F. Harder

Acute and chronic presentation of intestinal nonrotation in adults

Intestinal nonrotation has been recognized as a cause of obstruction in neonates and children and may be complicated by volvulus and intestinal necrosis. It is very rarely seen in the adult and may present acutely as a bowel obstruction and intestinal ischemia associated with midgut or ileocecal volvulus, or chronically as vague intermittent abdominal pain. The purpose of this communication is to reveal the pathogenesis and the surgical significance of intestinal nonrotation in adults and to review the English and German language literature since 1923 to establish the optimal therapeutic management. Between 1983 and 1992, we have managed and observed prospectively 10 adults with intestinal nonrotation. In four patients the nonrotation has been detected at emergency laparotomy owing to midgut or ileocecal volvulus. Four patients suffered from chronic symptoms of intermittent volvulus or small bowel obstruction and in two patients the nonrotation has been noted as an incidental finding at laparotomy for another condition. A survey of the literature from 1923 to 1992 revealed 40 adults with symptomatic intestinal nonrotation to which we contribute nine patients. We establish that in the acute symptomatic pattern, only emergency laparotomy can provide the correct diagnosis and decrease the risk of bowel disturbance. In the chronic situation, barium studies of the upper and lower gastrointestinal tract reveal varying degrees of midgut malrotation and confirm the nonrotation in each case. Also, in these forms the explorative laparotomy with a consequent staging of the abdominal situs is to be recommended. All reported cases at our institutions are without complaints after surgery. Adult patients with intestinal nonrotation and acute or chronic obstructive symptoms or those detected incidentally at laparotomy for other conditions should undergo a Ladd procedure because of the risk of midgut volvulus. In this operation, the nonrotation is left in place and the ascending colon is sutured at the colon descendens and sigmoideum. After this procedure the mesenteric pedicle is fixed and the risk of midgut torsion remains minimal.

Perioperative detection of disseminated tumour cells is an independent prognostic factor in patients with colorectal cancer

The objective of the present investigation was to assess the prognostic significance of disseminated tumour cells in peritoneal lavage, and peripheral and mesenteric venous blood in patients undergoing curative resection of colorectal cancer.

Identification of Sentinel Lymph Nodes in Colon Cancer Depends on the Amount of Dye Injected Relative to Tumor Size

Recent studies have shown that the sentinel lymph node (SLN) procedure might improve staging in colon cancer. However, low SLN identification and high false negative rates have also been reported. In a two-institution study, the SLN procedure with isosulfan blue 1% was performed according to a standardized protocol in 31 patients with open resections for colon cancer. Data were collected prospectively. The database was analyzed retrospectively to determine factors contributing to a low identification rate. The SLN identification rate was 87% and the false negative rate was 50%. Successful SLN identification was significantly associated with application of higher volumes of dye relative to the tumor diameter (p = 0.04) and more frequent tumor localization in the sigmoid colon (p = 0.04) as compared to missing SLN identification. The tumor diameter was not significantly different in the two groups. Sentinel lymph node identification in colon cancer depends on the amount of dye injected relative to the tumor size. Application of only 1 ml of dye—the amount generally recommended in the literature—is not sufficient in large tumors.

Ileocecal reservoir reconstruction with physiologic function after total mesorectal cancer excision

BACKGROUND/AIMSnAfter proctectomy for low rectal cancer and straight coloanal reconstruction, the main causes for increased daily stool frequency, urgency, and incontinence are the limited capacity and distensibility of the anastomosed colic segment in the pelvis. The authors postulated that a pedunculated (preserving the nerve) ileocecal interpositional graft (cecum-reservoir) placed between the sigmoid colon and the anal canal would greatly reduce these inconveniences.nnnMETHODSnThe authors evaluated the safety, defecation quality, and anorectal physiology of such a neorectum in 20 consecutive patients with rectal carcinoma between 5 and 10 cm above the anal verge who underwent total mesorectal excision.nnnRESULTSnNo perioperative morbidity related to the technique and no mortality was observed in these 20 patients. Six months after the operation, 16 patients showed excellent and 4 patients good defecation quality, with maximal tolerable volumes, compliance, and mean colonic transit times comparable to age- and gender-matched healthy volunteers. In addition, anal resting pressure was decreased, squeeze pressure was maintained, and the rectoanal inhibitory reflex remained positive in 80%.nnnCONCLUSIONSnThe cecum-reservoir as a neorectum, using an intact neurovascular colonic segment, is a safe technique, providing excellent defecation quality. It enables a nearly normal physiologic anorectal function, which is already seen 6 months postoperatively.

