Leukotriene synthesis by human gastrointestinal tissues.

The prostaglandin and leukotriene synthesizing capacity of human gastrointestinal tissues obtained at surgery was investigated using radioimmunoassay for prostaglandin E2, leukotriene B4 and sulfidopeptide leukotrienes. The leukotriene immunoassay data were validated by high-pressure liquid chromatography (HPLC). During incubation at 37 degrees C, fragments of human gastric, jejuno-ileal and colonic mucosa released considerably larger amounts of prostaglandin E2 than of leukotriene B4 and sulfidopeptide leukotrienes. Gastrointestinal smooth muscle tissues released even larger amounts of prostaglandin E2, but smaller amounts of leukotrienes than the corresponding mucosal tissues. Adenocarcinoma tissue released larger amounts of leukotriene B4, sulfidopeptide leukotrienes and prostaglandin E2 than normal colonic mucosa. Ionophore A23187 (5 micrograms/ml) did not stimulate release of prostaglandin E2 from any of the tissues investigated, but enhanced release of leukotriene B4 and sulfidopeptide leukotrienes. HPLC analysis demonstrated that immunoreactive leukotriene B4 co-chromatographed almost exclusively with standard leukotriene B4, while immunoreactive sulfidopeptide leukotrienes consisted of a mixture of leukotrienes C4, D4 and E4. Leukotriene synthesis by human gastrointestinal tissues was inhibited by the lipoxygenase inhibitor nordihydroguaiaretic acid (NDGA) and the dual enzyme inhibitor BW755C (3-amino-1-(trifluoromethylphenyl)-2-pyrazoline hydrochloride). Synthesis of prostaglandin E2 was inhibited by the cyclooxygenase inhibitor indomethacin as well as by BW755C. Incubation of gastrointestinal tissues in the presence of glutathione decreased the amounts of leukotrienes D4 and E4, while release of leukotriene C4 was simultaneously increased. On the other hand, incubation of tritiated leukotriene C4 with incubation media from human gastric or colonic mucosa resulted in conversion of the substrate to [3H]leukotriene D4 and [3H]leukotriene E4. The results indicate the capacity of human gastrointestinal tissues to synthesize the 5-lipoxygenase-derived products of arachidonate metabolism, leukotriene B4 and sulfidopeptide leukotrienes, in addition to larger amounts of prostaglandin E2. Furthermore, considerable activities of the sulfidopeptide leukotriene-metabolizing enzymes gamma-glutamyl transpeptidase and dipeptidase were detected in human gastrointestinal tissues. These enzymes might play an important role in biological inactivation and/or change of biological profile of sulfidopeptide leukotrienes generated in the human gastrointestinal tract.

A comparison of long term results of the standard Whipple procedure and the pylorus preserving pancreatoduodenectomy.

The standard Whipple procedure involves intestinal disturbances, such as dumping, diarrhea, dyspeptic complaints and the occurrence of ulcers of the anastomoses. A postoperative weight loss was observed ranging between 10 and 40 kilograms. Only a few patients were able to compensate after several months. It was thought that preservation of the intact stomach would prevent the complications arising from a loss of gastric reservoir function and thus the malnutrition could be improved postoperatively. Between 1985 and March 1992, we performed the pylorus-preserving Whipple procedure and treated a group of 43 patients with this method. In the same period, 15 patients were operated upon with the standard Whipple procedure. The present evaluation of the accumulated patient data, including extensive functional studies, led to the following results comparing the pylorus preserving Whipple procedure with the standard Whipple procedure. First, the capacity for food uptake and the development of body weight postoperatively is significantly better. Second, gastric or jejunal ulcers were not observed. Third, there were no clinical signs of digestive disorders, such as different forms of dumping. Nutrition and digestion were not impeded by the preserved opening mechanism of the pylorus. Fourth, the postoperative exocrine function was only slightly decreased. Fifth, glucose metabolism postoperatively was influenced only slightly by preservation of the pylorus. In taking the results of all the examinations into consideration, it can be said that the restricted organ loss in the Whipple procedure with pylorus preservation leaves the secretory and functional capacity of the upper part of the gastrointestinal tract almost unchanged.

