[Surgical History Taking and Clinical Examination: Establishing a Standardised System by Means of a Nation-Wide Academic Teaching Project]. / Chirurgische Anamneseerhebung und klinische Untersuchung: Etablierung eines Standards an der Universitätsmedizin Greifswald mithilfe eines deutschlandweiten universitären Lehrprojekts.

Background: History taking and systematic clinical examination are central techniques of physicians. Medicine in general and surgery in particular frequently require immediate decisions and start of therapies. So far, a standardised surgical system for history taking and clinical examination in teaching has been lacking at our faculty. A consensus of all medical faculties on a standardised system could be a tool to improve the medical teaching and education at our teaching institutions. Methods: The established Anglo-Saxonian system of history taking and clinical examination was adapted to our own clinical needs. Thereafter, this system was sent out to all chairmen of general and visceral surgery departments in German University Hospitals asking for evaluation and improvements. We adapted the system according to the chairmen's comments and suggestions. Since winter semester 2011 this system has been integrated into the clinical course of history taking and examination. It is compulsory for all 5th semester students (first clinical year/graduate course) at the Universitätsmedizin Greifswald. In addition, a video was produced demonstrating all major techniques of clinical examination. This video is available for all students on a password blocked site of the World Wide Web. Results: Altogether, 89 % of all contacted chairmen returned their comments and suggestions for improvements. After implementation of the new system, positive evaluations of students increased significantly from 63.5 to 77.0 % in general and abdominal surgery (p < 0.0001) and from 76.4 to 83.5 % in vascular and thoracic surgery (p < 0.0001). Conclusions: The presented system is a standardised tool of history taking and clinical examination applicable for students as well as qualified surgeons in daily routine work. It has been approved by the majority of the departments of surgery of all German university hospitals. Furthermore, it can be applied by other medical specialties, in particular, internal medicine. Furthermore, the standardisation of history taking and clinical examination can contribute to improve patients' safety as well as medical documentation. Also, the standardisation will be a sound basis for expert medical opinions in legal actions. Finally, it has improved the value of medical education at our medical faculty and could form the basis for the development of national medical standards.

Induction of M2-macrophages by tumour cells and tumour growth promotion by M2-macrophages: a quid pro quo in pancreatic cancer.

INTRODUCTION: More effective therapies are required to improve survival of pancreatic cancer. Possible immunologic targets include tumour associated macrophages (TAMs), generally consisting of M1- and M2-macrophages. We have analysed the impact of TAMS on pancreatic cancer in a syngeneic orthotopic murine model. METHODS: 6606PDA murine pancreatic cancer cells were orthotopically injected into C57BL6 mice. Tumour growth was monitored using MRI. Macrophages were depleted by clodronate liposomes. Tumours including microvessel density were evaluated using immunohistochemistry, immunofluorescence and/or cytometric beads assays. Naïve macrophages were generated employing peritoneal macrophages. In vitro experiments included culturing of macrophages in tumour supernatants as well as tumour cells cultured in macrophage supernatants using arginase as well as Griess assays. RESULTS: Clodronate treatment depleted macrophages by 80% in livers (p = 0.0051) and by 60% in pancreatic tumours (p = 0.0169). MRI revealed tumour growth inhibition from 221.8 mm(3) to 92.3 mm(3) (p = 0.0216). Micro vessel densities were decreased by 44% (p = 0.0315). Yet, MCP-1-, IL-4- and IL-10-levels within pancreatic tumours were unchanged. 6606PDA culture supernatants led to a shift from naïve macrophages towards an M2-phenotype after a 36 h treatment (p < 0.0001), reducing M1-macrophages at the same time (p < 0.037). In vivo, M2-macrophages represented 85% of all TAMs (p < 0.0001). Finally, culture supernatants of M2-macrophages induced tumour growth in vitro by 63.2% (p = 0.0034). CONCLUSIONS: This quid pro quo of tumour cells and M2-macrophages could serve as a new target for future immunotherapies that interrupt tumour promoting activities of TAMs and change the iNOS-arginase balance towards their tumoricidal capacities.

