Lectin-binding sites in human parathyroid tissue.

The aim of this study was to demonstrate several lectin-binding sites in human parathyroid tissue and to correlate these results with functional activity. The following lectins were tested for binding sites with certain carbohydrates (in parentheses): Arachis hypogea (PNA) (galactose), Ulex europaeus I (UEA) (fucose) and concanavalin A (ConA) (mannose). In addition to normal parathyroids used as controls (13 cases), we examined adenomas associated with a clinical picture of primary hyperparathyroidism of differing severity (31 cases), atrophic glands contralateral to a hyperfunctioning adenoma (7 cases), and secondary (renal) hyperplasia (12 cases). Use of PNA (with and without neuraminidase treatment) and UEA yielded negative staining in normal glands, a wide variety of reactions in adenomas, and frequent dense precipitates in atrophic parathyroids, whereas ConA yielded positive staining in all kinds of parathyroid tissue. Assessment of functional activity of adenomas by clinical parameters (pre-operative serum levels of calcium and parathormone) displayed a significant correlation with the semiquantitative grading of the histochemical reactions after PNA and UEA. Lectin-binding sites in parathyroid chief cells of adenomas are believed to indicate some of the cell structures or products directly involved in the secretory process, including degradation. Although ConA may recognize constituent parathyroid glycoproteins, the binding sites for PNA and UEA are thought to be partially associated with secretory glycoprotein (SP-I), as is known from animal experiments. The positive reaction of the atrophic gland may result from degradation enforced by exposure of primarily non-terminal carbohydrate components.

Role of arterial and cardiopulmonary mechanoreceptors in the regulation of arterial pressure during rest and exercise in conscious dogs.

Techniques have been developed to study the role of arterial and vagally innervated cardiopulmonary mechanoreceptors in conscious dogs during rest, exercise, and anxiety or emotional stress. These techniques involve, among others, bilateral reversible vascular isolation of the carotid sinuses and acute reversible interruption of the aortic baroreflex. The carotid sinus, the aortic arch, and the cardiopulmonary receptors tonically inhibit the vasomotor center in the resting dog. The arterial receptors, but not the cardiopulmonary receptors, minimize the lability in arterial pressure at rest and during exercise. During exercise, the arterial baroreceptors are reset to a higher operating point, limit the increase in arterial blood pressure that develops with increasing severity of exercise, and act to return the pressure quickly to the resting level when exercise ceases. The effects on arterial blood pressure are due to reflex changes in total systemic vascular resistance; cardiac output and heart rate are controlled independently of the arterial and cardiopulmonary mechanoreflexes. The cardiopulmonary reflexes have no evident role in the control of arterial pressure during exercise but, in the chronic absence of the arterial baroreflexes, act to decrease the total systemic vascular resistance when exercise ceases.

[Pleural infiltration by peripheral bronchial carcinoma. Is computed tomography reliable?]. / Pleurainfiltration bei peripheren Bronchialkarzinomen (BC). Ist die Computertomographie zuverlässig?

Pre-operative computed tomograms were obtained in 52 patients with histologically confirmed peripheral bronchial carcinomas and possible involvement of the pleura and thoracic wall was analysed. The results were compared with the operative and histological findings. Thickening of the pleura and of the sub-pleural fat line was observed in 24 cases. Amongst these patients there was only one case with histologically confirmed pleural infiltration. In 17 patients the sub-pleural fat line was obliterated, or could not be defined. Amongst these, 11 showed tumour extension to the pleura or soft tissues of the chest wall. It is concluded that the most suspicions sign of pleural tumour extension is absence of the sub-pleural fat line. The more frequently observed pleural thickening cannot be considered as a reliable sign for pleural involvement.

[Scintigraphic display of an ectopic parathyroid adenoma using 99mTc-MIBI--2 case reports]. / Szintigraphische Darstellung ektoper Nebenschilddrüsen-adenome mit 99mTc-MIBI--2 Fallbeispiele.