Simultaneous pancreas-/kidney transplantation--the Bochum experience.

Since the introduction of the bladder drainage technique, the number of pancreas transplants performed has now reached 1,000 per year worldwide. Most of these transplants have been performed in the United States. In contrast, the number of pancreas transplants performed in the Eurotransplant community has remained at a low level for several years. The results of a consecutive series of 40 simultaneous pancreas/kidney transplantations (SPK) performed between June 1994 and July 1996 demonstrate that high 1-year graft function rates of 87.1% for pancreas and 94.8% for kidney grafts can be achieved. Therefore, SPK can be recommended as a standard procedure for patients with insulin-dependent diabetes mellitus and end-stage renal disease in Germany, too.

[The diagnosis of bleeding small bowel tumours (author's transl)]. / Beitrag zur Diagnostik der blutenden Dünndarmtumoren.

Problems concerning the radiological diagnosis of bleeding, malignant, small bowel tumours are discussed with reference to two cases. The need for early selective visceral angiography is stressed; the significance of contrast pooling is pointed out and the value of recognising the tumour in arriving at a diagnosis and prognosis is discussed. In the presence of negative angiographic findings the small bowel enema has proved a very valuable method of examination. The vascular leiomyosarcomas of the small bowel are best demonstrated angiographically, whereas the avascular adenocarcinomas are best shown by small bowel enema.

[Intestinal occlusion and perforation as a complication in percutaneous endoscopic gastrotomy (PEG)]. / Occlusione e perforazione intestinale quale complicanza in gastrotomia endoscopica percutanea (PEG).

Complications in the removal of PEG have rarely been reported. Especially patients been operated for head and neck cancer can be a serious problem for the removal of percutaneous endoscopic gastrostomy. A case of an incomplete removal of PEG and occlusion of the lower bowel with subsequent perforation is reported.

[Leukotriene synthesis by gastrointestinal tissue and its pharmacologic modification]. / Leukotriensynthese durch gastrointestinales Gewebe und ihre pharmakologische Beeinflussung.

Tissues of the gastrointestinal tract synthesize leukotriene (LT) B4 and the sulfidopeptide-leukotrienes LTC4, LTD4 and LTE4 from endogenous substrate. Formation of leukotrienes was demonstrated using radioimmunoassay, high pressure liquid chromatography (HPLC) and bioassay. Under basal conditions the gastrointestinal tissues released minor amounts of leukotrienes only. Formation of lipoxygenase-derived products of arachidonic acid metabolism was, however, significantly increased in the presence of various stimuli. Thus, significant amounts of LTB4 and of sulfidopeptide-leukotrienes were released from colonic and gastric mucosa of guinea-pigs sensitized against ovalbumin when incubations were carried out in the presence of antigen. Antigen-induced leukotriene formation was not found in the muscularis propria and subserosal of ovalbumin-sensitized guinea-pigs. Release of cyclooxygenase-derived metabolites of arachidonic acid, on the other hand, was most abundant in the subserosal layer of the guinea-pig colon and was not influenced by the immunological reaction. Inhibitors of cyclooxygenase, such as indomethacin, reduced gastrointestinal formation of prostaglandins, but not of leukotrienes. Inhibitors of 5-lipoxygenase, however, significantly decreased leukotriene formation. Synthesis of LTB4 and of sulfidopeptide-leukotrienes was also found in human colonic mucosal tissue, using the divalent cation-ionophore A23187 as stimulating agent. HPLC analysis demonstrated that the sulfidopeptide-leukotrienes released were composed of a mixture of LTC4, LTD4 and LTE4. In addition, human colonic mucosal tissue contained high activities of enzymes that rapidly convert LTC4 to LTE4. As in most biological systems LTE4 is less active than LTC4 and LTD4 degrading enzymes might represent a local inactivating mechanism. Mucosal tissue of patients with Crohn's disease synthesized considerably more LTB4 and sulfidopeptide-leukotrienes than non-inflamed mucosa.(ABSTRACT TRUNCATED AT 250 WORDS)

