Protein metabolism in human colon carcinomas: in vivo investigations using a modified tracer technique with L-[1-13C]leucine.

To quantify the protein anabolism of tumors it is not sufficient simply to determine the level of protein synthesis. The decisive factor is the net balance. This is the first attempt to establish this parameter in human tumors in vivo. Intraoperative tumor leucine/protein metabolism was studied in 15 patients with resectable malignant colon tumors using a balance model and L[1-13C]leucine as the tracer substance. Comparative measurements were also carried out simultaneously for peripheral tissue (forearm); in addition, protein kinetics parameters were established for the whole body using a proven two-pool model (with the same tracer as above). In view of the frequently conflicting data on amino acid metabolism in tumors, the tumoral and peripheral exchange rates of 20 amino acids were also determined. In tumors, essential and branched-chain amino acid uptakes were found to be 1.68 +/- 0.59 (SE) and 1.52 +/- 0.23 mumol/100 g tissue/min, respectively; in peripheral tissue there was overall an amino acid release [-0.11 +/- 0.06 and -0.05 +/- 0.04 mumol/100 g/min; in either case P < 0.01 (tumor versus periphery)]. Tracer analyses yielded a net retention for the tumors but a protein loss for peripheral tissue (8.941 +/- 3.113 versus -0.557 +/- 0.53 g/kg/24 h; P < 0.01) and for the whole body (-0.363 +/- 0.04 g/kg/24 h). The tumors were divided into two prognostic groups on the basis of their histology. Significant differences were found between the two groups in terms of the net retention rate for 10 amino acids, including leucine; retention was elevated in tumors with an unfavorable prognosis, possibly due to a higher amino acid requirement because of more rapid growth or for export processes (mucus production). The protein balance model used here has proved satisfactory for our purposes and could also be used to directly evaluate dietary measures (e.g., adjuvant parenteral nutrition in connection with chemotherapy).

The surgical treatment of pancreatic carcinoma.

This is a report on 501 pancreatic and periampullary cancers treated at the Mannheim Surgical Clinic during the past 11 years. Modern diagnostic measures (computerized axial tomography, endoscopic retrograde cholangiopancreatography, and angiography), while failing to detect the early operable tumors, have contributed to a rise in the rate of resectability of cancers of the pancreatic head (from 5% to 21%). Tactical problems of surgical treatment include the extent of resection required (total or partial), the rationale of preliminary biliary decompression, the symptomatic but unidentified mass in the head of the pancreas, and concomitant celiac artery stenosis. In 118 duodenopancreatectomies performed for cancer and 81 performed for severe and complicated chronic pancreatitis, the operative and hospital mortality rate was 2.5%. Of the 28 patients whose pancreatic resections for cancer occurred more than 5 years ago, 10 reached the 5-year survival limit.

Adjuvant 5-fluorouracil and BCNU chemotherapy in gastric cancer: 3-year results.

One hundred-three patients with a potentially curative operation of a histologically proven gastric cancer were randomly assigned to a control and chemotherapy group after stratification according to tumor stage II and III. Chemotherapy courses with 5-fluorouracil (10 mg/kg/day) and BCNU (40 mg/m2/day) for 5 days were administered eight times in 6-8 week intervals. Age, sex, and tumor location were matched in the chemotherapy and control groups. Five patients declined treatment after randomization. Three years after initiating the study, the tumor has recurred in 38 of the 103 patients. There were 21 recurrences of 54 controls and 14 recurrences of 44 patients who received chemotherapy, and 17 and ten deaths, respectively, due to tumor relapse. The results of our study to data show a high degree of statistical probability that adjuvant chemotherapy with the regime used has no influence on the recurrence-free interval and survival time in gastric cancer.

The role of laparoscopy in the preoperative staging of pancreatic carcinoma.

Between January 1990 and December 1995, a total of 398 patients underwent laparotomy for pancreatic or periampullary carcinoma at the Surgical Clinic of Mannheim. The tumor was located in the pancreatic head in 290 patients (72.9%), in the body of the pancreas in 42 patients (10.6%), and in the pancreatic tail in 19 patients (4.7%). Forty-seven patients (11.8%) presented with periampullary carcinoma. The preoperative diagnostic workup included abdominal ultrasound, CT scan, endoscopic retrograde cholangiopancreatography, and angiography. One hundred seventy-two patients (43.2%) underwent a tumor resection, 150 (37.7%) had a palliative bypass operation, and 76 (19.1%) underwent only an exploratory laparotomy. Preoperative diagnosis had predicted unresectability in 66 (87%) of the patients who underwent exploratory laparotomy. In 76 patients the intraoperative findings showed an unresectable tumor, which was located in the head of the pancreas in 54 cases (71%), in the body of the pancreas in 17 (22.4%), in the tail region in four (5.3%), and in the periampullary region in one (1.3%). Local signs of unresectability were found in 47 patients (62%) and peritoneal or hepatic metastases in 29 (28.2%). Given that local inoperability can be reliably assessed only at laparotomy, this leaves just 29 (7%) of 398 patients who did not require palliation and whose signs of unresectability could possibly have been discovered by means of the laparoscopic approach. Laparoscopy (including laparoscopic ultrasound) should be used selectively in patients considered probably unresectable who do not require a palliative procedure immediately before the planned operation.