Radionuclide imaging of the parathyroid gland is used in the preoperative localization of parathyroid adenoma. Until recently radionuclide imaging of parathyroid tumors was performed using a dual-tracer subtraction technique with 201TI and 99mTcO4-. As an alternative radionuclide imaging with 99mTc-sestamibi (MIBI) has been introduced some years ago. The utility of preoperative parathyroid localization lies in its ability to direct surgical exploration, particularly of ectopic localizations. We present two cases of parathyroid adenoma in which radionuclide imaging with 99mTc-MIBI was successful in detecting atypical locations. In the first case remaining primary hyperparathyroidism was caused by a mediastinal gland. The second case suffered from a recurrence of secondary hyperparathyroidism caused by hyperplasia of the autotransplanted gland after removal of all four parathyroid glands.

[Somatostatin receptor status in non-medullary thyroid carcinoma]. / Untersuchungen zum Somatostatinrezeptor-Status bei nicht-medullären Schilddrüsenkarzinomen.

AIM: Recent in-vitro and in-vivo studies demonstrated a somatostatin receptor expression in some non-medullary thyroid carcinomas. In this study we investigated the somatostatin receptor status for this particular tumor entity in a larger patient group. SUBJECT AND METHODS: We compared 131-iodine with 111-In-pentetreotide scans in 24 patients with metastasizing, non-medullary thyroid cancer. The findings were correlated with other imaging modalities. Additionally, we performed receptor autoradiography in one patient, octreotide therapy in another patient and administration of 90-Y- and 111-In-DOTATOC in 2 consecutive patients. RESULTS: In the 15 patients with papillary or follicular carcinoma, 111-In-pentetreotide was inferior to 131-I in 8/15, equal in 1/15, and superior in 6/15 patients. In 8/9 of the patients with Hürthle cell carcinoma, metastases showed a 111-In-pentetreotide accumulation of various intensity, while 131-iodine scans were negative except for one patient. 111-In-pentetreotide was equal or superior compared to 201-Tl or 99m-Tc-sestamibi, but for the most part inferior in comparison with 18-F-FDG-PET. The findings of 111-In-pentetreotide scintigraphy correlated well with the receptor autoradiography and the accumulation of DOTATOC, but not with the therapeutic effect of "cold" octreotide on the thyroid cancer metastases. CONCLUSIONS: Several metastases of papillary and follicular carcinoma, and the majority of Hürthle cell cancer metastases can express somatostatin receptors. 111-In-pentetreotide scintigraphy is a promising tool for localization of metastases especially in Hürthle cell cancer or if PET is not available, and may be useful for selection of possible candidates, if therapeutic effective beta-emitting somatostatin analogues will be available for routine application.

Postoperative reduction of fibrinolysis as a prognostic factor of fatal outcome.

For the resection of an esophagus carcinoma a mortality rate of 2 to 30% was described. It is still unclear whether an abdominothoracic or transhiatal intervention is superior regarding the outcome. To investigate the prognostic value of fibrinolytic markers, plasmin-alpha2-antiplasmin (PAP) and D-dimer (DD) values were determined daily in the early postoperative period for 11 days. In addition, the course of PAP and DD concentrations was compared with the method of esophagectomy. Of the 28 patients enclosed in the study, 5 died between day 10 and day 34 owing to adult respiratory distress syndrome and septicemia. The PAP and DD concentrations increased in survivors after surgery until day 5 and day 7, respectively. The concentrations were twofold and 10-fold higher than the upper reference level. In contrast, four of five nonsurvivors showed an inadequate increase in PAP concentrations within the reference range, whereas the course of DD was inconspicuous. The sensitivity and specificity of PAP and DD in respect to a fatal outcome was calculated by receiver operating characteristic analysis based on all results: sensitivity 76% (PAP-cut off value 760 microg/L) and 49% (DD 6 mg/L), specificity 77% and 72%, respectively. The biochemical markers showed no significant differences between the abdominothoracic and transhiatal esophagectomy. In the abdominothoracic intervention, lower PAP and higher DD concentrations were observed. The results showed that the PAP concentrations could detect a fatal outcome within the first 5 days after surgery.

