[Successful treatment of secondary aortoesophageal fistula after thoracic endovascular aortic repair]. / Erfolgreiche Therapie einer sekundären aortoösophagealen Fistel nach Implantation eines endovaskulären Aortenstentgrafts.

HISTORY AND CLINICAL SYMPTOMS: A 58-year-old man was admitted to our hospital with acute chest pain and subfebrile temperatures. Two years ago, endovascular aortic stent-graft placement had been performed for acute type B aortic dissection complicated by malperfusion syndrome. DIAGNOSTIC ASSESSMENT: CT angiography showed a discrete soft-tissue attenuation mass between the aorta and esophagus. The patient developed progressive swallow disorder and esophago-gastro-duodenoscopy demonstrated deep esophageal ulcerations at the level of the implanted aortic stent-graft. Intravenous treatment with broad spectrum antibiotics was started. The FDG-PET/CT scan showed increased FDG uptake and air entrapment in the affected region establishing the diagnosis of aortoesophageal fistula formation. THERAPY AND OUTCOME: Given the generally poor condition of the patient and the high risk of any aggressive surgical intervention, a new limited surgical approach was chosen consisting of open transthoracic esophageal resection, blind closure of the stomach and cervical esophagostomy. A percutaneous endoscopic gastrostomy tube was placed. After three months, esophageal continuity was restored by retrosternal colon interposition. The presented therapeutic management resulted in a full recovery of the patient. CONCLUSION: Aortoesophageal fistula is a rare complication of thoracic aortic stent-graft placement. Patient may present with unspecific symptoms such as fever and rised inflammatory markers, but may also present with massive upper gastrointestinal bleeding. The herein presented limited therapy with esophageal resection represents a promising to the otherwise difficult therapy of aortoesophageal fistula.

Liver transplantation as a primary indication for intrahepatic cholangiocarcinoma: a single-center experience.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is not a widely accepted indication for orthotopic liver transplantation (OLT). The present study describes our institutional experience with patients who underwent transplantation for ICC as well as those with ICC who underwent transplantation with the incorrect diagnosis of hepatocellular carcinoma (HCC). PATIENTS AND METHODS: Data corresponding to ICC patients were reviewed for the purposes of this study. Patients with hilar cholangiocarcinoma and incidentally found ICC after OLT for benign diseases were excluded from further consideration. RESULTS: Among the 10 patients, 6 underwent transplantation before 1996 and 4 after 2001. Those who underwent transplantation in the early period had a preoperative diagnosis of inoperable ICC (n = 4) and ICC in the setting of primary sclerosing cholangitis (n = 2). In the latter period the subjects had a diagnosis of HCC in cirrhosis (n = 3) or recurrent ICC after an extended right hepatectomy (n = 1). Median survival was 25.3 months for the whole series and 32.2 months (range, 18-130 months) when hospital mortality was excluded (n = 3). Four patients are currently alive after 30, 35, 42, and 130 months post-OLT, respectively. Two patients died of tumor recurrence at 18 and 21 months post-OLT, respectively. One-, 3-, and 5-year survival rates were 70%, 50%, and 33%, respectively. CONCLUSIONS: The role of OLT in the setting of ICC may be re-evaluated in the future under strict selection criteria and with prospective multicenter randomized studies. Potential candidates to be included are those with liver cirrhosis and no hilar involvement who meet the Milan criteria for HCC.

[Frequency of decubitus ulcer in patients of a university medical center. Combination of routine documentation and cross-sectional study]. / Häufigkeit des Dekubitus in einem Universitätsklinikum. Kombination von Routinedokumentation und Querschnittstudie.

BACKGROUND AND OBJECTIVE: Pressure ulcer is a relevant issue for quality management and cost containment of hospitals. Cross-sectional studies are the typical design to estimate the frequency of pressure ulcers. The derived point prevalence rate is not as good for a case related reference value as the period prevalence rate. The interdisciplinary pressure ulcer project at the University Clinics in Essen combined a routine documentation with a cross-sectional survey, thus providing both measurements for the first time. PATIENTS AND METHODS: The routine and computer-based collection of information about pressure ulcers started in March 2003, using the patient administration system medico//s from Siemens. Findings are presented from 49,904 admissions, starting on 91/03/2004, discharged by 31/03/2004. The mean age was 48.7 +/- 22.4 years; 51.2 % were males, 48.8 % females. Additionally, a decubitus team examined patients from randomly selected wards each work-day. The real period prevalence rate was calculated using the observed period prevalence rate, the sensitivity and the point prevalence rate. RESULTS: In the routine documentation, 700 pressure ulcers had been recorded from 49,904 inpatient cases (period prevalence rate 1.4 %). The decubitus team did 5,415 examinations and 294 times detected at least one pressure ulcer (point prevalence rate 5.4 %). Estimated results in three different period prevalence rates: 3.0 % using sensitivity of the routine documentation, 3.7 % using sensitivity stratified for departments, and 2.3 % using the point prevalence rate for cases with short, medium, and long length of stay. CONCLUSIONS: The project presents for the first time reference values for pressure ulcer frequency in university clinics. A comparison with international rates is hindered by unpublished sensitivity values. In view of the higher point prevalence rate of 10 % present in the literature, a period prevalence rate of 5 % is a realistic reference value.

