[Percutaneous endovascular aneurysm repair without arteriotomy (Perclose system)]. / Perkutane endoprothetische Therapie des Aortenaneurysmas ohne Arteriotomie.

BACKGROUND AND OBJECTIVE: It is common clinical practice to perform an arteriotomy for the endovascular treatment of infrarenal and thoracic aortic aneurysms. Instead we used the percutaneous endovascular Perclose device to perform the aneurysm repair without arterial cut-down. PATIENTS AND METHODS: The Perclose device contains four needles with two suture loops for closing the femoral artery access site. The sutures were deployed after the arterial puncture, before introduction of sheaths (diameter 12 - 27 F = 4 - 9 mm). After the procedure the sutures were used to close the puncture site. We attempted to achieve hemostasis with the Perclose system in 104 femoral arteries in 60 patients (7 females, mean age 69 +/- 12 years). The mean vessel diameter was 10 +/- 2 mm. RESULTS: The percutaneous graft implantation was successfully achieved in 58 of 60 patients. The graft could not be forwarded into the aorta in two cases because of calcified iliac arteries. The Perclose suture technique was successfully used in 97 femoral arteries. In one case a false aneurysm developed and in another case a secondary hemorrhage occurred. Seven patients needed additional manual compression to achieve complete hemostasis. A surgical repair was not necessary. The time to hospital discharge ranged from 4.5 hours to 32 days (median: 18 hours). 20 patients stayed longer than 24 h in the hospital, only 2 of them for reasons related to the puncture site. CONCLUSION: Closing the access site with the Perclose system is technically feasible and effective, even with large sheaths up to 27 F = 9 mm. This technique reduces the invasiveness of the endovascular repair of aortic aneurysms and decreases the length of hospital stay, i. e. it allows treatment in outpatients.

The novel ependymin related gene UCC1 is highly expressed in colorectal tumor cells.

Normal cells differ from malignant tumor cells in the transcription levels of many different genes. Two colorectal tumor cell lines were compared with a normal colorectal cell line by differential display reverse transcription PCR to screen for tumor cell specific differentially transcribed genes. By this strategy the upregulation of a novel gene was detected designated as 'upregulated in colorectal cancer gene-1' (UCC1). The UCC1 gene transcript level is increased in cultured tumor cells and in two out of three analyzed colorectal tumor tissue specimens compared to normal cultured cells and to corresponding normal tissue samples. Remarkably, the UCC1 protein shows significant sequence similarity to the highly divergent piscine glycoproteins termed ependymins which are synthesized by leptomeningeal fibroblasts and secreted into the cerebrospinal fluid.

Seven genes that are differentially transcribed in colorectal tumor cell lines.

To identify genes which are differentially transcribed in colorectal tumor cells, we compared the two human tumor cell lines, SW480 and HCT116, with the cell line, NCM460, from normal colon epithelium as a control. Using the methods of differential display reverse transcription PCR and Northern blot hybridization, we detected the differential transcription of seven genes: cholecystokinin, reticulocalbin, Rab5 guanine nucleotide exchange factor Rabex5, caldesmon, differentiation related gene 1 (drg1), taxol resistant associated gene 3 (Trag-3) and the gene for the placental protein, diff33. The yet unidentified cDNA of the human Rabex5 gene and the 3' untranslated region of the human caldesmon gene were cloned.

A beta-catenin mutation in a sporadic colorectal tumor of the RER phenotype and absence of beta-catenin germline mutations in FAP patients.