[Results of stomach resection with Roux gastrojejunostomy for gastroduodenal ulcers]. / Ergebnisse der Magenresektion mit Gastrojejunostomie nach Roux wegen gastroduodenaler Ulcera.

In a follow-up study operative risk, postoperative functional disorders and incidence of anastomotic (recurrent) ulcer after partial gastrectomy with Roux-en-Y gastrojejunostomy for gastroduodenal ulcer were evaluated in 52 patients. Lethality for elective treatment was 0 and for emergency surgery (ulcer bleeding) 16.7%. 29.5% of the patients reported postoperative functional disorders. Because Roux-en-Y reconstruction prevented duodenogastric reflux, intragastric pH was low (median 2.2) and in the absence of ulcer protective, neutralizing reflux anastomotic ulcer occurred in 15.9% of the patients. With regard to the high rate of recurrent ulcer Roux-en-Y reconstruction after partial gastrectomy for primary ulcer surgery should be avoided and reconstruction procedures preferred, which guarantee duodenogastric reflux.

[Early diagnosis and reoperation in persistent primary hyperparathyroidism]. / Frühdiagnostik und frühzeitige Reoperation des persistierenden primären Hyperparathyreoidismus.

INTRODUCTION: The persistence rate of primary hyperparathyroidism after cervical exploration was estimated and early diagnosis and reoperation were evaluated in a prospective study. METHODS: Between 1 August 1987 and 31 October 1998, 370 patients underwent surgery. The postoperative course is known in 94.6 % of these patients (follow-up 1 month-10 years, median 24 months). RESULTS: Cervical exploration was successful in 97.5 % (n = 353) of the 361 patients with the first manifestation of primary hyperparathyroidism and in all patients with recurrence or persistence of the disease after initial operation elsewhere. In persistent primary hyperparathyroidism serum calcium levels remained elevated 4 days after surgery (n = 9, 2.5 %). Localization studies, preferably with (99m)Tc-MIBI-scintigraphy were attempted during the first postoperative week and could be performed in 4 patients. Four patients wished the procedure to be performed later. CONCLUSION: Within one week after the initial intervention the diagnosis of persistent primary hyperparathyroidism can be established and localization studies as well as cervical reexploration can be carried out. An interval of 3 months from the initial operation to reexploration of the parathyroid area is recommended if the reexploration is impossible within one week. Mediastinal reoperations or surgical interventions in the neck sparing the perithyroid area may be carried out without consideration of specific intervals.

[Intraoperative parathyroid hormone monitoring in neck exploration for renal hyperparathyroidism?]. / Intraoperatives Parathormonmonitoring bei der Halsexploration wegen renalem Hyperparathyreoidismus?

INTRODUCTION: In operations for renal hyperparathyroidism the value of intraoperative parathormone monitoring was investigated. PATIENTS AND METHODS: Intraoperative intact parathyroid hormone levels were determined (PTH Quick assay) in 40 patients undergoing first cervical exploration and in two patients with graft-dependent recurrence of renal hyperparathyroidism. RESULTS: In 33 patients, total parathyroidectomy with autotransplantation was carried out. The median parathormone levels decreased from 652 pg/ml to 120 pg/ml (19% of initial level) 5 min after total parathyroidectomy. In seven patients, fewer than 4 parathyroid glands each were identified during cervical exploration and "total parathyroidectomy (?)" without autotransplantation was performed. Intraoperatively median parathormone level decreased from 1193 pg/ml to 116 pg/ml (10% of initial level). In one of these seven patients, hyperparathyroidism persisted due to an ectopic fourth gland within the carotid sheath. In two of these patients, hypoparathyroidism occurred and a delayed autotransplantation of cryopreserved parathyroid tissue was carried out. On the first day after total parathyroidectomy with autotransplantation and "total parathyroidectomy (?)", median levels of intact parathyroid hormone were 1.9 pg/ml and 82.5 pg/ml, respectively. CONCLUSION: Intraoperative monitoring is not useful in first cervical exploration for renal hyperparathyroidism because it cannot predict complete resection of parathyroid tissue. The parathormone level on the first postoperative day allows precise evaluation of the efficacy of the surgical procedure.

