A. Petri

Late malignant transformation of chronic corrosive oesophageal strictures.

ZusammenfassungDie Zahl der Patienten mit Narbencarcinomen des Oesophagus, die durch verätzungsbedingte Strikturen entstanden sind, scheint in den letzten beiden Jahrzehnten angestiegen zu sein. 36 Patienten mit dieser Erkrankung wurden zwischen 1965 und 1984 chirurgisch behandelt; dies ist die zweitgrößte Fallzahl, die in der Literatur bisher beschrieben wurde. Patienten mit Narbencarcinomen machen 7,2% der Gesamtzahl an Oesophaguscarcinomen aus; dieses Verhältnis ist zur Zeit das höchste in der Literatur. Das Intervall zwischen der Verätzung und der Diagnosestellung eines Narbencarcinoms beträgt 46,1 Jahre; es liegt damit höher als die bisher allgemein angenommenen 30–35 Jahre. Das Intervall beträgt 50,9 Jahre bei den Patienten, die vor ihrem 12. Lebensjahr Lauge getrunken hatten, ist aber um 14 Jahre kürzer, wenn die Verätzung im Erwachsenenalter stattgefunden hatte. Die Langzeit-Überlebensrate erwies sich als ausgezeichnet: 45,6% der resezierten Fälle waren nach 5 Jahren noch am Leben, 14,4% nach 10 Jahren. Die Erklärung für die gute Prognose liegt darin, daß das Carcinom, welches sich in einer Laugenstriktur entwickelt, zunächst von einer rigiden Narbe ummauert ist, welche nur die intraluminale Ausbreitung erlaubt, wobei durch die Einengung des Lumens eine frühe Dysphagie hervorgerufen wird. Eine frühzeitige Dissemination wird aus dem gleichen Grunde verhindert. Bei kurativen Eingriffen wird die einseitige Resektion und der Ersatz vorgeschlagen. Patienten mit einer operationsbedürftigen Oesophagusverätzungsstriktur können sowohl durch eine Bypassoperation als auch Resektion behandelt werden, es muß aber darauf hingewiesen werden, daß sogar noch Jahre nach der Operation eine Malignitätsentwicklung im zurückbleibenden Teil der Speiseröhre möglich ist. Die totale Oesophagektomie wird daher an Stelle des Bypassverfahrens vorgeschlagen.SummaryThe number of patients with scar carcinoma of the oesophagus developing on the basis of a corrosive stricture seems to have been rising in the past two decades. 36 patients of this kind were treated surgically between 1965 and 1984; this is the second largest series in the literature. The patients with scar cancer comprised 7.2% of the overall oesophageal carcinoma cases; this ratio is currently the highest of all in the literature. The interval between the caustic burn and the diagnosis of scar carcinoma was found to be 46.1 years; this is higher than the 30–35 years generally accepted so far. It was 50.9 years in those patients who drank lye before the age of 12, but 14 years less when it happened in adulthood. The long-term survival time proved to be excellent: 45.6% of the resected cases were alive after 5 years and 14.4% after 10 years. The explanation of the good prognosis lies in the fact that carcinoma developing in a lye stricture is at first surrounded by a rigid scar which allows only its intraluminal growth, and it causes early dysphagia through luminal obstruction. Early dissemination is prevented for the same reason. One-stage resection and replacement is suggested in the radically operable cases. In patients with oesophageal corrosive stricture which needs operation, both a by-pass procedure and resection can be adopted, but it should be pointed out that malignancy may develop even years after the operation in the remaining part of the gullet. Total oesophagectomy is therefore suggested instead of bypass.The number of patients with scar carcinoma of the oesophagus developing on the basis of a corrosive stricture seems to be rising in the past decades. Thirty six patients with this condition were treated surgically in a 20 years period; this is the second largest series in the literature. Patients with scar cancer were 7.2% of all oesophageal carcinoma cases; this ratio is currently the highest of all in the literature. The interval between the burn and the diagnosis of scar carcinoma was 46.1% years; this is higher than the 30-35 years generally described so far. It was 50.9 years in those patients who drank lye before the age of 12, but 14 years less when it happened in adulthood. The long-term survival was excellent: 45.6% of the patients after resection were alive after 5 years and 14.4% after 10 years. The explanation of the good prognosis is that carcinoma develops in a lye stricture and is at first surrounded by a rigid scar which allows only intraluminal growth, so it causes early dysphagia through obstruction. Early dissemination is prevented because of the same reason. One-stage resection and reconstruction is the best way to treat the radically operable patients. In patients with esophageal corrosive stricture in need of operation, both a bypass procedure and resection can be performed, but it should be pointed out that malignancy may develop even years after the operation in the remaining part of the gullet. Total esophagectomy is therefore suggested instead of by-pass.

