J. Jähne

Surgery for metachronous solitary liver metastases of renal cell carcinoma.

PURPOSE The postoperative outcome and survival of patients undergoing surgery for metachronous solitary liver metastases of renal cell carcinoma were evaluated. MATERIALS AND METHODS Between 1983 and 1993, 17 patients with metachronous liver metastases of renal cell carcinoma underwent laparotomy for metastatic liver disease. All patients had undergone radical nephrectomy a mean of 3.6 years before the diagnosis of liver metastases. RESULTS Surgical resection was feasible in 13 of 17 patients with right hemihepatectomy in 9 (3 multivisceral resections), wedge resection in 4 and ex situ (mobilization and eversion out of the abdomen) resection in 1. Stage R0 resection (complete removal, negative surgical margins with no macroscopic disease left behind) was possible in 11 of 13 cases (85%). In patients with metastatic liver tissue resection the mortality rate was 31% (4 of 13) with additional significant morbidity in another 2. Mean survival of patients with nonresectable disease was 4 months, which increased to 16 months after resection. CONCLUSIONS Complete resection of metachronous liver metastases can be achieved in the majority of patients. However, significant morbidity and mortality as well as the limited prognosis even after R0 resection strongly suggest careful patient selection.

Morphological and molecular characterization of human gastric mucous cells in long-term primary culture

Abstract A primary cell culture of human gastric mucous cells was developed using enzymatic treatment of surgically obtained gastric mucosal specimens. Preferential attachment of gastric mucous cells during a preincubation step resulted in the enrichment of mucous cells [over 90% stained with periodic acid–Schiff (PAS) and mucin-type lectins] in the primary cell culture. Gastric mucous cells could be maintained in culture for 10 days. DNA synthesis peaked during the first 2 days in culture (8±1% bromodeoxyuridine-positive cells). During the entire culture period gastric mucous cells released high-molecular-weight glycoproteins into the medium, as determined by gel chromatography on a Sepharose CL-4B column and by metabolic labelling with [14C]-N-acetylglucosamine. Gastric mucin was verified by gas chromatographic analysis of the carbohydrate composition and fractionation of the void-volume fraction by density gradient centrifugation. Determination of the terminal glycosylation of the secreted glycoproteins by a lectin-ELISA revealed that there was a high quantity of α-l-fucose. Prostaglandin E2 significantly stimulated glycoprotein secretion during the entire cultivation period by 29–60%. Analysis of mucin-encoding MUC mRNA expression by reverse transcriptase polymerase chain reaction revealed that gastric mucous cells predominantly express MUC1 and MUC5AC, and to a lesser extent MUC6, which reflects the expression pattern obtained following analysis of biopsied samples of gastric mucosa. This primary cell culture model enables the regulation of mucin secretion and mucin gene expression in man to be investigated.

“Conservative” treatment of intra-abdominal complications after total gastrectomy with interventional radiological techniques

SummarySeptic complications following total gastrectomy usually require relaparotomy, which is associated with a high operative mortality. Due to the improvement of percutaneous drainage of abdominal abscesses we prefer this therapy for septic complications after total gastrectomy. Among 141 total gastrectomies, 14 patients developed subphrenic abscesses. While 2 patients required relaparotomy, 12 had interventional therapy by sonographically guided drainage and insertion of a pigtail catheter. The catheters were irrigated daily, and the patients received systemic antibiotics. Complete resolution of the abscess cavity was achieved, even in 1 case with simultaneous duodenal stump insufficiency without increasing morbidity. The hospital stay was prolonged for an average of 20 days by this “conservative” treatment. The management of septic complications following total gastrectomy with interventional techniques may reduce the number of operative reinterventions. The indication for such a therapy, however, needs to be evaluated on an individual basis.

100. Magencarcinom: Gastrektomie de principe

SummaryAmong surgical modalities of the gastric cancer total gastrectomy de principe and histology-oriented strategy are under discussion. In our own procedure we prefer total gastrectomy combined with extended lymph node dissection as the operation of choice justified by the results obtained. But caused by the lack of controlled studies these results cannot be used as an evidence. Nevertheless an exact analysis of the own material can show only an incidence of 5–30% in which total gastrectomy de principe may be a too extensive procedure in regard to the oncological point of view, but even these cases have to be examined in a randomised clinical study.ZusammenfassungUnter den chirurgischen Therapiekonzepten des Magencarcinoms steht weiterhin die Gastrektomie als Regeloperation im Vergleich zum histologieorientierten Vorgehen zur Diskussion. Im eigenen Vorgehen wird dabei die Gastrektomie als Regeloperation mit systematischer Lymphadenektomie bevorzugt; die Indikation erscheint aufgrund der erzielten Ergebnisse berechtigt. Bei fehlenden randomisierten Studien kann diese Beurteilung nur als vorläufig eingestuft werden; allerdings lässt sich bei exakter Analyse des eigenen Krankengutes nur ein Anteil von etwa 5–30% eruieren, bei dem die Gastrektomie eine Übertherapie darstellen mag.

