[Atypical lipomatous tumors of the stomach. Clinical, morphological and molecular findings]. / Atypische lipomatöse Tumoren des Magens. Klinische, morphologische und molekularbiologische Befunde.

Two cases of primary gastric atypical lipomatous tumors (ALT) are presented. In case No.1, a 7x4x3 cm submucosal ALT (lipoma-like subtype) of the antrum/pyloric region in a 60-year-old woman was completely resected. Using interphase dual-color-FISH, MDM2- and CDK4 amplifications could be detected in distinguished amplicons. The patient was continuously free of disease after 56 months. In case No. 2, a 3.5 cm (in diameter) submucosal ALT (lipoma-like subtype) of the gastric body in a 56-year-old woman was completely resected. FISH revealed MDM2 amplification while the CDK4 gene remained in diploid copies. This patient was continuously free of disease after 36 months. The morphologic and molecular biological findings of this rare primary gastric mesenchymal tumor are discussed in comparison with the corresponding soft tissue lesions.

Influence of time to treatment on early infarct-related artery patency after different thrombolytic regimens. ALKK-Study Group.

BACKGROUND: In an in vitro model, recombinant tissue-type plasminogen activator was significantly more effective than streptokinase in dissolving 24-hour-old human blood clots. Therefore there might be a difference in the effect of time to treatment on the efficacy of these fibrinolytics with different fibrin specificity in patients with acute myocardial infarction. METHODS AND RESULTS: The effect of the interval between symptom onset and initiation of therapy on the efficacy of 6 different thrombolytic regimens was studied in a retrospective analysis of 6 angiographic trials with similar design. The patency of the infarct-related artery was assessed by angiography 90 minutes after initiation of thrombolysis in patients who were seen within 6 hours after symptom onset. Patency rates of patients with an interval of 3 hours between symptom onset and start of therapy were compared. There was no difference for Thrombolysis in Myocardial Infarction (TIMI) grade 3 perfusion after front-loaded alteplase (72.5% vs 76. 3%) and reteplase (63.6% vs 63.2% ) between the 2 groups. In contrast, in patients treated with streptokinase (36.8% vs 27.6%, P =.09), anisoylated plasminogen streptokinase activator complex (59. 5% vs 34.8%, P =.004), and urokinase (62.3% vs 41.7%, P =.03), TIMI 3 patency decreased with the increasing interval between symptom onset and initiation of therapy. CONCLUSIONS: We conclude from our data that the thrombolytic efficacy of recombinant tissue-type plasminogen activator and reteplase does not decrease with the increasing interval between symptom onset and initiation of therapy. In contrast, after anisoylated plasminogen streptokinase activator complex, streptokinase, and urokinase treatment, a decrease in patency, especially TIMI-3 patency in patients treated after >3 hours after symptom onset, was observed. These results may influence the choice of the thrombolytic agent in patients who are seen >3 hours after symptom onset.

[Monstrous recurrence of serous cystadenocarcinoma of the pancreas]. / Monströses seröses Zystadenomrezidiv des Pankreas.

Serous cystadenoma of the pancreas is a rare benign tumor. The diagnostical management is easy, preoperative histological finding is difficult. The surgical relevance is revealed by the fact, that this tumor shows a high recurrence rate, especially if a complete resection is not feasible because of a difficult tumor localisation. The whole problematic nature of this disease is underlined by the following case report, which illustrates that in 5 years 4 surgical interventions because of recurrent symptoms were necessary. Each single operation improved quality of life for a different time period. First aim must be the radical resection of the tumor during primary operation, but this is not always possible because of unfavorable tumor localisation.

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.

[Abdominal actinomycosis in tubo-ovarian abscess]. / Abdominelle Aktinomykose bei Tubovarialabszess.

Diagnosis of actinomycosis as a specific infection is rather difficult. By a case report it is described that preoperative diagnostics and intraoperative situs do not always exactly clarify the situation. In most cases the definite diagnosis can only be achieved by histological findings followed by an adequate therapy.

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.

Double-blind, randomized comparison of systemic continuous infusion of 0.25 versus 0.50 mg/kg/24 h of alteplase over 3 to 7 days for treatment of deep venous thrombosis in heparinized patients: results of the European Thrombolysis with rt-PA in Venous Thrombosis (ETTT) trial.