Frostbite in a mountaineer.

Cold injury is an objective danger in mountain climbing as well as in many outdoor sports. With increasing number of people practising so-called extreme tourisms physicians can be confronted with frostbite. Thus we present a case of frostbite in a 35 year-old female mountaineer. She took part at a demanding high alpine trekking tour in the Himalayan-area requesting well trained mountaineers experienced in ice- and securing-techniques and good physical condition. At day 12, when the group reached the top of the Parchamo (Nepal, 6273 m), she developed frostbite at all toes leading to amputation finally. Risk factors, prognosis and options for initial treatment are discussed.

Pancreatic secretory response to intraileal amino acids: studies in dogs with an in situ neurally isolated ileum.

BACKGROUND: Intraileal carbohydrates and lipids affect the pancreatic exocrine secretion, but the effect of intraileal amino acids and the role of the extrinsic nerves of the ileum as mediators of the pancreatic bicarbonate and enzyme output are unknown. METHODS: Four dogs underwent total extrinsic denervation of the entire ileum. Thomas-like cannulas were placed into the stomach, duodenum (to collect pure pancreatic juice), and at the jejuno-ileal junction. Eight neurally intact control dogs received only the three fistulas. After recovery, in both sets of dogs, dose-response studies of the pancreatic secretory response to intraileal infusion with graded loads of tryptophan (0.12-10.0 mmol/h) were performed, given against an intravenous (iv) background of secretin (20.5 pmol/kg/h) and cerulein (29.6 pmol/kg/h). On separate days, control experiments with intraileal infusion of 0.15 M NaCl were performed. RESULTS: In both sets of dogs, iv secretin plus cerulein significantly (p < 0.05) increased pancreatic bicarbonate and protein output above basal. Intraileal tryptophan caused a dose-dependent decrease in the pancreatic bicarbonate and protein response to secretin plus cerulein. In the dogs with denervated ileum, this inhibition was significantly stronger than in the intact animals. In both sets of dogs, the 225-min integrated bicarbonate (IBR) and protein response (IPR) to all loads of tryptophan were significantly lower than in control experiments. Both IBR and IPR were significantly lower in the denervated as compared with the intact animals. CONCLUSIONS: 1) Extrinsic denervation of the entire ileum is a valuable preparation to study the role of nerves in the control of pancreatic exocrine secretion; 2) both in the intact and denervated animals the amino acid tryptophan induces an "ileal brake" of the hormonally stimulated pancreatic bicarbonate and protein output; 3) the extrinsic nerves of the ileum are probably not the dominant mediators of the inhibitory action of intraileal tryptophan but rather counteract this effect.

[Assessing the quality of life after pancreas-kidney transplantation]. / Einschätzung der Lebensqualität nach Pankreas-Nierentransplantation.

The pancreas-kidney transplantation strives for a reestablishment both of the physiological regulation of blood glucose levels without external insulin and of kidney function without the need of dialysis. Nevertheless, the postoperative morbidity of the combined transplantation is high. In long lasting diabetes type I, a strict selection of transplant candidates is necessary to minimize the risks of cardio-vascular complications. Between 1990 and 1997 only 17 of 44 patients really were accepted for transplantation in our unit. 13/17 patients are actually independent from external insulin and dialysis. Two other patients are free of dialysis, but the pancreas transplants had to be removed due to thrombosis or infection. In one case therapy-resistant acute rejection occurred and both organs had to be removed after two months. One women died four years after transplantation with a functioning kidney graft from myocardial infarction. 10 patients with stable transplant function are at work again. After normal pregnancy two women gave birth to healthy children, in one case twins. Drug regimen and outpatients visits are not seen as significant restrictions of the quality of life.

Pancreatic secretory response to intrajejunal tryptophan: studies in dogs with an autotransplanted entire jejunoileum.

