Feasibility and accuracy of TRUS in the pre-treatment staging for rectal carcinoma in general practice.

AIMS: Transrectal ultrasonography (TRUS) is the diagnostic tool of choice for local staging of rectal carcinoma. The accuracy in determining of tumour infiltration depth has been reported to reach 95% (on average, 85%). The aim of the study was to analyse the diagnostic accuracy of the TRUS in the clinical routine. PATIENTS AND METHODS: From 01/01/2000 to 12/31/2003, all patients with rectal carcinoma were enrolled in a prospective multicenter observational study. In case of complete findings of pre-operative TRUS and post-operative histological investigation of the surgical specimen on the tumour infiltration depth, overall accuracy of TRUS was determined. RESULTS: Overall, 13,610 patients with rectal carcinoma were enrolled in the study. Five thousand and fifty-six subjects (37%) underwent TRUS. In 3,501 patients, TRUS finding (uT-stage) could be compared with the result of the definitive histologic investigation (pT-stage). The accuracy of TRUS in all T-stages was 65.8%. The highest sensitivity was achieved in the T3-stage (74.9%), while in T2, T1, and T4, it was 59.6, 59.0 and 31.1%, respectively. In discriminating tumour growth limited to the rectal wall vs that through the rectal wall into the neighboring tissue, TRUS-associated accuracy was 76.5%. There were no differences between various tumour locations above the anocutaneous line. CONCLUSIONS: Diagnostic accuracy of TRUS in determining depth of tumour infiltration within or through the rectum wall in the routinuous diagnostic of rectal carcinoma does not reach the excellent published study results. A considerable improvement of the qualitative outcome in using this specific diagnostic tool appears to be recommendable to utilize its advantages such as high accuracy, efficacy, and practicability in the diagnostic process and deriving consequences for a possible neoadjuvant treatment as well as optimal planning of the surgical approach.

[Cavernous haemangioma in the Muscularis propria of the oesophagus and in the paraoesophageal tissue]. / Kavernöses Hämangiom in der Muscularis propria des Osophagus und im paraösophagealen Gewebe.

This is a case report of a 45-year-old woman who presented herself in our hospital with increasing retrosternal tenderness to pressure, dysphagia, and symptoms of reflux oesophagitis. The clinical examination and laboratory results showed no pathological findings. Oesophagogastroduodenoscopy revealed a bluish-livid, bulging mass from 32-38 cm aborally. A malignancy could not be excluded by biopsies with histological work-up, endoscopical ultrasound, nor CT-scan. By thoraco-abdominal surgery, a 5 cm large vascularised tumour of the outer layers of the oesophagus and the paraoesophageal tissue was resected. After intrathoracic oesophago-gastrostomy the patient could be discharged 17 days after surgery without further symptoms. Histology showed a benign tumour which was classified as cavernous haemangioma. To our knowledge, this is the first case of a haemangioma which involves the paraoesophageal tissue and the muscularis propria. The few published case reports of cavernous haemangioma of the oesophagus describe only an involvement of the mucosa and submucosa.

[Ruptured splenic artery aneurysm--a rare cause of recurrent gastrointestinal hemorrhages]. / Rupturiertes Milzarterienaneurysma--eine seltene Ursache rezidivierender gastrointestinaler Blutungen.

