[Patient selection as the key to success of metabolic surgery]. / Patientenselektion als Schlüssel zum Erfolg der metabolischen Chirurgie.

BACKGROUND: The indications for bariatric interventions consist of the objectives to improve the quality of life and to prolong survival by remission of obesity-associated comorbidities. Until now the selection criteria for patients to undergo surgery which allow a prediction of therapeutic success are obscure. OBJECTIVE: The aim of the study was to identify the prerequisites for selection of overweight and obese patients to undergo bariatric surgery. RESULTS: Obesity per se is a proven indication for bariatric surgery due to the associated increase in mortality; however, not all obese patients can be considered for weight reduction surgery. A decisive factor for patient selection is the evidence of behavioral change regarding nutrition, composition and frequency of meals as well as increased ambulation. In patients with psychiatric diseases and behavioral disorders responsible for obesity a specific therapy is mandatory as well as intensive counseling and adherence to a lifelong follow-up. DISCUSSION: It seems that therapeutic success on a long-term basis is only guaranteed by behavioral changes. Preoperative multimodal therapy does not influence the outcome but it seems possible that such treatment may contribute to increased adherence to the behavior necessary for therapeutic success. Nevertheless, such treatment must not constitute a barrier against bariatric surgery. However, patients who are not willing to change their pathological behavior do not qualify for weight-reducing surgery because otherwise therapeutic success is questioned.

[Importance of PET for surgery of recurrent thyroid cancer]. / Bedeutung der PET für die Chirurgie des Schilddrüsenkarzinomrezidivs.

BACKGROUND: The early detection of recurrent thyroid cancer and focussed surgery are essential for patients' prognosis. Using I-131 whole body scintigraphy is often not sufficient to detect recurrent carcinoma making other imaging methods necessary to identify the tumor. Recent studies showed that positron emission tomography-computed tomography (PET/CT) is able to identify recurrent carcinoma and metastasis at an early stage. OBJECTIVE: The aim of this study was an evaluation of the impact of PET/CT on diagnostic and operation strategies in recurrent thyroid cancer. METHODS: A review of the literature was carried out combined with a case report from the daily practice. Furthermore, flow charts were created to clarify the aftercare procedure. RESULTS: In patients with recurrent thyroid cancer PET/CT significantly increased the identification of recurrent tumors and metastases. Depending on the subtype of cancer, different tracers are used. The use of a metabolically active tracer which shows the increase of tumor metabolism and the morphological correlation of the tumor using a CT scan enable preoperative planning for a focussed surgical approach. CONCLUSIONS: The PET/CT procedure should be an integral part of the aftercare procedure in thyroid cancer for early identification of recurrent tumors and to enable focussed surgery.

[Modern treatment options for Zenker's diverticulum: indications and results]. / Aktuelle Behandlungskonzepte des Zenker-Divertikels--Indikationen und Ergebnisse.

Conventional transcervical therapy of Zenker's diverticulum comprises diverticulectomy, invagination, diverticulopexy and myotomy, which may be combined with the aforementioned methods. Transoral diverticuloesophagostomy is performed by diathermy, lasers or staplers through a rigid esophagoscope, or more recently by diathermy applied via a flexible endoscope. Morbidity of transcervical procedures ranges between 3 (myotomy) and 23 % (diverticulectomy + myotomy). The percentage of patients with at least significantly improved symptoms is 92 % or more, while recurrences occur in 5.7 (diverticulectomy alone) to 21 % (invagination). Transoral procedures have a morbidity of 9 (stapler) to 26 % (Laser), while symptoms improve in 91 (diathermy through rigid esophagoscope) to 99 % (diathermy via flexible endoscope), however in up to 64 % of patients reoperations are necessary. Small diverticula (Brombart I/II) can be treated by diverticulectomy (with/without myotomy) or flexible endoscopy, larger diverticula in general by all methods. Patients younger than 60 years should undergo diverticulectomy, elderly multimorbid patients should be treated by transoral procedures.