Thirty-two patients with acute, proximal-vein thrombosis were treated with heparin and alteplase (0.25 versus 0.5 mg/kg/24 h during 3-7 days) in a randomized, double-blind, multicenter, European (ETTT) trial. The treatment resulted in a decrease of the venographic Marder's score from 18 (6-25) to 13 (2-24) units (median, range) in Group I (0.25 mg/kg/24 h, n = 15, median decrease 3.0, p = 0.32) and from 17.5 (3-33) to 15.5 (0-27) in Group II (0.5 mg/kg/24 h, n = 16, median decrease 4.0, p = 0.23). Comparison of the sequential venograms could be performed in 14 cases of Group I and in 15 cases in Group II. A minority of patients showed substantial partial recanalization of the initially obstructed veins on the control venogram (one in each treatment group) and most of the control venograms showed either thrombus size reductions (5 in Group I, 7 in Group II) or no change or even deterioration (8 in Group I, 7 in Group II). Major bleedings were observed in 7 patients (7/32, 22%), 5 of them occurring in Group II (5/17, 29%). Thus, the results of the ETTT trial show that the used low dosages of alteplase administered intravenously over 3-7 days in heparinized patients cannot be recommended as a treatment for patients with deep venous thrombosis of lower limbs and/or pelvis. Further studies are needed to define a more suitable dosage regimen of alteplase in this indication.

[Operated mechanical ileus of the small intestine]. / Der operierte mechanische Dünndarmileus.

Causes, pathophysiology, diagnosis, therapy and a retrospective analysis of small bowel obstruction were reviewed. 85 patients were operated during a 5-year period. The etiology of obstruction were adhesions (45 cases), hernia (20 cases) and 20 other cases. The mortality rate for the series was 8%. The most important factor of prognosis is the early operative treatment.

[A paradoxical air embolism in a closed foramen ovale]. / Paradoxe Luftembolie bei geschlossenem Foramen ovale.

This case report deals with a patient who was being operated on for a tumor of the colon and who died from a paradoxical venous air embolism. Accompanying massive blood loss impedes differentiation of hemodynamic disturbances either due to venous air embolism or to hemorrhage, respectively. Air was aspirated from the radial artery catheter that was used for blood-pressure monitoring and for taking blood samples for laboratory analysis. At autopsy, no probe-patent foramen ovale could be demonstrated. The mechanism of air passing from the venous to the systemic circulation in our patient remains speculative; however, mechanical cardiopulmonary reanimation itself with its underlying thoracic pump mechanism has to be considered as contributing to the transport of air from the venous to the arterial side of the circulation.

[Rare pancreatic tumors from the viewpoint of our own patient sample]. / Seltene Pankreastumoren aus der Sicht des eigenen Krankenguts.

Four less common tumours of the pancreas are being presented with histological findings (malignant haemangiopericytoma, small cell type anaplastic carcinoma, microcystic cystadenoma, dysontogenetic cyst) from our own patient data. The discussion includes general considerations about preoperative staging and grading as well as the differential diagnosis of the kind of tumours.

Antithrombotic effects of three thrombin inhibitors in a rat model of laser-induced thrombosis.

The antithrombotic effects of three thrombin inhibitors (hirudin, NAPAP and argidipine) were investigated in an experimental thrombosis model using laser lesions of rat mesenteric venules. Furthermore, their in vitro anticoagulant activity (partial thromboplastin time, thrombin time, Heptest, inhibition of factor IIa and factor Xa) in human platelet poor plasma (PPP) and their in vitro and ex vivo activities were studied in rat plasma. All three thrombin inhibitors showed significant and dose-dependent antithrombotic effects after intravenous injection, if venules were damaged, which lasted for more than 4 but less than 8 h. The anticoagulant effect observed in vitro did not differ much between human and rat PPP. The two synthetic thrombin inhibitors NAPAP and argidipine were about as effective as hirudin in vitro; however, the ex vivo effect after intravenous injection of hirudin in rats was more pronounced than that observed with the two synthetic thrombin inhibitors. The antithrombotic effect of all three thrombin inhibitors in the laser model lasted much longer than the anticoagulant activity. This fact needs further investigations in the future.

Antimetastatic action of RX-RA 69, a new potent PDE-inhibitor in the Lewis lung carcinoma of the mouse.

RX-RA 69, a pyrimido-pyrimidine derivative, is a new potent PDA-inhibitor which inhibits tumor cell induced platelet aggregation in vitro. Also ex vivo an inhibition was found after pretreating mice with 1 mg/kg RX-RA 69 orally one hour before collecting the blood. The same dosage is able to prevent the drop in platelet count induced by injecting a large number of tumor cells into mice. The same dosage schedule in the amputation experiment resulted in a reduction of incidence of matastases in all treated groups; the best results, however, were obtained by starting the treatment two days after the amputation. In the spontaneous model an inhibition of metastases formation by 10-20 mg/kg RX-RA 69 starting from the fourth day after tumor cell implantation was found in four independent experiments. The mechanism of the antimetastatic action of this drug remains to be evaluated.