Revision surgery in pectus excavatum after failure of Nuss technique.

A 17-year-old female had undergone two failed pectus excavatum repairs using the Nuss technique. Each time the bar had shifted, one time displacing the heart. Revision surgery was carried out using the Erlangen technique, which proved to be a safe and successful method to remove the displaced bar and correct the pectus excavatum.

Laparoscopic lymph node assessment in pretherapeutic staging of gastric and esophageal cancer.

In gastric cancer lymph node metastases at the hepatoduodenal ligament and in esophageal cancer, metastases at the celiac axis are classified as distant metastases (M1 LYMPH) and implying a poor prognosis. In pretherapeutic staging, imaging procedures such as computed tomography of the abdomen or transcutaneous ultrasonic examination are of limited value in the assessment of enlarged or metastatic lymph nodes. Conversely, laparoscopic staging with subsequent biopsy of suspicious lymph nodes provides essential diagnostic information. After exclusion of distant metastases (liver, lung, bone) in 73 patients with esophageal-(n = 21) and gastric cancer (n = 52), staging laparoscopy, including laparoscopic ultrasound, were performed during an 18-month-period (July/ 93-December/94). After laparoscopic exclusion of peritoneal seedings, the hepatoduodenal ligament was examined and enlarged lymph nodes were biopsied. In a total of 73 patients, laparoscopy revealed previously undiagnosed liver metastases in 14 and peritoneal carcinosis in 19 patients. Additionally, in eight (esophageal cancer; n = 3, gastric cancer; n = 5) of the remaining 40 patients, lymph nodes in the M1-position were regarded suspicious and biopsied. In six of these, malignant spread was observed. Thus, in a further six of 40 patients, surgically incurable situations could be detected. In esophageal and gastric cancer, staging laparoscopy, including laparoscopic ultrasound and biopsy, is a sensitive technique to assess local tumor spread and distant metastases. The detection of M1- lymph node metastases is facilitated by the use of laparoscopic ultrasound. Tumor spread, which limits surgical curability, can be properly assessed and exploratory laparotomy avoided.

Is local excision of pT1-ampullary carcinomas justified?

We propose that local excision of carcinomas of the ampulla of Vater is justifiable under the following conditions: when the tumour is limited to the ampulla of Vater as diagnosed by pre-operative endoluminal sonography (uT1) and UICC-staging (pT1); and when it is graded G1 or G2 and there is no lymphatic infiltration and the tumour is completely resected (R0). Under these conditions peri-operative morbidity and mortality were significantly reduced compared with more extensive surgery. There was no local recurrence of tumour in our study and long-term survival rates were comparable with Whipple's procedure. This implies that lymphatic spread is limited in localized disease and the feasibility of the proposed procedure may therefore be analogous to localized resections in other malignant tumours, e.g. carcinoma of the rectum.

[Intrascrotal lipoblastoma in childhood: diagnostic strategies and therapy planning]. / Intraskrotales Lipoblastom im Kindesalter : Diagnostische Strategien und Therapieplanung.

Based on a case report of an intrascrotal lipoblastoma in childhood, we present the preoperative diagnostic algorithm and the main differential diagnoses in testicular and paratesticular tumors as well as their surgical management. An 8-week-old infant was admitted with a scrotal tumor known since birth. MRI showed a pinnate vessel supply, originating in the left internal iliac artery. The tumor was exposed operatively and could be completely removed. Intrascrotal lipoblastoma are rare. Like most testicular and paratesticular tumors in childhood lipoblastomas are benign. Today ultrasound and Doppler sonography are basic tools for diagnosis and surgical planning in testicular and scrotal tumors in childhood. In some cases MRI can provide additional important information for surgical planning. In contrast to adults testis sparing surgery is favoured in children.

[Acute calcinosis of the hand in an infant]. / Das akute Kalksalzdepot der Hand beim Kleinkind.

We report on an acute calcinosis in infants as a differential diagnosis to a trauma or an infect of the wrist.