German national case collection of familial pancreatic cancer - clinical-genetic analysis of the first 21 families.

BACKGROUND: The observation of a familial accumulation of ductal pancreatic adenocarcinoma (PC) and the increased risk for PC in certain hereditary tumor syndromes point to a genetic predisposition for PC. In order to evaluate the characteristics of familial PC, a German national case collection for familial pancreas cancer (FaPaCa) was established. PATIENTS AND METHODS: In FaPaCa, families of patients with PC are being collected, who have at least 1 first-degree relative with PC or with malignant melanoma. Histopathologic verification of tumor diagnoses, acquisition of clinical data, and full genetic counselling are prerequisites for the enrollment of PC families in FaPaCa. RESULTS: So far, 21 families fulfilled the criteria for partaking in FaPaCa. In 11 families, PC represented the sole tumor entity. Additional tumors included malignant melanoma in 5, breast cancer in 3, and prostatic, colon or lung cancer in 2 families. Compared to the preceding generation, a younger age at diagnosis of PC was observed in the offspring of PC patients (offspring median 53 years vs. parents median 75.5 years). CONCLUSION: The association of PC and breast cancer, and of PC and malignant melanoma suggests predisposing mutations in the BRCA2 or CDKN2A genes in about one third of the FaPaCa families. Mutational analyses in both candidate genes may help to identify individuals who are at an increased risk for developing PC. A shift towards a younger age at diagnosis in our PC families may indicate genetic anticipation and/or changes of patterns of exogenous risk factors.

Impact of modified radical neck dissection on biochemical cure in medullary thyroid carcinomas.

BACKGROUND: This study evaluated the outcome of total thyroidectomy and modified radical neck dissection in primary treatment of patients with medullary thyroid carcinoma (MTC). METHODS: Thirty-six patients with sporadic (n = 16) and hereditary (n = 20) MTC underwent thyroidectomy and systematic central and lateral lymph node dissection (unilateral, 23; bilateral, 13) between 1994 and 2000. Postoperative serum calcitonin levels were correlated with immediate or delayed surgery, tumor categories, and lymph node metastases. RESULTS: Sixteen of 36 (44%) patients with clinically evident MTC treated with central and lateral neck dissection exhibited normal basal and stimulated calcitonin levels at a median follow-up of 3.7 years. Lymph node involvement was detected in 75% of these patients and correlated with the TNM stages. Biochemical cure was achieved according to the T categories in 83% of the patients in stage T1, 42% in stage T2, and none of the patients in stage T4 (P = .011). Basal and stimulated calcitonin levels were found to be normal in 89% of the patients without lymph node involvement and in 30% of the patients with lymph node metastases (P = .005). CONCLUSIONS: Screening for MTC and primary treatment with total thyroidectomy and modified radical neck dissection are essential for biochemical cure of MTC.

Indications for and results of surgical therapy for male gynecomastia.

BACKGROUND: The objective of our study was to analyze factors determining diagnostic versus cosmetic indication and postoperative results in the treatment of gynecomastia. PATIENTS AND METHODS: Data from 100 patients and 141 breasts were analyzed retrospectively, and reevaluated by questionnaire (n = 81) and clinical examination (n = 33). Except for 2 patients, all underwent subcutaneous mastectomy through various incisions. RESULTS: Diagnostic surgery was exclusively performed in unilateral, nodular gynecomastia being preferentially of grade I. Higher grade, bilateral gynecomastia led mainly to cosmetic surgery. Minor complications (skin retraction, hypertrophic scars, hypesthesia, skin redundancy) occurred in 53% of patients and significantly more often in grade III or II gynecomastia. Each incision was preferentially associated with specific sequelae. However, 86% of patients were satisfied with surgical results. CONCLUSIONS: Laterality, consistency, grade, and age at onset of symptoms determine surgical indication. Despite the high number of sequelae due to preoperative grade and selected incision, most patients are satisfied with postoperative results.