Cytokine activation in patients undergoing open or laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic surgery is estimated to produce a minor surgical injury in comparison with open and laparoscopic cholecystectomies. Studies in the past compare almost data of the first hours until day two. However, the surgical injury and the wound healing metabolism has to be detected. METHODS: A prospective study was designed to investigate cytokine responses after surgical injury. Twenty-three patients with symptomatic cholelithiasis were admitted to the study. Eleven patients underwent conventional (open) and twelve patients laparoscopic cholecystectomy. Circulating concentrations of cytokines-including Interleukin-6 (IL-6), Tumor necrosis factor-alpha (TNF-alpha) and neopterin, were compared between both groups. In addition, association of the cytokines with clinical parameters including leucocytes, urea, fever and C-reactive protein (CRP) were assessed. We are using ELISA-test of Medgenix GmbH, Ratingen, Germany and BRAHMS Diagnostica, Berlin, Germany. RESULTS: Enhanced cytokine responses were observed in the conventional group compared to the laparoscopic group. On day 3 after operation, the second increase in cytokine levels (but smaller than the first increase) were observed in both groups. In the conventional group, a slightly high correlation ratio between the urea and cytokine levels was found. However, only neopterin and urea association on postoperative day 3 (r = 0.65) was significant (p < 0.05). There was no significant association between CRP and cytokine levels in both groups. CONCLUSIONS: Cytokine response after cholecystectomy demonstrates the lesser degree of surgical injury in the laparoscopic group, however, TNF-alpha demonstrates on day 4 a similar increase in both groups. This is a new result of studies working in this field. In conclusion, the benefit of laparoscopic surgery results only in the minimal access to the abdominal cavity, the wound healing metabolism is at last the same in both groups.

"Ring fixator" for treatment of lower leg fractures. A review of 30 cases treated by a new external fixation system.

Besides generally known therapeutic practice, indications can be discovered and more easily evaluated by using a "Ring Fixator". Applications include the following: (1) stage fractures of the tibia, (2) stabilisation of fractures of polytraumatized patients with no need for prior anatomical reduction and (3) closed lower limb fractures with severe soft tissue lesions. The major advantages of the "Ring Fixator" include the following: possible unlimited correction of primary and secondary dislocations without needing to transpose implanted Steinmann-pins or Schanz' screw; compatibility with ASIF external fixation systems for supplementary use of "Ring Fixator" elements; possible management of secondary dislocations and variable placement of pins or screws for subsequent wound debridement and muscle flap transposition. Results so far obtained using the "Ring Fixation" are illustrated by clinical examples.

[Kidney donation by the elderly--an emergency solution?]. / Nierenspende im Alter--eine Notlösung?

In 1994 the number of kidney donors once again decreased in Germany. On the other hand, more and more old people are being considered for renal transplantation; thus the shortage of transplants is becoming more severe. The kidneys of elderly donors might improve this situation. The results available are inconsistent. There is no doubt that kidney function declines with age, but the individual aging process depends mainly on concomitant disease, especially arterial hypertension. Transplantation of kidney from an elderly person requires appropriate selection of donors as well as good perioperative management. Doctors in medical intensive care units should contact transplant centres more often to evaluate potential elderly kidney donors. More open-minded assessment of certain situations is necessary in conservative medical disciplines.