Training in GI endoscopy: can we objectively predict the performance of trainees? A prospective correlation study.

BACKGROUND: No objective criteria have hitherto been available for assessing the individual talents and skills of trainees involved in GI endoscopy. The aim of our study was to compare the correlation of various psychological, psychomotor and cognitive tests (psy-tests) and of the subjective assessment of the trainer (expert assessment) at the beginning of the training with the objective performance of the trainees at the end of a one-week training period in upper GI endoscopy. METHODS: In a prospective study including 12 endoscopic centers, a total of 58 participants without any prior endoscopic experience were analyzed. During a practical training week in each center with the "Erlangen Endo-Trainer," an assessment using a "score card" protocol was used as reference method. Prior to the start of the training, various psy-tests (personality test, vigilance endurance test, test of spatial thinking and two tests of sensorimotor coordination) as well as assessment of the trainer were obtained. These parameters were compared with a blinded analysis of the performance at the end of the training. RESULTS: There was significant overall improvement during the training course. Multiple logistic regression analysis revealed that testing sensorimotoric coordination was significantly associated with defined improvement margins (odds ratio 11.46, p = 0.035). An expert's judgment on the prognosis correlated also significantly with the trainee's improvement (OR = 41.46; p = 0.018). Self-assessments were not significantly associated with performance or progress. CONCLUSIONS: Sensorimotoric tests may provide a reliable prediction of the trainee's learning progress. In contrast to self-assessment, the judgement of an experienced endoscopist provides the best guidance for the young candidate endoscopists prior to the start of his/her endoscopic training program.

[The Longmire gastrectomy in the animal model: postoperative changes in fat resorption and the hormones cholecystokinin and secretin]. / Die Gastrektomie nach Longmire im Tiermodell: Postoperative Veränderungen bei der Fettresorption sowie der Hormone Cholezystokinin und Sekretin.

In this animal study we investigated the absorption of free fatty acids and triglycerides after gastrectomy. The levels of the hormones cholecystokinin and secretin were measured in response to a controlled enteral fat load (Lipofundin 20% MCT emulsion). We studied fat absorption in three groups of animals: the gastrectomy group in which lipid emulsion was administered in the duodenum, and two groups of controls that received the same infusion in the duodenum or stomach, respectively. Infusing the fat load directly into the duodenum, rather than the stomach, resulted in delayed absorption of fatty acids. In the gastrectomized animals there was, in addition, increased absorption of triglycerides. Medium- and long-chain fatty acids were found to be an adequate stimulus for secretion of the gastrointestinal hormones cholecystokinin (CCK) and secretin. In the gastrectomized group, higher baseline levels of both CCK and secretin were observed. CCK showed no response to the lipid stimulus, whereas a secretin response was observed over and above the raised baseline level. The gastrectomized animals showed a markedly restricted growth rate, as measured by body weight; however, they continued to gain weight in a linear fashion up to the end of the study period. No alterations in morphology of CCK-secreting cells were found.

Incisional hernia repair: tensiometry for the selection of the appropriate procedure.

OBJECTIVE: To audit the early and late results of repairs of incisional hernias before and after the introduction of peroperative tensiometry. DESIGN: Retrospective study. SETTING: University hospital, Germany. PATIENTS: 675 operations on 553 patients in 18 years. INTERVENTIONS: Before we introduced tensiometry we closed 560 incisional hernias by direct suture and 63 by the inlay-onlay technique. Since we took up tensiometry the numbers were 9 and 43, respectively. MAIN OUTCOME MEASURES: Postoperative complications including recurrences. RESULTS: Recurrences developed in 246/560 (44%) after direct suture in the early series, compared with 2/9 (22%) after adoption of tensiometry. After inlay-onlay operations there were 4/63 (6%) recurrences before, and 1/43 (2%) after adoption of tensiometry. CONCLUSIONS: Tensiometry allows the surgeon to tailor his operation to the conditions that he finds during the operation.

[Verifying routine preoperative diagnosis between private practice and the surgical university clinic]. / Abstimmung der präoperativen Routinediagnostik zwischen niedergelassener Praxis und Chirurgischer Universitätsklinik.

