RESUMO
BACKGROUND: The surgical approach of choice in the treatment of symptomatic cholecystolithiasis is considered to be elective laparoscopic cholecystectomy (CCE) as the established gold standard. Today, approximately 80-90% of CCE are performed using a laparoscopic approach whereas the remaining portion undergoes primary conventional CCE, however, in 6% conversion is necessary. AIM: Since pathological aspects found intraoperatively and finally requiring conversion are correlated to an increased risk for complications, it appears reasonable to assess the risk factors prior to operation. PATIENTS AND METHODS: Through a well defined study period of 9 years, all consecutive patients who underwent CCE for cholecystolithiasis at the Municipal Hospital "HELIOS Klinikum Aue" were enrolled in a registry comparing laparoscopic and conversion CCE. Diverse parameters were tested as to whether they increase significantly the risk for conversion. The intensity of each factor-associated impact on a possible conversion was determined. RESULTS: From 2001 to 2009 1477 patients underwent CCE at the Municipal Hospital "Helios Klinikum Aue", out of them 131 (8.9%) cases were primarily treated by conventional CCE whereas in the vast majority (1346 subjects [91.1%]), laparoscopic CCE was the initial approach. However, conversion became necessary in 106 individuals resulting in a conversion rate of 7.9%. Comparing data obtained from laparoscopic CCE with those from open procedure after conversion, there were significant differences in operating time, complication rate and postoperative hospital stay (p = 0.01). Over the study period, there were 5 cases (0.37%) with iatrogenic injuries of the biliary system. Hospital mortality was 0.08% in the laparoscopic and 2.8% in the conversion group. The following parameters were found to have a significant impact on the risk for conversion (univariate analysis): elevation of CRP, preoperative ERCP, renal insufficiency, previous laparotomy, histological grade M3 (ulcerous, haemorrhagic necrotising cholecystitis, perforation of the gall bladder) and M4 (carcinoma of the gall bladder). While in the spectrum of preoperative factors former ERCP, elevation of CRP and terminal renal insufficiency were most relevant (2- to 3-fold each), histological grade M3 and M4, 7- and 14-fold, respectively, showed the greatest impact on conversion rate highlighting the profile of postoperative parameters. CONCLUSION: The main focus is directed to keep the conversion rate low. In case of diagnosing a severely inflamed gall bladder, a primarily open procedure or an early decision for conversion should be considered.
Assuntos
Colecistectomia Laparoscópica/estatística & dados numéricos , Colecistolitíase/cirurgia , Conversão para Cirurgia Aberta/estatística & dados numéricos , Complicações Intraoperatórias/cirurgia , Adulto , Idoso , Comorbidade , Estudos Transversais , Feminino , Neoplasias da Vesícula Biliar/epidemiologia , Neoplasias da Vesícula Biliar/cirurgia , Alemanha , Humanos , Complicações Intraoperatórias/epidemiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Prospectivos , Fatores de RiscoRESUMO
BACKGROUND: Hepatic recurrence is seen in approximately 40â% of patients undergoing hepatectomy for colorectal metastases. The authors assessed the benefit and the main prognostic factors for a second liver resection of recurrent colorectal metastases. METHODS: This study reports the experience with second liver resections for recurrent liver metastases at a German University Hospital. A total of 39 parameters from 60 patients were identified from a prospective database and analysed as to their influence on recurrence-free survival and overall survival. RESULTS: At a median follow-up of 26 months (range: 2-173 months) after second hepatic resection, recurrence-free survival at 3 and 5 years were 50â% and 37â%, respectively. The overall survival at three and five years were 61â% and 52â%, respectively. Recurrence was identified in 58.3â% of the patients. Recurrences involved exclusively the liver in 19 patients (31.6â%). By multivariate analysis (Cox proportional hazard model), a time interval between diagnosis of the liver metastases of less than 24 months after operation for colorectal primary carcinoma (HR: 6.47, p = 0.002), a CEA level of 4.0 ng/mL or more (HR: 3.48, p = 0.004) at the time of first liver metastases and a size of second liver metastases of 80 mm or more (HR: 4.73, p = 0.007) were independent prognostic factors for a reduced recurrence-free survival. A repeat recurrence of liver metastases without the option of curative resection was the only risk factor for overall survival after second hepatic resection (p = 0.009). In these cases, mortality risk was 4.51-fold, however, when the second liver recurrence was resectable, the mortality risk increased only 1.4-fold. CONCLUSIONS: Technically resectable recurrent colorectal hepatic metastases should be resected the same as the first metastases. Characteristics of the primary metastasis as well as parameters of the hepatic recurrence are shown to influence the prognosis of patients after resection of recurrent liver metastases. Repeat resection of colorectal liver metastases allows for improved survival in patients even after two previous liver operations.