[Gastrointestinal anastomoses and carcinoma in the operated on stomach]. / Gastroenterale Anastomosen und Carcinom im operierten Magen

This study examines the question of which type of gastroenteral anastomosis is predisposed to carcinoma of the gastric stump. Evaluation of operative or autopsy reports of 72 patients with carcinomas of the gastric stump following ulcer resection was undertaken. The interval after resection for ulcer was on the average 23 years. In 69 cases a Billroth II resection with retrocolic anastomosis (Polya type) had been performed; 7 patients had a Billroth II resection with enteroanastomosis (Braun's type); only 3 cases of Billroth I resection were found in the whole collective. From the results it may be concluded that carcinoma of the gastric stump develops predominantly in the remaining stomach following Billroth II resection with retrocolic anastomosis (without Braun's enteroanastomosis). When retrocolic anastomosis is performed, the duodenogastric reflux definitely passes through via atrophic gastritis to the development of a stump carcinoma. However, when Billroth I resection or Billroth II resection with enteroanastomosis is performed, the duodenogastric reflux is low or is quantitatively derived into the jejunum.

[Pancreas transplantation with bladder and intestinal drainage technique with systemic-venous and initial experiences with portal venous drainage. Which technique can be recommended today?]. / Pankreastransplantation in der Blasen- und Darmdrainagetechnik mit systemischvenöser und ersten Erfahrungen mit der portalvenösen Ableitung. Welche Technik kann heute empfohlen werden?

The experience worldwide with pancreas transplantation includes more than 9000 cases. In the most popular patient group (simultaneous pancreas-kidney transplantation, SPK) the graft-function rate at 1 year now reaches more than 80%. More than 90% of all pancreas transplants were performed using the bladder-drainage technique (BD) with systemic venous anastomosis. Late problems with the BD require enteric conversion in 10-20% in the long term. In the present study we report the results of 40 SPK using the BD (n = 20) and enteric drainage (ED) techniques (n = 20). After 3 months, the patients pancreas and kidney survival rates in the BD group were 100, 95 and 100% and in the ED group 100, 100 and 100%, respectively. No anastomosis leakage occurred in either group. In two cases of the ED group the pancreas grafts were drained portal venously via the superior mesenteric vein without surgical complications. With growing experience, excellent SPK results can be reached with both the BD and ED techniques.

[Combined pancreas/kidney transplantation as standard procedure in therapy of type I diabetic patients in renal failure]. / Die kombinierte Pankreas-/Nierentransplantation als Standardverfahren in der Therapie niereninsuffizienter Typ-I-Diabetiker.

Sinde the introduction of the bladder drainage technique, the number of pancreas transplants performed has now reached 1000/year worldwide. Most of these transplants have been performed in the United States. In contrast, the number of pancreas transplants performed in the Eurotransplant community has remained at a low level for several years. The results of a consecutive series of 20 simultaneous pancreas/kidney grafts (SPK) performed between June 1994 and October 1995 demonstrate that high graft function rates of 83.5% for pancreas and kidney grafts can be achieved. Therefore SPK can be recommended as a standard procedure for patients with insulin-dependent diabetes mellitus and end-stage renal disease in Germany, too.

[Diagnostic and therapeutic problems in amebic liver abscess]. / Diagnostische und therapeutische Probleme beim Amöbenabscess der Leber.

Abscesses of the liver represent the most common complications of amebiasis. In general they are treated non-surgically by the aid of Metronidazol. Complications, however, such as perforations, development of fistulas or septicemia may occur and necessitate surgical intervention. The role of CT in diagnostic problems and therapeutic management is discussed in three different cases with respect to other diagnostic techniques.

[Role of surgery in the treatment of severe acute necrotic pancreatitis]. / La place de la chirurgie dans le traitement des pancréatites aiguës nécrotiques graves.

Between May 1975 and December 1991, a total of 208 patients were operated upon for severe acute necrotic pancreatitis. The decision whether to operate on patients with clinical and biologic aggravation despite particularly sustained intensive care was taken after evaluation of ultrasound and CT scan images. Combining pancreatic body resections and necrotic tissue excision with laparostomy and staged lavage drainage reduced global mortality rate from 49.2 to 16.4 p. cent. The criteria used for determining the indication for surgical intervention, and the technical and tactical operative procedures applied allowing this improvement, are described and discussed.

