[Multiple recurrent retroperitoneal liposarcoma in a 66-year-old man]. / Multipel rezidivierendes retroperitoneales Liposarkom bei einem 66-jährigen Patienten.

In this article, the authors present the case of a 66-year-old man who was diagnosed with the first recurrence of his retroperitoneal liposarcoma 7 years after initial diagnosis. In the following 10 years, he needed a total of eight operations, chemotherapy, and radiotherapy because of another seven recurrences. This is the first report on a patient with eight recurrences of a retroperitoneal liposarcoma being in a relatively good general condition even 17 years after initial diagnosis.

Multicenter phase II trial to investigate safety and efficacy of gemcitabine combined with cetuximab as adjuvant therapy in pancreatic cancer (ATIP).

BACKGROUND: To investigate whether addition of cetuximab to standard adjuvant chemotherapy with gemcitabine improves outcome in pancreatic cancer, specifically whether the rate of disease-free survival (DFS) at 18 months (primary end point) exceeds the previously reported 35% of gemcitabine alone. PATIENTS AND METHODS: Prospective, open-label, multicenter, nonrandomized phase II study in 76 patients with R0- or R1-resected ductal adenocarcinoma of the pancreas included between October 2006 and November 2008. Gemcitabine and cetuximab were administered for 24 weeks. Secondary end points included overall survival (OS) and toxic effect. RESULTS: Seventy-three patients received cetuximab. Median DFS was 10.0 [95% confidence interval (CI) 8.9-13.6] months and the DFS rate at month 18 of 27.1% (16.7%-37.6%) was inferior to 35%. Median OS was 22.4 (18.2-27.9) months. Subgroup analyses revealed a nonsignificant increase in DFS for patients with versus without skin toxic effect ≥ grade 2 (median 14.7 versus 8.3 months, P = 0.073) and wild-type versus mutated K-Ras (median 11.5 versus 9.3 months, P = 0.57). Grade 3/4 toxic effects included neutropenia (11.0%), thrombopenia (7%), skin toxic effect (7%) and allergic reactions (7%). CONCLUSION: Addition of cetuximab to adjuvant gemcitabine does not seem to improve DFS or OS of unstratified pancreatic cancer patients. Trends for improved DFS in patients with wild-type K-Ras and skin toxic effect remain to be confirmed.

[An algorithm for postoperative pain management in visceral and thoracic surgery: an observational study]. / Algorithmus zur postoperativen Schmerztherapie in der Viszeral- und Thoraxchirurgie: Eine Verlaufuntersuchung.

INTRODUCTION: We report the results of an observational study of pain intensity before and after implementation of an algorithm for postoperative pain management. The algorithm included multiple factors for treatment. METHODS: Data of 130 consecutive patients with defined surgical procedures were extracted from charts before and after implementation of the algorithm. Our patients documented pain intensity at rest and on movement on a numerival rating scale (NRS) from 0 (= no pain) to 10 (=  worst pain). A successful pain management was definded as maximum pain intensity at rest ≤ 3 and on movement ≤ 5 on the NRS. For statistical analysis we used the Wilcoxon and the chi squared test. RESULTS: The frequency of a successful pain management increased from 49 % (individual pain management) to 85 % (algorithm) at rest 8 (p < 0.001), on movement the rates were 42 % and 86 %, respectively (p < 0.001). In the total group, we found a reduction of maximum pain intensity at rest (mean ±â€Šsd) from 4.05  ±â€Š 2.54 to 2.18 ±â€Š1.82 (p < 0.001) and with movement from 6.04 ±â€Š2.51 to 3.5 ±â€Š2.08 (p < 0.001). CONCLUSION: Implementing an algorithm for postoperative pain management resulted in a clinically relevant reduction of postoperative pain. Our findings reflect the result of a complex change in pain management, and therefore cannot be attributed to any single factors involved.

Effects of intravenous ketamine on gastrointestinal motility in the dog.

OBJECTIVE: The purpose of this trial was to clarify the effects of intravenous ketamine at anaesthetic and sub-anaesthetic dosages on gastrointestinal motility. DESIGN: 20 beagles (group 1: 3 mg/ketamine/kg/h, n = 10; group 2: 30 mg ketamine/kg/h, n = 10), were investigated. Gastric emptying (nuclide gastric emptying studies, liquid and semi-solid test meal), intestinal transit time (Hydrogen breath test with lactulose) and intestinal motor function (perfusion manometry with 8 measuring ports) were determined. As a control condition, the tests were performed on all dogs in the two groups during infusion of physiological saline solution. RESULTS: No significant differences in the motility patterns were present between 3 mg ketamine/kg/h and the control condition. For group 2, a moderately significant (p < 0.05) increase in the interdigestive motility index was observed for 30 mg ketamine/kg/h. However, this did not change the transit criteria. There was no significant difference between ketamine and control condition tests with regard to cycle and phase lengths or the propagation rate of the activity front. CONCLUSIONS: We conclude that ketamine provokes no basic changes in gastrointestinal motility, at either sub-anaesthetic doses. It can therefore be used to advantage in the continuous postoperative analgesia of intensive care patients, where repeated interventions are necessary and no cardiopulmonary contraindications are present.