Macrophages promote tumour growth and liver metastasis in an orthotopic syngeneic mouse model of colon cancer.

PURPOSE: Tumour-associated macrophages have been shown to promote proliferation, angiogenesis and metastasis in several carcinomas. The effect on colon cancer has not yet been clarified. Furthermore, Kupffer cells in the liver might initiate the formation of metastases by directly binding tumour cells. METHODS: An orthotopic syngeneic mouse model of colon cancer as well as a liver metastases model has been studied, using murine CT-26 colon cancer cells in Balb/c-mice. Macrophages were depleted in both models by clodronate liposomes. Tumour sizes and metastases were determined using 7-Tesla MRI. The macrophage and vascular density in the orthotopic tumours as well as the Kupffer cell density in the livers were evaluated using immunohistochemistry. RESULTS: Animals in the macrophage-depleted group displayed significantly smaller primary tumours (37 ± 20 mm(3)) compared to the control group (683 ± 389 mm(3), p = 0.0072). None of the mice in the depleted group showed liver or peritoneal metastases, whereas four of six control mice displayed liver and five out of six mice peritoneal metastases. The vascular density was significantly lower in the macrophage-depleted group (p = 0.0043). In the liver metastases model, animals of the Kupffer cell-depleted group (14.3 ± 7.7) showed significantly less liver metastases than mice of the two control groups (PBS liposomes, 118.5 ± 28.2, p = 0.0117; NaCl, 81.7 ± 23.2, p = 0.0266). The number of liver metastases correlated directly with the Kupffer cell density (p = 0.0221). CONCLUSION: Macrophages promote tumour growth, angiogenesis and metastases in this orthotopic syngeneic mouse model. Kupffer cells enhance the formation of metastases in the liver.

[Disease-adapted closure of the appendicular stump in laparoscopic appendectomy]. / Stadiengerechte Versorgung der Appendixbasis im Rahmen der laparoskopischen Appendektomie.

The frequency of laparoscopic appendectomy has dramatically increased with it now being the standard procedure for acute appendicitis in many hospitals in Germany. Hence, these hospitals require the personnel, the technique as well as the expertise to guarantee a top standard and quality of appendectomies at all times. Only this will meet the requirements of the high case load and the socio-economical importance of appendectomies. The closure of the appendicular stump is a critical step of this procedure. The three most commonly used techniques consist of the endo-loop, the clip and the endo-stapler. The endo-stapler has the advantage of offering closure and transection of the appendix in one step; it can be employed in all cases of appendicular inflammation; and it allows a partial caecal resection. However, it is quite expensive. The clip and the endo-loop offer the same cost-effectiveness, yet the clip appears to be simpler in use compared to the loop. Also, sharing this feature with the stapler, it offers the possibility of closing and transecting the appendix before dissecting the mesoappendix. A disadvantage of the clip not being shared with the loop is the limitation of clips to appendicular diameters of only up to 16 mm. In summary, we propose a cost-effective disease-adapted closure of the appendicular stump employing the clip in standard appendectomies, with the endo-loop being a good alternative. If clip or loop cannot be applied the stapler is the technique of choice. In particular, it should be used if the base of the appendix is inflamed. Adopting this pathway helps to control the still somewhat higher costs of laparoscopic appendectomies compared to classical open appendectomies.

[Consequences drawn from the evaluation of logbook-based surgical training for final year students]. / Konsequenzen aus der Evaluation eines chirurgischen PJ-Logbuchs.

