Therapeutic approaches of diametaphyseal radius fractures in children.

BACKGROUND: There are clear standards for when to operate on both distal epiphyseal and diaphyseal forearm fractures in children. However, paediatric surgeons are often faced with fractures in the transition zone between metaphysis and diaphysis. This aim of the study is to compare different treatment approaches for diametaphyseal forearm fractures, to classify different types of these fractures, and to define further assessment parameters and treatment recommendations. METHODS: This retrospective study included all patients with diametaphyseal radial fractures who were seen at a paediatric surgery clinic between 01.01.2010 and 31.12.2013. Patients were treated either non-surgically (C) or surgically using bicortical Kirschner wire (BC-KW), intramedullary K-wire (IM-KW), elastic stable intramedullary nailing (ESIN), or combined bicortical and intramedullary K-wire (BCIM-KW). RESULTS: During the study period, 547 patients presented with forearm fractures of which 88 patients (16%) had a fracture in the diametaphyseal region. The majority of diametaphyseal fractures were greenstick fractures (54.4%) followed by transverse fractures (44.3%). Distal fractures were predominantly treated with bicortical K-wiring (BC-KW, 40.5%) or non-surgically (C, 26.2%). Proximal fractures were treated by ESIN osteosynthesis (50%), followed by IM-KW (30%). Intermediate fractures were just as likely to be treated with one out of the 5 above-mentioned techniques. The ulna was involved in 64 of 88 cases. Depending on the type of fracture, it was treated either by ESIN osteosynthesis or non-surgically. No superior operative technique was identified. CONCLUSIONS: The description of diametaphyseal fractures as a separate entity is important, because the therapy of these fractures is heterogeneous and challenging. A classification into proximal, intermediate, and distal may be useful in clinical decision-making. Despite the retrospective nature of this study, our data suggest that the use of a K-wire or combined technique BCIM-KW-technique, whenever technically feasible, achieves better radiological results without secondary dislocation. Further prospective studies are needed to provide better guidance to trauma surgeons.

SNP g.1007A>G within the porcine DNAL4 gene affects sperm motility traits and percentage of midpiece abnormalities.

The flagellar beating of a spermatozoa's axoneme is caused by the varying activation and inactivation of dynein molecules. Dynein, axonemal, light chain 4 (DNAL4) is a functional candidate gene for sperm motility as it encodes a small subunit of the dyneins. We resequenced the porcine DNAL4 using three artificial insemination (AI) boars each with high (>68%) or low (<60%) motility, and detected 23 SNP. These were then genotyped for 82 AI boars. Using spermatological records, significantly negative genetic correlations between ejaculate volume (VOL) and the further spermatological parameters concentration (CONC) (r = -.43), motility of undiluted semen (MOTUD) (r = -.09), motility after 24 h (MOT1) (r = -.17) and after 48 hr (MOT2) (r = -.23) were estimated. Significantly positive correlations existed between CONC and MOT1 (r = .07) as well as MOT2 (r = .10), between MOTUD and MOT1 (r = .33), between MOTUD and MOT2 (r = .36), and finally between MOT1 and MOT2 (r = .70). Significantly negatively correlated were all motility traits with the parameters abnormal acrosome (AA) (MOTUD r = -.06; MOT1 r = -.08, and MOT2 r = -.1) and presence of cytoplasmic droplet (CD) (MOTUD r = -.07; MOT1 r = -.08; MOT2 r = -.07). Association analyses (single marker regression model; SMR) propose that SNP g.1007A>G, located in the second intron, reduces motility significantly (MOTUD -4.59%; MOT1 -10.33%; MOT2 -19.37%). According to the dominant-recessive model (DRM), genotype AA is always superior compared to genotypes AG and GG (i.e. MOTUD 67.67%, 64.16% and 53.91%; MOT1 54.17%, 43.75% and 28.44%; MOT2 44.12%, 24.91% and 4.97%). The average effect of gene substitution (g.1007A>G) on abnormal midpiece (AM) was 0.71%, the genotypic values-as expressed by LSmeans-were 0.1 (AA) and 0.81 (AG).

