Post-irradiation soft tissue sarcoma.

From 1975 to 1993, 11 of 375 patients treated for soft tissue sarcoma presented with post-irradiation sarcoma. The mean time interval between irradiation therapy and onset of the second neoplasm was 15.8 years (4-31 years). The total radiation dosage ranged from 12 to 60 Gy with a mean of 40 Gy. All patients had complete staging including CT or MRI of the tumour site, and CT of the lung. Surgical resection was the treatment of choice. Wide margins could be achieved in 10 patients. One had a marginal resection. Tumours included malignant fibrous histiocytoma, haemangiosarcoma, rhabdomyosarcoma, malignant schwannoma, fibrosarcoma and undifferentiated sarcoma. All patients were reassessed in our outpatient clinic. After a mean follow-up of 4.7 years (1.0-11.5 years), only 1 patient had died because of the tumour. Although post-irradiation sarcomas are rather infrequently observed, these tumours must be suspected when alterations or symptoms occur in a previously irradiated region. Early detection provides the chance of curative, wide margin resection.

Impact of radical systematic mediastinal lymphadenectomy on tumor staging in lung cancer.

The extent of lymphadenectomy in the treatment of non-small cell lung cancer is still a matter of controversy. While some centers perform mediastinal lymph node sampling with resection of only suspicious lymph nodes, others recommend a radical, systematic mediastinal lymphadenectomy (LA) to improve survival and achieve a better staging. Herein we report on the impact of LA on tumor staging in a controlled, prospective, randomized clinical trial comparing lymph node sampling and LA in a total of 182 patients with operable non-small cell lung cancer. Regardless of the type of lymphadenectomy performed, the percentage of patients with pathologic N1 or N2 (sampling: n = 23, 23.0%; LA: n = 22, 26.8%) disease was very similar in both groups, indicating that systematic radical lymphadenectomy is not an essential prerequisite to determine the N stage of a patient. In contrast, the number of patients detected to have lymph node involvement at multiple levels was significantly increased by LA. In the lymph node sampling group only 4 of 23 patients (17.4%) with N2 disease were found to have more than one lymph node level involved, whereas LA results in the detection of excessive N2 disease in 12 of 21 patients (57.2%; p = 0.007), which was associated with a shorter distant metastases-free (p = 0.021) and overall survival. In conclusion, LA is not essential to determine the N stage of a patient, but results in a more detailed staging of the N2 region, which is of prognostic significance. Therefore, it might be useful to identify patients with a higher risk for tumor relapse.

Angiogenesis, angiogenic growth factors, and cell adhesion molecules are upregulated in chronic pancreatic diseases: angiogenesis in chronic pancreatitis and in pancreatic cancer.

Recent epidemiologic evidence suggests that patients with chronic pancreatitis (CP) have an increased risk of developing pancreatic carcinoma (PCA). In spite of numerous similarities in both diseases, mechanisms for progression from CP to PCA are poorly understood. We hypothesized that enhanced angiogenesis might play a pivotal role in the etiology and histopathology of both CP and PCA, and thus form a possible link between precancer and carcinoma. In surgical specimens of 18 patients with CP, 10 with PCA, and 18 controls, absolute numbers of blood vessels and relative blood vessel density were assessed after immunostaining of endothelial cells for von Willebrand factor and PECAM-1 (platelet/ endothelial cell adhesion molecule-1). Furthermore, the expression of cell adhesion molecules ICAM-1 (intercellular adhesion molecule-1) and VCAM-1 (vascular cell adhesion molecule-1) and of VEGF (vascular endothelial growth factor) was investigated in all specimens. Both CP and PCA exhibited areas of high vascular density ("hot spots"). The mean number of blood vessels in these areas in PCA was 132.2+/-16.8 per mm2, and in CP, 99.2+/-7.4 per mm2. The mean vessel count in controls was 25.1+/-5.1. Relative vessel density was increased in both PCA (41.3+/-3.5%) and CP (30.6+/-2.6%) versus controls (8.0+/-0.8%). Both absolute vessel count and relative vessel density were significantly higher (p<0.05) in PCA than in CP. Enhanced expression of ICAM-1 in CP and PCA was seen in ductal cells in CP and cancer cells. In controls, ICAM-1 and VCAM-1 were expressed only at low levels in endothelial cells. VCAM-1 was strongly expressed in acinar cells as well as in ductal cells. In CP and PCA, VEGF was strongly expressed in ductal cells in CP as well as in cancer cells. We show for the first time that angiogenic activity is increased in both CP and PCA. Based on this study, we suggest that antiangiogenesis might be a novel target for prevention or therapy in chronic pancreatic diseases.