Assuntos
Neoplasias Colorretais/cirurgia , Hepatectomia , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Recidiva Local de Neoplasia/cirurgia , Adulto , Idoso , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/patologia , Comportamento Cooperativo , Intervalo Livre de Doença , Feminino , Alemanha , Hospitais Universitários , Humanos , Comunicação Interdisciplinar , Fígado/patologia , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Prognóstico , Modelos de Riscos Proporcionais , Reoperação , Carga TumoralRESUMO
Peripheral arterial occlusive disease is one manifestation of the systemic disease atherosclerosis. The initial therapy for every arteriosclerotic disease is aimed at reducing cardiovascular risk factors by lifestyle modification and medication. Patients who require surgical revascularisation need long-term antiplatelet therapy or anticoagulation. This therapy has to be differentiated according to the vascular territory involved and the method used for revascularisation. After local thrombendarterectomy, alloplastic bypass graft surgery of the aortic, aorto-iliac, aorto-femoral or femoro-popliteal region above the knee, long-term ASA 100 mg/d or clopidogrel 75 mg/d should be initiated. After alloplastic bypass grafting below the knee the combination of ASA 100 mg/d and clopidogrel 75 mg/d should be used. In contrast, after venous grafts the patency rate is improved by anticoagulation with vitamin K antagonists (INR 2-3), if there is a low risk of bleeding. If there is a contraindication to vitamin K antagonists, ASA 100 mg/d should be used. After revascularisation, a structured surveillance programme should be implemented aiming at controlling cardiovascular risk factors and monitoring the vascular state, as well as the anticoagulation and the antiplatelet therapy.
Assuntos
Doenças da Aorta/cirurgia , Implante de Prótese Vascular/métodos , Endarterectomia/métodos , Medicina Baseada em Evidências , Fibrinolíticos/administração & dosagem , Doença Arterial Periférica/cirurgia , Complicações Pós-Operatórias/tratamento farmacológico , Doenças da Aorta/diagnóstico , Aspirina/administração & dosagem , Clopidogrel , Relação Dose-Resposta a Droga , Quimioterapia Combinada , Artéria Femoral/cirurgia , Seguimentos , Humanos , Artéria Ilíaca/cirurgia , Coeficiente Internacional Normatizado , Doença Arterial Periférica/sangue , Doença Arterial Periférica/diagnóstico , Polietilenotereftalatos , Politetrafluoretileno , Artéria Poplítea/cirurgia , Complicações Pós-Operatórias/sangue , Desenho de Prótese , Ticlopidina/administração & dosagem , Ticlopidina/análogos & derivados , Veias/transplante , Vitamina K/antagonistas & inibidoresRESUMO
The dominant role for the emergence and establishment of intensive care medicine can be attributed to surgery. The first critical care units were developed in surgical university hospitals. Numerous scientific findings and interventional procedures have been contributed to intensive care medicine by surgeons and surgical disease symptoms shaped the character of the intensive care units. Currently 40% of the intensive care beds in Germany are assigned to surgical disciplines and surgery is the prerequisite for this operative intensive care. Nevertheless, both the human and ideational impact of surgery on intensive care medicine has decreased in recent decades. Through the formation of large interdisciplinary intensive care units, surgery continues to be threatened with losing its influence even further. Now and in the future, the role of surgery has to be the maintenance and enhancement of surgical specialized intensive care medicine. Surgery has to make surgical intensive care medicine interesting and attractive for physicians again.