Expression of chemoresistance-related genes and heat shock protein 72 in hyperthermic isolated limb perfusion of malignant melanoma: an experimental study.

Hyperthermic isolated limb perfusion (HILP) is considered an established treatment for multiple locoregional intransit metastases in malignant melanoma of the extremities. Various mechanisms such as the expression of chemoresistance genes and heat shock proteins by the tumor may be responsible for varying response rates and locoregional recurrences of the treatment. The aim of the experimental animal study was to investigate the direct impact of HILP on such mechanisms of resistance. Tissue temperature, administration of the cytostatic drug, and duration of perfusion were varied. Expression of the chemoresistance genes mdr1, mrp1, mrp2, and lrp and of heat shock protein 72 (HSP72) in the tumor tissue was analysed using RT-PCR and western blot analysis. The untreated SK-MEL-3 tumor expressed mdr1, mrp1, and lrp, but not mrp2. Neither variation of temperature, administration of the cytostatic drug, nor duration of perfusion changed the expression of this "resistance pattern". In contrast to the cytostatic drug, hyperthermia causes a persistent induction of HSP72. Both observations could offer a potential explanation for failure of HILP in malignant melanoma.

Anatomy and histology of the reproductive tract of the female Babirusa (Babyrousa celebensis).

The anatomy and histology of the female reproductive tract of the Indonesian wild pig Babyrousa celebensis was studied by means of reproductive tracts obtained from seven animals aged between two and 22 years of age. The ovary appeared to have the ability to ovulate up to four ova at one time. However, the combined ovarian output seemed to average 1.86 ova. Ovulation can take place at any time from puberty to old age (22 years). The opening to the uterine tube was indicated by a 'flower-like' array of tall, broad epithelial 'petals' arising from the luminal surface of the funnel. The mucosal surfaces of these structures were covered in a mixture of prominent ciliated cells and bulbous secretory cells. The uterine tube followed a tightly convoluted path to the tip of the uterine horn. The uterus was proportionately short. The anatomical construction of the uterus was similar to those of other suids in that the columnar endometrium was heavily folded, there was a rich supply of uterine glands in the lamina propria, and the uterus was provided with a good blood supply. The cervix was thick walled and had a spiral lumen.

Long-term functional outcome after hyperthermic isolated limb perfusion (HILP).

BACKGROUND: One of the biological characteristics of melanoma is the locoregional development of metastases that are difficult to treat by conventional tumour mass reduction. Locoregionally metastasised melanoma of the limb can effectively be treated by hyperthermic isolated limb perfusion (HILP). Postoperative complication rates are acceptable. Only few studies have examined long-term complications. This is the reason why we followed up patients in respect of long-term physical and psychological complications after HILP. MATERIALS AND METHODS: 312 patients with melanoma of the limb underwent HILP in our department between 1977 and 1983. Eighty-two patients that were still alive and no older than 80 years at the time of follow-up were contacted and invited to a physical examination. On average, follow-up took place 20 years after HILP. Thirty-nine patients were willing to participate in the study. Twelve of these patients were male and 27 female. The average age was 63.1 years (range 41 to 79). The average age at the point of perfusion was 42.1 years (range 19 to 59). In 10 cases the upper extremity was involved, in 29 patients the lower extremity. Patients were questioned on impairment of daily life and their health status using a standardised questionnaire. A physical examination was performed to document the impairments quantitatively. Ranges of motion, circumference and neurological deficits of the operated limbs were compared to the healthy limbs. RESULTS: At the time of follow-up examination all patients were without recurrent disease. A definite correlation between impairment of the general health condition and the operation could only be found in one patient with persisting lymph oedema. Thirteen patients still wore elastic stockings during the day, 9 of which regularly underwent lymphatic drainage. Most of the patients (58%) saw an improvement of their condition due to the treatment. 67% of the patients reported not having any or only slight impairment of everyday life. Only a few cases had disadvantages in their social and working life due to the perfusion. The physical examination of the upper limb showed an impaired range of motion of the shoulder in all planes in 50% of the patients. Relevant decrease in range of motion in the elbow was seen in two patients. The other examination results showed no significant differences in comparison to the healthy arm. The analysis of the lower limb showed relevant clinical reduction of range of motion in all three major joints. Significant differences were also found in the circumference of the leg compared to the healthy side. SUMMARY: According to our results and results from the literature it was possible to show that hyperthermic isolated limb perfusion is associated with an elevated risk of persisting impairment of range of motion of the treated limb. The impaired function is due to a persistent swelling of the limb because of lymph oedema on the one hand and local toxicity to the ligaments of the joints on the other. Response rates and results of HILP have greatly improved in the last years due to numerous modifications so that this treatment is the method of choice in locoregionally metastasised melanoma of the limb in spite of the long-term complication rate.