[Morbidity in concomitant interventions in neck exploration for primary hyperparathyroidism. Results of a prospective study]. / Morbidität von Begleiteingriffen bei der Halsexploration wegen primärem Hyperparathyreoidismus. Ergebnisse einer prospektiven Untersuchung.

A prospective follow-up study was undertaken in patients undergoing surgical therapy for primary hyperparathyroidism to establish the frequency of concomitant surgical procedures and their influence on the morbidity of cervical exploration. From 1 August 1987 to October 1995, 231 patients underwent cervical exploration for primary hyperparathyroidism. In 16 patients 18 (7.8%) concomitant abdominal and thoracic surgical procedures as well as surgical interventions for soft-tissue tumors were performed. A total of 133 patients (57.6%) underwent thyroid resections of varying extent; 4.8% had carcinoma of the thyroid. Catamnestic data were obtained on the basis of a standardized follow-up in 94.4% of all patients (1-9 follow-up examinations in 216 patients). Hematoma occurred after adrenalectomy in a patient undergoing a concomitant extracervical procedure. In patients with a first manifestation of primary hyperparathyroidism due to a solitary parathyroid adenoma (n = 189), an increase in the morbidity of parathyroid surgery performed in combination with a thyroid resection was observed. Furthermore, a relationship was established between the number of intraoperatively identified parathyroid glands and the incidence of permanent hypoparathyroidism (permanent hypoparathyroidism: initial cervical intervention with parathyroid exploration alone, 2.2%; with concomitant thyroid resection, 6.5%; after secondary thyroid resection and parathyroid exploration alone, 0%; after concomitant thyroid resection, 28.6%; four parathyroid glands identified intraoperatively, 3.1%; fewer than four parathyroid glands identified, 8.2%). The increase in the morbidity of parathyroid surgery in combination with thyroid resection is justifiable, because unsuspected thyroid carcinomas can potentially be treated curatively.

[Circular stapling anastomosis (EEA) following gastrectomy]. / Die zirkuläre Klammeranastomose (EEA) nach Gastrektomie.

After total gastrectomy because of gastric malignancies 31 oesophagojejunostomies performed in end-to-side fashion using a standard manual technique were compared with oesophagojejunostomies performed in end-to-end fashion by mechanical stapling (EEA). After manual suturing there was a leak in 29% and 25.8% out of all patients died. After automatic mechanical suturing anastomotic failure was seen in 12.9% with a postmortality rate of 3.2%. These results show, that by mechanical stapling a secure oesophagojejunostomy is possible and the risk of gastrectomy can be reduced.

[Crohn disease and squamous cell carcinoma of the anorectal transition]. / Morbus Crohn und Plattenepithelcarcinom des anorectalen Ubergangs.

Squamous cell carcinoma of the anorectal junction originated from anal fistulas in two female patients with Crohn's disease which have been suffering from anal and rectovaginal fistulas for many years. In addition one tumour showed paraneoplastic parathyroid hormone synthesis. This findings point out Crohn's disease as a premalignant lesion. Chronic fistulas associated with Crohn's disease must be followed up carefully by clinical examination, endoscopy and biopsy. To prevent malignancy and to cure the anal region and the origin of such fistulas, resective surgical technics should be taken into consideration early.

[Results of endoscopic, retroperitoneal adrenalectomy with special reference to the intraoperative course]. / Ergebnisse der endoskopischen, retroperitonealen Adrenalektomie unter besonderer Berücksichtigung des intraoperativen Verlaufs.

In 20 patients the hemodynamic and ventilatory data during endoscopic retroperitoneal adrenalectomy were checked retrospectively to analyze the hemodynamic and ventilatory effects of a pneumoretroperitoneum. After insufflation of CO2 into the retroperitoneal space we observed an increase in systolic blood pressure [median 180 mm Hg ([130-200)]. Analyzing the ventilatory parameters we noted that the minute ventilation had to be increased by a median value of 4.25 I (0.4-13) to reduce the increased carbon dioxide levels during CO2 insufflation. After insufflation of CO2 into the retroperitoneal space we observed no major complications. We therefore believe that retroperitoneal endoscopic adrenalectomy is also indicated in patients with cardiac or pulmonary diseases.