Results of Palliative Resections for Gastric Carcinoma

Background: Most of the patients with gastric carcinoma suffer from advanced tumors at the time of diagnosis, and in the majority of cases only palliative resections can be carried out. Patients and Methods: We retrospectively analyzed the results of 64 patients treated by surgery alone (palliative resections) in an 11-year time interval (1986–1997). Results: In more than 75% of our cases total gastrectomy was performed, and post-operative overall morbidity and mortality were 34.4% and 6.2% (4.1% after total gastrectomy), respectively. The median survival time was 10 months and the 5-year survival rate 6.9%. Conclusions: Palliative resections can be performed with an acceptable postoperative morbidity and mortality, but the impact on survival is minor. The indication may be given in symptomatic patients with dysphagia, gastric outlet obstruction or hemorrhage and impaired general condition, not allowing aggressive neoadjuvant or palliative chemotherapy.

Möglichkeiten und Grenzen der chirurgischen Therapie des Pseudomyxoma peritonei

In a retrospective study, the potential and limitations of surgical therapy of pseudomyxoma peritonei were studied in seven patients. In all patients the pseudomyxoma had originated from the appendix. All patients were primarily treated by surgery. An R0 resection at the first operation was possible in only one patient with a benign pseudomyxoma, while significant tumor debulking with improved symptoms was achieved in all other patients. If the tumor recurred relaparotomy was performed to obtain tumor reduction. The perioperative morbidity even after multiple relaparotomies was low. The survival rates ranged between 2 and 20 years with chemotherapy (5 - fluorouracil) which was of particular prognostic benefit in patients with malignant pseudomyxoma peritonei. Surgical therapy is the treatment of choice in pseudomyxoma peritonei, although an R0 resection is hardly feasible. Due to the low morbidity, relaparotomy in cases of tumor recurrence always appears to be indicated. In comparison to other gastrointestinal malignancies, the survival rates in pseudomyxoma peritonei, sometimes treated with additive chemotherapy, are superior.ZusammenfassungIn einer retrospektiven Analyse bei 7 Patienten wurden die Möglichkeiten und Grenzen der chirurgischen Therapie des Pseudomyxoma peritonei untersucht. Bei allen Patienten war die Appendix der Ursprungsort des Pseudomyxoma. Sämtliche Patienten wurden primär chirurgisch behandelt. Eine R0-Resektion war bei der Primäroperation in lediglich einem Fall mit allerdings benigner Histologie möglich, während bei den übrigen Patienten eine Tumorverkleinerung mit deutlicher Symptombesserung erzielt wurden konnte. Bei Nachweis eines Rezidivs wurden die Patienten einer Relaparotomie zugeführt, um erneut eine Tumorreduktion anzustreben. Die postoperative Morbidität auch nach Wiederholungseingriffen war gering. Die Überlebenszeiten lagen zwischen 2 und 20 Jahren, wobei besonders bei malignem Pseudomyxoma peritonei die additive Chemotherapie mit 5-Fluorouracil einen prognostischen Vorteil erbrachte. Die chirurgische Behandlung ist die Therapie der Wahl beim Pseudomyxoma peritonei, doch ist eine R0-Resektion nur in Ausnahmefällen möglich. Aufgrund der niedrigen Morbidität ist die Indikation zur Relaparotomie beim Rezidiv großzügig zu stellen. Im Vergleich zu anderen Malignomen des Gastrointestinaltrakts sind die Überlebenszeiten, möglicherweise auch durch die Anwendung einer additiven Chemotherapie, deutlich besser.