[Treatment of pancreatic injuries. Study of a series of 34 patients]. / Le traitement des traumatismes du pancréas. Etude d'une série de 34 malades.

Routine retrograde imaging of Wirsung's duct, an essential investigation of pancreatic injuries, should be carried out preoperatively and, in case of failure of the intervention, intraoperatively. Whereas simple drainage is sufficient treatment for injuries to the pancreatic parenchyma, lesions of Wirsung's duct require either duodeno-cephalic pancreatectomy or left pancreatic resection, depending on the site of the ductal wound, conservative treatment carrying the major risk of a post-traumatic acute pancreatitis with its particularly elevated mortality rate. Of the 34 cases, reported: 24 (70.6%) were treated by resection: 3 by duodenocephalic pancreatectomy and 21 by left pancreas resection, 6 (17.6%) by suture of the parenchyma and contact drainage and 4 (11.8%) by drainage of Wirsung's duct by catheter or excluded loop in Y. Mortality was 14.7% (5 of the 34 patients). Complications included pseudocysts requiring operative removal in 3 of the 6 patients treated by suture-drainage, and severe sepsis in 5 patients with a fatal outcome in 3 cases. Treatment was unsuccessful in 2 of the 4 patients treated by drainage by catheter or excluded loop in Y, whereas mortality was nil after pancreatic resection.

[Morphology and biological integration of autodermoplasties in large incisional hernias. Results of an experimental study]. / Morphologie et intégration biologique des auto dermoplasties dans les grandes éventrations. Résultats d'une étude expérimentale.

UNLABELLED: Their aim of the experimental study was to investigate the morphology and wound healing of "Kutisplastik"-technique, originally introduced by Loewe (1913) and Rehn (1914), from different conditions. We want to clarify the mechanism and development of revascularisation. RESULTS: The well known phases of wound healing also appear in the situation of a cutisplasty. In the exsudative reaction the cutis is covered from fibrin fibers. This leads to the development of granulation tissue. The cellular reaction demonstrates first the in-growth of capillary bundles and vessels in the collagen network of corium. The revascularisation is finished up to 14 days after the operation. The other part is the immigration of granulocytes and macrophages in the graft. The release of enzymes leads to the lysis of epidermal structures, cutaneous appendages and at least to collagen fibers of corium. There is also a proliferation from fibroblasts. The genesis from new collagen fibers is then observed so a scar tissue reveals. The "Kutisplastik"-technique contains that the epidermal side of the graft is turned upside-down towards the peritoneum and is sutured under as high tension as possible to the healthy fascia around. This morphology of healing is seen only under high-tension suturing. In the experimental mode of non-tension suturing there is a lack of success in cutisplasty for abdominal wall defects.

The change of therapy in esophagus carcinoma between 1975-1996.

196 patients were assigned to an operation because of esophagus carcinoma between 20.05.1975 and 30.09.1996. Whereas until 1984 the surgical treatment was predominantly characterized by the uni-cavity operation, we increasingly practice the bi-cavity operation since them. By this procedure the resection rate could be extended up to 70.1%. As to be expected, most of the carcinomas were positioned in the medium third of the esophagus, the predominant tumor type was the squamos cell carcinoma, 85% of the patients had a stage three tumor. The mortality rate was 19.1% within the period of 6 weeks after the operation.

The oncological approach to pylorus preserving pancreatoduodenectomy (PPPD) in pancreas malignancies.

There has been a considerable debate about whether pylorus preservation significantly detracts from the radicality in a palliative procedure where a conventional Whipple operation would have been curative. We know now, that the extending radicality of the Whipple operation does not improve the long-term survival rates. Our results of 127 PPPD and 54 Whipple procedures in pancreas malignancies from 1985 to 1996 showed the nutritional benefits of the PPPD group as compared to the standard Whipple group. 84% (99/121) vs. 24% (13/50) were able to gain postoperatively. The long-term survival rates of both groups and the results in the literature are similar.