As a signaling protein in the Wnt pathway beta-catenin plays a crucial role in the regulation of cellular proliferation. Recently, oncogenic beta-catenin mutations were described in human colorectal cancer and melanoma cell lines. Since activating mutations in the beta-catenin gene have similar effects on the biochemical level as inactivating mutations in the tumor suppressor gene APC, it is speculated that beta-catenin mutations may substitute APC gene inactivation in carcinogenesis. To address this question we analyzed twenty-three sporadic colorectal tumors of different progression states for mutations in the beta-catenin gene. Eighteen of these tumors showed the wildtype APC gene sequence. In only one of the tumors with wildtype APC a beta-catenin gene mutation was found. This tumor was of the RER (replication error) phenotype which may explain the finding that the mutation occurred in a sequential repeat motif of the beta-catenin gene. The second aim of this study was to investigate whether differences in the phenotypic variability in FAP (familial adenomatous polyposis coli) might be due to inherited alterations in the beta-catenin gene. For this we analyzed DNA from fourteen FAP patients from eight different families for germline mutations in the beta-catenin gene. We did not find any beta-catenin gene alteration in these samples. Our results indicate that somatic beta-catenin activating mutations contribute only to a minor part of human colorectal tumors and that germline beta-catenin mutations do not play a role in the variability of symptoms in FAP.

[Cost savings by disinfection for prevention of surgical wound dehiscence after gastrectomy]. / Kostensenkung durch Dekontamination zur Prävention der Nahtinsuffizienz nach Gastrektomie.

The aim of this study was to examine the effect of decontamination as compared to placebo medication on post-gastrectomy treatment costs. The results of a prospective double-blind placebo-controlled multicenter trial indicate that perioperative i.v. prophylaxis with cefotaxim and topical decontamination with polymyxin B, tobramycin, vancomycin and amphotericin B from the day before surgery until the 7th postoperative day is most effective in the prevention of esophagojejunal anastomotic leakage following total gastrectomy. For the cost analysis, only patients who had been decontaminated according to the study protocol (n = 90) were compared to the non-decontaminated patients (n = 103). The esophagojejunal leakage rate was 10.6% in placebo patients (n = 103) and could be reduced significantly to 1.1% in decontaminated patients (n = 90, P = 0.0061; two-tailed Fisher's exact test). There was only one asymptomatic leakage detected on Gastrografin swallow. The pulmonary infection (P = 0.0173) and overall complication rates (p = 0.0238) were significantly reduced in the decontamination group as well. During the observation period, 9 (8.7%) patients in the placebo group and 3 (3.3%) in the decontaminated group died (P = n.s.). Patients were followed up for the initial 42 postoperative days and treatment costs were calculated for this time period only. The parameters compiled in the study pertaining to use of medical resources formed the basis for the determination of the postoperative treatment costs. These were the costs for decontaminating drugs, intravenous antibiotics, reoperations and non-surgical reinterventions as well as daily treatment costs of the general ward, the intensive care unit (ICU) and rehabilitation. The average costs per patient in the placebo group amounted to DM 20,000 while the costs for decontaminated patients were only DM 16,200, which was due to a significantly lower number of patients requiring treatment in the ICU (P = 0.0082), significantly fewer patients requiring i.v. antibiotics (P = 0.0232) and fewer patients with reoperations (P = 0.0909). The prophylaxis employing decontaminating drugs in the amount of DM 400 lowered post-gastrectomy treatment costs by DM 3800 or 19%. The prophylaxis can be recommended, because it lowers morbidity, mortality and the costs of total gastrectomy.

The prevention of anastomotic leakage after total gastrectomy with local decontamination. A prospective, randomized, double-blind, placebo-controlled multicenter trial.

