[Reconstruction of the Bile Duct with the Umbilical Vein after Laparoscopic Cholecystectomy]. / Gallengangsrekonstruktion mittels Umbilikalvene nach laparoskopischer Cholezystektomie.

Background: Roux-Y hepaticojejunostomy is currently the standard surgical procedure for the reconstruction of the bile duct after iatrogenic transection in laparoscopic cholecystectomy. However, about 30 % of all hepaticojejunostomies develop a stenosis after some time and in 7 % a cholangiocellular carcinoma occurs. Therefore, alternative procedures have been investigated. Patients: Between September 2009 and October 2013 an iatrogenic bile duct lesion was treated in 6 consecutive patients by using the pedicled umbilical vein. The median follow-up period was 16 months. Methods: In 3 cases, the bile duct lesion was detected during cholecystectomy and reconstructed in the same session. In the other 3 cases, the reconstruction was performed between the fourth and the seventh day after cholecystectomy. The pedicled umbilical vein was used as a patch in 4 cases and as an interposition graft in the other 2 cases. Results: Two out of 6 patients suffered from cholangitis after bile duct reconstruction, which was brought to complete remission by temporary endoscopic dilatation treatment. Conclusion: The use of the pedicled umbilical vein is a new surgical option for the treatment of iatrogenic bile duct lesions and seems to provide advantages over hepaticojejunostomy regarding the development and treatment of anastomotic stenosis and the risk of cholangiocellular carcinoma.

Results of a randomised controlled trial between an ORC collagen hemostatic agent and a carrier-bound fibrin sealant.

INTRODUCTION: Despite ongoing optimisation of surgical techniques, hemostasis continues to be a fundamental challenge in many operations today. This randomised controlled trial compared the efficacy of a new hemostatic agent made of oxidised regenerated cellulose and collagen (ORC-Coll) with that of a conventional carrier-bound fibrin sealant (CBFS). METHODS: Hemostasis was investigated representatively in the case of post-thyroidectomy bleeding from the resection surface. To demonstrate that ORC-Coll (mediCipio® A) has at least the same hemostatic efficacy as CBFS (Tachosil®), the volume of drainage fluid at the time of drain removal was used as the primary endpoint in a non-inferiority test with a significance level of 5%. The secondary endpoints included number and size of hemostatic agents required, adhesion of the hemostatic agent to the bleeding surface, intraoperative hemostatic effect, duration of drainage and adverse events during a six-month follow-up period. RESULTS: A total of 150 patients (ORC-Coll: 75; CBFS: 75) were included. After operation, total volume of drainage fluid was 68.20±44.56mL in the ORC group and 68.21±40.20mL in the CBFS group. The non-inferiority of ORC-Coll compared to CBFS with regard to hemostatic efficacy was shown at a significance level of 5%. The results demonstrated effectiveness in achieving hemostasis without adverse events. CONCLUSIONS: ORC-Coll is an effective hemostatic agent and barrier sealant without blood components, which ensures reliable prevention of intra- and postoperative bleeding. With use of the new technique, any risks associated with the use of human blood components are a priori eliminated.

A phase I trial of interferon alpha-2b with folinic acid and 5-fluorouracil administered by 4-hour infusion in metastatic colorectal carcinoma.

Preclinical data suggest that both folinic acid and interferon may enhance the efficacy of 5-fluorouracil (5-FU) in colorectal carcinoma. We therefore initiated a phase I trial evaluating the doses, safety, and pharmacokinetics of the combination of recombinant interferon (IFN) alpha-2b with folinic acid (FA) and 5-FU. Seventeen patients with colorectal cancer who failed local chemotherapy received 5-FU as a 4-hour infusion, preceded by a bolus of FA and IFN. The 5-FU dose was escalated over the range of 400 to 650 mg/m2/d for a period of 7 days. Folinic acid was administered as a bolus in a fixed dose of 200 mg/m2/d and IFN as 5 million U/d subcutaneously on days 1 to 7. A total of 89 courses of therapy were completed for the 17 patients, of which there were 10 paired courses with a combination of 5-FU and IFN or 5-FU alone, being performed to analyze the pharmacokinetics and modulation of 5-FU by IFN. The maximum tolerated dose of 5-FU using this combination and a 4-hour schedule was 600 mg/m2/d for 7 days. The dose-limiting toxicity of this regimen was diarrhea. Mucositis and myelosuppression was not a marked problem at dose levels of 400 and 500 mg/m2/d for 7 days. However, at a dose level of 600 to 650 mg/m2/d for 7 days, grade 3 and 4 (WHO) leukopenia occurred in 50% and mucositis occurred in 33%. At a given dose of 5 million U, IFN did not significantly influence 5-FU serum levels. Mean steady-state serum levels of 5-FU at 500 mg/m2 given as a 4-hour infusion were 16.55 +/- 9.34 mumol/L and 18.23 +/- 12.77 mumol/L with and without IFN, respectively. Mean area under the curve (mumol/L x min) was 4,008 +/- 2,133 and 5,114 +/- 2,567 with and without interferon, respectively. Objective responses were seen in one of 17 of these heavily pretreated patients and stable disease was seen in seven of 17 patients. The recommended dose of 5-FU for use of phase II studies is 500 mg/m2/d for 7 days. We conclude that the toxicity of 5-FU plus FA with and without IFN alpha-2b can be reduced by using a 4-hour infusion instead of a bolus.