Assuntos
Cuidados Críticos/tendências , Cirurgia Geral/tendências , Comunicação Interdisciplinar , Escolha da Profissão , Comportamento Cooperativo , Currículo/tendências , Previsões , Cirurgia Geral/educação , Alemanha , Hospitais Universitários , Humanos , Satisfação no Emprego , Melhoria de Qualidade/tendências , Especialidades Cirúrgicas/educação , Especialidades Cirúrgicas/tendênciasRESUMO
Morbidity and mortality conferences have been entitled the "golden hour" of surgical education. There is a long-standing tradition for these conferences in the USA and the United Kingdom. In Germany they are still not fully integrated in the daily clinical work although the positive influence on quality improvement, patient safety and surgical education has been repeatedly proven. Some factors are still hampering the establishment of M & M conferences: the lack of time, worrying about shame and blame and last not least some deficit for a culture of discussions. The commitment of surgeons in leading positions is required for the establishment and further support of -these conferences. In addition to patient safety, one of the main goals is the continuing education of young surgeons. Structuring M & M conferences as well as an intelligent moderation by an experienced surgeon and lively, open and interactive discussions - all these factors are obviously of great importance for improving success in surgery.
Assuntos
Educação Médica Continuada/organização & administração , Cirurgia Geral/educação , Capacitação em Serviço/organização & administração , Erros Médicos/prevenção & controle , Melhoria de Qualidade/organização & administração , Alemanha , Humanos , Liderança , Avaliação de Resultados em Cuidados de Saúde/organização & administração , Segurança do Paciente , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controleRESUMO
BACKGROUND: The creation of a center for interdisciplinary operative intensive care through the fusion of several smaller intensive care units from various specialties is mainly driven by economic reasons. To specify some conditions for making such a fusion less expensive and to identify the impact of larger intensive care units on the quality of patients' treatment and on surgical training are the subjects of this study. MATERIALS AND METHODS: Based on a review of the literature and on our own experience in this field, the influence of the size of the unit should be analysed not just regarding the economic aspects but also concerning the medical and surgical training issues. RESULTS: The economic advantages of scale of a larger unit are limited because of management problems when reaching a number of more than ten to twelve patients. This number probably leads to an optimal quality in medical care - especially if the patients are treated by specialists. The claim for a specific surgical training is thereby conceeded. The economical and medical advantages by connecting subunits to a larger operative intensive care unit will be achieved by economies of scale. For coordinating and running such a large unit an experienced intensive care doctor should be appointed. CONCLUSION: The concept of an interdisciplinary surgical ICU is obviously most practicable and reasonable if subunits with approximately twelve beds are concentrated in one centre for operative intensive care. This offers an advantage concerning the organisation and for the philosophy of treating special diseases by specialised medical teams. The size maintains the advantage of economies of scale as well the economies of scope and also promises effective logistics. For the management, an experienced intensive care specialist, either an anaesthesiologist or a surgeon should be assigned. All subject-specific advanced skills in intensive care have to be covered by an interdisciplinary continuing education.