The European experience with laparoscopic cholecystectomy.

A retrospective survey of 7 European centers involving 20 surgeons who undertook 1,236 laparoscopic cholecystectomies was performed. The procedure was completed in 1,191 patients. Conversion to open cholecystectomy was necessary in 45 patients (3.6%) either because of technical difficulty (n = 33), the onset of complications (n = 11), or instrument failure (n = 1). There were no deaths reported, and the total postoperative complication rate was 20 of 1,203 (1.6%), with 9 being serious complications requiring laparotomy. The total incidence of bile duct damage was 4 of 1,203. The median hospital stay was 3 days (range: 1 to 27 days) and the median time to return to full activity after discharge was 11 days (range: 7 to 42 days).

Personal observations, opinions, and approaches to cancer of the pancreas and the periampullary area.

This article reviews the diagnosis, staging, surgical, and adjuvant treatment of pancreatic and periampullary cancer based on personal experience covering 25 years. In spite of remarkable progress, especially in regard to staging and surgical treatment, the authors conclude that with the modalities currently available, timely diagnosis and definitive cure of this particular cancer is rare.

[Radiologic differential diagnosis of adrenal gland cysts]. / Radiologische Differentialdiagnostik zystischer Nebennierenprozesse.

Cystic diseases of the adrenal glands, which were thought to be rare, are being found more frequently nowadays by means of sonography and computer tomography. Our experience of fifteen cases is reported; of these, ten were confirmed at operation. Contrary to expectations based on the relevant literature, only one of the operated cases proved to be an endothelial cyst of lymphangiomatous origin. All other patients had pseudo-cysts of the adrenals. These are due to bleeding into a normal or tumour-containing gland. About one quarter of the pseudo cysts showed circular calcification on the plain films, although the incidence of this is given as 8-15% in the literature. The cystic nature of these lesions can be readily demonstrated by ultrasound or CT. The latter also provided information concerning the wall of the cyst and of the remaining adrenal tissue. An aspiration biopsy of the cyst can be carried out under ultrasound or CT control; cytological examination will confirm the benign nature of the lesion. A benign lesion without symptoms requires no further diagnostic or therapeutic measures. If there is hypertension, as may occur with a cystic phäeochromocytoma or lymphangioma, angiography is still indicated. Hormone assays are possible following catheterisation of the vena cava combined with adrenal phlebography. The origin and extent of a malignant pseudo-cyst can be demonstrated by arteriography, if this information is lacking following CT.

[Combined use of MRI and MR cholangiopancreatography and contrast enhanced dual phase 3-D MR angiography in diagnosis of pancreatic tumors: initial clinical results]. / Kombinierter Einsatz von MRT, MRCP und kontrastverstärkter 2-Phasen 3D-MRA in der Diagnostik von Pankreastumoren: Erste klinische Ergebnisse.

PURPOSE: To evaluate the accuracy of a non-invasive "all-in-one" staging MR method in patients with pancreatic tumors. MATERIAL AND METHODS: 46 patients were prospectively evaluated by a combined MR imaging protocol including breath-hold T1- and T2-weighted pulse sequence, MRCP using a breath-hold 2D-RARE sequence, and breath-hold gadolinium-enhanced dual-phase 3D-MR angiography. RESULTS: All pancreatic tumors were detected by the combination of cross-sectional imaging and MRCP. In spite of the use of MRCP, definitive differentiation between pancreatic carcinoma and chronic pancreatitis was not possible in 3 (6.5%) out of 46 cases. High quality 3D-MR angiograms were obtained in 43 (93.5%) cases. In 6 (13%) patients 3D-MRA showed an aberrant right hepatic artery. The overall accuracy of MRI in assessing extrapancreatic tumor spread, lymph node metastases, liver metastases, and vascular involvement was 95.7%, 80.4%, 93.5%, and 89.1%, respectively. CONCLUSION: Due to its high accuracy, the "all-in-one" MR protocol may become the most important modality after clinical examination and ultrasound in the diagnostic work-up for most patients with suspicion of pancreatic tumors.

The Whipple partial duodenopancreatectomy for the treatment of chronic pancreatitis.

BACKGROUND/AIMS: Operations for chronic pancreatitis can be divided into drainage and resection procedures. The standard Whipple pancreatoduodenectomy is the preferred resection procedure for most cases of painful complicated pancreatitis centred in the pancreatic head. METHODOLOGY: The medical records of 134 patients who underwent standard Whipple pancreatoduodenectomy for complicated chronic pancreatitis were analyzed. Exocrine and endocrine pancreatic function was assessed. Pain intensity was estimated using a pain scoring system. Mean follow-up was 8.3 years and the follow-up rate was 62%. RESULTS: All patients underwent a standard Whipple pancreatoduodenectomy. Operative mortality was 0.7%. No postoperative complications were seen in 112 patients (83.6%). Re-laparotomy for adhesions, major septic complications, bleeding and pancreatic anastomotic leak were noted in 13 patients (9.7%). Delayed gastric emptying occurred in 1 patient (0.7%). Complete pain relief was noted in 66%. An increase in body weight was observed in 65% and 60% of the patients were able to return to work postoperatively. Postoperative exocrine insufficiency developed in 24% and postoperative diabetes in 12%. CONCLUSIONS: The Whipple standard procedure proves to be a safe and effective technique for the treatment of chronic pancreatitis. More important than any particular operative technique is the selection of an appropriate method of management for each individual patient.