Glutamine requirements in the generation of lymphokine-activated killer cells

The role of glutamine (GLN) in the generation of lymphokine-activated killer (LAK) cell activity was investigated. LAK cells were derived from healthy donors and peripheral blood mononuclear cells (PBMC) were obtained using either unseparated PMBC or DR(-) CD3(-) CD16(+) CD56(+) enriched cells. PBMC were cultured for 6 or 10 days in medium supplemented with recombinant interleukin-2 (rlL-2; 100 U/ml) in the presence of different concentrations of GLN. K562 (natural killer-NK-sensitive targets), 1301 and U-937 (NK-resistant targets) cells were used as targets in the cytotoxic assays. Furthermore, the limiting dilution (LD) culture system was applied as an alternative to the bulk cell culture system. It was found that GLN affects the lytic potential of cultured cells while the frequency of responding cells did not significantly differ between the compared cell cultures performed in the presence of different amounts of GLN. Data on cell proliferation with IL-2 stimulation showed significant differences in cultures performed in the presence or absence of GLN. The results of present investigation suggest a supportive role of GLN in the generation of LAK cells. GLN deficit affects LAK cell killing activity by limiting the number of generated effector cells while acquisition of broad-range killing capacity was not affected.

EXPRESSION OF HLA-DR IN GRANULOCYTES OF POLYTRAUMATIZED PATIENTS TREATED WITH RECOMBINANT HUMAN GRANULOCYTE MACROPHAGE-COLONY-STIMULATING FACTOR

MHC class II determinants are the restriction elements involved in antigen-specific activation of helper T lymphocytes and interaction with CD4 molecules. They are typically expressed on a limited number of cell types, mostly endowed with antigen-presenting capacity. Recently, expression of HLA-DR has been detected on granulocytes stimulated in vitro with GM-CSF. However, no evidence of in vivo expression in humans has been presented so far. We report here that class II determinant expression is detectable in vivo on peripheral blood granulocytes of polytraumatized patients upon intravenous administration of rhGM-CSF. Expression of these molecules appears to be an early effect of rhGM-CSF treatment, independent from endotoxemia or endogenous production of IL-6 or TNF-alpha, and rapidly declining upon discontinuation of therapy. Thus, this treatment might increase the number of cells potentially capable of presenting class-II-restricted antigens in these patients.

Function of Fast- and Slow-Twitch Rat Skeletal Muscle following Ischemia and Reperfusion at Different Intramuscular Temperatures

Fast- (peroneal) and slow-twitch (soleus) skeletal muscles of anesthetized Wistar rats were subjected to 3 h of tourniquet ischemia. The intramuscular temperature of the leg was adjusted to 22, 30 or 35°C (n = 12 per group) during ischemia. After 2 h of reperfusion, the muscles were electrically stimulated in vitro and muscular function was analyzed for maximal force, performance, contractility and fatigue. Contralateral nonischemic muscles served as controls. Three hours of ischemia at 30°C did not reduce the function of the peroneal muscles compared to nonischemic controls. The same ischemic stress significantly reduced the function of the soleus muscles compared to nonischemic controls. The postischemic function of the soleus muscles declined with increasing temperature. The postischemic function of the 35°C group of peroneal muscles was significantly reduced compared to the 22 and the 30°C groups, which did not differ. These results provide evidence that fast-twitch muscles are more resistant to ischemia than slow-twitch muscles. They furthermore show a fiber type-specific dependency of postischemic muscle function on intramuscular temperature during ischemia. Hypothermia-sensitive fast-twitch fibers predominate in the skeletal muscles of the extremities. Mild hypothermia could, therefore, reduce tourniquet ischemia-induced injury after surgery of the extremities.

Neurogene Appendicopathie: Ein häufiges, fast unbekanntes Krankheitsbild Auswertung von 816 Appendices und Literaturübersicht