A phase II trial of interferon alpha-2b with folinic acid and 5-fluorouracil administered by 4-hour infusion in metastatic colorectal carcinoma.

Preclinical data suggest that folinic acid as well as interferon alpha-2b may enhance the antitumor activity of 5-fluorouracil (5-FU). In a phase I trial, we recently showed that interferon alpha-2b (IFN), folinic acid and 5-FU can be safely administered with a 4-hour infusion of 5-FU. We therefore initiated a phase II trial evaluating the efficacy and safety of these three drugs. Forty-five evaluable patients with advanced metastatic colorectal cancer, documented progressive disease, and previously unexposed to chemotherapy were treated with sequential IFN 5 MU/d subcutaneously and folinic acid 200 mg/m2/d as bolus on days 1 to 7 followed by 5-FU in a 4-hour infusion at a dose of 500 mg/m2/d, resulting in a total dose of 3,500 mg/m2/course. This schedule was repeated on day 21. A total of 204 courses of therapy were completed. One of 45 patients (2%) achieved a complete response, and 13 of 45 patients (29%) achieved a partial response. An additional 16 patients (36%) had stable disease. The median time to disease progression was seven months (2 to 24 months). Despite the relatively high-dose intensity of 5-FU, toxicity was very mild. Grade 3 or 4 myelosuppression, stomatitis, and nausea/vomiting occurred in only three of 45 patients (7%). Four of 45 patients (9%) suffered from severe (grade 3/4) diarrhea. Neurotoxicity and infections of grade 2 to 4 did not occur. From these data we conclude that modulation of 5-FU with both folinic acid and IFN induces an overall response rate of 31% in disseminated colorectal cancer. Using a 4-hour application schedule of 5-FU, the therapeutic index can be improved even for high-dose intensity and requires further evaluation in combination with other modulators.

Combined haemoperfusion, haemofiltration and haemodialysis for systemic detoxification in locoregional 5-fluorouracil therapy.

Combined haemoperfusion, haemofiltration and haemodialysis (HPFD) was examined for its systemic effect on 5-fluorouracil (5-FU) kinetics after locoregional application to one female patient with liver metastases of a colon carcinoma. During each HPFD treatment, which lasted 4 h, 5-FU was given via a port-a-cath system into the hepatic artery on 4 separate days. The HPFD extraction rate was 99%. Extracorporal 5-FU clearance (89 ml/min) was 9% of total body clearance (1094 ml/min). The fraction eliminated within 4 h was only 6% of the applied dose (3500-4000 mg 5-FU). Sufficient extracorporal detoxification during combined HPFD can thus not be guaranteed in locoregional chemotherapy with a high dose of 5-FU.

Surgical therapy of gastrointestinal non-Hodgkin's lymphomas.

Within a period of 13 years 39 patients underwent surgery for primary gastrointestinal non-Hodgkin's lymphoma. The stomach was the most frequent site of involvement (26 cases) followed by the small intestine (10 cases) and the large bowel (three cases). Operative procedures included: total gastrectomy (n = 19), subtotal gastrectomy (n = 5), partial gastrectomy (n = 2), small bowel resection (n = 7), right hemicolectomy (n = 5) and sigmoid resection (n = 1). According to Musshoff's modification of the Ann Arbor system, we found stage I in nine, stage II in 12, stage III in two and stage IV in 16 patients. Histological typing according to the Kiel classification showed low-grade malignancy in 11 cases and high-grade in 28. Twenty-eight patients received chemotherapy and/or radiation in accordance with the tumour staging and type of malignancy. The follow-up data were analysed by the method of Kaplan and Meier. Including five patients who died post-operatively from perforated or bleeding lymphomas, the overall 5-year survival rate was 53.8%.

