasting for 24 h was accompanied by augmentation of the receptor protein level in the cytoplasmatic fraction of endothelial cells for this time period. Furthermore, changes in receptor protein levels in whole-cell lysate were negligible, indicating that the rapid and prolonged modulation of cell surface H2 receptor levels by histamine was regulated solely via internalization. The role of nitric oxide (NO) as a key mediator in histamine-stimulated cell responses was underlined by subsequent studies showing the attenuation of histamine-induced H2 receptor mRNA down-regulation and protein trafficking following NO synthase isozyme inhibition.

Association of p53 mutations, microvessel density and neoangiogenesis in pairs of colorectal cancers and corresponding liver metastases.

p53 suppressor gene mutations are a well known step which occurs in the late stages of the complex tumourigenesis of colorectal cancer. A deregulation of p53 protein function may be associated with increased neovascularization and aggressive tumour growth. In vitro studies have shown that these genetic alterations cause a loss of wild-type p53-induced anti-angiogenetic control and could possibly induce expression of the neoangiogenic vascular endothelial growth factor (VEGF). Therefore, this in vivo study was performed to assess p53 mutations, i.e. hot spots in exons 4-9, in primary colorectal cancers and in corresponding liver metastases in order to test whether there is an association between p53 mutated tumours with increased microvessel density (MVD) and VEGF overexpression. Twenty-two tissue samples taken from primary colorectal cancers and the corresponding liver metastases were immediately snap-frozen in liquid nitrogen and fixed in formaldehyde. After DNA extraction exons 4-9 were amplified and directly sequenced. Cryostat sections were stained immunohistochemically using antibodies against VEGF, CD34, and p53 protein. A modified semiquantitative Weidner score and interactive computerized image analysis was used to assess MVD. Overexpression of immunohistochemically detected p53 protein was found in 7 of the 11 primary tumours and liver metastases (64%). Sequencing showed 3 out of 11 primary tumours (27%) and 5 out of 11 liver metastases (46%) to have p53 point or frameshift mutations; these samples tested immunohistochemically positive for p53 protein. Two p53 mutations in samples of liver metastases were not detectable in the corresponding primaries. We detected one frameshift mutation in exon 4 that has not yet been described in the literature. Tumour samples with p53 mutations and increased VEGF immunoreactivity were associated with higher MVD (p<0.01 and p<0.05, respectively). However, there was no association detected immunohistochemically between p53 and MVD as well as p53 mutations and VEGF overexpression. Our data demonstrate specific genetic alterations in the coding regions of p53 suppressor gene in both primary colorectal cancers and corresponding liver metastases, these alterations are associated with an increase in MVD, but not in VEGF overexpression. In addition, a novel frameshift mutation in both colorectal cancer and metastasis is described.

Thrombin enhances adhesion in pancreatic cancer in vitro through the activation of the thrombin receptor PAR 1.

BACKGROUND: Thrombin, the central enzyme of the coagulation cascade, induces proliferation in different solid tumours. The effect is mainly mediated through the functional thrombin receptor PAR 1, a member of the G-protein coupled receptor family. The aim of this study was to assess the role of thrombin on adhesion of pancreatic cancer to extracellular matrix proteins and endothelial cells in vitro. MATERIALS AND METHODS: The human pancreatic adenocarcinoma cell line MIA PaCa-2 was treated with thrombin and the thrombin-receptor-activating peptide (TRAP), respectively. As a control the cells were pre-incubated with the thrombin-receptor-inhibiting peptide (T1). The cells were incubated on microtiter plates, which were pre-coated with extracellular matrix proteins (fibronectin, laminin, collagen IV) or human umbilical vein endothelial cells (HUVECs), for 30 and 60 min, respectively. The number of adherent cells were measured using the MTT method. ANOVA was used for statistical analysis. RESULTS: Thrombin enhanced the adhesion of MIA PaCa-2 cells to extra-cellular matrix proteins and endothelial cells significantly (P< or =0.001). The effects of thrombin could be mimicked by TRAP. Pre-incubation with T1 inhibited the effect. CONCLUSION: Thrombin enhances adhesion of pancreatic adenocarcinoma to extracellular matrix proteins and endothelial cells in vitro. The effect is mediated through the thrombin receptor PAR 1. The results emphasize the role of thrombin and PAR 1 in pancreatic tumour biology.

Detection of tumor cells in peritoneal lavages from patients with gastrointestinal cancer by multiplex reverse transcriptase PCR.