Limited Prognostic Value of Two-Field Lymphadenectomy in Surgery for Esophageal Carcinoma

The impact of lymphadenectomy on morbidity and long-term survival in patients with esophageal carcinoma remains controversial. Therefore, a prognostic study was undertaken in a consecutive series of 69 patients who underwent standard twofield lymphadenectomy for squamous cell carcinoma of the esophagus in our department from 1986 to 1991. All resected and metastatic lymph nodes were prepared, examined, and counted. Morbidity and mortality of the operation were documented. Survival was reevaluated in 1996 and analyzed in univariate and multivariate models with respect to prognostic factors including the number of metastatic lymph nodes and the ratio of invaded to removed lymph nodes. A median of 16 of lymph nodes were resected, with 2 being metastatic. Morbidity and mortality were 57.9% and 13.0%, respectively. The overall 5-year survival rate was 22% (median survival time 16 months). In multivariate analysis, the number of lymph node metastases was a strong independent prognostic factor, which had greater significance than tumor stage, ratio of invaded to removed lymph nodes, and whether the resection was potentially curative or palliative. While patients with 1 metastatic lymph node had a median survival time comparable to patients without metastases (21 versus 31 months, p = 0.093), survival time decreased to 7 months in case of 2 node metastases (p < 0.01) and was even lower when more than 2 nodes were involved. Thus, two-field standard lymphadenectomy for esophageal cancer may be of prognostic value only in patients with a very limited lymph node involvement. Schlüsselwörter Ösophaguskarzinom · Plattenepithelkarzinom · Zwei-Felder-Lymphadenektomie

Adjuvante und neoadjuvante Therapie beim Magenkarzinom

Auch bei angestrebter Standardisierung der Operationsverfahren sind die Behandlungsergebnisse des Magenkarzinoms trotz gesteigerter Resektionsraten einschlieβlich des Anteils tumorfreier Resektionen u

Sicherheitsempfehlungen bei offener intraperitonealer Chemotherapie

Der Einsatz einer offenen, intraoperativen, intraperitonealen Chemotherapie nach zytoreduktiver Chirurgie zur Behandlung des Pseudomyxoma peritonei oder einer Peritonealkarzinose macht die Etablierung von Sicherheitsempfehlungen zum Schutz des arztlichen und nicht-arztlichen Personals erforderlich. Unter Beachtung bereits bestehender Vorschriften wurden in enger Abstimmung mit dem betroffenen Personenkreis Masnahmen etabliert, die einen grostmoglichen Schutz intra- und postoperativ gewahrleisten. Nach Einfuhrung der Sicherheitsbestimmungen wurden in knapp 1,5 Jahren 17 Patienten mit einer offenen intraperitonealen Chemotherapie behandelt, ohne das es zu schweren Unfallen gekommen ist. Somit ist ein sicherer intraoperativer Umgang mit Zytostatika moglich, wobei sich die Indikation zu einem solchen Vorgehen z. Z. z. B. beim peritoneal metastasierten Appendix- und Kolon- sowie Ovarialkarzinom.

Abdominalchirurgisch relevante Aspekte des Suizidversuchs

In this retrospective study of 24 patients who were treated at our clinic during the last 22 years after having attempted suicide, we evaluated aspects concerning abdominal-and transplantation surgery. There was a predominance of “hard” (70%) versus “soft” (30%) methods for suicide attempt. Intra-abdominal injuries resulting from attempted suicide by stabbing or shooting should lead to laparotomy— the prognosis is then good. Surgical treatment after intoxication, especially caustic ingestion, depends on endoscopic and clinical findings. The highly increased rates of suicide significantly by kidney transplantation. The risk of suicide after transplantation is further diminished with improved immunosuppressive treatment. Only in a few cases there is an indication for liver transplantation— in some cases of fulminant hepatic failure caused by self-administered paracetomol overdose. Auxiliary liver transplantation may then be considered.ZusammenfassungSowohl die abdominal-als auch die transplantationschirurgisch relevanten Aspekte des Suizidversuchs werden anhand der eigenen Patienten retrospektiv über einen Zeitraum von 22 Jahren analysiert und dargestellt. Die Untersuchung der Methoden der Suizidversuche von 24 Patienten zeigte ein deutliches Überwiegen der sog. harten (70%) gegenüber den weichen (30%) Methoden. Bei abdominalen Verletzungen aufgrund eines Suizidversuchs ist die Indikation zur Laparotomie in der Regel bei Stich- und Schußverletzungen mit meist guter Prognose nach der chirurgischen Behandlung gegeben. Bei Intoxikationen, insbesondere Laugenverätzungen, wird die Operationsindikation abhängig vom endoskopischen Befund und der Klinik des Patienten gestellt. Die deutlich erhöhte Suizidgefährdung bei Patienten mit terminaler Niereninsuffizienz kann durch eine Nierentransplantation signifikant gesenkt werden. Aufgrund verbesserter Immunsuppression und damit verbesserter Transplantatfunktion nimmt die Suizidgefährdung nach Transplantation ab. In der Folge einer Paracetamolingestion in suizidaler Absicht ist nur in seltenen Fällen bei akutem Leberversagen eine Lebertransplantation indiziert, wobei in diesem Fall die auxiliäre Lebertransplantation als Differentialeingriff zu erwägen ist.