BACKGROUND: The current training programme for final year medical students does not meet the requirements of surgery and is obviously not able to encourage young physicians to become surgeons. After finishing the surgical trimester, the motivation to become a doctor decreases considerably more strongly than after any other specialty during the final year programme. This emphasises the urgent need for a consequent redesign involving modern educational programmes. METHOD: The present article represents a systematic analysis of 70 logbooks used by final year medical students, which accompanied them during the surgical trimester from August 2008 to December 2009 at the Department of Surgery at the University of Greifswald, Germany. This analysis was subsequently compared to an evaluation of the same students as to how valuable the logbook was for their surgical education by means of an anonymous questionnaire. RESULTS: The results indicate that the general quality of education during the surgical trimester was evaluated to be high, but that the use of a logbook in the current mode did not contribute to enhance medical/surgical training programmes. Although most of the requested examinations and procedures were carried out by at least 70 % of the students, less than half of them had the impression that the use of this specific logbook improved their education. The students ask for a more intense interaction with the tutor/mentor and request differentiated discussions about their personal stronger and weaker spots, as well as more bedside teaching, e. g., the terms of training ward rounds with the consultant surgeon. Besides, they demand more supervised practical skill training in contrast to the often commonly practiced "learning by doing". CONCLUSION: The logbook is a powerful and effective educational tool able to structure and examine medical training and skills. But the present evaluation of the surgical logbook indicates that there is a need to adapt the current version to student's and institution's requirements. Otherwise it will only be seen as a purely labour intensive obligation, which will consequently lead to frustration and will not enrich the surgical training programme within the final year of medical school.

A syngeneic orthotopic murine model of pancreatic adenocarcinoma in the C57/BL6 mouse using the Panc02 and 6606PDA cell lines.

BACKGROUND/AIMS: To develop a clinically relevant immunocompetent murine model to study pancreatic cancer using two different syngeneic pancreatic cancer cell lines and to assess MRI for its applicability in this model. METHODS: Two cell lines, 6606PDA and Panc02, were employed for the experiments. Cell proliferation and migration were monitored in vitro. Matrigel™ was tested for its role in tumor induction. Tumor cell growth was assessed after orthotopic injection of tumor cells into the pancreatic head of C57/BL6 mice by MRI and histology. RESULTS: Proliferation and migration of Panc02 were significantly faster than those of 6606PDA. Matrigel did not affect tumor growth/migration but prevented tumor cell spread after injection thus avoiding undesired peritoneal tumor growth. MRI could reliably monitor longitudinal tumor growth in both cell lines: Panc02 had a more irregular finger-like growth, and 6606PDA grew more spherically. Both tumors showed local invasiveness. Histologically, Panc02 showed a sarcoma-like undifferentiated growth pattern, whereas 6606PDA displayed a moderately differentiated glandular tumor growth. Panc02 mice had a significantly shorter (28 days) survival than 6606PDA mice (50 days). CONCLUSION: This model closely mimics human pancreatic cancer. MRI was invaluable for longitudinal monitoring of tumor growth thus reducing the number of mice required. Employing two different cell lines, this model can be used for various treatment and imaging studies.

Laser-supported diaphanoscopy: a new technique in laparoscopic-endoscopic rendezvous procedures allowing better and more tissue-sparing tumor resection than wedge resection.

BACKGROUND: Locating gastrointestinal stromal tumors (GIST) during laparoscopic surgery continues sometimes to be difficult and inaccurate. In addition, the methods used for tumor mapping often do not lead to precise location of tumors. Also, they are too expensive or too complex for an easy surgical approach. Furthermore, the standard wedge resection often sacrifices too much healthy tissue. METHODS: The current study introduces an innovative tissue-sparing method using laser-supported diaphanoscopy (Endolight) for exact location of GIST during laparoscopic surgery. The instrument was developed by the authors' group. This study retrospectively evaluated two groups of patients experiencing GIST. The first group of 10 patients was treated by standard wedge resection. The second group of 10 patients was treated by Endolight-guided laparoscopic resection during a laparoscopic-endoscopic rendezvous procedure. RESULTS: After precise location of GIST using Endolight, all patients could be successfully resected. The largest resection margins using Endolight (9.8±3.8 mm) were significantly smaller than the largest resection margins using wedge resection (stapler) without Endolight (21.5±9.1 mm; p<0.0001). The average surgery time for the group treated by standard wedge resection was 65 min (range, 28-108 min). The surgery time required for the group treated by Endolight-guided resections ranged from 48 to 189 min (average, 123 min). The number of marks used for Endolight resections ranged from four to seven depending on the location and size of the tumor. CONCLUSION: The reported technique allows the precise location of GIST, leading to exact and tissue-sparing transmural laparoscopic resection of these tumors compared with standard wedge-resection. Laser-supported diaphanoscopy using the newly developed innovative device offers new perspectives and a highly effective technique for resecting GIST that combines an endoscopic with a laparoscopic approach.