Assuntos
Comportamento Cooperativo , Cuidados Críticos/tendências , Comunicação Interdisciplinar , Programas Nacionais de Saúde/tendências , Equipe de Assistência ao Paciente/tendências , Redução de Custos/tendências , Cuidados Críticos/economia , Cuidados Críticos/organização & administração , Grupos Diagnósticos Relacionados/economia , Grupos Diagnósticos Relacionados/organização & administração , Grupos Diagnósticos Relacionados/tendências , Educação Médica Continuada/tendências , Previsões , Cirurgia Geral/educação , Alemanha , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/tendências , Humanos , Programas Nacionais de Saúde/economia , Equipe de Assistência ao Paciente/economia , Equipe de Assistência ao Paciente/organização & administração , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/organização & administração , Qualidade da Assistência à Saúde/tendênciasRESUMO
Cysts of the pancreas most often develop after chronic or acute inflammation of the pancreas. Cystic neoplasia of the pancreas have been increasingly recognized in clinical practice and 90% are represented by four types: serous microcystic (SCN), mucinous cystic (MCN), intraductal papillary-mucinous (IPMN) and solid pseudopapillary (SPN) neoplasia. IPMN is the most common form nowadays and main duct and branch duct types can be differentiated by morphology. This classification is of prognostic and therapeutic relevance. While main duct IPMNs have a high risk of malignant progression and resection is therefore recommended, branch duct IPMNs have a much lower risk of harboring malignancy. Small branch duct IPMNs (<2 cm) without symptoms or mural nodules can be managed by periodic surveillance. Recently, it has become clear that IPMN constitutes a heterogeneous group with at least four subtypes. Their stratification reveals that the various subtypes of IPMN have different biological properties with different prognostic implications, but the subclassification is usually not known prior to surgery. Moreover, even differentiation between inflammatory and neoplastic cysts can be challenging. Clear indications for resection are local complications (jaundice or gastric outlet obstruction), large and increasing tumors, symptoms or secretion of mucinous fluid from the papilla of Vater.
Assuntos
Cisto Pancreático/cirurgia , Neoplasias Pancreáticas/cirurgia , Carcinoma Ductal Pancreático/diagnóstico , Carcinoma Ductal Pancreático/patologia , Carcinoma Ductal Pancreático/cirurgia , Cistadenocarcinoma Mucinoso/diagnóstico , Cistadenocarcinoma Mucinoso/patologia , Cistadenocarcinoma Mucinoso/cirurgia , Cistadenocarcinoma Papilar/diagnóstico , Cistadenocarcinoma Papilar/patologia , Cistadenocarcinoma Papilar/cirurgia , Cistadenocarcinoma Seroso/diagnóstico , Cistadenocarcinoma Seroso/patologia , Cistadenocarcinoma Seroso/cirurgia , Diagnóstico Diferencial , Humanos , Pâncreas/patologia , Pancreatectomia , Cisto Pancreático/diagnóstico , Cisto Pancreático/patologia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/patologia , PrognósticoRESUMO
Training in technical skills is essential for advanced surgical education. Training is moving more and more from the operating room to surgical training laboratories. A crucial impulse for this development came from Davos, where the first skills course was organized in 1984 after the formation of the Working Group for Gastro-intestinal (GI) Surgery (AGC Davos). Since this first course more than 5,000 residents have successfully completed the GI skills training course in Davos and many of the alumni are themselves teaching surgery today. The level and quality of this course has remained stable for 27 years on a high quality level although teaching has continuously been adjusted to modern techniques. The language of this international workshop is English. The number of applications exceeds the course capacity every year, which is an indication for the need of such training courses and should be principally included into the skills curriculum for surgeons.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/educação , Educação de Pós-Graduação em Medicina/normas , Cirurgia Geral/educação , Sociedades Médicas , Competência Clínica , Simulação por Computador , Currículo/normas , Humanos , Internato e Residência , Laparoscopia , Modelos Anatômicos , Suíça , Interface Usuário-ComputadorRESUMO
Vascular injuries are an uncommon finding. In times of peace vascular injuries occur in approximately 1-4 % during traffic accidents. Especially challenging is the treatment of open fractures combined with arterial lesions. These fractures are usually accompanied with severe soft tissue damage and injuries to neurological structures. The overall prognosis of these trauma patients is dependent on fast and sufficient diagnostics and therapy. In particular, for unstable patients time-consuming diagnostics can be dispensed and a primarily operative therapy should be targeted. Vascular reconstruction by direct suture is sometimes only possible with interposition and should be the primary goal. Interposition should be performed with autologous vein material because of the high risk of infection. Here we demonstrate on the basis of our patients the interdisciplinary -management of such trauma patients in our hospital.