OBJECTIVE: A prospective, randomized, double-blind, placebo controlled multicenter trial was undertaken in 205 patients treated with total gastrectomy for gastric malignancies to evaluate whether local antimicrobial measures reduce the incidence of esophagojejunal anastomotic leakage. SUMMARY BACKGROUND DATA: Anastomotic leakage of the esophagojejunostomy is always a septic complication of total gastrectomy for gastric malignancies, but it never has been attempted to prevent this complication with the administration of topical antimicrobial agents during the critical phase of anastomotic wound healing. METHODS: To evaluate the efficacy and safety of topical decontamination, the study was carried out as a prospective, randomized, double-blind and placebo-controlled clinical multicenter trial in patients with total gastrectomy for gastric cancer. Patients received either placebo or decontamination with polymyxin B (100 mg), tobramycin (80 mg), vancomycin (125 mg), and amphotericin B (500 mg) four times per day orally from the day before the operation until the seventh postoperative day. All patients received a perioperative intravenous prophylaxis with cefotaxime 2 x 2 g. Other interventions including the administration of antibiotics and fluids, were not affected by the study protocol. RESULTS: Of 260 patients who were randomized, total gastrectomy was not carried out in 55 patients. They dropped out of the study. Patients receiving an esophagojejunostomy were observed until day 42, when they were discharged from the clinic or died. An intention-to-treat analysis of the data was carried out. Among the 103 recipients of placebo, there were 11 (10.6%) with an anastomotic leakage of the esophagojejunostomy, and among the 102 recipients of decontamination, there were 3 (2.9%) with an anastomotic leakage of the esophagojejunostomy (p = 0.0492). Pulmonary infections were observed in 23 patients (22.3%) receiving placebo and in 9 patients (8.8%) who were decontaminated (p = 0.02). There were 11 deaths (10.6%) among the recipients of placebo and 5 deaths (4.9%) among the recipients of decontamination (p = 0.1). CONCLUSIONS: Decontamination with polymyxin, tobramycin, vancomycin, and amphotericin B during anastomotic wound healing is safe and effective in the prevention of esophagojejunal anastomotic leakage after total gastrectomy.

[Carcinoma metastasis in cutaneous osseous metaplasia. Differential diagnosis of osseous tumor metaplasia]. / Carcinommetastase in cutaner ossärer Metaplasie. Differentialdiagnose ossärer Tumormetaplasien.

The formation of metastases in heterotopic ossifications is a very rare finding. The example of a 63-year old male who underwent Billroth II procedure because of recurrent duodenal ulcers 30 years ago and median laparotomy of the upper abdomen because of blunt abdominal trauma 9 years ago shows the formation of metastasis of a carcinoma found in the gastroenteral anastomosis in a focus of heterotopic ossification, which was located in the scar of the upper abdominal laparotomy.

[Aggressive volume therapy for prevention of acute renal failure in multiple trauma patients]. / Aggressive Volumentherapie zur Prävention des akuten Nierenversagens Polytraumatisierter.

Immediate fluid resuscitation is of the utmost importance for patients with multiple trauma. Evaluation of this form of treatment for the prevention of acute renal failure was the purpose of this study. Of 262 patients with multiple trauma, 112 were in shock on admission. The patients were treated with large volumes of Ringer's lactate and sodium bicarbonate until urine production was 60-100 ml/h. Hemoglobin and electrolytes were substituted according to the laboratory findings. There were 32 patients who developed renal complications, such as bacteriuria (13), hematuria (7), reduction of renal function (3), and acute renal failure (9). The renal failure did not develop during the first 24-48 h but during treatment in the intensive care unit, mostly in the course of multiple organ failure. Death supervened in 35 of the 262 patients (13.5%). Thus, immediate rapid fluid replacement with large volumes of crystalloid solutions can prevent acute renal failure.

Transforming growth factor alpha inhibits secretion of gastric acid.

Transforming growth factor alpha (TGF-alpha), a protein secreted by transformed cells and related to epidermal growth factor (EGF), was tested for its effects on gastric acid secretion. Guinea pig gastric mucosae were mounted in Ussing chambers and the rate of acid release was monitored by the pH-stat method. When administered prior to the secretagogue, TGF-alpha prevented the histamine-induced increase in the rate of acid secretion. Similarly, TGF-alpha caused a decrease in the rate of acid release in tissues that had already been stimulated with histamine. These data show that TGF-alpha inhibits gastric acid secretion in a manner similar to EGF and that the two growth factors share at least one physiological action unrelated to their mitogenic properties.

