[Metastasis of prostate carcinoma to the lamina submucosa of the distal rectum in ulcerative colitis 2 years after transrectal prostate biopsy and radical prostatovesiculectomy]. / Metastase eines Prostatakarzinoms in der Lamina submucosa des distalen Rektums bei Colitis ulcerosa 2 Jahre nach transrektaler Prostatabiopsie und radikaler Prostatovesikulektomie.

Transrectal ultrasound-guided prostate biopsy is the standard technique to detect prostate cancer histologically. Based on a few case reports, it is known that prostate biopsy can cause a seeding of tumor cells. We report the case of a 64-year-old man who 2 years after radical prostatectomy for prostate cancer underwent proctocolectomy because of ulcerative pancolitis. In the lamina submucosa of the distal rectum a micrometastasis of the prostate cancer was found. A possible reason for this metastasis is an implantation of prostate cancer cells due to the transrectal biopsy of the prostate.

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.

Improved sensitivity of fuzzy logic based tumor marker profiles for diagnosis of pancreatic carcinoma versus benign pancreatic disease.

BACKGROUND: The definite diagnosis of pancreatic tumors of unknown origin remains a clinical challenge. Imaging techniques may fail to differentiate malignant tumors from inflammation, especially in chronic pancreatitis. In a considerable number of cases, the definitive diagnosis needs laparotomy. Single tumor markers as CA 19-9 or CEA are of limited value in these cases because of their limited sensitivity and specificity. This study was performed to find out, whether a classification method based on fuzzy logic analysis of tumor marker profiles is feasible in patients with pancreatic carcinoma and benign pancreatic disease. PATIENTS AND METHODS: Tumor markers and other clinical and laboratory parameters of 74 consecutive patients, either with histologically proved pancreatic carcinoma (n = 43) or presumed benign pancreatic disease (n = 31) assessed by ultrasound, endoscopic retrograde pancreatography, or computed tomography were analysed in order to detect their diagnostic value in the multi-dimensional approach of fuzzy logic analysis. RESULTS: Given a specificity of 95%, sensitivity was considerably increased by the fuzzy logic method (83%) compared with the best single tumor marker CA 19-9 (65%). CA 19-9, CYFRA 21-1 and CA 15-3 gave the most considerable contributions to the classification system, whereas CEA, CA 125, CA 72-4, AFP, liver enzymes, lipase, amylase, bilirubin, and ferritin were of no or little value. CONCLUSIONS: Tumor marker profiles analysed with the fuzzy logic method may have an improved sensitivity compared with single standard tumor markers. The diagnostic efficacy should be proved in patients with pancreatic tumors of unknown origin.

IgM-enriched immunoglobulin (pentaglobin) positively influences the course of post-surgical intra-abdominal infections.

BACKGROUND: Polyvalent IgM-enriched intravenous human immunoglobulin (IVIG) preparations are discussed to be beneficial regarding sepsis outcome. MATERIALS AND METHODS: Sixty-four patients with abdominal infection were treated with Pentaglobin or Albumin. Serum levels of endotoxin and chemokines were determined. RESULTS: Incidence of fever was 19/28 in the pentaglobin and 18/26 in the albumin group, the percentage of days with fever was 34 +/- 26 for pentaglobin and 43 +/- 25 for albumin (mean +/-SD). Procalcitonin levels of the pentaglobin treated patients fell under the upper limit of normal on day six whereas levels of albumin patients remained elevated. CONCLUSION: Pentaglobin has a positive influence on the course of post-surgery intra-abdominal infection.

[Intestinal occlusion and perforation as a complication in percutaneous endoscopic gastrotomy (PEG)]. / Occlusione e perforazione intestinale quale complicanza in gastrotomia endoscopica percutanea (PEG).

Complications in the removal of PEG have rarely been reported. Especially patients been operated for head and neck cancer can be a serious problem for the removal of percutaneous endoscopic gastrostomy. A case of an incomplete removal of PEG and occlusion of the lower bowel with subsequent perforation is reported.

Spontaneous intracerebral hemorrhage following carotid endarterectomy. Experience of 328 operations from 1983-1988.

In a consecutive series of 328 carotid endarterectomies there were two cases of postoperative intracerebral hemorrhage. The patients with transient ischemic attacks and subsequent major cerebral infarction had repair of their very tight carotid stenosis. Each developed intracerebral hemorrhage after a symptom free interval and hypertension was uncontrolled during the postoperative period. Hypertension is a significant complication of carotid endarterectomy and may be a prominent factor in the development of intracerebral hemorrhage after carotid endarterectomy. Also defective cerebrovascular autoregulation in chronic ischemic brain regions may predispose patients to intracerebral hemorrhage.

