Theo Junginger

Factors Influencing Morbidity and Mortality after Pancreaticoduodenectomy: Critical Analysis of 221 Resections

n= 209) or total (n= 12) pancreaticoduodenectomy, in 12 cases combined with portal vein resection, was performed. Surgical complications were seen in 25%, but less than half of them were severe. General complications were seen in 18.5%. The 30- and 90-day mortality rates were 3.1%, and 5.7%, respectively. In a regression analysis the intraoperative blood loss, preoperative serum bilirubin, diameter of the pancreatic duct, and occurrence of surgical and nonsurgical complications had an independent influence on mortality. In addition to the experience of the surgeon in selecting the patients and his or her personal technical skills when performing a pancreaticoduodenectomy, better anticipation and management of postoperative complications is essential for improving the results of this operation.

Outcome after surgery for primary hyperparathyroidism: ten-year prospective follow-up study.

Abstract. Clinical outcome after surgery for primary hyperparathyroidism was evaluated in a prospective long-term, follow-up study. From August 1, 1987 to August 31, 1998 a total of 360 patients were prospectively investigated and included in a follow-up study. All patients underwent follow-up examinations at regular surveillance intervals. The postoperative course is known for 94.5% of all patients. Follow-up was 1 month to 10 years (median 24 months; mean 34.5 ± 29.8 months). Asymptomatic primary hyperparathyroidism was rare (6%), and its true frequency could be confirmed only postoperatively because some of the patients were unaware of mild symptoms of hypercalcemic syndrome prior to surgery. Surgical cure was obtained in 97.7% of patients after initial cervical exploration; and successful parathyroidectomy provided long-term relief of symptoms. Within 2 years postoperatively, 84% of the patients recovered fully from hypercalcemic syndrome; in 58% of these patients recovery occurred within the first month after surgery. Skeletal symptoms persisted in 24% of patients 2 years postoperatively. To date no patient has developed recurrence of primary hyperparathyroidism. During follow-up in our study population mortality was significantly higher than the expected mortality risk for the German population as a whole (p= 0.00024). The present prospective follow-up study yielded conclusive outcome research data after operative therapy for primary hyperparathyroidism. The high cure rate and low morbidity, as well as the increased mortality, in our study population during follow-up after successful operative therapy for the disease emphasize the importance of early diagnosis and early surgical treatment for primary hyperparathyroidism, even in the absence of manifest symptoms.

Prognostic value of DNA analysis in colorectal carcinoma

Background. Reported experiences regarding the prognostic significance of DNA content in colorectal carcinoma have been a matter of controversy.

Diagnosing and Staging of Pancreatic Carcinoma – What Is Necessary?

The aim of the present prospective observational study was to diagnose and stage pancreatic carcinoma with a minimum of diagnostic procedures. Our experiences in 307 patients with a histologically confirmed pancreatic carcinoma show that for diagnosing pancreatic carcinoma sonography and computed tomography are sufficient in 95% of the cases. The combination of both has a sensitivity equal to that of endoscopic retrograde cholangiopancreatography (ERCP; 96.8 vs. 98.7%; n.s., χ2 test). ERCP is only indicated in cases with negative sonography and computed tomography, and suspicion of pancreatic cancer. For tumor staging, the routine performance of angiography cannot be recommended in view of the fact that although it provides greater sensitivity for the evaluation of an infiltration of the portal vein (80% for angiography vs. 22% for sonography or computed tomography), it is associated with a lower positive predictive value (56.4 vs. 68 and 72%) which results in a lower accuracy. Despite recent advantages in diagnostic technology, less than 50% of unresectable tumors were identified preoperatively at a 10% false-positive rate. The major reason for unresectability is infiltration into the mesenteric axis, which cannot be identified laparoscopically. Laparoscopy or percutaneous biopsy is recommended only in the presence of a tumor with suspicion of distant metastasis detected by radiological imaging and requiring histological confirmation. In conclusion, sonography and computed tomography as the only diagnostic images are sufficient for diagnosing and staging of pancreatic carcinoma in more than 95% of the patients. Only a small number of patients needs further diagnostic procedures.

Factors influencing survival after resection of pancreatic cancer : a DNA analysis and a histomorphologic study

Background. The influence of DNA content on prognosis in stomach cancer has been investigated rarely, and the results are controversial.