Pyogenic liver abscess -- 20 years' experience. Comparison of results of treatment in two periods.

Abstract.Background and aims: Our aim is to give an audit of our experience over the past two decades in the form of a retrospective study. Patients/methods: In two equal periods between 01.01.1982 and 31.03.2001, 56 patients (37 males and 19 females) with pyogenic liver abscess were treated. Image-guided percutaneous drainage was performed in 22.2%/20.6% of the patients; the remainder were treated with open drainage with or without biliary tract reconstruction and liver resection. For antibiotic perfusion of the liver an umbilical vein cannula was inserted in 40.7%/24.1%. Microbiological findings, types of therapy, complications and mortality, etiology, patient characteristics, symptoms, and laboratory data were investigated. The results in the two groups were compared and analyzed statistically. Results: The most common cause of abscess, biliary disease, was seen more often in the second period. Solitary liver abscesses were more frequent. The only characteristic biochemical finding was an elevated alkaline phosphatase level. There were more positive cultures in the second period (70.4%/79.3%), and the number of Escherichia coli or Enterobacter aerogenes infections also increased. In the first period the mortality was 18.5%, whereas in the second no patients were lost. Conclusion: We suggest the importance of individualized therapy based on an early and exact diagnosis. The first treatment step should be image-guided drainage, but under well-defined circumstances open drainage can also be performed with good results.

Experience with different methods of treatment of nonparasitic liver cysts.

Abstract Background and aims. In a search for the optimal management of nonparasitic liver cysts, a study was made of the effectiveness of different methods. Patients and methods. Between 1 January 1982 and 15 December 2001 we treated 132 patients with nonparasitic liver cysts. In 72 patients 31 cysts were treated with enucleation, 60 with deroofing, and 24 with stitching by laparotomy; two liver resections were also performed. In a further 34 patients 36 cysts were treated with deroofing by minimally invasive surgery. In an additional 26 patients 32 cysts were treated with various interventional radiological methods. Results. There was no mortality. The morbidity rate after laparotomy was significant (22.2%). The rate of recurrence after enucleation and deroofing was 6.5% and 13.8%, respectively, but there were no recurrences after stitching and liver resection. The recurrence rate following laparoscopic deroofing was 19.4%, and that following interventional radiological procedures was 50%. Conclusions. Treatment is required only if cysts are highly symptomatic or if growth is detected. Interventional radiological methods do not prove more favorable than surgery. Laparoscopic fenestration is preferred because of its low morbidity and the short period of hospitalization. Traditional surgical methods should be reserved merely for cases in which laparoscopic deroofing is not feasible.

Endothelin-a receptor antagonist treatment improves the periosteal microcirculation after hindlimb ischemia and reperfusion in the rat.

Objectives: To examine the microcirculatory changes in the rat tibial periosteum after hindlimb ischemia and reperfusion and to evaluate the effects of endothelin‐A (ET‐A) receptor antagonist therapy in this condition. The healing and functioning of vascularized bone autografts depend mainly on the patency of the microcirculation, and the activation of ET‐A receptors may be an important component of the tissue response that occurs during ischemia‐reoxygenation injuries.

Ischemic stricture of the intrathoracic Roux loop used for esophagoplasty

ZusammenfassungDrei Fälle von Strikturen der intrathorakalen Roux-Schlinge nach Ersatz des unteren Drittels des wegen Krebs resezierten Oesophagus werden berichtet. 6 Wochen nach Rekonstruktion traten in jedem Fall fibrotische Strikturen auf, die auf Ischämie zurückzuführen waren, in einem Fall wegen eines reduzierten Butflusses während Digitalisierung, in den beiden anderen Fällen wegen vasculärer Kompression der Versorgungsgefäße wegen nicht zufriedenstellender Dilatation des Hiatus.SummaryThree cases of stenosis of a Roux loop are presented, following the replacement of the lower third of the esophagus resected for cancer. In each case fibrotic stenosis developed 6 weeks after reconstruction, which was attributed to ischemia: in one case it was due to reduced blood flow during digitalization and in the other two cases to the vascular compression of the supplying vessels because of unsatisfactory dilatation of the hiatus.