HISTORY AND CLINICAL FINDINGS: A 51-year-old asthenic patient attended the hospital with syncope, head injury, tarry stool and severe anemia. There was a history of alcohol and nicotine abuse, but no known preceding diseases of the liver or gastrointestinal tract. Except hypotension, examination of the patient did not show any further abnormalities. DIAGNOSTIC PROCEDURE: An upper and lower endoscopy did not show any evidence of a bleeding source although the stomach was full of hematin. An abdominal ultrasound demonstrated signs of a chronic pancreatitis and a big cystic structure in the area of the pancreatic tail. Pulsed and color Doppler imaging followed by angiography led to the diagnosis of a pseudoaneurysm of the splenic artery. TREATMENT AND COURSE: After confirming the diagnosis, a laparotomy was performed. It revealed a pseudoaneurysm arising from the splenic artery that had penetrated the stomach and caused bleeding. Resection of the aneurysm, the stomach fundus, the left pancreas and the spleen was performed. 10 days after laparotomy, the patient was discharged from hospital in a good clinical condition. CONCLUSION: Pseudoaneurysms of the splenic artery are an uncommon cause of gastrointestinal bleeding. The most important factor in detecting a pseudoaneurysm is considering the diagnosis. It is necessary to check for a pseudoaneurysm secondary to pancreatitis with pulsed or color Doppler imaging especially if a pseudocyst was first diagnosed with abdominal ultrasound. Because of the high mortality of a pseudoaneurysm, surgical resection or interventional radiology should be done as early as possible.

[Neuroendocrine tumors of the gastrointestinal tract. Prospective analysis of 29 patients and review of the literature]. / Neuroendokrine Tumoren des Gastrointestinaltraktes. Prospektive Analyse von 29 Patienten und Literaturübersicht.

Neuroendocrine tumors are rare and can be observed in different gastrointestinal organs. The diagnosis often is made by incidence like in carcinoids of the appendix vermiformis, or special clinical symptoms may develop due to tumor growth. 29 consecutive patients were evaluated prospectively during 30 months. In 21 of them, the first diagnosis was obtained after an operative procedure. In 3 cases, the tumor was found incidentally during another oncological procedure. In 4 patients, the histological examination of biopsy specimens had shown an undifferentiated adenocarcinoma. In 8 of the patients, recurrent surgery was necessary because of recurrency of the disease. The mean observation time of all patients was 10.6 months. 6 of 29 patients died on disease-related symptoms. The results are discussed based on the literature with special regard to organ-related characteristics of different gastrointestinal neuroendocrine tumors.

Intraoperative gamma probe detection of neuroendocrine tumors.

UNLABELLED: Previous studies of the intraoperative use of a handheld gamma probe to localize metastases and primary tumors of colorectal cancer have shown improved assessment of tumor spread and changes in surgical management based on added information gained by radioimmunoguided surgery. We conducted a prospective study to determine whether intraoperative radiodetection is able to reveal microscopic and occult disease of neuroendocrine tumors [medullary thyroid carcinomas (MTCs), gastroenteropancreatic (GEP) tumors]. METHODS: After the injection of 180 MBq [111In-diethylenetriaminepentaacetic acid (DTPA)-D-Phe1]pentetreotide and/or 500 MBq 99mTc-dimercaptosuccinic acid (DMSA) (both for double-nuclide scintigraphy), preoperative somatostatin receptor imaging (12 patients with GEP tumors) and double-nuclide scintigraphy (10 patients with relapsing MTCs were performed. The results were combined with the information obtained from conventional imaging modalities (CT and sonography). Intraoperative radiodetection was performed 24 hr after administration of [111In-DTPA-D-Phe1]pentetreotide or 4 hr after the injection of 99mTc-DMSA using a handheld gamma probe. RESULTS: Intraoperative gamma counting localized 70 somatostatin receptor-positive lesions of GEP tumors, whereas preoperative receptor imaging visualized 74%, surgical palpation visualized 44% and radiological imaging modalities localized only 43%. In 10 patients with recurrent MTCs, the surgeon was successful in localizing and removing 30 tumor lesions using the gamma probe. Twenty-seven of 30 lesions demonstrated tumor involvement, whereas 3 lesions were false-positive (lymphadenitis). Double-nuclide scintigraphy revealed 67% (Octreoscan, 7 of 20; 99mTc-DMSA, 13 of 20), surgical palpation revealed 60% and conventional imaging methods (CT, sonography) revealed only 50% of all lesions detected intraoperatively by the handheld gamma probe. The smallest lesion identified by the handheld probe (not palpated by the surgeon) was a lymph node metastasis (5-mm diameter). CONCLUSION: The preliminary data show that intraoperative handheld gamma probe detection of microscopic and occult endocrine tumors is feasible and more sensitive than external scintigraphy and conventional imaging.