Magnetic resonance imaging (MRI)-based indication for neoadjuvant treatment of rectal carcinoma and the surrogate endpoint CRM status

AimIs it possible to reduce the frequency of neoadjuvant therapy for rectal carcinoma and nevertheless achieve a rate of more than 90% circumferential resection margin (CRM)-negative resection specimens by a novel concept of magnetic resonance imaging (MRI)-based therapy planning?Materials and methodsOne hundred eighty-one patients from Berlin and Mainz, Germany, with primary rectal carcinoma, without distant metastasis, underwent radical surgery with curative intention. Surgical procedures applied were anterior resection with total mesorectal excision (TME) or partial mesorectal excision (PME; PME for tumours of the upper rectum) or abdominoperineal excision with TME.ResultsWith MRI selection of the highest-risk cases, neoadjuvant therapy was given to only 62 of 181 (34.3%). The rate of CRM-negative resection specimens on histology was 170 of 181 (93.9%) for all patients, and in Berlin, only 1 of 93 (1%) specimens was CRM-positive. Patients selected for primary surgery had CRM-negative specimens on histology in 114 of 119 (95.8%). Those selected for neoadjuvant therapy had a lower rate of clear margin: 56 of 62 (90%).ConclusionBy applying a MRI-based indication, the frequency of neoadjuvant treatment with its acute and late adverse effects can be reduced to 30–35% without reduction of pathologically CRM-negative resection specimens and, thus, without the danger of worsening the oncological long-term results. This concept should be confirmed in prospective multicentre observation studies with quality assurance of MRI, surgery and pathology.

DNA image cytometry. A prognostic tool in squamous cell carcinoma of the esophagus

In 45 patients who underwent an esophagus resection due to a squamous cell carcinoma, in addition to the TNM classification and usual morphologic criteria, the paraffin‐embedded material underwent deparaffinization, was rehydrated, and was mechanically and enzymatically processed into a single‐cell solution. For evaluating the DNA histogram this was analyzed with the help of automatic single‐cell cytophotometric study. The method, contrary to that of flow cytometric study, allows for the selective analysis of tumor cells due to the electronically, previously given selection criteria, whereas artifacts, stroma, and infection cells remain excluded from analysis. The multivariate analysis shows that the prognosis is only correlated with DNA content of the tumor cells. Patients with diploid tumors had a median survival time of 32 months as compared with the 22 months of patients with hypotriploid tumors, and 6.5 months with hypertriploid tumors. DNA cytometric analysis should be included when diagnosing patients with esophagus carcinoma.

Expression of CD44 variant proteins in adenocarcinoma of Barrett's esophagus and its relation to prognosis

None of the commonly used staging criteria accurately determine the prognosis of a patient with adenocarcinoma of Barretts esophagus. The authors therefore assessed the expression pattern and prognostic impact of CD44 standard and CD44 isoforms CD44v4, v5,v6,v7, and v10 in adenocarcinoma of Barretts esophagus.

Prognostic Value of Immunohistochemical Expression of Beta-1 Integrin in Pancreatic Carcinoma

Background: Prognostically relevant factors based on the histological assessment of the resected pancreas are known. However, the knowledge of additional factors associated with the prognosis is helpful in planning the therapy for an individual patient. β1 Integrin expression is known to have a prognostic influence in some malignant tumors. No data are, however, available on the prognostic value of β1 integrins in pancreatic carcinoma. Method: We investigated paraffin-embedded specimens of 19 patients undergoing surgical treatment for periampullary carcinoma and of 42 patients for ductal pancreatic carcinoma by immunohistochemistry to assess the expression pattern and the prognostic impact of β1 integrins. Neither histomorphological parameters nor the survival time of the patients were known at the time of the investigation. Results: No correlation was established between histomorphological parameters and β1 integrin expression in periampullary or ductal pancreatic carcinoma, respectively. Patients with periampullary carcinoma and β1 integrin overexpression had a significantly poorer prognosis than patients without overexpression of β1 integrins (median survival: 18.3 vs. 58.4 months). In ductal pancreatic carcinoma β1 integrin expression had no influence on prognosis. Conclusion: β1 Integrins exert an influence on prognosis in periampullary carcinoma but not in ductal pancreatic carcinoma. However, further investigations in larger patient samples are required to confirm these results.

A modified prosthesis for the treatment of malignant esophagotracheal fistula

Esophagotracheal fistula is usually a sequela of irradiation or laser treatment of advanced carcinoma of the esophagus or the tracheobronchial tree. Resection of the tumor in these cases is not possible, and palliative bypass surgery is highly risky. The peroral placement of a prosthesis is less invasive, but conventional prostheses often fail to occlude the fistula. The authors regularly use an endoscopic multiple‐diameter bougie for dilation. After dilation, a specially designed prosthesis is pushed through the tumor stenosis to block the fistula. This procedure can be done without general anesthesia. The funnels of conventional prostheses cannot cover the fistula when there is either a wide, proximal esophagus above the fistula or a high fistula. To cope with this particular situation, a special fistula funnel was developed. It perfectly occludes the fistulas in all patients. Of 21 patients, 19 were discharged without further aspiration.