Quality of life in chronic pancreatitis--results after duodenum-preserving resection of the head of the pancreas.

Studies on chronic pancreatitis have focused predominantly on pain measurement, morbidity, and mortality. In this prospective follow-up study the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ) was reevaluated for patients suffering from chronic pancreatitis. Pain intensity was quantified using a specially designed pain score. Twenty-five patients with chronic pancreatitis underwent duodenum-preserving pancreatic head resection. The QLQ, Spitzer's quality of life index, and the pain score were assessed twice before surgery, before discharge, and 6 and 18 months after surgery. The interscale reliability (Cronbach's coefficient alpha > or = 0.70) was confirmed for all multiitem scales except preoperative working ability. Test-retest stability for the QLQ was 94%. The QLQ correlated closely with Spitzer's quality of life index (r = 0.985, p < 0.001) and changes in body weight (r = 0.764, p < 0.001). After 18 months physical status, working ability, emotional and social functioning, and global quality of life had improved by 44, 50, 50, 60, and 67%, respectively, showing good responsiveness of the QLQ. The pain score decreased by 95% (p < 0.001). The EORTC quality of life questionnaire represents a reliable and valid measure of quality of life in patients with chronic pancreatitis.

Surgical treatment of chronic pancreatitis and quality of life after operation.

In conclusion, surgical therapy in patients with chronic pancreatitis may be characterized as follows: 1. Independently, several investigators have found intraductal and intraparenchymatous hypertension in patients with chronic pancreatitis. Decompression of the ductal system as the main principle of surgical therapy achieves clinical pain relief in most patients with chronic pancreatitis. The precondition is a consequent drainage of the main pancreatic duct and tributary ducts of second and third order up to the prepapillary region. The presence of an inflammatory tumor in the head of the pancreas or ductal abnormalities in the prepapillary region or a pancreas divisum requires performance of an extended drainage operation (LPJ-LPHE) to achieve pain relief and an improved quality of life. An extended drainage operation effectively manages complications arising from adjacent organs, such as distal common bile duct stenosis, segmental duodenal stenosis, and internal pancreatic fistulas. The extent of decompression has to be tailored to the anatomic and morphologic situation of the patient. 2. In patients with chronic pancreatitis, the main pancreatic duct is usually dilated. A small duct (3-5 mm) is only small for the surgeon. For the sclerosing entity of chronic pancreatitis with a truly small duct, that is, less than 3 mm in diameter ("small duct disease"), a longitudinal V-shaped excision of the ventral pancreas, as opposed to left resection, provides a new perspective for a sufficient drainage. 3. In the presence of segmental portal hypertension, a simple or extended drainage operation does not result in a normalization of the portal venous blood flow; however, how often relevant upper gastrointestinal hemorrhage develops from segmental portal hypertension is unclear. Therefore, the clinical relevance of this special problem needs further evaluation. 4. Postoperative morbidity of LPJ-LPHE is significantly lower in comparison to resectional procedures, such as PD, PPPD, and DPRHP. A lower perioperative mortality rate is not justified anymore as a relevant criterion in favor of drainage procedures because resectional procedures are burdened by a minimal or no mortality in experienced centers; however, PD and PPPD are greatly hampered by a significantly decreased postoperative global quality of life as opposed to the LPJ-LPHE. This is reflected by a significantly lower rate of social and professional rehabilitation. 5. The incidence of exocrine and endocrine organ dysfunction is lower after LPJ-LPHE compared with PD or PPPD, but not compared with DPRHP. Preservation of the gastroduodenal passage and the continuity of the bile duct with its associated feedback mechanisms of exocrine pancreatic secretion and glucose metabolism seem to be responsible for this phenomenon. 6. An early surgical or endoscopic interventional drainage of the hypertensive pancreatic duct system possibly offers the chance to favorably manipulate the natural course of chronic pancreatitis with regard to a delayed onset of exocrine or endocrine insufficiency. 7. Late mortality reflects continued alcohol abuse rather than the effect of an operative procedure.