[Liver transplantation and splenectomy in idiopathic portal hypertension]. / Lebertransplantation und Splenektomie bei idiopathischer portaler Hypertension.

Idiopathic portal hypertension (IPH) was diagnosed in a 30-year-old man. Clinical signs were splenomegaly, leucothrombocytopenia, and esophageal varices of fourth degree. The histology of the liver biopsy showed portal fibrosis with no evidence of cirrhosis. No causing agent or known disease could be found for the histopathological and clinical features. Due to a severe deterioration of general condition and a decline of synthetic liver function, liver transplantation and splenectomy were performed. The histological examination of the explanted liver revealed features of IPH, demonstrating portal fibrosis and dilated vessels adjacent to portal tracts; no cirrhosis was found. The postoperative recovery was without any severe complications. The duration of hospitalization was 28 days. Following liver transplantation, the esophageal varices disappeared and leucocytes, platelets as well as parameters of hepatic synthesis reached normal values. Initially, the immunosuppression was composed of prednisolon, tacrolimus, and antibodies against IL-2 receptors (BT 563) and was later continued with prednisolon and tacrolimus. Within the follow-up observation of 26 months, there was no evidence for graft rejection, severe infection, or occurrence of portal hypertension. Up till now the patient is in good condition with normal graft function. Liver transplantation may be a curative therapy for patients with advanced disease of IPH but the long-term follow-up after transplantation has to show whether IPH can reoccur.

[Clinical value of somatostatin receptor scintigraphy. Studies of pre- and intraoperative localization of gastrointestinal and pancreatic tumors]. / Zur klinischen Wertigkeit der Somatostatinrezeptorszintigraphie. Untersuchungen zur prä- und intraoperativen Lokalisation von GEP-Tumoren.

BACKGROUND: [111In-DTPA-D-Phe1]-pentetreotide scintigraphy is able to detect neuroendocrine tumors not shown by radiological methods. PATIENTS AND METHODS: In 270 patients with neuroendocrine gastroenteropancreatic tumors (GEP tumors) 400 somatostatin receptor scintigraphies were performed. 70 patients (38 female, 32 male, aged 28 to 74 [56 +/- 12.6] years) underwent surgery and follow-up over 2 years. The aim of the present study was the comparison of preoperative somatostatin receptor scintigraphy with radiological methods (sonography, CT) and intraoperative localization of GEP tumors with a hand-held gamma-probe. RESULTS: Somatostatin receptor scintigraphy was successful in localizing primary tumors in all patients. Liver- and lymph node metastases could be visualized with a sensitivity of 94 and 95 percent. In 7 patients 35 lesions could be identified by intraoperative tumor localization using a hand held gamma probe. Radiological methods identified only 11, surgical palpation 15 and preoperative somatostatin receptor scintigraphy 27 lesions. CONCLUSION: Somatostatin receptor scintigraphy improves detection of small and occult GEP tumors. Intraoperative probe counting with a hand-held gamma probe can identify tumors even when they are small and impalpable, but receptor positive.

Xenotransplantation of human thyroid carcinomas in athymic nude mice.

A nude mouse xenotransplantation model was established for human thyroid carcinomas of different histological types. Best results of serial passages were obtained in anaplastic cancers. The models allowed investigations under in vivo conditions. Hormonal influences were tested, and imaging procedures were possible. In most aggressive anaplastic carcinoma cell lines, growth inhibition of cytostatic drugs, cytokines and nutritional effects were investigated.

Effect of Graves' intrathyroidal lymphocytes. Effect of Graves' disease intrathyroidal lymphocytes (ITL) on xenotransplants of human thyroid tissue in athymic nude mice.

