Adenocarcinomas of esophagus and cardia in comparison with gastric carcinoma.

Since the carcinomas of the cardia and the adenocarcinomas of the esophagus show many similarities in their histological and morphological descriptions, a detailed comparative study was attempted on the basis of 66 esophageal carcinomas in adenoid differentiation, 359 carcinomas of the cardia, 1288 gastric carcinomas in infracardial localisation, and 492 squamous carcinomas of the esophagus. The evaluation yielded no significant differences between the adenocarcinomas of the esophagus and the cardia neither in age and sex distribution nor with regard to the classifications of Borrmann, WHO, Ming, and Laurén, but a significant discrimination was possible between esophageal and cardial adenocarcinoma together, on the one hand, and infracardial gastric carcinoma on the other. Furthermore, esophageal adenocarcinomas were localized preferentially in the lower third, unlike squamous carcinomas of the same organ. These results suggest that esophageal adenocarcinoma and carcinoma of the cardia must be considered as one separate entity, probably originating from a common stem cell. They further suggest that the cardia belongs to the esophagus rather than to the stomach.

Endodermal germ cell carcinoma (endodermal sinus tumor) of the vagina in infant girls.

An endodermal sinus tumor (endodermal germ cell carcinoma) was diagnosed in a 1-year-old girl in the vagina after hemorrhage; the tumor was completely removed by radical abdominal surgery. Postoperative polychemotherapy was performed for two years with Actinomycin D, Adriamycin, Vincristin, and Cyclophosphamide. The infant is now tumor-free for 26 months, showing almost normal somatic and psychic development. The characteristic histological patterns and clinical course of this strongly malignant tumor are demonstrated, based on 25 published case reports of endodermal sinus tumors in the vagina of little girls (aged 5-26 months). This neoplasm in early infancy has to be separated from the clear-cell adenocarcinoma of the vagina which occurs after puberty in adolescent girls and young women, and is induced by stilbestrol therapy to the mother during early pregnancy.

Comparative studies of cardia carcinoma and infracardial gastric carcinoma.

In a part retrospective, part prospective study, 354 carcinomas of the cardia were compared with 1259 infracardial gastric carcinomas with regard to the age and sex of the patients, macroscopic classification, microscopic classifications, depth of invasion, and survival rates. Mortality rates are generally higher in cardia carcinoma than in stomach carcinoma. The difference is due to the significantly poorer survival of cardia carcinoma patients in stage I, while mortality rates in stages II, III, and IV of both types are approximately similar. Highly significant differences were also found with regard to sex ratio, incidence of macro- and microscopic subtypes, and invasive growth. The typical cardia carcinoma occurs preferentially in men, is mostly well-delineated, and is manifested as an ulcerated or polypoid, well-differentiated tumor of expansive growth, corresponding to Laurén's intestinal type. These results confirm the concepts of McPeak and Warren, MacDonald, and Siewert et al., that the carcinoma located in the cardia must be seen as a separate entity of gastric carcinoma.

Results and prognostic factors of splenectomy in idiopathic thrombocytopenic purpura.

BACKGROUND: Splenectomy is the therapy of choice after relapse following different immunosuppressive treatments for idiopathic thrombocytopenic purpura, which is still the most frequent cause of thrombocytopenia. STUDY DESIGN: A prospective clinical study was undertaken to evaluate the rate of complete remission in idiopathic thrombocytopenic purpura after splenectomy, to reveal the influence of preoperative immunosuppression on the postoperative course in groups of patients with different responses to treatment, and to describe possible prognostic factors predicting the postoperative course of idiopathic thrombocytopenic purpura. Difino's classification of remission was used. After fulfilling criteria for admission into the study, 72 patients who had undergone splenectomy (male to female ratio, 1:1.4) were examined. RESULTS: Early postoperative mortality and morbidity rates were 3 percent each. The following degrees of remission were achieved: complete remission, 72 percent; partial remission, 15 percent; partial remission affording further medical support, 6 percent; and no remission, 4 percent. Platelet counts differed significantly between complete and partial remission, but not between patients who did or did not experience a response to different preoperative medical strategies (Tukey-Kramer test, p < .05; t test, not significant). The correlation of megakaryocytopoiesis and the site of thrombocytolysis to the stages of remission was significant (Fisher's exact test). Patients with hyperplasia of splenic follicles had significantly higher platelet counts 2 years after operation than did those without hyperplastic splenic follicles (Student-Newman-Keuls test). CONCLUSIONS: Splenectomy is a low morbidity and low mortality procedure. It is, therefore, a treatment of choice after relapse following immunosuppressive courses. Isolated splenic thrombocytolysis and hyperplasia of megakaryocytopoiesis and of splenic follicles correlated with better postoperative outcome (ie, stable remission and platelet counts) and could serve as possible prognostic factors for the postoperative course in idiopathic thrombocytopenic purpura.

