Randomized controlled clinical trials-support but not substitute of decision-making in surgery.
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Clinical Competence↗
Biomedical subjects
H G Beger
Publications and source records attributed to H G Beger.
The art of surgery in the 21st century: based on natural sciences and new ethical dimensions.
BACKGROUND AND AIMS: In the future, new surgical techniques will only be introduced in clinical practice if evidence-based results--frequently the results of controlled clinical trials--are presented. Unlike any other medical discipline, surgeons provide their diagnostic and operative skills through the surgeons' hand and the use of technical equipment, which ranges from instruments and devices employed during operation to the use of surgical robots. RESULTS: Analysing the fundaments of surgery on the turn of the century, there is only a little doubt about the increasing impact of data deriving from natural sciences on knowledge in medicine and management of diseases. The natural scientific method of detecting, measuring, and verifying facts is the methodological basis of surgery as well. The autonomy of the surgeon's clinical decision making is significantly restricted by the definition of guidelines. They shift the decision from a single patient to a collective panel. Patient safety and the efficiency of new treatment modalities compared with previous standards are the criteria for the judgement of innovative surgery today. The communication and interaction between surgeon-scientist and patients is guaranteed legally by written consensus. But beside of the high probability of benefit from therapy and written consensus, the surgeon-patient relation is determined by these factors: limitation of time for care of an individual patient, increase of time for administration and documentation, increase of bureaucratic barriers for medical research, and health cost constraints. CONCLUSION: The medical mandate to cure a sick patient is an individual mandate to take action. Measures, numbers, and images are only preconditions for a surgeon's action in daily clinical work; they can never replace it. The call for an ethical imperative in scientific surgery that is dependent on technology is justified when the state of science and uncritical use of surgical skills and financial constraints have major impact on providing medical care.
Decision Making↗
Antibiotic prophylaxis in severe acute pancreatitis.
Severe acute pancreatitis is considered to be a subgroup of acute pancreatitis with the development of local and/or systemic complications. A significant correlation exists between the development of pancreatic necrosis, the frequency of bacterial contamination of necrosis and the evolution of systemic complications. Bacterial infection and the extent of necrosis are determinants for the outcome of severe acute pancreatitis. The late course of necrotizing pancreatitis is determined by bacterial infection of pancreatic and peripancreatic necroses. Mortality increases from 5-25% in patients with sterile necrosis to 15-28% when infection has occurred. The use of prophylactic antibiotics has been recommended in patients with necrotizing pancreatitis. Several controlled clinical trials demonstrated a significant reduction in pancreatic infections or a significant reduction of hospital mortality. However, the results of these clinical trials are controversial and not convincing. Recently, the largest randomized placebo-controlled, double-blind trial has been able to demonstrate that antibiotic prophylaxis with ciprofloxacin and metronidazole has no beneficial effects with regard to the reduction of pancreatic infection and the decrease of hospital mortality. The clinical data from this placebo-controlled trial do not support antibiotic prophylaxis in all patients with necrotizing pancreatitis, but in specific subgroups of patients with pancreatic necrosis and a complicated course.
Acute Disease↗
Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series.
BACKGROUND: Surgical treatment of necrotizing pancreatitis (NP) has undergone considerable changes during the past 2 decades. In this study, we report our experience of necrosectomy and continuous closed lavage over the past 19 years in an attempt to define changes in patient characteristics and outcome at an academic referral center. METHODS: Among 1520 patients admitted with acute pancreatitis, 392 had NP, 285 of whom underwent operative treatment. The total series was evaluated separately for treatment period A (May 1982 until April 1993) and treatment period B (May 1993 until May 2001). RESULTS: Intraoperative bacteriology revealed sterile necrosis in 145 and infected necrosis in 140 patients. Preoperative disease severity did not differ between the groups; however, the extent of pancreatic parenchymal necrosis was less in patients with sterile necrosis (P < .003). Postoperative complications were more frequent in infected necrosis (78%) than in sterile necrosis (61%) (P < .004), with mortality rates of 27% and 23%, respectively. The analysis of the 2 treatment periods revealed that during period B, there was a decrease in operatively treated patients with sterile necrosis (P < .0005). The preoperative systemic disease severity was significantly higher in these patients than in patients with infected necrosis. CONCLUSIONS: Surgical treatment of NP by necrosectomy and closed lavage carries an overall mortality of 25%. Patients with sterile necrosis and early onset high disease severity may represent a distinct clinical entity in whom the optimal treatment strategy remains to be defined.
APACHE↗
[Cystic tumors of the pancreas-radical or organ-preserving resection?].
Cystic tumors comprise only 1% of all pancreatic tumors, although there is an increasing number of publications about them. These tumors divide into other tumor entities, some of them benign and some of them borderline or malignant. Therefore, the kind of therapy is presently under discussion. Between 1986 and 2003, we treated 97 patients with cystic tumors of the pancreas, evaluated the data retrospectively, and followed the patients up. Sixty-seven percent were treated by radical resection and 32% by organ-preserving resection. With 41%, postoperative "new" diabetes mellitus was significantly more frequent after radical resection than after organ-preserving resection at 24% ( P<0.01). Long-term survival was worst after mucinous cystadenocarcinoma (59% after 36 months), and 90% of all other patients lived longer than 36 months. We conclude that organ-preserving resection should be considered in all serous cystic tumors and solid pseudopapillary tumor of the pancreas. All mucinous cystic tumors are of malignant or borderline nature and should be treated as such by radical resection.