Colon interposition for esophageal replacement: isoperistaltic or antiperistaltic? Experimental results.

BACKGROUND: Isoperistaltic colon is preferred to antiperistaltic colon for esophageal replacement, but experimental data do not exist to support this practice. METHODS: In 7 dogs a 20 cm long colon loop was interposed between the skin and the small bowel, isoperistaltically in 3 dogs and antiperistaltically in 4 dogs. Three months later five strain-gauges were implanted and evacuation was investigated by motility testing, barium studies, and scintigraphy. RESULTS: Motility recording showed normal colon motility in the excluded loops. Quiescent states (duration 40.2 +/- 13.6 minutes) were followed by contractile states (duration 7.5 +/- 2.4 minutes, frequency 3.3 +/- 0.6 per minute). The main peristaltic direction of isoperistaltic loops was isoperistaltic, and the main peristaltic direction of antiperistaltic loops was antiperistaltic. Evacuation took place exclusively during the contractile status. Half time emptying was more rapid in isoperistaltic loops (35 +/- 11 vs 69 +/- 16 minutes). The content of antiperistaltic loops was held back by antiperistaltic activity. Application of oatmeal porridge into the loops shortened the quiescent status from 40.2 to 13.2 +/- 4.8 minutes. CONCLUSIONS: The colon graft for esophageal replacement is an active system. Food is stored during the quiescent states and evacuated during the contractile states. The original peristaltic direction is preserved so that retroperistalsis in antiperistaltic loops may lead to patient discomfort and pulmonary complications.

[Radioimmunoscintigraphy using SPECT: methodology, problems and clinical experiences]. / Radioimmunszintigraphie mit SPECT: Methodik, Probleme und klinische Erfahrungen.

Radioimmunoscintigraphy (RIS) with 111In-and 131I-labelled monoclonal antibodies (MAbs) against CEA and/or CA 19-9 was performed in 83 patients with various gastrointestinal carcinomas. A total of 276 body regions could be examined. The results of planar scintigraphy and SPECT were compared intraindividually. Using 111In-labelled MAbs the sensitivity of RIS was significantly improved by SPECT (88.9 vs. 52.4% with planar scintigraphy, p less than 0.01). For 131I-labelled MAbs the effect was smaller (83.9 vs. 65.6% with planar scintigraphy, n.s.). This finding can be explained by different kinetics and biodistribution of the used MAb preparations. 111In-labelled MAbs with long whole-body retention and rapid blood clearance reveal ideal qualities for SPECT; on the other hand, the short whole-body retention of 131I-labelled MAbs leads to small count rates and therefore long counting times that make delayed SPECT unsuitable in clinical practice.

Quantitative analysis of anti-CEA antibody accumulation in human colorectal carcinomas.

In order to obtain quantitative data on intratumoral antibody accumulation we analyzed resected colorectal adenocarcinomas of 25 patients who had undergone immunoscintigraphy 4-14 days earlier. All had been injected with 0.5-1.0 mg intact anti-CEA antibody (BW 431/26) labelled with 70-80 MBq131I. Correlation of tissue radioactivity concentrations with tumor characteristics revealed significantly higher values in necrotic compared to viable as well as in CEA-positive compared to CEA-negative viable tumor tissue indicating action of both specific and unspecific uptake mechanisms. In contrast, diagnostic results of immunoscintigraphy were influenced by tumor size only. 11 of 12 false-negative findings were obtained in tumors < 4 cm in diameter. Since ex-vivo scintigraphy of resected specimens correctly visualized all but one of these lesions, it is concluded that technical limitations of scintigraphy are the main cause of negative results of radioimmunoimaging with 131I-labelled antibodies.

Radioimmunoscintigraphy with 111In labelled monoclonal antibody fragments (F(ab')2 BW 431/31) against CEA: radiolabelling, antibody kinetics and distribution, findings in tumour and non-tumour patients.