Multicenter pilot study of 5-fluorouracil, folinic acid, interferon alpha-2b and degradable starch microspheres via hepatic arterial infusion in patients with nonresectable colorectal liver metastases.

BACKGROUND: It is necessary to establish therapeutic regimens for patients with nonresectable hepatic metastases of colorectal carcinoma. A new regional chemotherapy regimen was tested in a prospective study in three centers. PATIENTS AND METHODS: An arterial port system was implanted in 95 patients. From January 1994 to March 1999, intra-arterial treatment was applied via the hepatic artery using 450 mg starch microspheres with 5 million IU recombinant interferon-alpha 2B, 500 mg/m2 folinic acid and 600 mg/m2 5-FU body surface for 5 days with a 14-day interval. RESULTS: The tumor response rate was 70%. Median disease progression was 17 months, median survival 24 months. The subgroup analysis shows a significant advantage (p<0.00001) for patients with a liver tumor involvement of <25% and a median survival of 39 months compared to a tumor involvement of 25-50% (24 months) and >50% (14 months). Major toxicity problems were observed in 11%. However, there was no termination of therapy on account of these problems. CONCLUSION: Intra-arterial chemotherapy with our new regimen was useful in patients with colorectal liver metastases who had only an intrahepatic tumor burden of <50%.

[Diagnosis of deep venous thrombosis of the leg using color-coded duplex sonography]. / Diagnostik der tiefen Beinvenenthrombose mit der farbkodierten Duplexsonographie.

One hundred and twenty-nine lower limbs in 103 patients with suspected deep leg vein or pelvic vein thrombosis were examined by colour-coded duplex sonography and the results compared with phlebography. The deep veins could be demonstrated from the popliteal to the distal external iliac vein and internal structure and blood-flow could be evaluated. The procedure can diagnose not only occluding thrombus, but also thrombus with surrounding blood flow and post-thrombotic changes. Fresh venous thromboses can be recognised with a sensitivity of 96% and a specificity of 97%. Colour-coded duplex sonography is a simple, rapid and reliable method in all patients with suspected deep vein thrombosis. Our experience suggests that it can replace phlebography for the above-mentioned venous territories and problems.

Treatment and prevention of amputation neuromas in hand surgery.

We tried to solve the problem of postamputation neuroma formation by a new operative procedure: the technique of centro-central nerve union with autologous transplantation. The results found in animal experiments corresponded with our clinical experience. Although we carried out this procedure in hand surgery only, we feel there is no reason for not recommending this operation as a routine procedure in all amputations.

[The fully implantable minimally invasive hepatic artery catheter for locoregional chemotherapy of nonresectable liver metastases in defective conventional implanted therapy catheters]. / Der vollimplantierbare minimal-invasive Arteria hepatica-Katheter zur locoregionären Chemotherapie nicht-resektabler Lebermetastasen bei Defekten von konventionell implantierten Therapiekathetern.

Dysfunction of arterial access devices used in association with intra-arterial chemotherapy for the treatment of unresectable liver metastases usually requires stopping the therapy or relaporotomy and reimplantation of a new arterial catheter. In this article our initial experience of a new technique, the so-called MIAH catheter (minimally invasive hepatic artery catheter) in 36 patients (age 37-78 years) are reported. The MIAH catheter was percutaneously inserted into the subclavian artery under sonographic guidance and advanced via the descending aorta selectively into the hepatic artery. Finally it was connected to a totally implantable pump. There were no deaths related to the operation. Operative or early complications occurred in 5 cases (13.8%); late complications were seen in 13 patients (36.1%). Nevertheless continuation of intra arterial chemotherapy was possible in all cases. In cases of dysfunction of conventional arterial access devices the MIAH catheter makes it possible to continue intra-arterial chemotherapy without requiring laporotomy.

[Hidradenitis suppurativa--treatment with myocutaneous island flap or the traditional method]. / Hidradenitis suppurativa--Behandlung mit myokutanem Insellappen oder herkömmlicher Methode.