Operation-sequel carcinoma--an experimental study.

Gastric-stump carcinoma, a special form of gastric carcinoma, is seen as a late complication of gastric surgery performed on the carcinoma-free stomach. In the present experimental series a considerable number of carcinomas were observed, for the first time, in rats after gastric surgery without additional application of a carcinogen. The rate of malignancies arising in the gastric stump correlates closely with the intensity of the duodenogastric reflux provoked by different surgical procedures. The important role of duodenogastric reflux for the development and growth of gastric stump carcinoma is thus established beyond doubt. While bearing in mind the need for caution in translating experimental results to man, this study does suggest the value of reflux-preventing techniques in the surgical management of gastric diseases. Patients who have undergone an operation are at increased risk of developing carcinoma, and therefore require consequent and regular follow-up examination. The introduction of surgical prophylaxis and careful postoperative surveillance are the only effective methods for the prevention of gastric stump carcinoma.

Monitoring of tissue-pO2 for invasive diagnostics in angiology and vascular surgery.

Hypoxic and ischemic states are the main problem makers in angiology and vascular surgery. It is therefore suggestive to employ the technique of tissue-pO2 measurement for the verification and support of diagnostic and therapeutic measures. Two forms of registration are possible: continuous monitoring of partial oxygen pressures in eight different places and registration in the form of pO2-histograms, which represents a kind of "representative opinion poll" held in the tissue. The effects of a surgical intervention (endarterectomy, bypass operation) and the efficacy of blood flow-promoting drugs were studied in several series. In 9 patients the effect of the blood flow-promoting agent pentoxifylline (3,7-dimethyl-1-(5-oxohexyl)-xanthine) was studied. The pO2-histograms exhibited a shift to the right by an average of 7 mmHg after administration of this drug. Moreover, findings obtained with sodium nitroprusside and nitroglycerin during induced hypotension indicate that the continuous measuring of tissue-pO2 and recording of oxygen pressure distribution curves (pO2-histogram) provide the clinician with essential guidance data for the improvement of diagnostics and therapeutic control.

Theory and methods of local tissue-pO2 monitoring in experimental angiology.

The platinum-multiwire-surface electrode after Kessler and Lübbers gives the opportunity of direct measuring of the local tissue-pO2-pressure; this 8-wire electrode with a Pt-wire-diameter of 15 microns operates on the polarographic principle. Each Pt-wire has a hemispheric collecting area of about 30 microns. Pressure ischemia by compression of capillaries is prevented by proportioning the weight (2.1 g) of the electrode. Data output is done by continuous pO2 measuring; pO2 histograms. During the continuous pO2 measurement the electrode stays on the tissue measuring point thus enabling the direct record of quickly proceeding reactions. The pO2-histogram exhibits the statistical distribution of the local partial oxygen pressures in a studied organ, a quasi sample inquiry is performed in the tissue, based on minimum 100 single values that are obtained by repeated manual repositioning of the electrode. By this, values are obtained on the level and distribution of local pO2 in the tissue so that condition and function of the microcirculation can be objectively assessed. Immediate alterations in the local tissue pO2 suggest regulatory adjustment after hemodynamic changes. Technical problems connected with pO2 measurement in clinical use (sterilization, data acquisition and presentation) are described. The presented technique gives the chance to exactly assess the effects of vasoactive drugs on the microcirculation and to quantify the results of operations, for example after bypass-surgery.

Effect of intraoperative fluid administration and colloid osmotic pressure on the formation of intestinal edema during gastrointestinal surgery.