In an attempt to shorten the preoperative in-patient period and to avoid unnecessary investigations, a cooperative patient management model was established for a number of surgical operations at the University Department of Surgery, Anaesthesiology and their referring Specialist and General Practitioners. The latter were requested to carry out the previously defined preoperative routine investigations, which allowed for a marked reduction in hospital diagnostics. Ambulatory preoperative patient management and a new admission routine resulted in a 57% decrease of the average preoperative in-patient stay for the observed procedures.

DNA microarrays: a new diagnostic tool and its implications in colorectal cancer.

Effective treatment of colorectal cancer requires early detection and diagnostic and prognostic accuracy in characterizing patients of various risk groups. The development of DNA microarray makes it possible to analyze thousands of genes in a single tissue sample in one experiment and to characterize the biological behavior of colorectal cancer cells. Different cluster algorithms have been used to analyze large datasets on gene expression data, and initial results show significant differences between colorectal cancer and normal colon tissue. Although more than 6000 genes have been analyzed between colorectal cancer and normal tissue, different expression levels have been found in only 100-500 transcripts depending on the cluster algorithm. Most transcripts belong to genes involved in cell growth regulation, differentiation of cells, ribosomal proteins or metalloproteinase. A future goal in microarray technology will be the development of clustered gene chips which characterize each tumor type specifically and focus on gene expression that specifies cell identity.

[Reconstruction of incisional hernias with defined tensiometrically controlled tension--a possibility for anatomically correct reconstruction of the abdominal wall]. / Die Rekonstruktion von Narbenhernien unter definierter, tensiometrisch gemessener Spannung--Eine Möglichkeit zur anatomisch korrekten Wiederherstellung der Bauchwand.

The repair of incisional hernias of the abdominal wall is characterized by high rates of recurrence if arbitrary tension is applied. A rationale for selecting the appropriate reconstruction technique as defined by intraoperative tension measurements has proven effective and successful. Here, the inlay/onlay technique tolerates up to 3.5 kilopounds (kp). Our results show that using this technique, complete reconstruction is possible in 65% of cases with a recurrence rate of 2.3%.

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.

The Erlangen Endo-Trainer: life-like simulation for diagnostic and interventional endoscopic retrograde cholangiography.

The Erlanger Endo-Trainer offers a large spectrum of training possibilities in endoscopic techniques using life-like biological specimens. We organised the first pilot study of interventions at the papilla and the bile duct under x-ray control. Specially prepared upper visceral porcine organ packages including the esophagus, stomach, duodenum, liver, gallbladder and bile ducts were implanted into the Endo-Trainer. Furthermore, small stones were introduced into the bile duct. The test study was carried out by a senior endoscopist assisted by his endoscopy nurse. The following steps could therefore be carried out as a structured team-training scheme: Introduction of the side-viewing endoscope and passage into the duodenum; identification and adjustment at the papilla; cannulation of the papilla; selective bile duct imaging with contrast application under x-ray vision; placement of a guidewire; papillotomy; stone extraction and finally placement of a plastic stent. The special value of this type of simulation is the fact that endoscopic techniques can be trained in the usual manner with real tissue-feeling using regular commercial instruments. Although there is general consent that individual practice on the patient cannot be completely replaced by simulator training, a suitable and realistic simulation model can be of great value, for initial steps prior to "real" patient contact as well as for refining techniques and tactics.

[Spontaneous splenic rupture in metastatic malignant melanoma]. / Spontane Milzruptur bei metastasierendem malignem Melanom - Kurzbericht -

Spontaneous splenic rupture is a rare cause of non-traumatic haemorrhage and is of infectious origin in most instances. We present a patient under treatment for abdominal manifestations of metastatic malignant melanoma who developed signs of haemorrhagic shock and where, upon emergency laparotomy, metastases were found to have caused rupture of the spleen. The patient recovered after splenectomy and was continued on systemic chemoimmunotherapy. One year after the incident he died of cerebral metastases.