BACKGROUND/AIMS: Cytological examination of peritoneal lavages is a useful predictor of peritoneal recurrence in gastrointestinal carcinoma patients. Nevertheless, it may be inadequate for those patients with lavages containing only few cancer cells. In the present study, sensitive detection of free cancer cells could be achieved through amplification of cytokeratin 19, carcinoembryonic antigen, alpha-fetoprotein mRNAs by means of multiplex reverse transcriptase polymerase chain reaction and nested polymerase chain reaction. METHODOLOGY: The multiplex reverse transcriptase polymerase chain reaction assay was used to examine lavage samples from 64 patients with various gastrointestinal malignant lesions (colorectal n = 27; duodenal carcinoma n = 1; gastric n = 7; pancreatic n = 4; hepatocellular carcinoma n = 2; gallbladder n = 1; cholangiocellular carcinoma n = 2 and 20 colorectal liver metastases. Specificity was assessed by examination of 15 donors without malignancies. In addition, nested polymerase chain reaction was used to improve the sensitivity of the assay for the detection of alpha-fetoprotein transcripts. RESULTS: Peritoneal lavages from 12 of 64 gastrointestinal carcinoma patients were positive for carcinoembryonic antigen mRNA. Carcinoembryonic antigen proved a specific marker, as no false-positives were detected in any patients without gastrointestinal cancer. alpha-fetoprotein mRNA was detected exclusively in peritoneal lavages from tumor patients, i.e., in 16 of 27 colon cancer patients, 14 of 20 patients with colorectal liver metastasis, 2 of 7 patients with gastric cancer, two patients with hepatocellular carcinoma and 2 of 4 patients with pancreatic cancer. Cytokeratin 19 mRNA was not found a useful marker, since control patients without malignancies were also positive. CONCLUSIONS: Our data suggest that carcinoembryonic antigen- and alpha-fetoprotein mRNA in peritoneal lavage are potentially useful specific markers for early diagnosis of metastasis of gastrointestinal cancer. It has been shown that alpha-fetoprotein-specific nested reverse transcriptase polymerase chain reaction can detect not only hepatocellular carcinoma cells, but also malignant cells from other gastrointestinal carcinomas. In contrast, cytokeratin 19 mRNA lacks specificity for gastrointestinal cancer.

Prospective randomised trial on adjuvant hepatic-artery infusion chemotherapy after R0 resection of colorectal liver metastases.

BACKGROUND AND AIMS: The liver represents the predominant site of cancer relapse after curative resection of hepatic metastases from colorectal carcinoma. Adjuvant intra-arterial chemotherapy was therefore considered a promising therapeutic approach in high-risk patients. PATIENTS/METHODS: From July 1984 to December 1985, a total of 42 consecutive patients underwent R0 resection of colorectal liver metastases. Thirty patients with mesenteric lymph-node metastases (Dukes C) were randomised into two groups. In 14 group-A patients, a hepatic artery port catheter was placed during liver resection. Four courses of adjuvant chemotherapy were administered at 4-week intervals, consisting of mitomycin C (8 mg/m2, day 1) and 5-fluorouracil (800 mg/m2, days 1-5). Sixteen group-B patients served as controls. The 12 patients with no mesenteric lymph-node metastases (Dukes A/B) were included in the follow-up program. RESULTS: After 5 years, 64% of Dukes A/B patients and 29% of Dukes C patients were alive (P<0.01). The probability of remaining free of recurrent disease after 5 years and 10 years was 55% and 18%, respectively (P<0.01). No significant difference in either 5-year survival (25% vs 31%) or long-term disease-free status (15% vs 23%) was detected between groups A and B. The initial tumour relapse was shifted towards extrahepatic sites in group-A patients, but no difference was obtained regarding the definite distribution of recurrent disease. CONCLUSION: Routine application of adjuvant regional chemotherapy after R0 liver resection is not warranted.

The middle colic vein: an alternative source of portal inflow in orthotopic liver transplantation complicated by portal vein thrombosis.