The effects of intraoperative changes in plasma colloid osmotic pressure (COP) on the formation of intestinal edema were studied in patients during modified Whipple's operation (hemipancreato-duodenectomy). Eighteen patients (ASA physical status I or II) were randomly assigned to one of three groups. They received either lactated Ringer's (RL group, n = 6), 10% hydroxyethyl starch (HES group, n = 6), or 20% human albumin (HA group, n = 6) as a volume replacement solution, which was given to maintain central venous pressure (CVP) at the preoperative level. Jejunal specimens were obtained after the first transsection of the jejunum and prior to the jejuno-jejunostomy. Their water fraction (g H2O/g tissue dry weight) was measured gravimetrically. COP was determined prior to induction of anesthesia and upon removal of the second jejunal sample. In the RL group, 3,850 +/- 584 ml (data are means +/- SEM) of volume replacement solution were infused from induction of anesthesia to removal of the second jejunal sample. In the HES group, 1,358 +/- 45 ml were infused, and in the HA group, 463 +/- 49 ml were infused. During this time, COP decreased from 20.3 +/- 0.5 mmHg to 14.1 +/- 0.6 mmHg in the RL group, remained at 22.0 +/- 0.9 mmHg in the HES group, and increased from 20.7 +/- 0.9 mmHg to 28.1 +/- 0.9 mmHg in the HA group.(ABSTRACT TRUNCATED AT 250 WORDS)

[The so-called spontaneous nodular panniculitis (Weber-Christian lipodystrophy)]. / Sogenannte spontane herdförmige Pannikulitis (Weber-Christiansche Lipodystrophie)

Enlarged lymph nodes and a tumor, the size of a man's fist, were found in the abdomen of a female patient of 63. Histologic diagnosis determined a non-suppurative panniculitis with typical proliferation of foam cells and reactive inflammatory infiltration attaining the stage of granulomatosis. The disease is seen as granulomatous histiocytosis; a sure explanation of its pathogenesis is not yet possible.

[Protection of sutures of the injured esophagus using polyglactin 910 (Vicryl) mesh]. / Die Protektion der Naht des verletzten Oesophagus mit Polyglactin 910-(Vicryl)Netz.

Dehiscence of suture after operative treatment of esophageal rupture is a quite frequent and dangerous complication. Several methods of reinforcement of suture with autologus material have been suggested of which the use of a pleura flap was the most successful one. After experimental investigations in the Department of Surgery of the University Hospital of Münster the securing of suture was performed by using Polyglactin 910 (Vicryl) meshgrafts. In 8 patients where the mesh grafts were used, a secondary leakage could be avoided. Considering our experiences, securing of suture by the use of Polyglactin 910 mesh-grafts is a recommendable method.

[Surgical management of achalasia]. / Die chirurgische Therapie der Achalasie.

As long as its etiology is uncertain, achalasia can only be treated symptomatically. Basically, conservative dilation treatment and operative cardiomyotomy can be performed. Although dilation treatment can save the patient the operative procedure, it has relative disadvantages. For this reason since 1973 we treat achalasia through cardiomyotomy with Nissen's fundoplication method. We have operated on 25 cases using this method. These are examined and the results reported.

[Arguments for a revised concept in the therapy of acute pancreatitis. On the indications for conservative, endoscopic and surgical procedures]. / Argumente für ein abgewandeltes Konzept in der Therapie der akuten Pankreatitis. Zur Indikation konservativer, endoskopischer und chirurgischer Verfahren.

From January 1, 1973 to October 31, 1987 we treated 271 patients suffering from acute pancreatitis at the Department of General Surgery at the University Münster, Westphalia. 159 (58.7%) presented with stage I, 75 (27.7%) with stage II, and 39 (13.6%) with stage III disease according to the Mainz classification for acute pancreatitis. In 147 cases an endoscopic sphincterotomy (EST) was performed. At a low method-specific morbidity (5.4%) we observed a mortality rate of 0% for stage I, 8% for stage II, and 22% for stage III. Altogether, a mortality rate of 13.3% was calculated for the necrotizing forms of acute pancreatitis after EST, compared to 36.5% for a conventionally (conservative therapy, operation) treated group.

[Therapeutic problems of cancers of the gallbladder]. / Problèmes thérapeutiques posés par les cancers de la vésicule biliaire.