Forty seven patients with suspected malignant disease (mainly colorectal cancer) were studied with 111In labelled F(ab')2 fragments of an anti-CEA monoclonal antibody (BW 431/31). The kinetic data revealed a long whole body retention of the label (62% after 4 days) and a rapid blood clearance (77% within 24 h, 89% within 48 h) leading to an early positive tumour contrast 24 h p.i. and optimal scintigrams 48 h p.i. Diagnostic results were promising in local recurrences of colorectal cancer (8/10 positive = 80%) though false positive findings in patients with inflammatory bowel disease occurred probably due to cross-reaction with a human granulocyte antigen. Liver metastases and tumours neighbouring liver and spleen were often missed (10/27 = 37%) because of high nonspecific uptake in these organs. Thus BW 431/31 proved to be a suitable compound for radioimmunodetection, however, further improvements to optimize tumour affinity and specificity of the antibody are mandatory.

Pancreatic cancer detected by positron emission tomography with 18F-labelled deoxyglucose: method and first results.

In order to evaluate the utility of positron emission tomography (PET) with 18F-labelled deoxyglucose (FDG) for detection of pancreatic cancer 15 patients with pancreatic masses shown by computed tomography were investigated. Static PET scans covering an axial field of view of 15 cm were obtained 45 min after intravenous injection of 150-300 MBq FDG. Focally increased FDG accumulation was present in 12 out of 13 patients with histologically proven adenocarcinoma, in particular in eight of nine lymph node and four of five liver metastases. Scans of two patients with chronic pancreatitis confirmed by surgery revealed a normal FDG distribution. Contrast between tumour and normal tissue depended the metabolic situation prior to FDG injection. High ratios were found in fasting patients whereas no elevated FDG uptake was measured in an insulin-dependent diabetic suffering from carcinoma of the pancreatic head. We conclude that FDG PET might have the potential for detection and even differentiation of pancreatic carcinoma from chronic pancreatitis. Further studies are necessary to substantiate these preliminary findings and to optimize results in diabetic patients.

Principles of radical surgery in gastric carcinoma.

The principles of radical surgery for gastric carcinoma are discussed on the basis of 102 patients treated between 1985 and 1988. Early gastric carcinomas accounted for 11.8% of the cases. Tumor stage, localization and histopathological Lauren grading were the most important parameters influencing the decision on the extent of the excision. Thirteen (22.4%) of the 58 operations done with curative intent were subtotal gastrectomies for small antral tumors. The remaining 45 patients required total gastrectomy with splenectomy. A lymphadenectomy of compartment II was obligatory in all radical procedures. Despite high co-morbidity of the patients the postoperative mortality was 3.1% for total gastrectomy, 4.8% for subtotal gastrectomy and 6.3% for palliative bypass procedures.

[Results of treatment in esophageal cancer]. / Behandlungsergebnisse des Oesophaguscarcinoms.

204 patients were treated for esophageal cancer from 1.1.1986 until 1.6.1992 (carcinoma of the hypopharynx: n = 12, adenocarcinoma of the endobrachyesophagus: n = 82, primary esophageal cancer: n = 110). Out of the primary esophageal cancers 84 tumors (76%) were resected and 24% had palliative endoscopic and/or irradiation therapy. The stage distribution of the resected patients was: stage I: 7.1%, stage IIa: 35.7%, stage IIb: 11.9%, stage III: 33.3%, stage IV: 11.9%. The total morbidity of the resected patients amounted to 32.1%, the 30 days mortality to 7.1%, and the in hospital mortality to 9%. These data show no significant difference to the results of palliative endoscopic procedures (morbidity: 42.3%, mortality: 7.7%). None of the conservatively treated patients survived longer than 12 months whereas resected individuals had a 5-year-survival rate of 20%. The most predictive factors for prognosis were: Depth of tumor invasion (p less than 0.01), R-classification (p less than 0.05), and the lymphonodular status (p less than 0.05). A perioperative irradiation was effective in T3- and T4-tumors.

[Surgical therapy of chronic constipation]. / Chirurgische Therapie der chronischen Obstipation.

Results of the surgical treatment for conservative intractable constipation in 70 adult patients are reviewed. 49 patients with severe symptoms have been treated by partial colectomy as sigmoid colectomy (n = 23) or left hemicolectomy (n = 26). 33 patients underwent colectomy with cecorectal anastomosis (n = 25) or ileorectal anastomosis (n = 8). Out of these patients with colectomy seven had undergone previous segmental colonic resection or internal sphincterotomy. Of those patients with cecorectal anastomosis who were dissatisfied, three underwent ileorectal anastomosis. Overall, a mortality rate of 3.3% and morbidity rate of 22.5 resp. 54.5% for partial and total colectomy were observed. The most frequent occurring complication after colectomy was small bowel obstruction in 30% requiring laparotomy in 40%. Of 45 patients who underwent partial colectomy, 34 (75%) had normal bowel function or were markedly improved. In 28 of 32 patients (87.5%) treated by colectomy a successful result has been achieved. The operation of sigmoid colectomy or left hemicolectomy may be recommended as a treatment for constipation only in patients with less severe symptoms or patients with recurrent sigmoid volvulus. For those patients with severe constipation, at present, colectomy with ileorectal anastomosis seems to be the surgical procedure that offers the greatest probability of improvement. However, the significant morbidity claimed the need for a careful patient selection.