Assuntos
Artérias/lesões , Fraturas Expostas/cirurgia , Lesões dos Tecidos Moles/cirurgia , Adolescente , Adulto , Idoso , Amputação Cirúrgica , Anastomose Cirúrgica , Artérias/cirurgia , Transplante Ósseo , Fixadores Externos , Extremidades/irrigação sanguínea , Feminino , Fraturas Expostas/mortalidade , Alemanha , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/mortalidade , Traumatismo Múltiplo/cirurgia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Reoperação , Lesões dos Tecidos Moles/mortalidade , Retalhos Cirúrgicos , Veias/transplante , Adulto JovemRESUMO
BACKGROUND: Skill courses for surgery offer a good but cost and personnel-intensive possibility to obtain practical and theoretical knowledge by the employment of a close teacher-pupil contact of a large group of surgeons. The goal of the study presented here was to evaluate the satisfaction and benefits of the practical course for visceral surgery in Warnemünde after 10 years of course experience. MATERIAL AND METHODS: All participants in the annual course for visceral surgery were included since 1999. During this 1-week course conventional and laparoscopic exercises are performed under direct guidance of an experienced tutor. The participants are divided into 3 groups based on their surgical experience (e.g. <3 years, 3-5 years, >5 years). All participants received a standardised questionnaire before and after successful course completion for the collection of relevant data (e.g. demography, training, surgical experience and course evaluation). RESULTS: A total of 1,062 participants (435 female, 627 male, mean age 37 years) participated in the course. The average surgical experience of the participants was 5 years. Of the participants 489 came from a hospital of basic medical care, 499 from a hospital of maximum medical care and 74 from a university hospital. Of the participants 96% had no or only little experience with skill courses (1,020 out of 1,065) and 827 participants had no or only few possibilities for training outside of the operation room (78%). The conventional part of the course was evaluated by 77% of the participants as very good and by 50% as very good for the laparoscopic part. Only 8.3% of the participants were willing to finance the costs of the course by themselves. CONCLUSIONS: The practical course for visceral surgery leads to a subjective success in learning. Participation in the course leads to a high satisfaction and offers a cost-intensive possibility for a standardised surgical training. But there are too few experiences with skill courses and possibilities for surgical training outside the operation room so far.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/educação , Educação Médica Continuada , Adulto , Atitude do Pessoal de Saúde , Currículo , Feminino , Seguimentos , Alemanha , Humanos , Laparoscopia , Masculino , Avaliação de Programas e Projetos de SaúdeRESUMO
Diabetes mellitus is a common disease among patients with pancreatic cancer and chronic pancreatitis, disorders of the exocrine pancreas. Different clinical features of diabetes are associated with these two conditions: hyperinsulinemia and peripheral insulin resistance are the prevailing diabetic traits in pancreatic cancer, whereas reduced islet cell mass and impaired insulin secretion are typically observed in chronic pancreatitis. Whether or not a causal relationship exists between diabetes and pancreatic carcinoma is an intriguing but unanswered question. Diabetes often precedes pancreatic cancer and is thus regarded as a potential risk factor for malignancy. Conversely, pancreatic cancer may secrete diabetogenic factors. Given these findings, there is increasing interest in whether close monitoring of the glycemic profile may aid early detection of pancreatic tumor lesions.