Data of 32 patients who were operated for gallbladder carcinoma were evaluated in a retrospective meta-analysis. Results were compared with endoscopic retrograde cholangio-drainage (ERCP) using large size 12/14-French gauge endo-prostheses with side flaps to prevent migration. According to the TNM classification 84% of patients were classified as stage IV, 12.5% were in a stage III and 3% were in a stage II. Only 22% of cases were operated for cure (cholecystectomies, lymphadenectomy, wedge resection of the liver). All patients died in between one year on cancer, average survival was 158 days in TNM stage II, 183 days in stage III and 75 days in stage IV. Early complication rate was in stage III and 75 days in stage IV. Early complication rate was at 28% due to cardiac and pulmonary complications. No one died as a result of the operation. Endoscopic bile duct drainage (ERCP) for gallbladder carcinoma (n = 21) was shown to be superior to surgical results with an average survival of 160 days. Early complication rate (30 day interval) was at 5.6% (n = 1014), mostly due to tube occlusion with cholangitis; clinical mortality was 2.6% only (n = 393). Occlusion of the endoscopic 12/14-French gauge tube was seen after 213 days in average. Endoscopic therapy was shown to represent an independent way in gallbladder cancer treatment not only for patients defined as not suitable for operation. All own results were compared to the literature, therapeutic regimen in gallbladder carcinoma is summarized as an organigramm.

The routine use of Roux-en-Y anastomosis in gastric surgery.

In the Surgical Clinic of the University of Münster Billroth II resection with Roux-en-Y gastroenterostomy was introduced 1974--with a specific modification-- and has now been performed in every case where primary or additional resections of the stomach were indicated. The main advantage is seen in the tensionless gastroenteral anastomosis even in cases with high resection. In ulcer surgery, the method permits to remove safely the main gastrin-producing parts of the stomach, and to reduce the mass of acid-producing parietal cells. At the same time it is possible to avoid duodeno-gastric reflux which is held responsible for promoting carcinomas in the gastric remnant. The use of the Roux loop guarantees reflux-free resection and provides an effective prophylaxis of gastric stump carcinoma. After this type of operation bile reflux is never seen on endoscopy.

Morphological changes in the operated stomach under the influence of duodenogastric reflux. Clinical follow-up over 20 years.

The chronic changes in the gastric mucosa arising years or even decades after surgery and interpreted as a precancerous state are causally related to the unphysiological irritation due to duodenogastric reflux. It was the objective of our study to determine whether there is an increase in alterations in the gastric mucosa of the operated stomach, as a function of postoperative interval and the particular surgical procedure performed, with consideration for the varying degrees of resultant duodenogastric reflux. Specifically, there were 320 patients and three different operative procedures studied with postoperative follow-up averaging a period of up to 20 years. The synopsis of the results shows not only a progression of the premalignancy apparent in the morphology of the mucosa, but also provides an indication of the varying intensity of duodenogastric reflux associated with each of the operative methods.

Gastric stump carcinoma--new aspects deduced from experimental results.

The actual influence of surgical technique on the pathogenesis of gastric stump carcinoma has not been fully explained, even under experimental conditions. We attempted to elucidate the problem by a series of experiments with Wistar rats assessing the postoperative consequences of Billroth I resection, B II resection with Roux-en-Y gastroenterostomy, B II resection with Braun's anastomosis, and plain gastroenterostomy without resection, and defining their influence on the development of carcinoma in the gastric remnant. Based on general clinical observations and randomized endoscopic and radiologic examinations, the date for killing and autopsy was fixed on the 56th after the surgical intervention. The number of malignant neoplasms was found to rise in proportion with the intensity of duodenogastric reflux resulting from the respective operative procedures: No tumors were found after B II resection with Roux-en-Y gastroenterostomy, but tumor incidence in the other groups rose from 10% in the animals subjected to B I resection, to 23.1% in those with B II resection plus Braun's anastomosis, and finally to 30% in animals with B II resection only, but no Braun's anastomosis. Gastroenterostomy without any resection even produced a tumors incidence of 70.8%. The present paper is presumably the first to report about gastric carcinomas that arose after surgery alone, without additional carcinogen exposure.