[Results of Parks postanal repair in idiopathic anal insufficiency]. / Ergebnisse der posterioren Raffung nach Parks bei der idiopathischen analen Inkontinenz.

To assess the functional results of postanal repair of faecal incontinence we carried out clinical, physiological and radiological studies in 31 patients. Continence was improved in 26 (84%) patients, 19 (62%) of whom regained normal continence at a minimum of 12 months follow-up. A successful clinical outcome after postanal repair does appear to be related more to an improvement in sphincter pressures than to any reduction of the anorectal angle.

[Prognostic improvement by R1 and R2 lymphadenectomy in stomach carcinoma]. / Zur Frage der Prognoseverbesserung durch R1- und R2-Lymphadenektomie beim Magencarcinom.

In 1986 systematic R2 lymphadenectomy was introduced into the surgery for gastric carcinoma in our institution. In an historic analysis 381 patients of the years 1980-1992 were investigated. The effect of R2 lymphadenectomy was studied after R0 resection and exclusion of inhospital mortality. 81 matched pairs of patients with and without lymphadenectomy (LA) were restaged according to the latest classification of the UICC (1987) and compared in an univariate and multivariate analysis. A significant improvement of the estimated 5-year survival-rate was only seen in UICC-stages II (p = 0.05), IIIA (p = 0.01) and patients without lymph node metastases (pN0, p = 0.01). The multivariate analysis did not show an independent effect of LA on prognosis but of the oncological parameters pT and pN (p = 0.0001). We conclude that LA improves the prognosis of gastric carcinoma in certain early stages but the effect is not as impressive as expected.

[Prognostic factors for development of peritoneal carcinosis in stomach carcinoma]. / Prognosefaktoren für das Auftreten einer Peritonealcarcinose beim Magencarcinom.

OBJECTIVE: Several adjuvant therapy concepts have been developed to improve the treatment of gastric cancer patients. Dealing with intraperitoneal chemotherapy, it seems to be useful to determine suitable prognostic factors for the occurrence of peritoneal carcinosis, as it is possible to select patients who may profit from this therapy. METHODS: Between June 1975 and December 1999 resection of gastric cancer was performed in 575 patients. From 1 January 1986 clinical data were recorded prospectively, before that time, retrospectively. The complete data concerning preoperative diagnosis, operation, histology, postoperative course and survival time were documented in an Excel file for statistical analysis. Multivariate analysis was performed using the chi-squared logistic regression test. RESULTS: Significant correlation was found between the occurrence of peritoneal dissemination and tumour stage pT3, pN2, G3, cancer of the whole stomach and cancer at the anastomotic site after partial gastric resection. Lauren classification, signet-ring cell cancer, liver metastasis and tumour localisation in the distal or proximal stomach showed no significant correlation to peritoneal carcinosis in the multivariate analysis. However, only one-third of patients with liver metastasis had simultaneous peritoneal dissemination. CONCLUSION: The results show a clinical correlation of tumour localisation, infiltration of the serosa, lymph node metastasis and grading with peritoneal dissemination. The present data serve as a basis for further histochemical and molecular biological investigations e.g. of the expression of adhesion molecules to determine the risk of peritoneal tumour dissemination after gastric cancer.

[Hepatic ischaemia during Whipple resection: case report of a rarely required revascularisation]. / Hepatische Ischämie bei der Whipple-Operation. Kasuistik einer selten notwendigen Revascularisation.

With the performance of a partial duodenopancreatectomy, the collateral vascular bed between the coeliac trunk and the superior mesenteric artery is reduced. Normally, this does not lead to ischaemia of the upper abdominal organs. However, we present the rare case of a patient in whom a Whipple resection in combination with a hyploplastic coeliac trunk led to hepatic and splenal ischaemia and aorto-hepatic bypass grafting. The indication for preoperative arteriography is in discussion, since variations or alteration of the upper abdominal vessels are known to be common but manifest organ ischaemia during resection is a rare complication. Patients with signs of general arteriosclerosis or those in whom upper abdominal resection has been performed previously may benefit from angiography. In other cases a test occlusion before vessel ligation is considered to be suitable in assessing the need for vascular surgical intervention.