Differential effects of gastrointestinal hormones on the blood flow of the alimentary tract of the dog.

The blood flow of the alimentary tract in anesthetized dogs was measured with radioactively labeled 15-micron microspheres before and after i.v. application of the gastrointestinal hormones glucagon, vasoactive intestinal polypeptide (VIP), secretin, and somatostatin. After 5 min glucagon in a dose of 75 micrograms/kg bolus + 5 micrograms/kg X min-1 infusion increased significantly the blood flow in liver, stomach, duodenum, jejunum, ileum, and colon as well as the cardiac output by 160%, 761%, 662%, 576%, 817.3%, 320%, and 108%, respectively. A dose of 3 ng/kg X min-1 resulted in reduction of the circulation in liver, gastric fundus, duodenum, and colon by 27.7%, 19.1%, 16.2%, and 10.7% after 5 min while the cardiac output was not affected. Vasoactive intestinal polypeptide (VIP) infused in a dose of 3.3 pmol/kg X min-1 for 5 min increased the blood flow in the pancreas by 30% and reduced it in the spleen and gastric corpus by 26.9% and 41.5%, respectively. Secretin, another member of the glucagon family, after a 5-min infusion of a dose of 0.5 CU/kg X min-1 increased the cardiac output by 49.96% and the renal circulation by 120.7%. In the gastrointestinal tract circulation of the gastric antrum was stimulated by 474%, of the duodenum by 93.5% and of the ileal mucosa by 178%. Infusion of the pancreatic hormone somatostatin (3.5 micrograms/kg bolus followed by infusion of 3.5 micrograms/kg X h-1) increased the blood flow in the liver by 13%, in the pancreas by 23.15%, and in the spleen by 29.8%, while it reduced it in the fundic mucosa by 17.1% and corpus mucosa by 28.8%. In summary, the gastrointestinal hormones examined exert marked and distinct effects on the circulation of the gastrointestinal tract, each hormone in different parts of the digestive tract. Thus, the local microcirculation of the gastrointestinal tract seems to be subject to hormonal in addition to nerval control.

[Modified partial duodenopancreatectomy with preservation of the stomach, proximal gastric vagotomy and pancreatic duct occlusion]. / Modifizierte partielle Duodenopankreatektomie mit Erhaltung des Magens, proximal gastraler Vagotomie und Pankreasgangocclusion.

From 1979 till 1984 a modified partial duodenopancreatectomy was performed in 22 patients with preservation of the stomach, proximal gastric vagotomy, and occlusion of the pancreatic duct. If occlusion of the duct was performed without a pancreatojejunostomy 6 of 12 patients developed a spontaneously healing pancreatic fistula. In 10 patients with duct occlusion and a pancreatojejunostomy no fistulae were observed. Exocrine and, if necessary, endocrine pancreatic insufficiency could be compensated sufficiently medically and by diet. In comparison to the original Whipple's operation preservation of the stomach seems to influence favourably the body weight and thus the quality of life. The proximal gastric vagotomy is performed to prevent anastomic ulcers.

Effects of epidermal growth factor on acid secretion from guinea pig gastric mucosa: in vitro analysis.

Epidermal growth factor (EGF) has been tested on guinea pig gastric mucosa mounted in Ussing chambers to investigate the suitability of using in vitro methods for examining EGF's effects on acid secretion. Epidermal growth factor reduced the rate of histamine-induced acid secretion to near basal levels when applied to the serosal gastric surface at nanomolar concentrations. Inhibitory effects were evident 10-15 min after EGF treatment and were maximal by 40 min. Cyclic adenosine monophosphate-induced secretion was also reduced by EGF, although the effect occurred more slowly than in histamine-treated tissues. Epidermal growth factor increased transmucosal resistance in histamine-treated, but not cyclic adenosine monophosphate-treated mucosa; potential difference was unaffected. Nerve growth factor had no effect when tested in the in vitro system. The EGF binding protein was found to enhance slightly the inhibitory activity of EGF on acid secretion. When applied to the luminal (mucosal) gastric surface, EGF inhibited secretion marginally but only at micromolar concentrations. These results indicate that EGF acts directly upon cells within the gastric mucosa, and is most effective when applied to the serosal gastric surface. They further suggest that in vitro preparations of intact gastric mucosa can be used for analyzing the inhibitory effects of EGF on gastric acid secretion.