[Hepaticolithiasis. Rare benign disease of the intrahepatic bile ducts]. / Hepatikolithiasis. Seltene benigne Erkrankung der intrahepatischen Gallenwege.

Hepaticolithiasis is a rare disease of the intrahepatic bile ducts endemic to east Asia which also is known as oriental cholangiohepatitis. Beside strictures and metabolic disturbance, the main cause of intrahepatic stones is acquired or congenital malformation of the intrahepatic biliary ducts. In the following we show a case of hepaticolithiasis and concurrent pancreatic metaplasia.

Hyperthermic isolated limb perfusion (HILP) in malignant melanoma. Experience with 101 patients.

AIMS: To analyse results with a standardized HILP procedure in terms of response rate, recurrence pattern and complication rate. PATIENTS AND METHODS: From 1992 to 2003 HILP with melphalan and dactinomycin was performed in 101 patients with loco-regional metastases of malignant melanoma of the limbs. Among these were 66 women and 35 men with a median age of 62 years. Forty patients were in M. D. Anderson stage IIIA, 51 patients in stage IIIAB and 9 had stage IV disease at the time of perfusion. If not been done before, regional lymph node dissection preceded limb perfusion in the same setting. RESULTS: A complete response (CR) was observed in 58 out of 87 evaluable patients. Twenty-one patients achieved a partial response (PR) and eight patients were non-responders. The overall response rate was 90.8%. The median recurrence-free interval after CR was 21 months. Severe toxicity (Wieberdink IV/V) was observed in five patients necessitating fasciotomy in four of them and above knee amputation in one patient. All further cases presented with grade II-III toxicity. The overall survival was 42 months, with a 5-year survival rate of 38%. Survival significantly differed according to stage of disease. CONCLUSION: HILP is an effective treatment for loco-regional tumour relapse of malignant melanoma of the extremities and has improved by modification of technique. In the absence of regional lymph node and distant metastases long-term survival can be achieved in responders.

[The "inspection jejunostomy" after complex reconstructions of the central bile ducts]. / Anlage eines inspektionsstomas bei komplexen rekonstruktionen an den zentralen gallengängen.

INTRODUCTION: Hutson and Russell described in 1984 a surgical technique, where a modified Roux-en-Y hepaticojejunostomy with the afferent limb brought up as jejunostomy after complex reconstructions of the central bile duct was performed [4]. It facilitates endoscopic retrograde access to the biliary tree for control examinations and biopsies in complicated reconstructive procedures after bile duct resection. We report our experience with this operative procedure. METHODS: After having performed complicated bile duct resection, the reconstruction was performed as a modified Roux-en-Y hepaticojejunostomy with the 20 cm afferent limb brought up as terminal jejunostomy in the right upper abdominal quadrant. Postoperative follow-up comprised endoscopic and radiologic controls of the biliary tree every 3 months for one year; ileostomy resection was performed one year later if the postoperative course was undisturbed. RESULTS: From 03/1995 to 07/2006 we performed this operation in 25 patients (mean age 62 yrs.). Indications were previous lesions of the common bile duct after laparoscopic (n = 10) or open cholecystectomy (n = 5), common bile duct resections in cholangiocellular carcinoma and gallbladder carcinoma with unclear intraoperative safety margins (n = 4), malignant granulosa cell tumour and simultaneous cholangiocellular carcinoma, focal nodal hyperplasia, Mirizzi-syndrome, cystadenoma of the pancreas head, cyst of ecchinococus granulosos and one patient with intrahepatic recurrent stone formation after orthotopic liver transplantation. The endoscopic and radiologic (cholangiography) diagnostic procedures--performed every 3 months postoperatively--were uneventful. CONCLUSIONS: The modified Roux-en-Y hepaticojejunostomy with the afferent limb brought up as jejunostomy permits good control and intervention possibilities in complicated bile duct surgery after bile duct lesions, tumor resection with unclear resectional margins and in recurrent intrahepatic stone formation.