Endoscopic transanal vacuum-assisted rectal drainage (ETVARD): an optimized therapy for major leaks from extraperitoneal rectal anastomoses.

BACKGROUND AND STUDY AIMS: A major leak from a rectal anastomosis is an important surgical complication. Endoscopic transanal vacuum-assisted rectal drainage (ETVARD) is a new method for treating nonseptic major anastomotic leaks after extraperitoneal rectal anastomoses. PATIENTS AND METHODS: Between January 2002 and March 2007 a total of 17 patients (mean age 61.2 years) who developed anastomotic leakage after resection of the rectum or rectosigmoid colon were prospectively evaluated. Their treatment began with endoscopic debridement of the leak/cavity; nylon sponges were then endoscopically fitted into the cavity. Continuous suction was applied via suction tubes inserted into the sponges. Repeat endoscopies and sponge exchanges, including further debridement were essential. RESULTS: In 16/17 patients ETVARD was successful, relieving patients quickly from infectious symptoms and other complaints; one patient eventually required a Hartmann's procedure. Cavity sizes varied from 2 cm x 2 cm to 10 cm x 13 cm. The mean duration of drainage was 21.4 days, with a mean of 5.4 sponge exchanges and 10.7 endoscopies, and a mean total time to closure of the cavity of 53.1 days. The total time to closure of the cavity was directly dependent on the size of the cavity ( P< 0.015). Fifteen patients received additional intramural fibrin glue injections. In eight patients ETVARD was continued on an outpatient basis. There was no advantage demonstrated for patients with diverting loop ileostomies. Patients with anastomoses that were 6 cm or less from the anocutaneous line had considerably longer healing times. The healing time depended significantly on age ( P< 0.036). Follow-up endoscopies have shown only minor anastomotic changes in two patients. CONCLUSIONS: ETVARD is a well-tolerated and effective therapeutic option for the treatment of major leaks after extraperitoneal rectal anastomoses. In most cases ETVARD obviates the need for additional surgery, in particular diverting loop ileostomy.

[Critical odontogenic infection involving the mediastinum. Case report]. / Kritische odontogene Infektion mit Mediastinalbeteiligung. Ein Fallbericht.

BACKGROUND: Occasionally, trivial odontogenic infections may develop into complex diseases. This may even result in an unrestrained phlegmonous spread causing life-threatening complications. These problems have decreased since the introduction of antibiotics and also due to improved oral hygiene and improved diagnostic measures resulting in optimized medical treatment. However, life-threatening forms are still seen, in particular if infections spread along the cervical fascial sheaths down towards to the mediastinum. Over the past decade the number of critical infections has increased in other medical specialties. This is usually explained by the development of multiresistant pathogens in the context of nosocomial infections. PATIENTS AND METHODS: We reviewed the patients' records of the past 15 years at the Department of Oral and Maxillofacial Surgery of the University Hospital Kiel to assess a possible increase of odontogenic infections with life-threatening complications. From 1990 to 2004, four patients with odontogenic infections exhibiting critical phlegmonous spread were treated in the intensive care unit. Two patients developed bacterial mediastinitis which could be controlled by intravenous antibiotics only. One patient progressed to general septic mediastinitis and eventually died of cardiorespiratory arrest. The last patient also had septic mediastinitis and developed right pleural empyema. Several operations were necessary before the disease could be controlled. This patient's case report is presented in detail. CONCLUSION: The prognosis of patients with mediastinitis crucially depends on (a) early diagnosis including computed tomography of the neck and thorax, (b) early radical surgical intervention, and (c) optimized pathogen-oriented antibiotic treatment.