Abstract.Background: Neurogenic appendicopathy (NA) represents an almost unknown pathology which clinically cannot be differentiated from acute appendicitis. The diagnosis can only be established histologically. Nerve proliferation and an increased number of endocrine cells are typical for NA. This study characterizes the epidemiology, histology, clinical appearance and therapy of NA. We evaluated the incidence of NA in macroscopically normal specimens from patients presenting the symptoms of acute appendicitis and in incidental appendectomies. Patients and methods: 816 routine appendix specimens were examined at the Institute of Pathology, Universitity of Basel, for the presence of NA. We analyzed the indication for appendectomy, the histological form and the age and sex of the patients. Results: 140 appendices (17.1 %) showed the histological criteria for NA. 25 % of incidental appendectomies were positive for NA, as opposed to 53 % of the macroscopically normal specimens of patients presenting the symptoms of acute appendicits (P < 0.0001). NA is more frequent in men than in women (19.5 % versus 14.5 %, P = 0.057). Out of the total of 140 NA, 105 (12.9 %) were classified as central, 12 (1.5 %) as intramucosal and 5 (0.6 %) as submucosal forms of NA. 18 times (2.2 %) the histologic subtype of NA was not specified. Conclusions: This study establishes that NA is a frequent, often asymptomatic pathology. In more than half of the macroscopically normal specimens of patients presenting symptoms of acute appendicitis NA can be diagnosed, significantly more than in incidental appendectomies. Therefore it is imperative to remove and analyze a macroscopically normal appendix in a patient presenting symptoms of acute appendicitis if no other intraabdominal pathology can be found.Zusammenfassung.Einleitung: Die neurogene Appendicopathie (NA) ist ein wenig bekanntes Krankheitsbild, welches klinisch nicht von der akuten Appendicitis abzugrenzen ist. Die Diagnose kann einzig mit der Histologie sicher gestellt werden, die Nervenproliferationen und eine Vermehrung endokriner Zellen zeigt. Die vorliegende retrospektive Arbeit hat zum Ziel, Epidemiologie, Histologie, Klinik und Therapie der NA zu charakterisieren und der Frage nachzugehen, wie häufig die NA in makroskopisch blanden Appendices im Rahmen einer Unterbauchsymptomatik und in gelegenheitshalber entfernten Wurmfortsätzen gefunden werden kann. Patienten und Methodik: 816 Appendices aus dem Routineeinsendematerial des Pathologischen Instituts der Universität Basel wurden auf das Vorliegen einer NA untersucht und bezüglich Indikation zur Appendektomie, histologischer Formen, sowie die Alters- und Geschlechtsverteilung ausgewertet. Resultate: In 140 Appendices (17,1 %) fand sich eine NA. In der Gruppe der Gelegenheitsappendektomien belief sich die Häufigkeit der NA auf 25 %, in den trotz Appendicitissymptomatik makroskopisch blanden Appendices auf 53 % (p < 0,0001). Die NA kam in unserem Patientenkollektiv bei Männern häufiger vor als bei Frauen (19,5 % versus 14,5 %, p = 0,057). Von den 140 NA erfüllten 105 (12,9 %) die histologischen Kriterien der zentral-obliterierenden Form, 12 (1,5 %) der intramucösen und 5 (0,6 %) der submucösen Form; 18mal (2,2 %) konnte die NA keiner histologischen Form zugeordnet werden. Schlussfolgerungen: Die vorliegende Studie zeigt, dass die NA ein häufiges, oft asymptomatisches Krankheitsbild ist. In mehr als der Hälfte der trotz Appendicitissymptomatik makroskopisch blanden Appendices liegt eine NA vor, signifikant häufiger als bei Gelegenheitsappendektomien. Deshalb sollte bei intraoperativ blander Appendix trotz Appendicitissymptomatik ohne Hinweis auf andere entzündliche Veränderungen im Bauchraum der Wurmfortsatz entfernt und histologisch aufgearbeitet werden.

Advanced breast biopsy instrumentation for the evaluation of impalpable lesions: a reliable diagnostic tool with little therapeutic potential

OBJECTIVEnTo assess the potential of advanced breast biopsy instrumentation (ABBI) to clarify the diagnosis of impalpable mammographic lesions and to remove the entire malignant lesions with clear margins.nnnDESIGNnProspective assessment in a consecutive series of patients.nnnSETTINGnUniversity hospital, Basel, Switzerland.nnnSUBJECTSn139 patients presenting with 144 impalpable microcalcifications or solid nodular densities evident on screening and follow-up mammograms that were suspicious of malignancy.nnnMAIN OUTCOME MEASURESnFeasibility, sensitivity, efficiency in obtaining definitive diagnoses in an outpatient clinic under local anaesthesia, feasibility of complete removal of a primary malignancy, and intervention-related morbidity.nnnRESULTSnThe ABBI procedure was successful in 135/144 (94%); an accurate diagnosis was made in 129/130 patients followed up (99%), sensitivity for malignant lesions was 31/32 (97%) and there were 2 complications (2%). Margins of the biopsy cylinder contained a malignant lesion in 26/31 (84%).nnnCONCLUSIONSnExcisional biopsy using the ABBI system is a reliable diagnostic tool with a low morbidity. As in other published series margins were often not clear of tumour and therefore the therapeutic use of the ABBI procedure is limited.

Endoscopic Surgery to the Axilla — A Substitute for Conventional Axillary Clearance?

Nonpalpable, mammographically detected breast cancers are on the increase. The percentage of patients with histologically involved nodes is therefore decreasing. Axillary clearance aims at reducing the probability of later clinical involvement of the axilla and at establishing a sound basis for adjuvant treatment planning. Minimally invasive techniques have been applied to a growing number of surgical procedures now including exploration of the axilla. The technique used and results achieved in a series of 50 consecutive patients treated by liposuction and axilloscopy by one single surgeon, including all the patients from the very first attempt, are presented here. Patients were excluded with palpable lymph nodes or a primary tumor in the direct vicinity of the axilla that could be injured by the liposuction canula. The average number of lymph nodes removed was 13.4. Thirty-four percent of patients had involved nodes. The mean number of involved nodes in these patients was 3.1. After a median follow-up time of only 15 months no axillary recurrences or trocar site metastases have been found in the first 40 patients. Using a self-assessment questionnaire, the patients rate this technique as excellent. There was no lymphedema. The cosmetic result is certainly better than after conventional axillary clearance. Great experience of laparoscopic surgery and an excellent knowledge of the axillary anatomy are prerequisites for the practice of axilloscopic treatment of the axilla. The working space within the axilla is small and a number of structures need absolutely to be preserved. A longer follow-up period than the one so far achieved in this series or any other in the literature to date is necessary before this technique can be generally recommended.