It has been suggested that ITL are of importance in the pathogenesis of human autoimmune thyroid disease. Aim of our study was to investigate function and morphology of xenotransplanted human thyroid tissue in nude mice following systemic application of lymphocyte preparations from patients with Graves' disease (GD) and non-toxic nodular goiter (NTG). ITL obtained from 13 patients with GD and peripheral blood lymphocytes (PBL) from 12 patients with NTG were injected into nude mice bearing 8 weeks old xenografts of normal human thyroid tissue. ITL- and PBL-subsets were analyzed by flow cytometer (FACScan) before engraftment. Two days after injection the thyroid transplants were examined histologically (HE) as well as immunohistologically by staining with: CD3, CD31, CD45R, HLA class II, ICAM-1, VCAM-1, IgG, IgM and Ki67. Flow cytometry showed a significant higher number of the lymphocyte-subsets CD3, DR+ and CD4 in GD-ITL as compared to the subsets in NTG-ITL. After injection of GD-ITL to the nude mice also a significant higher number of CD3+ human lymphocytes was found in the transplants. GD-lymphocytes stimulated thyroid tissue function significantly more pronounced than NTG-lymphocytes (histomorphological evaluation). In addition, a significant increase of HLA-class II, ICAM-1-, VCAM-1-, CD45-expression and number of Ig presenting plasma cells were observed only after injection of GD-ITL. Our data demonstrate, for the first time in vivo (nude mouse model), that GD-lymphocytes of both peripheral and intrathyroidal origin selectively migrate into human thyroid transplants ("homing"). They survive there for at least two days and induce significant functional as well as histological changes, like expression of gene products and IgG synthesis. These results suggest an important role of ITL in the pathogenetic mechanisms and clinical course of GD.

[Intraoperative autotransfusion and use of cell saver systems]. / Intraoperative Autotransfusion und Verwendung von Cell-Saver-Systemen.

In the last two years we have performed intraoperative autotransfusion by a cell-saving-system in 46 patients causing a 70%-reduction in the need of homologous blood transfusion. 20% of these patients did not need homologous blood at all. Besides minimizing transfusion-associated risks, intraoperative autotransfusion had an evident cost-sparing effect.

An improved model for rat liver transplantation including arterial reconstruction and simplified microvascular suture techniques.

For experimental liver transplantation in the rat, the models that have been used most frequently do not include reconstruction of the arterial blood supply to the liver. In these procedures, specially developed cuff anastomoses rather than the conventional microvascular suture technique are used almost exclusively in the recipient operation, so that the anhepatic time is minimized. In this study the technical details of an improved rat model for orthotopic liver transplantation are described. During the donor operation in this experimental method, the liver is prepared with an arterial pedicle that includes the abdominal segment of the aorta, permitting perfusion in situ of the portal vein as well as the hepatic artery. The transplantation of the excised donor organ into the recipient site is carried out with simplified microvascular suture techniques and includes reconstruction of the arterial supply to the liver. Anastomosis of the bile duct is accomplished by choledocho-choledochostomy with a splint technique and supplemental suturing. For the entire procedure, magnifying glasses with 2- to 2.5-fold magnification are sufficient. When this technique has been mastered, the average duration of the anhepatic phase is about 20 min, well below the critical 30-min limit for survival of the experimental animals. As proficiency increased, the perioperative mortality was reduced to 9.2% (n = 130). With the combination of portal and arterial in situ flushing during the donor operation and the rearterialization of the transplant during the recipient operation, the clinical conditions can be approximated more closely than is possible when the transplanted rat liver is supplied only by the portal vein. Use of microvascular suture techniques, without cuff anastomoses, reduces the need for ex situ handling of the donor organ.

In vivo effects of TSH receptor antibodies in xenotransplanted human thyroid tissue.