Systemic and local immunosuppression in pancreatic cancer patients.

Pancreatic cancer is characterized by an extremely poor prognosis. For the development of more effective immunotherapies, the systemic and local immunological escape mechanisms need to be further elaborated. These mechanisms may include the secretion of immunosuppressive cytokines, the local hindrance of tumor-infiltrating lymphocytes (TILs), or the loss of the signal transducing CD3 zeta-chain of TILs. In this study, we have analyzed these parameters in 116 patients suffering from pancreatic ductal adenocarcinoma. Mean concentrations of interleukin (IL)-10 and transforming growth factor-beta1/2 were considerably higher than in control sera (P < 0.0001). Disseminated tumor cells were found in 16 of 39 cases. In 28 of 33 surgical specimens, TILs did not reach tumor cells in significant numbers, being "trapped" in the peritumoral tissues. We suggest this as a simple but highly effective tumor escape mechanism. In cases of a TIL/tumor cell contact, CD3 zeta was mostly lost. Overall, 27 of 33 surgical specimens, 9 of 19 peritumoral lymph nodes, and 13 of 25 peritoneal lavage specimens showed significant loss of CD3 zeta (P < 0.02). Elevated concentrations of IL-10/TGF-beta1/2 were, in all but one of three cases, correlated with a CD3 zeta loss in corresponding specimens. Patients with disseminated tumor cells also showed a CD3 zeta loss in all but two corresponding tumor specimens. These results present strong evidence for an active systemic immunosuppression in pancreatic cancer, as shown by elevated IL-10 and TGF-beta1/2 serum levels as well as the presence of disseminated tumor cells. Killing of tumor cells by potentially cytotoxic TILs is obviously suppressed by the prevention of a direct TIL/tumor cell contact and the inactivation of TILs, as shown by a severe loss of CD3 zeta. In addition to active immunization strategies, successful immunotherapies have to focus on restoring in vivo T-cell function to improve the almost always fatal prognosis of pancreatic cancer.

Expression and function of galectin-3, a beta-galactoside-binding protein in activated T lymphocytes.

A soluble beta-galactoside-binding lectin, galectin-3 has been shown to be involved in cell adhesion and activation of immune cells. Although galectin-3 is known to be expressed in various types of cells, it has not been shown whether galectin-3 is expressed in T lymphocytes. We present evidence here that galectin-3 is expressed in activated murine T lymphocytes including CD4+ and CD8+ T cells but not in resting T cells. Galectin-3 expression was induced by anti-CD3 mAb or mitogen and enhanced by common gamma-chain signaling cytokines, IL-2, IL-4, and IL-7, in activated T lymphocytes, whereas the inflammatory cytokines including TNF-alpha and IFN-gamma did not. Galectin-3 expression and proliferation were down-regulated by withdrawal of IL-2 and gamma irradiation. Antisense but not sense phosphorothioated oligonucleotides for galectin-3 inhibited galectin-3 expression and blocked proliferation of T cells significantly. This study suggests that up-regulation of galectin-3 plays an important role in proliferation of activated T lymphocytes.

B7.1 costimulation increases T-cell proliferation and cytotoxicity via selective expansion of specific variable alpha and beta genes of the T-cell receptor.

