Preoperative selective embolization with vascular coiling of giant sacrococcygeal teratoma.

Sacrococcygeal teratoma is one of the most common congenital tumors. Its optimal management requires interdisciplinary care by obstetricians, radiologists, pediatric surgeons, and neonatologists. Early surgery entailing complete tumor excision is the main therapy aim, but a substantial risk of life-threatening complications remains, especially uncontrollable intraoperative hemorrhage. To reduce the risk of bleeding in a female neonate with a giant sacrococcygeal teratoma, we successfully coil-embolized the tumor's main feeding arteries. Her subsequent complete surgical resection was uneventful, and the child is well with favorable reconstructive and functional status of all involved and adjacent organ systems.

Acute antidepressant treatment differently modulates ERK/MAPK activation in neurons and astrocytes of the adult mouse prefrontal cortex.

The onset of action of antidepressants (ADs) usually takes several weeks, but first molecular responses to these drugs may appear already after acute administration. The Extracellular Signal-regulated Kinase/Mitogen-Activated Protein Kinase (ERK/MAPK) signaling pathway is a target of ADs and an important pathway involved in cellular plasticity. In major depressive disorder (MDD), especially the prefrontal cortex (PFC) and hippocampus (Hip) are most likely affected in depressive patients and recent work revealed a hyperactivated ERK signaling in the rat PFC after chronic stress, a precipitating factor for MDD. Strong evidences support that not only neurons but also astrocytes participate in neuronal activity and may therefore additionally be a substrate of AD action. In this study, we show by Western blot that neither fluoxetine (FLX) nor desipramine (DMI) preferentially affects the activation of one of the two ERK isoforms, ERK1 and ERK2, with respect to the other. Further immunohistochemical analysis in the PFC revealed that basal levels of phospho-activated ERK (pERK) are mostly found in neurons in contrast to very few astrocytes. Both ADs can inhibit neuronal pERK as early as 15 min after drug administration with peculiar regional and layer specificities. Contrarily, at this time point none of the two ADs shows a clear modulation of astrocytic pERK. We propose that this mechanism of action of ADs may be protective against an exacerbated cortical ERK activity that may exert detrimental effects on susceptible neuronal populations. Our findings on acute effects of AD treatment in the adult mouse PFC encourage to examine further how this treatment might influence pERK in animal models of depression to identify early targets of AD action.

Practice of dilatation after surgical correction in anorectal malformations.

BACKGROUND: In order to prevent stricture of the neoanus after surgical correction, regular dilatation is recommended. There is a lack of knowledge about the performance of anal dilatation and the occurrence of pain. The aim of our investigation was to describe the practice of dilatation and to identify possible risk factors for painful procedures. METHODS: Congenital Uro-Rectal Malformations Network is a German interdisciplinary multicenter research network. With standard questionnaires, physicians interviewed 243 patients and/or their parents at home, additional 103 patients born since 2009 were assessed through their treating physicians. RESULTS: In total, 88 % of the patients received dilatations. Treatment lasted for 7 months in median (range 1-156 months), until the age of 13 months (range 1-171 months). In 69 % painful dilatation was reported; without a significant differences in age or gender. In 32 % bleeding was reported. In 30 % at least one dilatation was performed under general anesthesia. In 11 % some kind of analgesia was used. Type of fistula, dilatations lasting longer than 10 months and Hegar size above 15 were relevant factors for experience of pain. There were about 16 % postoperative strictures of the neoanus, without reported differences in dilatation procedures; but there was a relation to type of malformation. CONCLUSION: Considering the high number of painful treatments, predictors for painful dilatations should be further clarified through standardized documentation and prospective evaluation in order to improve follow-up.

Potato disc tumor induction assay: a multiple mode of drug action assay.

The study reported herein utilized the Agrobacterium tumefaciens-induced potato disc tumor assay. The objective was to verify the detection of antineoplastic activity in the potato disc tumor induction assay, regardless of the mode of antineoplastic drug action. Camptothecin, paclitaxel, podophyllin, vinblastine and vincristine were tested, each with a different mode of action. All drugs tested inhibited tumor induction. The order of activity was: camptothecin = paclitaxel = vinblastine < podophyllin = vincristine. No effect on the viability of the bacterium was detected. The A. tumefaciens-induced potato disc tumor assay was an effective indicator of antitumor activity regardless of the mechanism of drug action. Thus, this assay would be acceptable as a primary general screen for antineoplastic activity of various crude extracts, as well as for purified fractions, regardless of mode of inhibitory action on tumor formation.

Hepatopathy in two infants with short-bowel syndrome and cytomegalovirus infection.