Assuntos
Complicações do Diabetes , Pancreatopatias/etiologia , Animais , Carcinoma Ductal Pancreático/complicações , Carcinoma Ductal Pancreático/metabolismo , Complicações do Diabetes/epidemiologia , Diabetes Mellitus/etiologia , Humanos , Pancreatopatias/complicações , Pancreatopatias/epidemiologia , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/metabolismo , Fatores de RiscoRESUMO
Kallikreins play an important role in tumour microenvironment and as cancer biomarkers in different cancer entities. Previous studies suggested an upregulation of KLK10 and KLK6 in pancreatic ductal adenocarcinoma (PDAC). Therefore, we evaluated the clinicopathological role of these kallikreins and their value as biomarkers in PDAC.Differential expression was validated by DNA-microarrays and immunohistochemistry in normal and malignant pancreatic tissues. Sera concentrations of both kallikreins were evaluated using ELISA. In silico analysis of possible protein interactions and gene silencing of KLK10 in vitro using siRNAs gave further insights in the pathomechanisms.Gene expression analysis and immunohistochemistry demonstrated a strong expression for KLK10 and KLK6 in PDAC. Statistical analysis showed that co-expression of these kallikreins correlated with an R1-resection status (P=0.017) and worse outcome for overall survival (P=0.031). Multivariate analysis proofed that co-expression is an independent prognostic factor for survival (P=0.043). Importantly, KLK10 knockdown in AsPC-1 cells significantly reduced cell migration, whereas computational analysis suggested interaction of KLK6 with angiogenetic factors as an important mechanism.Co-expression of KLK10 and KLK6 plays an unfavourable role in PDAC. Our results suggest that this effect is likely mediated by an interaction with the factors of the extracellular matrix and enhancement of cancer cell motility.
Assuntos
Adenocarcinoma/química , Carcinoma Ductal Pancreático/química , Calicreínas/análise , Neoplasias Pancreáticas/química , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/patologia , Linhagem Celular Tumoral , Movimento Celular , Proteínas do Olho/fisiologia , Perfilação da Expressão Gênica , Inativação Gênica , Humanos , Imuno-Histoquímica , Calicreínas/genética , Calicreínas/fisiologia , Fatores de Crescimento Neural/fisiologia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Prognóstico , Serpinas/fisiologiaRESUMO
Familial tumors of the gastrointestinal tract, which often appear as autosomal-dominantly inherited tumor syndromes, account for only a small proportion of all gastrointestinal tumors. With the opportunities of modern molecular diagnostics, identifying the pathogenic mutation in families is often possible, with the option of predictive molecular testing and differentiation between mutation carriers and noncarriers. Thus a good chance exists for detection of early tumor stages by individually tailored surveillance programs and for improving prognosis by early intervention and prophylactic resection. Clinical manifestation, molecular basis at the root, individual surveillance programs, and their consequences for the treatment of familial gastric cancer, familial adenomatous polyposis coli, hereditary nonpolyposis colorectal cancer, Peutz-Jeghers syndrome, juvenile polyposis, hyperplastic polyposis, and familial pancreatic cancer are presented.
Assuntos
Síndromes Neoplásicas Hereditárias , Polipose Adenomatosa do Colo/diagnóstico , Polipose Adenomatosa do Colo/genética , Polipose Adenomatosa do Colo/cirurgia , Adolescente , Adulto , Idoso , Criança , Colonoscopia , Neoplasias Colorretais Hereditárias sem Polipose/diagnóstico , Neoplasias Colorretais Hereditárias sem Polipose/genética , Neoplasias Colorretais Hereditárias sem Polipose/cirurgia , Feminino , Gastrectomia , Humanos , Masculino , Pessoa de Meia-Idade , Síndromes Neoplásicas Hereditárias/diagnóstico , Síndromes Neoplásicas Hereditárias/genética , Síndromes Neoplásicas Hereditárias/cirurgia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/cirurgia , Síndrome de Peutz-Jeghers/diagnóstico , Síndrome de Peutz-Jeghers/genética , Síndrome de Peutz-Jeghers/cirurgia , Guias de Prática Clínica como Assunto , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/genética , Neoplasias Gástricas/cirurgiaRESUMO
BACKGROUND/AIMS: The advent of contrast-enhanced ultrasound (CEUS) has called into question the efficacy of standard ultrasonographic techniques. In this study, we evaluated B-mode and color-duplex imaging and CEUS in the detection of liver metastases, using intraoperative and histological findings as a reference. MATERIALS AND METHODS: Before laparotomy, 108 patients suspected of having liver metastases were prospectively examined with B-mode and color-duplex imaging, followed by contrast-enhanced ultrasound (2.4 ml SonoVue). Patients with unresectable tumors (n=8) were excluded from the analysis. The sonographic diagnosis in the remaining 100 patients was compared to the intraoperative and histological findings. RESULTS/FINDINGS: CEUS improved the sensitivity for detecting liver lesions from 56.3% (B-mode) to 83.8% (CEUS) (p=0.004). In particular, the contrast agent led to an improvement in ultrasonographic detection in the following cases: nodular metastases smaller than one centimeter; after adjuvant chemotherapy; for tumors near the surface of the liver; and for lesions situated around the ligamentum teres. INTERPRETATION/CONCLUSIONS: CEUS provides significant improvement in the detection of liver metastases, and should therefore, be performed routinely in the surveillance of cancer patients.
