Cancer of the rectum--palliative endoscopic treatment.

Three methods of palliative endoscopic treatment of malignant strictures of the rectum are presented: laser therapy and its combination with the implantation of either plastic prostheses, or self-expanding metal stents. The aim of all procedures is to avoid a colostomy at least in older patients with shorter life expectancy and incurable tumours. The additional application of a stent maintains the luminal patency and prevents the repetition of laser therapy. Since 1988 we have treated 60 patients with these techniques. First, two to six sessions of laser therapy were necessary for recanalization of the stenosis. In the time following this the patients returned two to eight times for regular laser therapy before they died from the carcinoma. In spite of laser therapy one patient developed an obstruction and another suffered from an iatrogenic perforation of the rectal cancer. In both cases a stoma was fashioned. To avoid repetitive laser sessions we successfully inserted a plastic endoprosthesis in seven cases. In another two cases the implantation failed because of perforation and the patients had to undergo surgery. For the next 10 cases we have used flexible self-expanding metal stents. Serious complications or signs of re-obstruction were not observed until the patients' death. The survival time ranged from 2 to 25 months.

Postprandial bile-duct kinetics under the influence of 4-methylumbelliferone (hymecromone).

The physiological correlate of biliary colic is a rapid increase in pressure in the presence of biliary obstruction. The relaxing action of hymecromone on the biliary tract provides a pharmacotherapeutic approach. As the symptoms usually occur postprandially we used ultrasonography to examine whether hymecromone was able to reverse the contraction of the common bile duct (CBD) after ingestion of a standardized test meal. The study was designed as prospective, double-blind randomized crossover study versus placebo in 20 healthy volunteers. The width of the CBD was measured ultrasonographically in the fasting subjects and at 1, 3, 5, 10, 15 and 20 minutes after ingestion of a test meal. Then the subjects were given either 400 mg of hymecromone or placebo and the measurement series was repeated. After ingestion of the test meal the width of the CBD decreased by a maximum of 20% after 15 minutes. While there was only a slight increase in the width of the CBD after subsequent administration of placebo, a maximum increase of 36% was measured 10 minutes after administration of hymecromone. The postprandial contraction of the CBD can be reversed within a short time by i.v. administration of hymecromone.

Laparoscopic fluorometry: a new minimally invasive tool for investigation of the intestinal microcirculation.

The aim of this study was to develop and establish a new system of laparoscopic fluorometry for the purpose of investigating the intestinal microcirculation. In 25 pigs (German Landrace, 16-25 kg body weight), ischemia was established in two segments (A, irreversible; B, reversible ischemia; C, internal control) of the small intestine by a laparoscopic technique. Microcirculation in the segments was assessed by laparoscopy at a second-look operation 24 h later by means of the fluorescence system Endoscan. The fluorescence of the three bowel segments was measured by arbitrary dye fluorescence units (DFU) 15 min after starting reperfusion, before and after injection of sodium fluorescein (NaFlu, 0.25 mg/kg body weight). The dividing line between viable and nonviable bowel tissue was established from the inflow and outflow rates of NaFlu with the aid of ROC (receiver operating characteristic) curves. The specificity and sensitivity of the new method were evaluated by correlating the results with the viability of each intestinal segment as predicted by three laparoscopically experienced surgeons and by histological examination. By means of the calculated separation sharpness (fluorescence index at 2 min >0.5, outflow factor of NaFlu at 10 min >20%), the overall predictions of intestinal viability in all 25 animals achieved a sensitivity of 93.5% and a specificity of 94.1% by laparoscopic fluorometry, versus a sensitivity of 70.8% and a specificity of 87.5% for the prediction of bowel viability by ordinary laparoscopic technique. Used as an adjunct to conventional laparoscopy, laparoscopic fluorometry brought significant gains in sensitivity and specificity in the distinction between reversible and irreversible intestinal ischemia.

Temperature controlled angioplasty (preliminary results in heritable hyperlipidemic rabbits).

The purpose of this investigation has been to demonstrate the safety of temperature controlled angioplasty (TCA) with a coaxial heating element, particularly during heat application, and to ascertain the short- and long-term arterial tissue response in 7 month old homozygous Heritable Hyperlipidemic rabbits. In 7 animals, a defined segment of the abdominal aorta was treated with TCA for 40 seconds at 175 degrees C, and 2 animals served as untreated controls. At sacrifice, 1 day, 1 and 2 weeks after TCA, in one animal each a coagulation necrosis with condensation of elastic fibers was found. One year later, 1 of 2 animals revealed irregularly structured elastic fibers combined with only minor atherosclerotic lesions. Treated segments of the second animal and of the 2 remaining animals 2 years after TCA did not appear to differ from the control segments. In conclusion, the TCA never resulted in perforation or carbonization or in adhesion of the heating element to the vascular wall, representing a safe angioplastic technique.

[Aortofemoral bypass and extensive profunda-plasty in combined arterial occlusive disease of the pelvic-femoral type--a stage oriented analysis]. / Aortofemoraler Bypass und ausgedehnte Profundaplastik bei der kombinierten arteriellen Verschlusskrankheit vom Becken-Oberschenkeltyp--eine stadienorientierte Analyse.