In children with short-bowel syndrome and the need for long-term parenteral nutrition, hepatic dysfunction is a multifactorial phenomenon that has not been completely understood. Alterations in gut motility lead to intraluminal stasis which is thought to be a major etiologic factor for bacterial overgrowth and subsequent cholestasis, especially when the ileocecal valve is absent. We report on two infants with short-bowel syndrome caused by gastroschisis and intestinal atresia. The intestinal lengths after resection were 18 and 55 cm. Long-term parenteral nutrition (PN) was obligatory due to intestinal shortness in the first patient and dilatation of the preatretic bowel segment with ineffective peristalsis in the second patient. Despite multiple trials of enteral nutrition and medical therapy for gut decontamination and stimulation of bowel motility, hepatopathy developed in both patients in a similar period of time and to about the same degree. At the age of 4 and 6 weeks, respectively, increasing bilirubin values were measured. Deterioration of liver function and thrombocytopenia at the age of 3 to 4 months led to the diagnosis of acute cytomegalovirus (CMV) infection. Treatment with ganciclovir followed. Both patients died of acute liver failure at the age of 7 and 9 months, respectively. Additional hepatic injury secondary to CMV infection might have contributed to the rapid deterioration of liver disease. Screening for further hepatotoxic factors, especially infectious etiologies, is therefore recommended in children with short-bowel syndrome. Liver transplantation should be considered early in cases of progressive hepatic dysfunction.

[An unusual course of fetal gastroschisis]. / Aussergewöhnlicher Verlauf einer fetalen Gastroschisis.

We report on prenatal diagnosis of gastroschisis at 20th gestational week. In addition to gastroschisis intraabdominal intestinal stenosis was detected. As a consequence cesarean section was planned close to term. Control examinations in the last trimester didn't confirm initial diagnosis so that the recommended mode of delivery was changed. However postpartum diagnosis again confirmed the early diagnosis of gastroschisis including spontaneous necrosis of dislocated intraamniotic intestinal parts. The course demonstrates that even at unambiguous prenatal diagnosis control examinations are recommended as dynamic changes may occur in the second and third trimester. Thus mode of delivery may have to be adapted close to term to reduce maternal risk.

[Acute cholecystitis--surgical therapy]. / Akute Cholezystitis--operative Therapie.

Acute cholecystitis as a rule requires operative treatment. When it occurs as a complication of gall stone disease, early cholecystectomy within two to three days has been accepted as a safe procedure. If possible, the laparoscopic approach should be preferred. In cases of technical difficulties conventional open cholecystectomy should be planned as a primary approach or be performed by conversion of the laparoscopic approach. Cholecystostomy performed as an interventional procedure is indicated in high-risk patients due to comorbidity only. For acalculous cholecystitis, however, this approach is regarded as the initial procedure of first choice.

[Sequelae of cholecystectomy--a prospective study]. / Folgezustände nach Cholezystektomie--Eine prospektive Studie.

In a prospective study designed to assess the situation following cholecystectomy carried out at the Department of Surgery of the University of Freiburg, 105 patients were examined between August, 1988 and December, 1989. Out of 80 patients who were followed up, 64 had undergone cholecystectomy alone and the remaining 16 had been additionally subjected to exploration of the common bile duct. 80% of the patients reported that their preoperative symptoms had disappeared altogether, 8% admitted some improvement and 10% complained that their condition was unchanged. Specific questioning resulted in the reporting of persistent symptoms in 54%, and these consisted mostly of general complaints such as dyspepsia, flatulence, food intolerance and dull upper abdominal pain. These complaints were vanished or appeared with equal frequency following operation. Objective clinical findings could not be confirmed. Comparison between the pre- and postoperative signs in these patients established a statistically significant correlation (p < 0.05) between the patient's age and the severity of the preoperative symptoms on the one hand and a satisfactory postoperative outcome on the other. This also applied to patients for whom an examination of the bile duct was necessary.

Laparoscopic cholecystectomy after unsuccessful shock-wave therapy.

Extracorporeal shock-wave therapy of gallstones was begun at the Surgical Department of the University of Freiburg, Germany, in March 1988; 85 patients were treated up to September 1991. The stone-free rate differed with the gallstone group. Patients with solitary stones less than 20 mm in diameter showed a significantly higher rate after 18 months of lithotripsy and dissolution therapy than patients with multiple stones (p < 0.01), that is, 83% and 49%, respectively. Open cholecystectomy was necessary for seven patients with complications following fragmentation. After starting laparoscopic cholecystectomy, eight patients decided in favor of this procedure because of constant biliary symptoms. These patients had a mean duration of dissolution therapy of 19 months. The minimal invasive procedure is an alternative for patients with unsuccessful lithotripsy and lysis who initially demanded conservative treatment. Indication for shock-wave therapy is limited to only a small group of patients with solitary cholesterol gallstones less than 20 mm who reject laparoscopic surgery.

[Extracorporeal piezoelectric gallstone lithotripsy: initial surgical experience with a new treatment. Technique and indications]. / Extrakorporale piezoelektrische Gallensteinlithotripsie: erste chirurgische Erfahrungen mit einer neueren Therapie. Technik und Indikationen.