[Unusual coincidence of partially active endocrine tumors]. / Ungewöhnliche Häufung von partiell endokrin aktiven Tumoren.

We report on a female patient who developed five different tumors between the age of 53 and 62 years. The following tumors were diagnosed, three of which showed endocrine activity: uterine myoma; hemangiopericytoma of the meninges; pleural mesothelioma; preperitoneal leiomyoma; medullary carcinoma of the thyroid (sporadic form) in a hyperthyroid goiter. Coexistence of hyperthyroidism and medullary carcinoma of the thyroid is rare. Paraneoplastically induced hypoglycemia--in this patient induced by the pleural mesothelioma and less by the preperitoneal leiomyoma--is of similarly infrequent occurrence. Tumors of epithelial or mesenchymal origin may cause hypoglycemia as a result of peptide secretion, exerting an insulin-like effect. The detection of IGF-I and IGF-II in the serum confirms the diagnosis. Insulinoma can be differentiated by the absence of hyperinsulinemia.

[Prospective observational study of surgical therapy of renal hyperparathyroidism]. / Prospektive Beobachtungsstudie zur operativen Therapie des renalen Hyperparathyreoidismus.

A prospective long-term follow-up study in patients who had had surgical therapy for renal hyperparathyroidism was launched to investigate the results of surgical treatment and to evaluate possible correlations between preoperative laboratory values and the course of symptoms. From August 1987 to December 1995, 79 patients underwent surgery for renal hyperparathyroidism. It was the first neck exploration for 72 patients. Total parathyroidectomy with autotransplantation to a forearm was our preferred procedure (n = 67). The postoperative course of all patients is know. We carried out one to nine reexaminations (median 4) in 74 of 79 patients. The follow-up period ranged from 1 month to 5 years with a median of 18 months. After the operation transient hypocalcaemia occurred in 84.4% of patients. Postoperative hypocalcaemia correlated negatively with the preoperative levels of alkaline phosphatase and intact parathyroid hormone. Within the first month after surgery 60% of the preoperatively affected patients completely recovered from pruritus, whereas the skeletal syndrome took longer to disappear. One year after surgery 75% of the patients with pruritus and 79% of those with skeletal syndrome had became asymptomatic. After total parathyroidectomy with autotransplantation, patients with preoperatively elevated concentrations of alkaline phosphatase (> 200 U/I) experienced faster relief from joint pain than patients with preoperatively normal concentrations (P = 0.0297). To date 4.5% of the patients developed recurrent hyperparathyroidism after total parathyroidectomy with autotransplantation. Morbidity of surgery for renal hyperparathyroidism is influenced by patients' risk factors. Postoperative hypocalcaemia correlates negatively with the grade of renal osteopathy at the time of operation. Preoperative concentrations of alkaline phosphatase influence the rapidity of the relief from joint pain.

[Prognostic value of e-cadherin in papillary thyroid carcinoma]. / Prognostische Bedeutung des e-Cadherin beim papillären Schilddrüsencarcinom.

The prognostic significance of e-cadherin in papillary thyroid carcinoma was evaluated in a retrospective study. From September 1985 to December 1996, 113 patients underwent surgery for papillary thyroid carcinoma. Seventy-eight formalin-fixed, paraffin-embedded tissue samples were available for immunohistochemical analysis of e-cadherin expression. In 74 of these 78 patients the postoperative course is known for 2 months to 35.2 years (median 3.6 years, mean: 4.9 +/- 4.8 years). Reduced or negative e-cadherin expression (< or = 20%) was associated with advanced T categories of the primary tumours and higher rates of synchronous lymph node involvement and distant metastasis. During follow-up in this group of patients locoregional tumour recurrence occurred more frequently and survival was shorter than in patients with tumours which exhibited e-cadherin expression of > 20%. Statistical analysis revealed e-cadherin expression (< or = 20%/ > 20%), synchronous distant metastasis (M0/pM1, cM1) and radicality of resection (R0/R1, 2) as significant risk factors for survival. Our findings provide evidence that e-cadherin is a prognostic factor in papillary thyroid carcinoma.