Weekly 24-h infusion of high-dose 5-fluorouracil (5-FU) with folinic acid (FA) in adjuvant therapy of colon cancer.

After curative resection (R-0) of primary colon cancer or curative metastases resection, the efficacy, toxicity and compliance of a weekly 24-h infusion of high-dose 5-FU with folinic acid was examined in a prospective feasibility trial. From June 1995 to June 1997, 19 patients were included, 11 patients with UICC stage III and 8 patients with UICC stage IV colon cancer. The patients received weekly 500 mg/m2 of calcium folinic acid (Rescuvolin) as a 1-2 h-infusion on an outpatient basis following a 24-h infusion of 2,000 mg/m2 5-FU via a pump system (intermate LV5 Baxter). The adjuvant therapy was administered for 6 months. 90% of the patients received the planned 18 chemotherapy applications. The total 5-FU dose given to each patient amounted to 34.4 g/m2 in 6 months, thus corresponding to 95% of the planned 5-FU total dose. The main toxicity was diarrhea CTC toxicity grade 3 in the case of 16% of the patients. After a median follow-up of 51 months (range: 37-59 months), 82% of the patients (9 out of 11) with stage III remained free of recurrence. The 2 cases of recurrence belonged to the pN2 subgroup. In stage IV only 12% of the patients (1 out of 8) remained free of recurrence. On an adjuvant basis, a weekly 24-h infusion of high-dose 5-FU with folinic acid is accompanied by a good complicance and a high-dose intensity of 5-FU. Now it is tested within randomized phase III trials of the "Arbeitsgemeinschaft Gastroenterologische Onkologie (AGO)" of the "Deutsche Gesellschaft für Verdauungs- und Stoffwechselerkrankungen" for UICC stage III colon cancer. Concerning stage IV, adjuvant therapy was not effective, a fact that seems to justify new drugs and new therapeutic strategies.

Transcription of cytokeratins 8, 18, and 19 in bone marrow and limited expression of cytokeratins 7 and 20 by carcinoma cells: inherent limitations for RT-PCR in the detection of isolated tumor cells.

The suitability of "real-time" quantitative reverse transcriptase polymerase chain reaction (RT-PCR) for the detection of isolated carcinoma cells in bone marrow was investigated by evaluating the expression of cytokeratin (CK)7, CK8, CK18, CK19, and CK20 in 17 gastrointestinal cancer cell lines, 64 control bone marrow specimens from noncancer patients, and 30 bone marrow specimens from patients with gastric or colorectal cancer. RT-PCR products for CK8 and CK18 were detected in all cancer cell lines, but only 16, 5, and 11 cell lines provided evidence for CK19, CK7, and CK20 transcription. Variable numbers of bone marrow specimens from noncancer patients demonstrated background transcription of CK8 (78.1%), CK18 (95.3%), CK19 (35.9%), CK20 (29.6%), and CK7 (16.7%). Maximal background transcription for CK8, CK18, and CK19 ranged from 52.2 to 56.1 copies/10(3) copies glyceraldehyde-3-phosphate dehydrogenase (GAPDH), the corresponding values of 0.06 and 0.76 copies for CK7 and CK20 being distinctly lower. When maximal background values were used as a threshold value to define positivity in tumor cell dilution experiments, sensitivity levels of one tumor cell in 10(4) bone marrow cells were determined for CK7 and CK20 RT-PCR assays. Maximal background expression values of the different CKs as obtained in the control series were exceeded once (CK20), twice (CK18 and CK19), and 18 times (CK7) in bone marrow specimens from cancer patients, with none of these specimens exceeding the maximal background expression value of CK8. We conclude that RT-PCR for CK8, CK18, and CK19 cannot be recommended for the detection of isolated tumor cells in bone marrow of cancer patients. On the other side, the limited number of gastric and colorectal cancer cell lines expressing CK7 and CK20 indicates that assay sensitivity for these CKs might be limited because of their selective expression by carcinoma cells.