121 patients with multilevel, lower extremity arterial occlusive disease were treated by aortofemoral reconstruction and extended profundoplasty. Early and late results of 201 limbs were analyzed according to their preoperative grade of ischemia. In the case of moderate claudication the success rate was 43% postoperatively and 81% after 5 years. When having severe claudication the success rate was 62% and 79% after 5 years. The revascularisation of the deep femoral artery helps developing the collateral arteries, responsible for an improvement after a considerable period of time. In limbs with rest pain we got a success rate of 78% postoperatively and 76% after 5 years. In the case of gangrene the primary success rate was 40% and 68% after 5 years. Angiographically, severe arteriosclerotic lesions were documented in the deep femoral artery and popliteal artery when limb-threatening ischemia was present. Nevertheless, the combined aortofemoral and extended deep femoral artery reconstruction was efficient in treating the multilevel occlusive disease; subsequent femoro-distal bypass was necessary only in case of threatening ischemia for 9.3% of limbs. Our findings show there is no indication for simultaneous aortofemoral and femoro-distal bypass grafting in the treatment of the multilevel disease.

[Pump-assisted intraoperative colon lavage]. / Pumpenassistierte intraoperative Colonlavage.

We report about a time saving method of on-table lavage of the colon. For irrigation a balloon-catheter is inserted into the colon through a small caecotomy. This catheter is connected to an irrigation pump which we usually use for abdominal lavage in peritonitis. After mobilisation the oral end of the later colonic anastomosis is led over the lateral abdominal wall into a plastic tube. Now a continuous irrigation with a controlled flow-rate of 1 l/min is achieved with the aid of the lavage pump. As irrigation liquid we use Ringer's solution. Pressure is limited by an overflow mechanism. In addition after rearrangement the high irrigation flow of the system allows a thorough cleansing of the rectal stump. Between 1992 and 1995 we carried out intra-operative colonic irrigation using the method set out above in 24 patients. The average volume was 8.9 l of Ringer's solution. The irrigation itself lengthened the operation time by an average of 10 min.

[Changes of the acid-base status, serum lactate concentration and purine metabolism in reconstructive arterial surgery]. / Veränderungen im Säure-Basen-Status, der Serum-Lactat-Konzentration und im Purinstoffwechsel bei arteriellen Gefässrekonstruktionen.

Hypoxic damages are normally determined by acid-base status as well as lactate and pyruvate levels. Since several other illnesses lead also to raised levels of these parameter, they are not specific for tissue hypoxia. In animal experiments it was shown that purine metabolites, especially hypoxanthine, are a very exact indicator for hypoxia. To test its validity in clinical situations the changes in acid-base status, lactate, pyruvate and purine metabolism were measured in 17 patients undergoing reconstructive aortic surgery. Blood samples were taken just before and after declamping of the aorta systemically and from the femoral vein. After declamping especially the systemic hypoxanthine levels increased 3 fold, due to a 20 times higher hypoxanthine concentration in the femoralis vein. The concentration changes of hypoxanthine in percent correlated very good with the aorta clamping time (R = 0,85). The changes in acid-base status and lactate levels were erratic and showed no correlation with the duration of ischemic period. Systemic hypoxanthine concentrations are a more specific and reliable parameter for hypoxic damages.

[Primary gastrointestinal lymphomas]. / Primäre gastrointestinale Lymphome.

From 1980 up to 1987 seven patients with primary gastrointestinal lymphoma were treated at the surgical department of the Medical University of Lübeck; six of them were women. The mean age was 73.3 years. The tumors were located in the stomach (4), the large bowel (2) and the small intestine (1), representing disease at Ann-Arbor-stage IE (5) and IIE (2). All patients underwent primary surgery, except one due to his bad general conditions. Irradiation-therapy followed in one case, chemotherapy in two cases when relapse of disease was revealed. Three patients are still alive (0.8 to 6.8 years) without evidence of recurrent lymphoma. The success of surgery as a curative treatment is closely related to the stage of disease; both are important factors influencing prognosis. Surgery is still necessary for diagnosis, tumor-staging and prevention of regional complications as bleeding or perforation, especially when conservative therapy is performed.

[Is the thyroidectomy a surgical standard procedure for therapy of Graves' disease?]. / Stellt die Thyreoidektomie ein Standardverfahren zur Behandlung des Morbus Basedow dar?

Surgery is an important therapeutic option in the treatment of Graves' disease. Nevertheless it is still controversial discussed wether the extent of resection correlates with the rate of surgical complications and the therapeutic success. Therefore we performed a retrospective analysis on 75 surgically treated patients. 58 of these 75 patients were examined after a median interval of 34.2 months. The examination focussed on the appearance of temporary and permanent palsy of the recurrent laryngeal nerve, hypoparathyroidism, recurrences, and on the postoperative course of thyroid-stimulating-hormone-receptor antibody (TSH-ab) titers. Total thyroidectomy has been performed in 51 and bilateral resection with a remnant thyroid volume less than 2 ml each side in 24 patients. We could not confirm a significant difference concerning the postoperative complication rates between both groups. In the bilateral resection group we saw 3 cases of recurrent goitre and a more unfavourable course of TSH-ab titers than in the thyroidectomy group. For these reasons we propose the total thyroidectomy as surgical standard procedure for therapy of Graves' disease.