Assuntos
Meios de Contraste , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/secundário , Fosfolipídeos , Hexafluoreto de Enxofre , Ultrassonografia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeRESUMO
Pancreatic ductal adenocarcinoma (PDAC) is a fatal disease and one of the cancer entities with the lowest life expectancy. Beside surgical therapy, no effective therapeutic options are available yet. Here, we show that 4-phenylbutyrate (4-PB), a known and well-tolerable inhibitor of histone deacetylases (HDAC), induces up to 70% apoptosis in all cell lines tested (Panc 1, T4M-4, COLO 357, BxPc3). In contrast, it leads to cell cycle arrest in only half of the cell lines tested. This drug increases gap junction communication between adjacent T3M-4 cells in a concentration-dependent manner and efficiently inhibits cellular export mechanisms in Panc 1, T4M-4, COLO 357 and BxPc3 cells. Consequently, in combination with gemcitabine 4-PB shows an overadditive effect on induction of apoptosis in BxPc3 and T3M-4 cells (up to 4.5-fold compared to single drug treatment) with accompanied activation of Caspase 8, BH3 interacting domain death agonist (Bid) and poly (ADP-ribose) polymerase family, member 1 (PARP) cleavage. Although the inhibition of the mitogen-activated protein kinase-pathway has no influence on fulminant induction of apoptosis, the inhibition of the JNK-pathway by SP600125 completely abolishes the overadditive effect induced by the combined application of both drugs, firstly reported by this study.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/farmacologia , Carcinoma Ductal Pancreático/tratamento farmacológico , Comunicação Celular/efeitos dos fármacos , Junções Comunicantes/efeitos dos fármacos , Inibidores de Histona Desacetilases , Neoplasias Pancreáticas/tratamento farmacológico , Fenilbutiratos/farmacologia , Antracenos/farmacologia , Apoptose/efeitos dos fármacos , Caspase 8/metabolismo , Ciclo Celular/efeitos dos fármacos , Linhagem Celular Tumoral , Proliferação de Células/efeitos dos fármacos , Desoxicitidina/análogos & derivados , Desoxicitidina/farmacologia , Relação Dose-Resposta a Droga , Resistencia a Medicamentos Antineoplásicos/efeitos dos fármacos , Ensaios de Seleção de Medicamentos Antitumorais , Sinergismo Farmacológico , Ativação Enzimática/efeitos dos fármacos , Humanos , Fatores de Tempo , Células Tumorais Cultivadas , GencitabinaRESUMO
HISTORY AND CLINICAL FINDINGS: A 55 year old female patient was diagnosed because of painless jaundice and weight loss. She had undergone conventional cholecystectomy 15 years before. INVESTIGATIONS: Bilirubin level before ERCP and stent implantation was 287 micromol/l at maximum. A subtotal stenosis was found in the proximal common hepatic duct. Endosonographically, a mass of 14 mm diameter was seen. She was suspected of having a Klatskin tumour Bismuth type II. Tumour markers (CEA, CA19-9) were within normal ranges. TREATMENT AND COURSE: One month after stent implantation open surgery was performed suspecting a malignant tumour of the bile duct. A solid tumour at the hepatic bifurcation was resected completely. Reconstruction was performed by hepatico-jejunostomy was formed and the blind end of the jejunum was anastomosed to the gastric antrum to form an "access loop". Upon histological analysis no malignancy was found. However, a distinct fibrosis within the suspicious area was seen, formed around braided suture material. CONCLUSION: Preoperative distinction between benign and malignant bile duct stenosis can be difficult, even impossible. Thus, every resectable bile duct tumour should undergo surgery even and especially if a histological diagnosis cannot be reached preoperatively and the condition of the patient is adequate.