In two sets of dogs with gastric, duodenal, and jejunal fistulas, we studied the effect of atropine (14 nmol/ kg/h) on the pancreatic secretory response to intrajejunal tryptophan (0.12-10.0 mmol/h; given against a secretin background) before (n = 7) and after extrinsic denervation of the jejunoileum (orthotopical autotransplantation; n = 6). Plasma levels of cholecystokinin were determined by radioimmunoassay. The incremental bicarbonate response to tryptophan was not significantly different between the two sets of dogs. Atropine had no effect on the incremental bicarbonate response to tryptophan. In both sets of dogs, intrajejunal tryptophan caused a dose-dependent increase in pancreatic protein output, which was reduced by atropine. The tryptophan-stimulated levels of plasma cholecystokinin were not significantly altered by denervation and or atropine. We conclude that in dogs (1) intrajejunal tryptophan stimulates pancreatic bicarbonate and protein secretion via release of hormones, (2) extrinsic denervation of the jejunoileum does not significantly alter the incremental bicarbonate and protein responses to intrajejunal tryptophan, (3) the cholinergic intrinsic nerves of the jejunoileum and the hormone cholecystokinin are probably involved in control of the pancreatic protein response to tryptophan, and (4) the release of cholecystokinin by intrajejunal tryptophan does not depend on the extrinsic and intrinsic cholinergic nerves of the jejunoileum.

[Results of peripheral arterial vascular injury in polytraumatized patients]. / Ergebnisse peripherer arterieller Gefässverletzungen beim polytraumatisierten Patienten.

The therapeutic concept of limb salvage or immediate amputation is controversial in patients with multiple trauma. Sixty-three multiple trauma patients (injury severity score ISS > 18 patients) with blunt arterial injuries were investigated. Twenty-seven had injuries of the upper limb and 36 patients of the lower limb. In 33 cases a limb salvage procedure was performed (group I), while in 30 cases the limb was amputated (group II). Neither group showed a significant difference in age (I: 33 +/- 3, II: 30 +/- 3 years), ISS (I: 30 +/- 2, II: 29 +/- 2 patients), time of ischemia (I: 238 +/- 30, II: 203 +/- 20 min) ICU stay (I: 18 +/- 4, II: 19 +/- 4 days). Lethality and morbidity were slightly increased in group I (death: I: n = 8; II: n = 4; MOF: I: n = 5; II: n = 3; Sepsis: I: n = 11, II: n = 4). No differences were found in the incidence of local infections (I: n = 12, II: n = 10). Secondary amputations were performed in 7 patients after 12 +/- 2 days (range 3-40; median: 5 days). We conclude that limb salvage did not increase the risk for severe complications. Lethality and morbidity were related to the severity of the injury. To prevent complications, secondary amputations had to be performed early.

Combined preoperative chemotherapy and radiotherapy in patients with locally advanced esophageal cancer. Interim analysis of a phase II trial.

PURPOSE: The prognosis of patients with locally advanced esophageal cancer (LAEC) remains poor when treated with local modalities. An intensive preoperative program with chemoradiotherapy was used to evaluate the curative resection rate, pathologic response, and survival of patients with LAEC. PATIENTS AND METHODS: Ninety patients with LAEC were treated preoperatively with chemotherapy (three courses of fluorouracil, leucovorin, etoposide, and cisplatin [FLEP]) followed by concurrent chemoradiotherapy (one course of cisplatin plus etoposide in combination with 40 Gy of radiation). Transthoracic esophagectomy was performed 4 weeks after the end of radiation. RESULTS: Seventy-two patients were included in this evaluation. Forty-four (61%) underwent a complete tumor resection, and 16 (22%) had no tumor in the resected specimen (pathologic complete response [PCR]). The operative mortality rate was 15%. At a median follow-up time of 22 months (range, 12 to 41), the median survival duration of all 72 patients was 17 months (range, 1 to 41+). The calculated survival rates at 3 years were 33%, 42%, and 68% for all patients, patients after complete resection, and patients with PCR, respectively. CONCLUSION: This combined treatment modality is active in LAEC, with a PCR in 33% of the patients undergoing surgery. The results appear improved compared with those reported with surgery alone, by approximately doubling the 3-year survival rate. The high efficacy of preoperative chemoradiation warrants evaluation of the role of surgery in LAEC.

[Liver complications in HELLP syndrome]. / Leberkomplikationen des HELLP-Syndroms.