"Ring fixator" for treatment of lower leg fractures. A review of 30 cases treated by a new external fixation system.

Besides generally known therapeutic practice, indications can be discovered and more easily evaluated by using a "Ring Fixator". Applications include the following: (1) stage fractures of the tibia, (2) stabilisation of fractures of polytraumatized patients with no need for prior anatomical reduction and (3) closed lower limb fractures with severe soft tissue lesions. The major advantages of the "Ring Fixator" include the following: possible unlimited correction of primary and secondary dislocations without needing to transpose implanted Steinmann-pins or Schanz' screw; compatibility with ASIF external fixation systems for supplementary use of "Ring Fixator" elements; possible management of secondary dislocations and variable placement of pins or screws for subsequent wound debridement and muscle flap transposition. Results so far obtained using the "Ring Fixation" are illustrated by clinical examples.

Cytokine activation in patients undergoing open or laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic surgery is estimated to produce a minor surgical injury in comparison with open and laparoscopic cholecystectomies. Studies in the past compare almost data of the first hours until day two. However, the surgical injury and the wound healing metabolism has to be detected. METHODS: A prospective study was designed to investigate cytokine responses after surgical injury. Twenty-three patients with symptomatic cholelithiasis were admitted to the study. Eleven patients underwent conventional (open) and twelve patients laparoscopic cholecystectomy. Circulating concentrations of cytokines-including Interleukin-6 (IL-6), Tumor necrosis factor-alpha (TNF-alpha) and neopterin, were compared between both groups. In addition, association of the cytokines with clinical parameters including leucocytes, urea, fever and C-reactive protein (CRP) were assessed. We are using ELISA-test of Medgenix GmbH, Ratingen, Germany and BRAHMS Diagnostica, Berlin, Germany. RESULTS: Enhanced cytokine responses were observed in the conventional group compared to the laparoscopic group. On day 3 after operation, the second increase in cytokine levels (but smaller than the first increase) were observed in both groups. In the conventional group, a slightly high correlation ratio between the urea and cytokine levels was found. However, only neopterin and urea association on postoperative day 3 (r = 0.65) was significant (p < 0.05). There was no significant association between CRP and cytokine levels in both groups. CONCLUSIONS: Cytokine response after cholecystectomy demonstrates the lesser degree of surgical injury in the laparoscopic group, however, TNF-alpha demonstrates on day 4 a similar increase in both groups. This is a new result of studies working in this field. In conclusion, the benefit of laparoscopic surgery results only in the minimal access to the abdominal cavity, the wound healing metabolism is at last the same in both groups.

Left cerebral hemi-neglect following carotid TEA: diagnostic, pathogenetic and therapeutic considerations.

OBJECTIVE: This paper describes the first case report in the literature of a hemi-neglect following carotid desobliteration. The disorder is explained in detail and diagnostic as well as pathogenetic aspects are discussed in depth. SUBJECT: Hemi-neglect syndrome is thought to be a rare complication after carotid-desobliteration. It describes a neuropsychological disorder which can affect motor, sensory and visual modalities, either singly or in combination. The diagnostic approach is rather simple but requires thorough clinical assessment. It can be caused by embolic or hemodynamic reasons; the clinical findings in either case are highlighted and discussed in detail. CONCLUSIONS: Pre-operative diagnostic evaluation and perioperative management of patients with ICA-stenosis should be undertaken in close co-operation between surgeons and neurologists. This way, the risk of developing neurological complications (i.e. neglect) after surgery can be estimated in the individual case. In high risk cases, indication for surgery should be seen critically.

[Myelosarcoma of the proximal jejunum. A rare primary condition of acute myelogenous leukemia]. / Myelosarkom des proximalen Jejunums Eine seltene Erstmanifestation der akuten myeloischen Leukämie.

Myelosarcoma (chloroma) is a rare primary condition in patients with either a myelodysplastic syndrome, or an acute or chronic leukemia. It is an extramedullary neoplasm which does not commonly present with changes in peripheral blood or bone marrow. The rarity and histomorphological similarity to malignant non-Hodgkin lymphoma renders the diagnosis notoriously difficult. Due to its coincidental or secondary manifestation followed by myelogenous leukemia, this tumor needs to be seen as a primary systemic disease. We present a 40 year old man with myelosarcoma of the jejunum and discuss this entity and its therapeutic options.

[Prospective comparative observational study on the antibiotic treatment of secondary peritonitis in Germany -- efficacy and cost analysis]. / Antibiotische Behandlung der sekundären Peritonitis in Deutschland. Prospektive vergleichende Beobachtungsstudie zur Wirksamkeit und den Behandlungskosten.