[Drainage operation as therapeutic principle of surgical organ saving treatment of chronic pancreatitis]. / Die Drainageoperation als Therapieprinzip der chirurgischen organerhaltenden Behandlung der chronischen Pankreatitis.

Intraductal and intraparenchymal hypertension represent the rationale for surgical drainage procedures in the treatment of chronic pancreatitis. "Simple" drainage procedures such as longitudinal pancreaticojejunostomy according to Partington-Rochelle have to be distinguished from "extended" drainage operations, e.g. the combination of longitudinal pancreaticojejunostomy with limited local excision of the pancreatic head. This "extended" drainage procedure according to Frey is just as effective as resective procedures in terms of persistent pain relief and definitive management of pancreatitis-associated complications of adjacent organs, i.e. distal common bile duct and duodenal stenosis. This operation also addresses an inflammatory mass in the pancreatic head. In contrast to "simple" drainage procedures the Frey operation allows reliable exclusion of pancreatic carcinoma. With low perioperative morbidity and zero mortality the Frey procedure significantly improves quality of life and leads to social and occupational rehabilitation.

[Haemosuccus pancreaticus as a rare initial manifestation of chronic pancreatitis]. / Haemosuccus pancreaticus als seltene Erstmanifestation einer chronischen Pankreatitis.

Haemosuccus pancreaticus is an unfrequent but known cause of an upper gastrointestinal bleeding. Pathogenesis of spontaneous severe hemorrhage of the pancreatic duct includes chronic pancreatitis generated pseudocysts or aneurysms of the visceral arteries. We present two cases of severe spontaneous gastrointestinal bleeding as a first manifestation of chronic pancreatitis, in which the diagnosis chronic pancreatitis was not known and the patients denied any gastrointestinal symptoms in their medical history at the time of hemorrhage.

[Drainage versus resection in surgical therapy of chronic pancreatitis of the head of the pancreas: a randomized study]. / Drainage versus Resektion in der chirurgischen Therapie der chronischen Kopfpankreatitis: eine randomisierte Studie.

Drainage and resection are the principles of surgery in chronic pancreatitis. The techniques of duodenum-preserving resection of the head of the pancreas as described by Beger and Frey combine both to different degrees. In a prospective randomized trial both procedures were compared: 74 patients were randomly allocated to either Beger's (n = 38) or Frey's, (n = 36) group. In addition to routine pancreatic diagnostic work-up a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Assessment of endocrine and exocrine function included oral glucose tolerance test, serum concentrations of insulin, C-peptide, and HbA1c, as well as fecal chymotrypsin and pancreolauryl test. The mean interval between symptoms and surgery was 5.1 years (1-12 years). The median follow-up was 30 months. There was no mortality. Overall morbidity was 27% (32% Beger, 22% Frey). Complications from adjacent organs were definitively resolved in 91% (92% Beger, 91% Frey). A decrease in pain score of 95% and 93% after Beger's and Frey's procedure, respectively, and an increase of 67% in the overall quality-of-life index in both groups were observed. Endocrine and exocrine function did not differ between the two groups. Both techniques of duodenum-preserving resection of the head of the pancreas are equally safe and effective with regard to pain relief, improvement of quality of life, and control of complications affecting adjacent organs. Neither procedure leads to further deterioration of endocrine and exocrine pancreatic function.