[Effect of primary surgical therapy on the course of C-cell carcinoma of the thyroid gland]. / Einfluss der primären chirurgischen Therapie auf den Verlauf des C-Zell-Karzinoms der Schilddrüse.

The effect of the type of initial surgery for medullary thyroid carcinoma on the outcome is obscure. Some 40 patients with hereditary medullary thyroid carcinoma underwent either thyroidectomy and modified radical neck dissection (n = 18), subtotal thyroid resection (n = 10), or thyroidectomy (n = 12), partly with selective lymphadenectomy, as initial surgery. Patients who underwent thyroidectomy and modified radical neck dissection as their first operation had higher cure rates and lower morbidity. Thus the initial procedure is decisive for the further outcome in patients with hereditary medullary thyroid carcinoma.

[Surgical therapy of gynecomastia and its results]. / Chirurgische Therapie der Gynäkomastie und ihre Ergebnisse.

The objective of our study was to evaluate the factors which lead to operative therapy of gynaecomastia for cosmetic or diagnostic reasons and to assess the postoperative results. 100 patients with gynaecomastia underwent subcutaneous mastectomy (n = 98) or total mastectomy for gynaecomastia through different incisions, with subjectively satisfactory results in 93% of all patients, although cosmetically unsatisfactory results occurred in more than 50% of all patients. Although the surgical objective is achieved by current operative therapy, many patients experience cosmetically unsatisfactory results, which demands the evaluation of other operative strategies with a potentially higher rate of cosmetically adequate results.

[Calcium metabolism after thyroidectomy with modified radical neck dissection and parathyroid gland autotransplantation]. / Kalziumstoffwechsel nach Thyreoidektomie mit modifiziert radikaler Neckdissektion (MRN) und Nebenschilddrüsenautotransplantation (NSDaTx).

The issue of parathyroid autotransplantation in oncologic thyroid surgery is discussed controversially. In a series of 15 patients who underwent bilateral modified radical neck dissection for thyroid malignancy, parathyroid autotransplantation was carried out. Six months after surgery only one patient was hypoparathyroid, requiring permanent medication, thus autotransplantation is a safe procedure for the prevention of accidental hypoparathyroidism.

Immunohistochemical heterogeneity of nerve cells in the human adrenal gland with special reference to substance P.

Neurons in the human adrenal medulla, stained by the NADH-diaphorase reaction, were counted and their neurochemical markers were investigated by double labeling immunofluorescence with special reference to substance P. The findings indicate a significant participation of intramedullary nerve cell bodies in human adrenal innervation with 40.4 neurons/mm3 adrenal medulla. Substance P-immunoreactive neurons, which made up approximately 20% of all neurons, exhibited heterogeneity by co-localization of immunoreactivities for dynorphin, for cholecystokinin, and for neurofilament triplet. Substance-P-immunolabeled neurons were always nonreactive for calcitonin gene-related peptide, for vasoactive intestinal polypeptide, or for tyrosine hydroxylase, the rate-limiting enzyme of catecholamine synthesis. These chemical phenotypes of intramedullary neurons reveal immunohistochemical similarities with postganglionic neurons in parasympathetic ganglia or with enteric neurons, suggesting a hitherto unrecognized functional significance of the intrinsic nervous system in the human adrenal gland.

Immunohistochemical correlation of human adrenal nerve fibres and thoracic dorsal root neurons with special reference to substance P.