[Diagnosis of dysfunctions of replanted parathyroid gland tissue by bilateral analysis of intact parathyroid hormones in cubital vein blood. A prospective study]. / Diagnostik von Dysfunktionen replantierten Nebenschilddrüsengewebes durch seitengetrennte Analyse des intakten Parathormons im Kubitalvenenblut. Eine prospektive Untersuchung.

AIM: In a prospective long-term follow-up study after operative therapy of hyperparathyroidism the value of bilateral determination of parathyroid hormone levels in cubital venous blood after total parathyroidectomy/autologous parathyroid gland reimplantation (musculus brachioradialis) for diagnosis of dysfunctioning grafted tissue is evaluated. PATIENTS AND MATERIAL: From August, 1, 1987 to March, 31, 1994 68 of 243 patients operated on for hyperparathyroidism underwent total parathyroidectomy. Autologous reimplantation of parathyroid gland was carried out simultaneously in 64 patients. Twice delayed reimplantation of cryopreserved tissue was carried out, and there was no reimplantation in two patients up to this day. Three patients were operated on for hyperfunctioning parathyroid autograft after former total parathyroidectomy/reimplantation. RESULTS: During follow-up 5 patients developed dysfunction of (reimplanted) parathyroid gland. Because of low or unprovable levels of intact parathormone the gradients of intact parathyroid hormone between grafted and nongrafted forearm were about 1:1 in postoperative hypoparathyroidism as well as in hypofunction of parathyroid gland. After successful replantation of cryopreserved parathyroid tissue gradients of intact parathyroid hormone increased (> 1:10). In hyperfunction of grafted parathyroid tissue hormone gradients were high (> 1:20 to 1:45,3) because of excessive high levels of intact parathormone in the cubital vein of the graft bearing arm. Successful reduction of parathyroid graft was followed by decrease of parathyroid hormone gradients. CONCLUSION: Regular follow-up of intact parathormone gradients together with intact parathyroid hormone levels and serumcalcium analysis allow the determination of parathyroid graft function. Also differentiation between graft dependent hyperparathyroidism and hyperfunctioning parathyroid tissue in the neck or mediastinum seems to be possible by bilateral determination of intact parathormone. Normal values or a normal range for intact parathyroid hormone gradients can not yet be defined.

[Perforation of gastroduodenal ulcer: a risk analysis]. / Gastroduodenale Ulkusperforation: Eine Risikoanalyse.

In 90 patients who, between 1.1.1986 and 31.12.1991, underwent surgery for a perforated gastric/duodenal ulcer, the importance of age, sex, ulcer history, ulcer site, free/covered perforation, extent of peritonitis, duration of history and the pre-operative risk assessment (ASA classification) was analysed with respect to the risk of dying of the perforated ulcer. The univariate analysis showed the following to be prognostically relevant factors: time interval between onset of acute symptoms and surgery (less than or equal to 24 hours: mortality rate 12%, greater than 24 hours: mortality rate 21%; p = 0.006); physical status of the patient as reflected in the ASA category prior to surgery (mortality: ASA II 0%, ASA III 8%, ASA IV 32%; p = 0.009), and the presence of a spontaneous pneumoperitoneum (free perforation 21% mortality, covered perforation 5% mortality; p = 0.049). Investigation of the overall influence of the univariate relevant factors in the logistic model showed a relative risk of 4.9 for duration of history, and of 5.4 for the ASA classification. The mortality risk for a patient who is operated on more than 24 hours after onset of the acute symptoms is 4.9 times that of a patient operated on within 24 hours. In the ASA classification, the mortality risk increases by 5.4 from one category to the next higher one.