Multi-visceral resection for locally advanced gastric cancer.

Fifty-three of sixty-four patients who underwent gastrectomy for gastric carcinoma presented with advanced gastric cancer. 8 patients underwent palliative gastrectomy. In 17 patients gastrectomy and lymphadenectomy was performed. In 28 patients with locally advanced gastric carcinoma, extended resection was performed. Patients who underwent splenectomy were only included if tumorous adherence to the spleen was present. Hospital mortality and morbidity were 3.6% and 25% in extended resection and 5.9% and 18% in gastrectomy and lymphadenectomy alone. R0 resection was performed in 26/28 and in 16/17 patients, respectively. In R0 (complete) resections the mean one and two-year-survival rates were 64% and 44% in extended resection, and 67% and 47% in gastrectomy and lymphadenectomy. In patients (11) with residual tumour (R1/R2) mean one and two-year-survival rates were 27% and 0%, respectively. If complete resection (R0) is achieved, extended resection for locally advanced gastric carcinoma provides survival time, which is comparable, stage for stage, with survival rates observed after R0 resection for cancer limited to the stomach.

Effective treatment of symptomatic gastroesophageal reflux disease by laparoscopic fundoplication.

Full text is available as a scanned copy of the original print version.

Modifications of the duodenum-preserving pancreatic head resection.

Surgery for chronic pancreatitis has gained wide acceptance because of excellent results regarding pain alleviation and control of complications arising from adjacent organs. After the introduction of the duodenum preserving pancreatic head resection by Beger almost three decades ago, many modifications have been proposed, evaluated and compared. This article reviews the variety of operations, the reported results and potential advantages. Besides the Beger- and Frey procedure, none of the modifications have been properly evaluated in a prospective randomised trial. Both procedures managed to relief the outlined problems while achieving low operative mortality and morbidity. Only the operations according to Beger and Frey can be considered standard procedures in chronic Pancreatitis.

Hemostasis with the ultrasonically activated scalpel. Effective substitute for electrocautery in surgical patients with pacemakers.

In patients with implanted pacemaker/cardioverter defibrillator (ICD), the use of electrocautery can lead to serious pacemaker dysfunction. The ultrasonically activated scalpel, however, which has been introduced mainly for the use in laparoscopic surgery, could potentially avoid the outlined problem, since no electrical current flows while in use. This hypothesis was tested in a pacemaker patient undergoing laparoscopic cholecystectomy. During the procedure, no abnormal rhythms or ECG interferences were detected while working in close vicinity to the device. Thus, the ultrasonically activated scalpel provides adequate hemostasis and does not bear the risk of pacemaker dysfunction.

Verapamil and flunarizine protect the isolated perfused rat liver against warm ischemia and reperfusion injury.

Using the model of the isolated perfused rat liver, we investigated the influence of the two pharmacologically different calcium channel blockers, verapamil and flunarizine, on changes of ion homeostasis, liver weights, pH deviations and enzyme activities during warm ischemia (37 degrees C) and reperfusion. The LDH and GLDH activities were determined and the calcium, potassium, and sodium concentrations were measured in the effluent. Warm ischemia (180 min) caused an increased enzyme release, a high influx of calcium and sodium into the liver and a massive potassium efflux current. Normoxic reperfusion led to a further increase in hepatic enzyme release and although the loss of potassium ceased, the calcium influx into the liver continued. By the end of reperfusion the liver weight had increased significantly (P < 0.01) in the control group. The two calcium entry blockers were added to the perfusate in various concentrations. Both substances protected the liver against warm ischemia and normoxic reperfusion damage, but they did not inhibit calcium inflow. However, the potassium efflux was significantly reduced by all concentration tasted (P < 0.001). After reperfusion the liver weights were significantly lower in the treated groups (P < 0.001) than in control animals. Thus, the calcium entry blockers verapamil and flunarizine protect liver cells against damage caused by warm ischemia and reperfusion. Furthermore, they prevent the disruption of intracellular potassium homeostasis, which seems to be related to improved volume regulation of liver cells.