[Inspection jejunostomy after complex reconstruction of the central bile duct. Indication, description, and personal experience]. / Das Inspektionsstoma nach komplexen Rekonstruktionen an den zentralen Gallengängen. Indikationen, Beschreibung der Operationsmethode und Erfahrungsbericht.

INTRODUCTION: A modified Roux-en-Y hepaticojejunostomy that allows postoperative endoscopic access was first described in 1984. We report our experience with this operative procedure. METHODS: After complicated bile duct resection, reconstruction was performed as a modified Roux-en-Y hepaticojejunostomy, with the 20 cm afferent limb brought up as in terminal jejunostomy in the right upper abdominal quadrant. Postoperative follow-up consisted of endoscopic and radiologic control of the biliary tree every 3 months for 1 year; ileostomy resection was performed 1 year later if the postoperative course was undisturbed. RESULTS: From March 1995 to February 2002, we performed this operation in 17 patients (mean age 56 years). The endoscopic and radiologic (cholangiography) diagnostic procedures--every 3 months postoperatively--were uneventful. CONCLUSIONS: The modified Roux-en-Y hepaticojejunostomy described here permits good control and intervention in complicated surgery for bile duct lesions, tumor resection with unclear resectional margins, and recurrent intrahepatic stone formation.

Peritoneal carcinomatosis of colorectal cancer: incidence, prognosis, and treatment modalities.

BACKGROUND AND AIMS: Intraperitoneal carcinomatosis accounts for 25-35% of recurrences of colorectal cancer. Studies demonstrate that peritoneal carcinomatosis is not necessarily a terminal condition with no options for treatment or cure. RESULTS: The combination of aggressive cytoreductive surgery and intra-abdominal hyperthermia chemotherapy improves long-term overall survival in selected patients but is a time-consuming procedure (approx. 12 h) and entails high mortality (5%) and morbidity (35%)). Most commonly used drugs are mitomycin C and platinum compounds, which have synergistic toxic effects on tumor cells when hyperthermia is applied. CONCLUSION: Since combined treatment seems promising only in peritoneal carcinomatosis stages I and II, the precondition for a reasonable combined treatment is careful staging. The mode of chemotherapy, the kind of drugs used for chemoperfusion, the timing of surgery, and the role of additional systemic chemotherapy must be evaluated in randomized studies.

Receptor revision of immunoglobulin heavy chain genes in human MALT lymphomas.

BACKGROUND/AIMS: Rearrangement of immunoglobulin gene segments, leading to B cells with functional receptors, is thought to be largely restricted to developing immature B cells in bone marrow. However, accumulating evidence suggests that mature B cells occasionally modify their antigen specificity by VH segment replacements during the germinal centre reaction to enhance antigen affinity, or to overcome self reactive antigen receptors. Although malignant B cells maintain the features of their normal counterparts in most instances, to date, such replacements have not been described for human B cell lymphomas. METHODS: Rearranged immunoglobulin heavy chain genes from two extranodal marginal zone B cell lymphomas were amplified, cloned, and sequenced. Sequences with identical CDR3 regions were selected and aligned to each other and public databases. RESULTS: VH replacements were seen in two extranodal marginal zone B cell lymphomas. In line with the hypothesis that in mature B cells these replacements are associated with active somatic hypermutation, in addition to VH replacement, different mutation patterns were seen in the revised VH portions. In the remaining common 3'-VH regions, these mutations could be used to establish a phylogenetic relation between the sequences, rendering the possibility of artefactual chimaeric polymerase chain reaction products very unlikely. CONCLUSIONS: These results support the view that VH replacements are a further mechanism for reshaping antigen affinity and specificity, and indicate that these receptor modifications are not restricted to normal and reactive germinal centre B cells, but may also occur in close association with the development of malignant B cell lymphomas.