BACKGROUND: Optimal T-cell activation requires not only ligation of the T-cell receptor (TcR) but also delivery of costimulatory signals by various accessory molecules. The interaction of the costimulatory molecule B7.1 (CD80) with its receptor CD28 provides a strong positive signal to T cells. METHODS: The B7.1 gene was transduced into cultured human ovarian, breast, and pancreatic tumor cells by using a retroviral vector. Autologous as well as allogeneic naive T-cells were stimulated with either wild-type or B7.1-transduced tumor cells in a mixed lymphocyte tumor cell culture (MLTC). In addition to cytolytic activity, T-cell proliferation, T-cell subset composition, and the frequencies of TcR variable (V) alpha and beta genes were compared in T cells from both types of MLTC. RESULTS: Introduction of the B7.1 gene into tumor cells was successful in all tumors to a varying degree. Those tumors expressing high levels of B7.1 induced significantly higher levels of T-cell proliferation than wild-type tumor cells. T-cell subset composition did not markedly differ between T cells stimulated with wild-type tumor cells or B7.1-expressing tumor cells. However, T cells stimulated with B7.1-expressing tumor cells showed a significantly increased cytolytic potential. The increased cytotoxic T lymphocyte activity was associated with a higher frequency of specific TcR V alpha and V beta genes. In addition, B7.1 costimulation promoted oligoclonality among the responding T cells. CONCLUSIONS: These data suggest that costimulation through B7.1 promotes T-cell proliferation and cytotoxic activity through clonal expansions of T cells bearing antigen-specific TcR V alpha and V beta genes and through promotion of oligoclonality. The data also suggest that promoting B7.1-mediated costimulation is an important aspect of immune therapies.

Soluble MUC1 secreted by human epithelial cancer cells mediates immune suppression by blocking T-cell activation.

Solid tumors may secrete factors that mediate immune suppression in patients. We investigated the effect of supernatants from 25 human tumor cell lines on T-lymphocytes from healthy donors. A profound inhibition of proliferation, cytokine secretion and cytotoxic activity was seen when T-cells were cultured in concentrated tumor supernatants from 6 cell lines fractionated into high (>100 kDa) m.w. molecules. Interestingly, the inhibitory effects were reversed when the tumor supernatant was removed. Cell cycle studies of inhibited T-cells showed most of them were growth arrested in the G(0)/G(1) phase similar to naïve T-cells. In addition, these T-cells did not express IL2-receptors and expression of CD54 (ICAM-1) and CD58 (LFA-3) resembled that of resting T-cells. Protein gel electrophoresis of the tumor supernatants and western blot analysis demonstrated the presence of soluble MUC1 in the inhibitory tumor supernatants but not in control supernatant. Most importantly, depletion of soluble MUC1 by immunoprecipitation from the tumor supernatants neutralized the inhibitory effects on T-lymphocytes. Therefore, our results show that MUC1 shed by cultured epithelial tumor cells mediates inhibition of T-cell proliferation and function by inducing cell growth arrest.

Pancreatic cancer cells can evade immune surveillance via nonfunctional Fas (APO-1/CD95) receptors and aberrant expression of functional Fas ligand.

BACKGROUND: The Fas (APO-1/CD95) receptor/Fas ligand (FasR/FasL) system plays a key role in immune surveillance. We investigated the possibility of a tumor escape mechanism involving the FasR/FasL system in pancreatic cancer cells. METHODS: Fourteen pancreatic cancer cell lines and 3 pancreatic cancer surgical specimens were studied for their expression of FasR and FasL by flow cytometry, immunoblotting, and immunohistochemistry, FasR function was tested with an anti-FasR antibody. FasL function was assessed by coculture assays using pancreatic cancer cells and FasR-sensitive Jurkat T-cells. RESULTS: FasR was expressed in normal pancreas, in 14 of 14 pancreatic cancer cell lines, and in 3 of 3 surgical specimens. However, only 1 of 14 cancer cell lines expressed functional FasR when grown in monolayer, although 3 additional cell lines displayed functional FasR when cultured in suspension. Normal pancreas did not express FasL, whereas 14 of 14 cancer cell lines and 3 of 3 surgical specimens expressed FasL. FasL expressed by pancreatic cancer cells mediated killing of Jurkat T-cells in coculture assays (P < .005). CONCLUSIONS: These data suggest that pancreatic cancer cells have 2 potential mechanisms of evading Fas-mediated immune surveillance. A nonfunctional FasR renders them resistant to Fas-mediated apoptosis. The aberrant expression of functional FasL allows them to "counterattack" activated Fas-sensitive T-cells. Alone or in unison, these tumor escape mechanisms may contribute to the malignant and often rapid course of pancreatic cancer disease.