AIMS: Cephalosporins and broad-spectrum penicillins in combination with metronidazole are suitable for treatment of secondary peritonitis. The aim of this study was to compare the clinical and bacteriological efficacy, length of hospital stay (LOS), treatment costs of ceftriaxone (CRO) in combination with metronidazole vs standard regimens (SR) 1 and 2. METHODS: Patient data were subjected to matched-pairs analysis according to four different categories of the Mannheim peritonitis index. RESULTS. From January 1998 to March 2000, a total of 365 patients from 59 surgical wards in German hospitals were included. Clinical efficacy was 90.2% vs 70.4% ( P=0.004) for CRO/SR 1 and 78.3% vs 82.6% for CRO/SR 2. Bacteriological efficacy was comparable. Antibiotic treatment costs were 593/539 Euros for CRO/SR 1 and 466/750 Euros for CRO/SR 2, i.e., costs for CRO were 37.9% lower than with SR 2. CONCLUSION: Based on clinical, bacteriological, and pharmacoeconomic results, ceftriaxone in combination with metronidazole can be regarded as a first-line antimicrobial treatment of secondary peritonitis.

[Treatment of pancreatic injuries. Study of a series of 34 patients]. / Le traitement des traumatismes du pancréas. Etude d'une série de 34 malades.

Routine retrograde imaging of Wirsung's duct, an essential investigation of pancreatic injuries, should be carried out preoperatively and, in case of failure of the intervention, intraoperatively. Whereas simple drainage is sufficient treatment for injuries to the pancreatic parenchyma, lesions of Wirsung's duct require either duodeno-cephalic pancreatectomy or left pancreatic resection, depending on the site of the ductal wound, conservative treatment carrying the major risk of a post-traumatic acute pancreatitis with its particularly elevated mortality rate. Of the 34 cases, reported: 24 (70.6%) were treated by resection: 3 by duodenocephalic pancreatectomy and 21 by left pancreas resection, 6 (17.6%) by suture of the parenchyma and contact drainage and 4 (11.8%) by drainage of Wirsung's duct by catheter or excluded loop in Y. Mortality was 14.7% (5 of the 34 patients). Complications included pseudocysts requiring operative removal in 3 of the 6 patients treated by suture-drainage, and severe sepsis in 5 patients with a fatal outcome in 3 cases. Treatment was unsuccessful in 2 of the 4 patients treated by drainage by catheter or excluded loop in Y, whereas mortality was nil after pancreatic resection.

[Role of surgery in the treatment of severe acute necrotic pancreatitis]. / La place de la chirurgie dans le traitement des pancréatites aiguës nécrotiques graves.

Between May 1975 and December 1991, a total of 208 patients were operated upon for severe acute necrotic pancreatitis. The decision whether to operate on patients with clinical and biologic aggravation despite particularly sustained intensive care was taken after evaluation of ultrasound and CT scan images. Combining pancreatic body resections and necrotic tissue excision with laparostomy and staged lavage drainage reduced global mortality rate from 49.2 to 16.4 p. cent. The criteria used for determining the indication for surgical intervention, and the technical and tactical operative procedures applied allowing this improvement, are described and discussed.

[Morphology and biological integration of autodermoplasties in large incisional hernias. Results of an experimental study]. / Morphologie et intégration biologique des auto dermoplasties dans les grandes éventrations. Résultats d'une étude expérimentale.

UNLABELLED: Their aim of the experimental study was to investigate the morphology and wound healing of "Kutisplastik"-technique, originally introduced by Loewe (1913) and Rehn (1914), from different conditions. We want to clarify the mechanism and development of revascularisation. RESULTS: The well known phases of wound healing also appear in the situation of a cutisplasty. In the exsudative reaction the cutis is covered from fibrin fibers. This leads to the development of granulation tissue. The cellular reaction demonstrates first the in-growth of capillary bundles and vessels in the collagen network of corium. The revascularisation is finished up to 14 days after the operation. The other part is the immigration of granulocytes and macrophages in the graft. The release of enzymes leads to the lysis of epidermal structures, cutaneous appendages and at least to collagen fibers of corium. There is also a proliferation from fibroblasts. The genesis from new collagen fibers is then observed so a scar tissue reveals. The "Kutisplastik"-technique contains that the epidermal side of the graft is turned upside-down towards the peritoneum and is sutured under as high tension as possible to the healthy fascia around. This morphology of healing is seen only under high-tension suturing. In the experimental mode of non-tension suturing there is a lack of success in cutisplasty for abdominal wall defects.

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.