Inflammations of the apocrine sweat glands are characterized by painful, nodose and often superficially phlogistic infiltrates with a tendency towards abscess-formation and fistulation. These foci of inflammation are situated particularly in the armpit as well as the anal and genital region. The failure of conservative therapy--e.g., application of antibacterial ointments, red light, short-wave therapy or irradiation--is followed by a surgical intervention which involves excising the abscess cavity and leaving the wound open for secondary closure by granulation. The resultant scar is an impairment both functionally and cosmetically, particularly in the axilla; and, in many cases, a new focus of inflammation eventually develops in the immediate vicinity. For multiple occurrence of sudoriparous abscesses in the axilla with undermining of the surrounding cutaneous soft tissue mantle and fistulation, we therefore suggest the following therapeutic concept as an alternative to conventional methods: radical removal of the focus of inflammation far into the healthy tissue with concomitant excision of all sweat glands in the affected area and coverage of the resultant defect with a partial myocutaneous island flap from the latissimus dorsi muscle.

[Intrathoracic hemorrhage of the intra-abdominal organs following diaphragmatic rupture. A rare cause of hemothorax]. / Intrathorakale Blutung aus intraabdominellen Organen nach Zwerchfellruptur. Eine seltene Ursache des Hämatothorax.

After posttraumatic diaphragm ruptures in some cases life threatening haemorrhages from intraabdominal organs (especially from the spleen) into the thorax were found. In general, the diagnosis cannot be established by peritoneal lavage or abdominal sonography. And in case of emergency, there is often not enough time to obtain a computed tomography. It is therefore extremely important for the patient's prognosis that the surgeon initially performing treatment be aware of this cause of bleeding. Correct interpretation of the chest x-ray, for instance in the case of stomach air in a left basal shadow above the diaphragm, can confirm the suspicion, and the urgently required operation can be performed in time.

[Combined regional chemotherapy and radiotherapy of liver metastases]. / Kombinierte reginale Chemotherapie und Strahlenbehandlung bei Lebermetastasen.

In an attempt to treat patients with non-resectable liver metastases more effectively, hepatic arterial chemotherapy (12 g 5-FU in 3 weeks) was combined with simultaneous whole liver irradiation (8 Gy every week, total dose of 24 Gy). 54 of the 64 patients receiving this treatment had liver metastases from colorectal carcinoma. The objective response rate, judged by CAT scan, was nearly 60%. The median survival of responders was 18 months in contrast to 8 months for nonresponders. There have been 5 lethal complications, 3 of which were related to the combined modality. For safer and better results a more exact selection is needed.

[Therapeutic protocols in the treatment of liver metastases]. / Therapiestrategien zur Behandlung von Lebermetastasen.

The liver is the main site for metastatic spread from many cancer, particularly those of the colorectum. Surgical treatment of liver metastases is nowadays a safety therapeutical approach, which has been improved by the development of modern imaging procedures, clear indications and standardized surgical techniques. In carefully selected patients the 5-year survival ranges between 30-40%. Unfortunately only 20% of the patients with liver metastases are candidates for this potentially curative therapy. Palliative modalities remain for the majority of patients with unresectable metastases limited to the liver. Although various types of intrahepatic arterial chemotherapy, sometimes in combination with whole liver irradiation or embolization shows a higher response rate than systemic chemotherapy no significant impact on survival time has been proven. One of the main unsolved problem is the extrahepatic spread. For getting better results--median survival of responders ranges between 18 to 24 months versus 8 months of non-responders--a more exact selection is needed.

[Characteristics of appendicitis in patients over 70 years of age]. / Die Besonderheiten der Appendizitis jenseits des 70. Lebensjahres.

Chart review of our patients who were operated for acute appendicitis was performed to characterize the appendicitis in the elder patients. Celiotomy revealed perforation of the appendix in almost 40%, frequently in patients with unspecific symptoms and no leucocytosis. While mortality was 9.2% in the ninteeneighties, non of our patients died during the last 5.5 years. This might be attributed to emergency operation, improved anaesthesia and intensive medical care.

[Surgical and oncologic principles of the removal of the rectum]. / Chirurgische und onkologische Prinzipien der Rektumamputation.

Excision of the rectum should take in account that the main lymphatic spread follows the cranial route and that dissection of the rectal wall should be performed across its adjacent anatomical lamellae. It is not clear whether an extensive pelvic dissection and high ligature of the inferior mesenteric artery are beneficial. Spontaneous or iatrogenic perforation of the tumour considerable increases the incidence of local recurrence. The frequency of postoperative urinary and sexual dysfunction ranges from 3.5-57% and 14-38% respectively. The reported surgical mortality averages 5-6%.