From the data presented it can be concluded that the xenotransplantation model is well suited for studies concerning pathogenesis, diagnosis and therapy of AITD. Human thyroid transplants of Graves' disease tissue, depending upon extrinsic stimulators, lose all signs of hyperfunction after transplantation into athymic nude mice, but hyperfunction can again be induced in the transplants by injections of sera or immunoglobulin fractions from patients with active Graves' disease, containing stimulating TSH receptor antibodies. Our data demonstrate that thyroid function and growth are independent phenomena and can be differentiated by means of the xenotransplantation model. Furthermore the presented results indicate that TSH receptor antibodies are able to alter the expression of gene products in human thyroid transplants of Graves' disease, emphasising their important role in inducing/perpetuating immune phenomena related to AITD.

[Multi-visceral upper abdominal resection and orthotopic liver transplantation--a surgical treatment concept for regionally metastatic tumors of the endocrine pancreas]. / Multiviscerale Oberbauchresektion und orthotope Lebertransplantation--ein chirurgisches Behandlungskonzept für regionär metastasierende Tumoren des endocrinen Pancreas.

Islet cell carcinoma is rare. Even in advanced metastasizing tumors, relatively long survival times were reported. Aim of surgical treatment is complete removal of the tumor mass, if possible. When not, palliative procedures were described to be efficient in some of the cases. In the literature, among the first patients with regional metastasizing intraabdominal malignancies and upper abdominal exenteration, some cases with neuroendocrine tumors were reported. Aim of the following study is to describe the results in 4 patients with metastasizing islet cell carcinomas, which were treated by multi-visceral upper abdominal exenteration and combined orthotopic liver transplantation.

Simplified microvascular suture techniques for rat liver transplantation as a microsurgical model with arterial blood supply.

The methods for liver transplantation in the rat mainly used do not include reconstruction of the arterial blood supply to the liver. Furthermore, to ensure a short anhepatic phase these methods almost all entail specially developed cuff anastomoses in the recipient operation instead of the conventional microvascular suture technique. Thus an acceptable survival rate can be attained in the experimental animals. This detailed description of simplified microvascular suture techniques is intended to present an alternative to the cuff anastomoses used almost exclusively. In the donor operation with this method, the liver is dissected with an arterial pedicle including the abdominal segment of the aorta, and the liver is flushed in situ not only via the portal vein, but also via the hepatic artery. The organ is implanted in the recipient animal using simplified microvascular suture reconstruction of the arterial blood supply to the liver. Use of telescopic spectacles with 2-fold magnification has proven to be adequate for the entire procedure. With mastery of this method of rat liver transplantation, the average duration of the anhepatic phase is about 20 min, substantially below the 30-min limit which is critical for the survival of the experimental animals. The donor operation requires about 60 min, and the recipient operation 70 to 80 min. With this method, the spectrum of investigations on liver transplantation which are possible in the rat is substantially extended in that clinical conditions can be reproduced very much more exactly by combination of portal and arterial in-situ flushing in the donor operation and rearterialization of the transplant in the recipient operation, as compared to the transplanted rat liver being supplied only with portal venous blood.

A rapid non-radioactive fluorescence assay for the measurement of both cell number and proliferation.

Measuring the incorporation of radioactive thymidine into the cell nucleus gives important information as to cell activation and proliferation. In this study the DNA-intercalating fluorochromes, Hoechst 33342 and Hoechst 33258, were tested as an alternative to the classical [3H]thymidine assay. Mitogen and alloantigen stimulated lymphocytes as well as FK 506 and CsA inhibited lymphocytes were treated with the two dyes, and the cell number and proliferation rates by means of measured fluorescence values. Of these tested fluorochromes H33342 appears to be an appropriate alternative to the [3H]thymidine assay. It mirrors the cell number in a fast and convenient manner without any pretreatment of the cell suspension which can remain in the culture plates. The complete assay procedure including data analysis can be performed rapidly and the standard deviations are small. This dye may also prove to be of value in other assay procedures, e.g., adhesion experiments.