Assuntos
Colestase/etiologia , Colestase/cirurgia , Ducto Colédoco/patologia , Ducto Colédoco/cirurgia , Stents , Anastomose Cirúrgica/métodos , Neoplasias dos Ductos Biliares/diagnóstico , Neoplasias dos Ductos Biliares/patologia , Bilirrubina/sangue , Colecistectomia , Colestase/patologia , Diagnóstico Diferencial , Feminino , Fibrose , Ducto Hepático Comum , Humanos , Icterícia , Jejuno/cirurgia , Tumor de Klatskin/diagnóstico , Tumor de Klatskin/patologia , Pessoa de Meia-Idade , Antro Pilórico/cirurgia , Resultado do Tratamento , Redução de PesoRESUMO
The complete rotation of the gall bladder followed by acute inflammation is a very rare and dangerous event. Volvulus of the gall bladder almost seems to be caused by an abnormal motility of this organ. Because of the rarity of this disease, the preoperative diagnosis frequently is correct. With this report of three cases who had laparoscopic or conventional surgery within a period of 7 years at our department, the peculiarity of this disease is demonstrated.
Assuntos
Antibacterianos/administração & dosagem , Colecistectomia Laparoscópica , Colecistite/cirurgia , Emergências , Doenças da Vesícula Biliar/cirurgia , Doença Aguda , Idoso de 80 Anos ou mais , Colecistite/diagnóstico , Edema/diagnóstico , Edema/cirurgia , Feminino , Vesícula Biliar/patologia , Doenças da Vesícula Biliar/diagnóstico , Cálculos Biliares/cirurgia , Humanos , Masculino , Necrose , Tomografia Computadorizada por Raios X , Anormalidade Torcional , Falha de Tratamento , UltrassonografiaRESUMO
AIM: Evaluation of b-mode and colour-duplex imaging, contrast-enhanced ultrasound (CEUS) and CT for the detection of liver lesions in comparison to intraoperative and histological findings. METHODS: Before laparotomy, 100 patients with suspected liver lesions were prospectively examined with b-mode and colour-duplex imaging followed by contrast-enhanced ultrasound (SonoVue) and CT-scan. Patients with nonresectable tumours (n=44) were excluded from the analysis. The diagnostic findings of 56 patients who displayed liver lesions were compared to the intraoperative and histological findings. RESULTS: CEUS enhanced the sensitivity for the number of detected lesions from 53 % (b-mode) to 86 % (CEUS) (p = 0.001), while CT-scan reached 76 %. The specificity of the three methods differed only slightly (87 % to 89 %). Contrast agents lead to an improvement in the results of ultrasound, particularly in cases of nodular metastases smaller than one centimeter (n = 7), after adjuvant chemotherapy (n = 4), near the surface (n = 6) and in lesions situated around the Lig. teres (n = 6). CONCLUSIONS: CEUS leads to a significant improvement in the detection of liver lesions. For patients after adjuvant chemotherapy as well as for cases of small nodular metastases a CEUS should be carried out as a routine.