[Results of a prospective study of laparoscopic appendectomy]. / Ergebnisse einer prospektiven Studie zur laparoskopischen Appendektomie.

Laparoscopic appendicectomy for acute appendicitis is being increasingly criticized, because of the possible complications, the technical effort required and the high costs. The results of the present prospective study performed between May 1992 and March 1994 on 222 appendectomies (110 conventional and 112 laparoscopic) are intended to serve as a tentative guide. The use of endoscopic stapling and cutting devices, as well as the observance of exclusion criteria make laparoscopic appendicectomy a safe operation. It can be employed routinely and shows certain advantages for the patient e.g. fewer disturbances of wound healing and shorter postoperative hospitalization. Although laparoscopic appendicectomy has brought us valuable experience, it is by no means the method of choice and for the time being, it is unlikely to replace conventional appendicectomy.

[Vascular surgery within the scope of visceral surgery-oncologic interventions]. / Gefässchirurgie im Rahmen visceralchirurgisch-onkologischer Eingriffe.

The surgeon dealing with oncological operations within the abdominal cavity will be frequently confronted with vascular problems. These include surgically relevant vascular anomalies, arteriosclerotic changes, tumor infiltration of vessels and iatrogenic vascular lesions. The diagnosis, indications and, above all, the vascular surgical techniques applied during oncological procedures on the pancreas and liver are described in this review.

[Uses and risks of drainage following elective colon resection. A prospective, randomized and controlled clinical study]. / Nutzen und Risiken einer Drainage nach elektiven Colonresektionen. Eine prospektive, randomisierte und kontrollierte klinische Studie.

The results of a controlled randomized and prospective clinical study including 113 patients from March 1987 until August 1988 showed that prophylactic drainage in elective resection for cancer of the colon was not necessary. 60 patients received a drain, 53 patients were not drained. The drain turned out to be ineffective even concerning its expected function of draining intraabdominal fluid: its diagnostic and therapeutic value failed in clinical practice. The rate of surgical complications--i.e. anastomotic leakage, impaired wound healing and relaparotomy--was significantly higher in the drained group. In elective colon resection the use of a drain as a routine procedure cannot be recommended.

[Mesh wrapping of the liver. A very promising method for managing severe liver trauma]. / Mesh-Wrapping der Leber. Eine vielversprechende Methode zur Versorgung des schweren Lebertraumas.

Mesh-wrapping is a quick and technically feasible method to achieve definitive hemostasis in severe liver trauma. It can be combined ideally with conventional procedures. Mesh-wrapping has the same spectrum of indications in severe liver trauma as packing with gauze pads. Whereas packing seems to be superior in cases with bleeding from juxta-caval injuries, Mesh-wrapping is considered to be superior in coagulopathy. The Mesh-wrapping technique provides a highly selective, tight compression confined to the liver and does not produce an increased intraabdominal pressure. The mesh is resorbable and therefore reoperation for removal is not necessary. In cases of postoperative fluid collections the Mesh-wrapping can easily be punctured. Because of its own bacteriostatic capacity Mesh-wrapping seems to be superior when the patient has concomitant gastrointestinal injuries. In summary we think that Mesh-wrapping is a useful alternative in the more conservative, organ preserving spectrum of liver trauma management.

[Urologic complications of Crohn disease]. / Urologische Komplikationen bei Morbus Crohn.

A report on urologic complications of Crohn's disease observed in 9 out of 51 operated patients. Primary resection of the diseased bowel segment is of decisive importance in the treatment of these vesicoenteric fistulae or ureteric stenoses. Additional ureterolysis is required only in case of extensive retroperitoneal fibrosis.

[Ultrafast magnetic resonance tomography changes the standard in pancreas diagnosis]. / Die ultraschnelle Magnetresonanztomographie verändert den Standard in der Pankreasdiagnostik.

BACKGROUND: Since the introduction of MRI, including imaging of the hepato-pancreatic duct system (MRCP) and 3D-MR angiography (3D-MRA), new pancreatic diagnostic procedures have been developed. METHODS AND PATIENTS: We report on 143 patients with benign and malignant diseases of the pancreas, who only received MRI preoperatively. All radiologic findings were confirmed intraoperatively. RESULTS: For resectability, MRI obtained sensitivity of 96.0% and specificity of 89.5% and for classification sensitivity of 99.1% and specificity of 95.2%. CONCLUSION: Based on our experience, the benign vs malignant nature of the disease, MRI is a safe and reliable method for pancreatic tumors being able to become the standard diagnostic procedure in the future.