In a 5 years period 5 female patients suffering from a severe HELLP syndrome were treated. The problems concerning diagnostic and treatment are discussed. 3 patients had to be operated on in an emergency state. The operations were performed because of acute and severe abdominal bleeding. Two of the patients needed liver transplantation as an emergency procedure, one of them died after hepatectomy on the list. Another one died 7 weeks after successful transplantation in a state of prolonged sepsis. The two conservatively treated and the one transplanted patient are still alive and well.

[Liver complications of HELLP syndrome--an indication for emergency liver transplantation?]. / Leberkomplikationen des HELLP-Syndroms--eine Indikation zur notfallmässigen Lebertransplantation?

Three patients were treated suffering from a severe HELLP-syndrome. The problems as far as the diagnostic and therapy are concerned are discussed. All three patients had to be operated on in an emergency state. The operations were performed due to acute and severe abdominal bleeding. Two of the patients needed liver transplantation as an emergency procedure, one of them died after hepatectomy waiting for a graft. Another one died seven weeks after successful transplantation due to prolonged sepsis. The third patient is more than one year after transplantation alive and doing well.

Acute liver necrosis in the HELLP syndrome: successful outcome after orthotopic liver transplantation. A case report.

We discuss the case of a 30-year-old primipara woman who developed a liver rupture as a complication of the HELLP syndrome. A liver necrosis and bleeding made a hepatectomy necessary. A portocaval shunt was able to maintain the patient until she underwent urgent liver transplantation. In an excellent state of recovery, the woman and her baby were discharged from the hospital 66 days after having been admitted.

[Autotransplantation of the kidney. Indications and results]. / Die Autotransplantation der Niere. Indikationen und Ergebnisse.

Renal autotransplantation is an established but rarely used therapy in cases of renal vessel lesions, tumours of the kidney and ureter, long-distance ureter lesions, complex nephrolithiasis and retroperitoneal fibrosis. The indications and results of renal autotransplantation are discussed using three case reports and compared to the literature. In cases of central intrarenal tumours and aneurysms of the kidney, autotransplantation is indispensible in order to save the organ. For long-distance ureter lesions as well as for retroperitoneal fibrosis, autotransplantation of the kidney gives excellent results. In difficult clinical situations ileum segment interposition is an alternative treatment.

[De novo malignant tumors during drug immunosuppression. The findings following 1245 cadaveric kidney transplants in 1080 patients]. / De-novo-Malignome unter medikamentöser Immunsuppression. Befunde nach 1245 Leichennierentransplantationen bei 1080 Patienten.

Thirty new malignant tumours were found in 1080 patients (634 men, 446 women; mean age 37.6 +/- 13.6 years) after a median follow-up period of 5 years following 1245 cadaveric kidney transplantations performed between 1972 and 1990. The mean dialysis period before transplantation had been 4.0 +/- 3.1 years. Regarding the type of tumour, carcinomas were by far the most frequent, while there was only one lymphoma. The annual malignancy incidence for renal transplant patients was 0.5%. This is 3.5 times higher for men and 4.2 times for women than in the normal population. Immunosuppression with azathioprine and/or antithymocytic globulin (n = 395) produced the same malignancy incidence (0.54%) as with cyclosporin (n = 685; 0.60%). On the other hand, malignant tumours occurred much earlier under cyclosporin than under azathioprine/antithymocytic globulin (27 and 68 months, respectively).

Patterns of prohormone processing. Order revealed by a new procholecystokinin-derived peptide.

An 83-amino acid cholecystokinin peptide with a sulfated tyrosine and an amidated carboxyl terminus (CCK-83) was purified from human intestinal mucosa. The purified peptide was chemically characterized, and its bioactivity was compared to CCK-8. Several post-translational processing steps such as cleavage at basic residues, sulfation, and amidation are necessary to form biologically active cholecystokinin from its nascent prepropeptide. The discovery of CCK-83 gives new insight into the order of preprohormone processing. The processing of prepro-CCK appears to be in the order of: 1) signal peptidase cleavage, 2) tyrosine sulfation, 3) cleavage after a carboxyl-terminal pair of basic residues, 4) carboxypeptidase B-like cleavage of these basic residues, 5) amidation (which results in the formation of CCK-83), and 6) cleavage at monobasic residues by endopeptidases (which results in the smaller molecular forms of cholecystokinin). The characterization of biologically active CCK-83 with a sulfated tyrosine and an amidated carboxyl terminus establishes the site of signal peptidase action and suggests an order of post-translational modifications that give rise to the various molecular forms of cholecystokinin.