Inhibition of gastric secretion by fat and hypertonic glucose in the dog: role of gastric inhibitory peptide.

1. The gastric and intestinal phases of gastric secretion were selectively evoked by 'meals' of 5% liver extract or saline in five dogs provided with a special cannula that allowed complete separation of the stomach from the duodenum. 2. The gastric phase in response to liver extract administered into the stomach amounted to an increase in acid output equivalent to about 70% of the maximum output in response to histamine. There was also a significant rise in the concentration of gastrin but not of gastric inhibitory peptide (GIP) in the serum. 3. The addition of fat (2 or 4% corn oil) or glucose (20%) to this liver extract meal inhibited secretion of gastric acid by 50 and 30%, respectively, without affecting the concentration of gastrin or GIP in the serum. 4. The 5% liver extract in the duodenum stimulated an increase in gastric acid output amounting to about 40% of the maximum response to histamine. Serum gastrin and GIP levels were not affected. Additional fat (0.5-4.0%) or glucose (10-20%) reduced acid secretion under these conditions by between 50 and 80% without affecting serum gastrin concentrations. Significant increases in the concentration of GIP in the serum occurred in response to intraduodenal glucose (5%), and to fat at the highest dose used (4%). 5. Intraduodenal infusions of glucose (5-20%) significantly increased serum GIP levels. Gastric secretion in response to 5% liver extract in the stomach was significantly inhibited at the highest dose (10 or 20%) although gastrin release was unaffected. 6. These results show that intraduodenal fat and glucose both exhibit potent inhibitory effects on post-prandial gastric acid secretion but that there is no correlation between the changes in serum GIP concentration and the inhibition of gastric secretion under these conditions. 7. We conclude that GIP is unlikely to mediate fat-induced inhibition of gastric secretion, but it is still possible that it might be involved in the inhibition that occurs during intestinal perfusion with hypertonic glucose solutions.

[Erythromycin determination in organ tissues (author's transl)]. / Zur Bestimmung des Erythromycins in organen.

The recovery rates of erythromycin after in vitro and in vivo administration were studied comparatively in liver, lung, and kidney. Using buffer standards the recovery rate in homogenates of in vitro administered erythromycin decreased with increasing protein concentration. At constant protein concentration the erythromycin administered recovered correlated linearly. Mincing the tissues with scissors was not found to be adequate, even when followed by a diffusion period of up to 24 hours. Similarly, shock freezing resulted in lower values. Even and optimal breaking down of tissues was found after homogenisation or ultrasonics. The recovery rates were not raised by treating the tissue with trypsin. There was no evidence of enzymatical erythromycin degradation in liver homogenates under the assay conditions.

[Gastric inhibitory polypeptide (GIP) (author's transl]. / Gastric Inhibitory Plypeptide (GIP).

Gastric inhibitory polypeptide (GIP) is released from the duodenum and jejunum following the ingestion of glucose, fat and amino acids. This hormone potentiates the glucose-induced insulin release from the beta-cells of the pancreas. The role of GIP as "incretin" is discussed. The method of the radioimmunoassay for the determination of GIP in serum samples is described. The lower limit of sensitivity of the GIP radioimmunoassay is in the range of 30-50 pg per ml serum. The described radioimmunoassay is sensitive enough to determine fasting levels of GIP in normal subjects (287 +/- 59 pg/ml). The clinical and pathophysiological importance of GIP is discussed by means of various diseases (obesity, maturity-onset diabetes mellitus, duodenal ulcer disease).