The extracorporeal piezoelectric lithotripsy (EPL) is a new method for non-operative therapy of symptomatic gallbladder and problematic bile duct stones. The rare intrahepatic calculi were similarly disintegrated. Best results were reached with EPL as adjuvant measure or combined with oral cheno- and ursodeoxycholic acid therapy. EPL compared to other lithotripsy techniques is performed without any analgesia. That means advantage and patient's benefit.

Large-bile-duct stones--extracorporeal piezoelectric lithotripsy as adjuvant measure for endoscopic basket extraction.

Extracorporeal piezoelectric lithotripsy (EPL) was performed in 12 patients with large-bile-duct stones and intrahepatic stones. The Piezolith 2300 lithotripter (Wolf, Knittlingen, FRG) was used in all patients in whom routine endoscopic approaches for removal of the calculi had failed or were considered inappropriate because of large stone size or difficult localization. In 9 of the 12 patients the stones were fragmented. Complete stone clearance from the bile ducts was obtained in 8 of 10 patients by EPL alone or combined with one of the following: endoscopic extraction, mechanical lithotripsy or installation of solvents. Adjuvant EPL in conjunction with endoscopic therapy increased the success rate of nonsurgical treatment for bile duct stones from 73% to 95%. No clinically significant side effects or complications were noted.

[Litholysis and lithotripsy of gallstones. State of the art and prospects]. / Litholyse und Lithotripsie bei Gallensteinen. Entwicklungsstand und Perspektiven.

The combination of dissolution and shockwave treatment for cholesterol stones is successful in 80% of the patients. The indication is strictly limited to cholesterol stones of between ten and thirty millimeters in diameter, or three stones of similar mass. In 80% of common duct stones which cannot be removed by endoscopy, shockwave treatment is a successful adjuvant procedure. It is estimated that recurrent stones will occur in 50% of the cases after five years. As long as the problem of recurrent stones persists, the group of stone carriers suitable for conservative treatment cannot be definitevely defined.

[Preoperative staging of rectal cancer: endosonography versus computerized tomography]. / Präoperatives Staging des Rectumcarcinoms: Endosonographie versus Computertomographie.

In a prospective study in 49 patients with rectal carcinoma the correlation of pre- and post-operative staging by CT and endorectal ultrasound (EU) was compared according to TNM-classification. With CT the pre/postoperative results correlated in T1 in 9/10, in T2 in 10/16, in T3 in 13/15 and in T4 in 6/8 patients. By EU identical results were found in all T1, in 10/12 T2, in 17/20 T3 and in 6/7 T4 stages. Overall, pre- and postoperative identical results were found by CT in 38 and by EU in 43/49 patients. Overestimation of the tumor stage was similar with both methods: 5 by CT and 4 by EU. Underestimation of the stage was more often by CT in 5 than by EU in 2 cases. (CT: accuracy 77.5%, sensitivity 88.3%, specificity 94.4%; ES: accuracy 87.7% sensitivity 91.5%, specificity 97.8%). Criteria for interpretation are discussed. In early tumor stages the depth of tumor invasion can be better evaluated by EU. In late stages both methods give important information for surgical strategy.

[The value of transrectal sonography and computerized tomography in the diagnosis of rectal cancer]. / Wertigkeit der transrektalen Sonographie und der Computertomographie in der Diagnostik des Rektumkarzinoms.

In a prospective study in 49 patients with rectal carcinoma the correlation of pre- and postoperative staging by CT and endorectal ultrasound was proven according to TNM-classification. With CT the pre/postoperative results correlated in T1 in 9/10, in T2 in 10/16, in T3 in 13/15 and in T4 in 6/8 patients. By endorectal ultrasound identical results were found in all T1, in 10/12 T2, in 17/20 T3 and in 6/7 T4 stages. Totally, pre- and postoperative identical results were found by CT in 38 and by endorectal ultrasound in 43/49 patients. Overestimation of the tumor stage was similar with both methods: 5 by CT and 4 by endorectal ultrasound. Underestimation of the stage was more often by CT with 5 than by endorectal ultrasound with 2 cases (CT: accuracy 77.5%, sensitivity 88.3%, specificity 94.4%; endorectal ultrasound: accuracy 87.7%, sensitivity 91.5%, specificity 97.8%). Criteria for interpretation are discussed. In early tumor stages the depth of tumor invasion can be better evaluated by endorectal ultrasound. In late stages both methods give important information for the surgical strategy.

[Dissolution of a bile duct stone with methyl tert-butyl ether]. / Auflösung eines Gallengangsteines mit Methyl-tertiärem Butyläther.

Methyl-t-butylether is a new agent to dissolve gallstones. The substance proves to be very successful and acts very rapidly. A percutaneous transhepatic drainage supplies an adequate access route to dissolve calculi within the bile ducts. We report the case of a patient where before insertion of an internal stent a stone in the common bile duct was dissolved within 3 1/2 hours.