Applying a double-labelling immunofluorescence technique, six types of substance P-containing nerve fibres were distinguished in the human adrenal gland according to the immunohistochemical colocalization of (I) calcitonin gene-related peptide (CGRP), (II) cholecystokinin, (III) nitric oxide synthase, (IV) dynorphin, (V) somatostatin, and (VI) vasoactive intestinal polypeptide. Fibre populations I to IV in their mediator content resembled the respective subpopulations of primary sensory neurons in human thoracic dorsal root ganglia, while populations V and VI revealed no correspondence with dorsal root neurochemical coding. Nerve fibres with the combination substance P/nitric oxide synthase occurred only in the adrenal cortex, whereas all other fibre types were present in both cortex and medulla. As revealed by immuno-electron microscopy, substance P-immunolabelled axon varicosities (a) exhibited synaptic contacts with medullary chromaffin cells or with neuronal dendrites, (b) were directly apposed to cortical steroid cells and (c) were separated from fenestrated capillaries only by the interstitial space. These findings provide immunochemical support for an assumed sensory innervation of the human adrenal gland, and additionally suggest participation of substance P in efferent autonomic pathways. Furthermore, the results are indicative for a differentiated involvement of substance P in the direct and indirect regulation of neuroneuronal and neuroendocrine interactions.

Preganglionic sympathetic neurones, innervating the guinea pig adrenal medulla, immunohistochemically contain choline acetyltransferase and also leu-enkephalin.

Applying retrograde neuronal tracing combined with double labelling immunofluorescence, preganglionic nerve cell bodies in the intermediate grey matter of the guinea pig thoracic spinal cord, projecting to the adrenal gland, co-exhibited immunolabelling for choline-acetyltransferase (ChAT) and sometimes, also for leu-enkephalin. Likewise, ChAT-immunoreactive nerve fibres, forming a dense meshwork in the adrenal medulla, partly contained immunostaining also for leu-enkephalin. Some of the intramedullary nerve cell bodies were ChAT-positive but were non-reactive for leu-enkephalin. The findings provide evidence for an extrinsic (preganglionic) and an intrinsic (postganglionic) cholinergic nerve system in the guinea pig adrenal medulla, the preganglionic system utilising leu-enkephalin as co-mediator.

[Gamma nail osteosynthesis of per- and subtrochanteric femoral fractures. 4 years experiences and their consequences for further implant development]. / Gammanagel-Osteosynthese per- und subtrochanterer Femurfrakturen. 4-Jahres-Erfahrungen und ihre Konsequenzen für die weitere Implantatentwicklung.

The Gamma nail can be used in all types of per- and subtrochanteric fractures because of its biomechanical characteristics. In this prospective evaluation of our 330 patients treated between November 1989 and November 1993 the usefulness of the Gamma nail for the osteosynthesis of all types of fracture was evaluated. The rate of intraoperative and postoperative complications but also gait function, postoperative weight bearing, general complications, and survival were analysed. We compared the results of four therapy periods to evaluate the importance of the expertise of the surgeon and the 'learning curve'. The Gamma nail osteosynthesis was performed in 72-98% in unstable per- and subtrochanteric fractures. The nail diameters used shifted to the 12 mm nail (99%) and the 130 degrees angle (93%) in the fourth examination period. The intraoperative complication rate is highly dependent from the expertise of the surgeon and the experience with the system. The rate decreased from 42.2% in the first to 17.2% in the fourth examination period. The most important complications were: additional fractures (1.7%), distal locking screw problems (7%), femoral head rotation (2,4%), and not sufficient fracture reduction (4.1%). Whereas in general these did not influence the postoperative management the use of a too short femoral neck screw lead to instability. Postoperative local complications were: rotation of the femoral head and neck (0.6-5.5%), related to the gliding of the neck screw (0.6-4%), fracture at the end of the nail (1.8-4%), fatigue break of the nail (1 case) and hematoma (1.2-8.3%). In all these cases reoperation was needed. To reduce the rate of intra- and postoperative complications a new gliding nail (GN) is presented. Due to the double T-profile of the femoral neck blade the implant is stable for neck rotation. The blade has a collar which makes it impossible to implant the blade to deep in the femoral neck. The larger nail profile at the femoral neck perforation reduces the risk of implant failure. The implant can be used as dynamic compression as well as static implant both in the direction of femoral neck and shaft.