Laparoscopic treatment of nonparasitic cysts of the liver with omental transposition flap.

BACKGROUND: Between 1991 and November 1994, 18 patients with large, solitary, nonparasitic liver cysts underwent laparoscopic deroofing; the last 13 of them also received an omental transposition flap in addition. METHODS: Using three to four trocars, the cystic contents were first aspirated, and the cyst derooted widely using diathermia. An omental transposition flap was fashioned and stapled into the cyst cavity itself. RESULTS: Postoperative complications included one case of pulmonary atelectasis. Another patient developed a subhepatic bile collection which was aspirated percutaneously. On average, patients were discharged on the 4th (2-14) postoperative day. Follow-up was performed with abdominal ultrasound for 2-43 months (mean 19 months). There were two early cyst recurrences, both in cases without an omental transposition flap (overall recurrence rate, 11%; in patients with omental flap, 0). CONCLUSIONS: Deroofing in combination with an omental transposition flap is a safe and effective therapy for symptomatic solitary liver cysts and can be performed using minimal-access surgical techniques.

Toxic megacolon caused by cytomegalovirus colitis in a multiply injured patient.

Cytomegalovirus (CMV) colitis is a rare event that has been described mainly in immunocompromised patients with immunosuppressive medication or HIV infection. An association with severe trauma has not been described previously. We report a formerly healthy, multiply injured 75-year-old male who subsequently developed what appeared to be pseudomembranous colitis. By the time the diagnosis of toxic megacolon on the basis of CMV colitis was established, he had succumbed to multiple organ failure. Whenever pseudomembranous colitis is clinically suspected but not confirmed in a critically ill formerly healthy patient, CMV colitis should be excluded. Once the diagnosis is confirmed, generous resection of all affected colon is mandatory in view of the limited benefit of antiviral therapy in CMV-induced toxic megacolon.

[Prognostic value of gastric tonometry in peritonitis due to intestinal perforation and laparoscopic versus conventional management in the swine model]. / Prognostischer Wert der gastralen Tonometrie bei Perforationsperitonitis und laparoskopischer versus konventioneller Versorgung im Schweinemodell.

After a 12 hour period of experimental peritonitis induced by gastric perforation mortality was significantly higher in the laparoscopically treated group of pigs when compared to the open procedure. In both groups the treatment was simple oversowing of the defect plus peritoneal lavage. Septic shock associated with peritonitis and subsequent "multi organ failure syndrome" could accurately be predicted with gastric tonometry. In both groups the decline of pHi in septic animals that died was higher than expected.

[Effect of pneumoperitoneum on ultrastructure of parietal peritoneum in experimentally induced peritonitis in the rat]. / Einfluss eines Pneumoperitoneums auf die Ultrastruktur des parietalen Peritoneums bei der experimentell induzierten Peritonitis der Ratte.

Aim of this study was to analyse the effect of gastric perforation induced peritonitis and a pneumoperitoneum (PP) on the ultrastructure of the parietal peritoneum. After randomisation rats allocated to groups I and II were subjected to standardized gastrotomy simulating gastric perforation. After a 12-h-interval a PP was induced in groups I and III. After PP for 60 min a primary fixant was injected intraperitoneally as the abdominal wall was still extended, as well as 30 s, 2 h and 12 h after release of the PP. In groups II and IV simple puncture of the abdomen was performed. Animals were sacrified and tissue specimens taken from the parietal peritoneum of the left diaphragm were analysed using raster electronic miroscopy (REM: 100x to 5000x). In group II (gastric perforation without PP) microvilli appeared shrunk and coarse, while integrity of the mesothelial cell layer remained intact up to 2 h after abdominal puncture. In group I (gastric perforation with PP) distortion of the mesothelial cell layer with concomittant opening of stomata to the submesothelial tissue was observed already in specimens harvested as the abdominal wall was still extended. Concomittantly scarce microvilli appearing coarse and thickened were laid flat on top of the mesothelial cells. After desufflation a rapid process of mesothelial desintegration with disruption from the submesothelial layer and vanishing of microvilli occurred. In REM analysis of parietal peritoneum premature distortion and desintegration of the mesothelial cell layer was observed after exposure to increased abdominal pressure and to gastric perforation-induced peritonitis.