BACKGROUND: Portal vein thrombosis (PVT) was previously considered a contraindication to orthotopic liver transplantation (OLT) since adequate portal blood supply is mandatory for graft function and patient survival. Improvements in surgical technique, however, have meant that this problem now can be circumvented in most instances. Nevertheless portal vein thrombosis remains an obstacle in OLT and is associated with increased incidence of primary non-function and long-term liver failure. METHODS: A 55-yr-old patient underwent OLT for secondary biliary cirrhosis associated with hepatitis C infection and complicated by long standing PVT. Involvement of the portal, mesenteric, and splenic veins prevented standard portal venous reconstruction. Portal inflow was accomplished by a side-to-end anastomosis between the middle colic vein and the donor portal vein. RESULTS: Hepatic reperfusion and subsequent liver function were excellent. Portal blood flow, as measured by color-enhanced Doppler ultrasound, was normal following surgery until discharge. The post-operative course was complicated by abdominal wound dehiscence and recurrent cytomegalovirus (CMV) infection. The patient was discharged in good clinical condition, with excellent liver function and patent portal vein 89 d after OLT. CONCLUSIONS: The middle colic vein is a novel, not previously described, source of portal venous inflow for OLT complicated by extensive splanchnic venous inflow thrombosis.

Characterization of functional thrombin receptors in human pancreatic tumor cells (MIA PACA-2).

In this article, the "tethered ligand" thrombin receptor was identified on human pancreatic tumor cells, MIA PaCa-2, using immunofluorescence studies with a monoclonal anti-thrombin receptor antibody. Pharmacological characterization, using 3H-labeled thrombin receptor activating peptide-6 (TRAP-6) as radioligand, demonstrated a single class of high-affinity binding sites (KD = 9.1+/-1.8 x 10(-7) M) and a binding capacity of 13.9+/-0.7 fmol/mg protein. These binding sites represent functional thrombin receptors, as shown by alpha-thrombin- and TRAP-6-induced mobilization of free intracellular calcium, protein kinase C translocation from cytosol to the cell membrane, and stimulation of DNA synthesis in MIA PaCa-2 cells. These results provide the first identification of tethered ligand thrombin receptor in human pancreatic cancer cells and suggest thrombin receptor involvement in mechanisms of human pancreatic tumor progression.

Thrombin receptor activation results in calcium signaling and protein kinase C-dependent stimulation of DNA synthesis in HEp-2g laryngeal carcinoma cells.

BACKGROUND: Recently, the expression of the "tethered ligand" thrombin receptor in carcinosarcoma and melanoma cells has been shown. However, the role of the thrombin receptor in tumor cell metabolism still is undefined. METHODS: In this article, the "tethered ligand" thrombin receptor was identified on human epidermoid carcinoma cells (HEp-2g cell line) by using immunofluorescence studies with a monoclonal antithrombin receptor antibody and radioligand binding. Furthermore, the effects of alpha-thrombin and thrombin receptor activating peptides (TRAP)-6 on calcium mobilization, protein kinase C (PKC) translocation, and DNA synthesis were estimated. RESULTS: Pharmacologic characterization using [3H]TRAP-6 as a radioligand demonstrated a single class of high affinity binding sites (dissociation constant [KD] = 7.2 +/- 2.2 x 10(-7) M) and a binding capacity of 27 +/- 3.4 fmol/mg protein. The function of these binding sites was demonstrated by alpha-thrombin- and TRAP-6-induced mobilization of free intracellular calcium, and translocation of PKC from cytosol to cell membrane. Moreover, alpha-thrombin and TRAP-6 induced an increase in [3H]thymidine incorporation in HEp-2g cells that could be blocked by the PKC inhibitor bisindolylmaleimide. CONCLUSIONS: To the authors' knowledge, the results of this study demonstrate for the first time functional thrombin receptors in epidermoid carcinoma cells. The thrombin receptor appears to be involved in growth regulation in HEp-2g cells by a PKC-dependent mechanism.

Cholecystokinin B-type receptor signaling is involved in human pancreatic cancer cell growth.

Cholecystokinin (CCK) is known to stimulate pancreatic cancer cell growth, but no detailed CCK receptor subtype characterization and investigation of CCK receptor-mediated cellular responses in human pancreatic cancer cells have been reported thus far. In this study, CCK binding sites were identified in human pancreatic cancer cells (MIA-PaCa-2) using radioligand binding studies. Pharmacological characterization demonstrated a single class of high-affinity CCK sites on MIA-PaCa-2 cells (326 +/- 18 pM, receptor density 16.9 +/- 2.3 fmol/mg protein). These CCK binding sites displayed a typical CCKB binding profile as shown in competition studies by using different CCK-related compounds and non-peptide CCK antagonists discriminating between CCKA and CCKB sites. CCKB receptor-connected effector systems have been characterized in MIA-PaCA-2 cells, and their involvement in CCK-8S-induced proliferative effects on MIA-PaCa-2 cells has been demonstrated.