Longitudinal V-shaped excision of the ventral pancreas for small duct disease in severe chronic pancreatitis: prospective evaluation of a new surgical procedure.

OBJECTIVE: The technique of longitudinal V-shaped excision of the ventral pancreas for small duct chronic pancreatitis is presented and its efficacy in terms of pain relief and improvement of quality of life is evaluated. SUMMARY BACKGROUND DATA: Small duct chronic pancreatitis has been regarded as a classical indication for more or less extensive resection, in which the therapeutic success of pain relief is offset by the considerable risk of significant perioperative mortality and morbidity and the burden of substantial loss of pancreatic function. METHODS: Thirteen patients with severe pain who were diagnosed with small duct pancreatitis (defined as maximal Wirsungian ductal diameter of 2 mm) underwent longitudinal V-shaped excision of the ventral pancreas. In addition to routine pancreatic workup, a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Assessment of exocrine and endocrine function included fecal chymotrypsin and the pancreolauryl test as well as oral glucose tolerance, serum concentrations of insulin, C-peptide, and hemoglobin A1c. The interval between symptoms and surgery ranged from 12 months to 10 years (mean, 5.4 years). Median follow-up was 30 months (range, 12-48 months). RESULTS: There were no deaths. Overall morbidity was 15.4%. In 92% of patients, complete relief of symptoms was obtained. Median pain score decreased by 95%. Physical status, working ability, and emotional and social functioning scores improved by 40%, 50%, 67%,, and 75%, respectively. Global quality-of-life index increased by 67%. Occupational rehabilitation was achieved in 69% of patients. Exocrine and endocrine pancreatic function was well preserved. CONCLUSIONS: In small duct chronic pancreatitis, longitudinal V-shaped excision of the ventral pancreas is a safe and effective alternative to resection procedures. The new technique provides pain relief and improvement of quality of life, thus offering the benefit of a resection procedure without its burden.

[Current diagnosis and therapy of soft tissue sarcomas in the adult]. / Aktuelle Diagnostik und Therapie bei Weichteilsarkomen im Erwachsenenalter.

Soft tissue sarcomas embrace a wide variety of rare tumours. This often means excision without wide margins, and the unexpected malignancy leads to diversity of postoperative treatment. As a rule all lesions of a soft tissue tumour should be biopsied if persisting for more than 6 weeks. The extent of the biopsy is determined by the tumour characteristics, but should not aggravate later resection of a malignant tumour. Preoperative diagnostic studies should be standardised and include MNR, while the tumour is characterised according to the recent edition of the UICC GTNM system. The primary tumour should be excised in a limb-sparing way with wide margins, if necessary including the neighbouring fascia. Local recurrence should be approached aggressively like primary tumours, with curative intention. In cases of distant metastases, which usually occur in the lungs, a grading-associated approach is necessary. In G3 metastases chemotherapy should be administered before the surgical intervention. Radiation therapy is saved for patients in whom the tumour cannot be resected with wide margins or is larger than 10 cm maximum diameter. In the light of current knowledge, radiation therapy should be given as an adjuvant for patients whose tumour was resected without wide margins and for tumours larger than 10 cm in diameter. The use of palliative chemotherapy is still controversial and identification of new prognostic markers for patient selection is necessary. Since most patients with soft tissue sarcoma die from distant metastases and not the primary or locally recurrent tumour, the need for effective chemotherapy in an adjuvant setting is obvious. Controlled studies with as many enrolled patients as possible are necessary if valid data are to be collected. The management of soft tissue sarcoma patients is in principle multidisciplinary and should be confined to specialised centres.