Adult↗
Comparative analysis of extracellular matrix proteins in chronic pancreatitis: differences between pancreatic head and tail.
OBJECTIVES: In patients with chronic pancreatitis (cP) with an inflammatory mass in the pancreatic head, the degree of fibrosis in the pancreatic head compared with the tail should be determined and differences in the expression pattern of collagen types I, III, and IV; laminin; vitronectin; and fibronectin should be evaluated. METHODS: From 12 patients with alcohol-induced and idiopathic cP who underwent surgery due to local complications, 24 corresponding cP tissue samples from the pancreatic head and the resection margin were obtained. The degree of fibrosis was calculated using a computer-assisted method (Adobe Photo Shop). The expression pattern of extracellular matrix proteins (ECMPs) was investigated by immunostaining using the streptavidin-peroxidase technique. RESULTS: In each case, the degree of fibrosis was higher in the pancreatic head than in the resection margin. For alcohol-induced cP, the median degree of fibrosis in the head was 64% versus 47% in the resection margin, and for idiopathic cP, it was 40% versus 32%. Staining intensity of collagen type IV and laminin in the head was higher than in the resection surface. In degenerative tissue, collagen types I, III, and IV and laminin were moderately expressed, fibronectin was weakly expressed, and vitronectin was not expressed, with no differences between the head and resection margin. Basement membranes in the head and the resection margin predominantly consisted of collagen types I, III, and IV and laminin. In ductal epithelia, collagen type IV staining in the head was stronger than in the resection margin. CONCLUSIONS: In cP with an inflammatory mass in the head, the degree of fibrosis in the pancreatic head is higher than in the resection margin. Differences in the expression pattern of ECMPs could be detected for collagen type IV and laminin. These results underline the hypothesis of the pancreatic head being the pacemaker of cP in which collagen type IV and laminin may play an important role.
Adult↗
Laboratory markers of severe acute pancreatitis.
BACKGROUND: A large array of parameters has been proposed for the biochemical stratification of severity and prediction of complications in acute pancreatitis. However, the number of accurate and readily available variables for routine application is still limited. METHODS: The literature was reviewed for laboratory markers of acute pancreatitis with special regard to their clinical usefulness and test performance for stratifying severity and monitoring disease progression. RESULTS: Several parameters, such as trypsinogen and procarboxypeptidase B activation peptide, PMN-elastase, interleukin-6 (IL-6) and 8 (IL-8), serum amyloid A (SAA), and procalcitonin (PCT), can differentiate between mild and severe acute pancreatitis within 48 h of disease onset with favorable diagnostic accuracy. Because fully automated assays have become available, IL-6, IL-8, PCT, and SAA are the most interesting parameters in this respect. For monitoring disease progression beyond 48 h, acute-phase proteins, IL-6, IL-8, and PCT are valuable markers. PCT is the first biochemical variable for predicting severe pancreatic infections and overall prognosis throughout the course of acute pancreatitis with high sensitivity and specificity. CONCLUSIONS: Among all the biochemical variables available, C-reactive protein is still the standard for a fast, reliable, and cost-effective assessment of severity in acute pancreatitis. PCT substantially contributes to an improved stratification of patients at risk to develop major complications and deserves routine application.
Acute Disease↗
[Pancreatic cancer. The relative importance of neoadjuvant therapy].
Neoadjuvant radiochemotherapy in patients suffering from pancreatic cancer is presently not well established. Neoadjuvant radiochemotherapy is recommended to be applied in 5-8 weeks. The full dose of radiotherapy is between 50 and 54 Gy with 5FU used as radiosensitator. In patients with resectable pancreatic cancer, particularly in UICC-stage II neoadjuvant radiochemotherapy, this results in an improvement in survival: the median survival is between 15 and 30 months. In about 15% of the patients with resectable pancreatic cancer (UICC I-III), neoadjuvant radiochemotherapy results in downstaging. In combination with a R0-resection,neoadjuvant radiochemotherapy effects a reduction of local recurrence. Results from controlled clinical trials are necessary to objectify the benefits of neoadjuvant radiochemotherapy.
Adult↗
Progress in gastrointestinal tract surgery: the impact of gastrointestinal endoscopy.
BACKGROUND: Gastrointestinal (GI) tract surgeons were challenged with the development of two revolutionary surgical specialities: laparoscopic and endoscopic surgery. Minimal access surgery currently is the surgical speciality with the greatest impact on patient care. Regarding the competitive treatment methods (open, laparoscopic, and intraluminal endoscopic management), each new treatment must be evaluated on the evidence of the patient's benefit, surgical morbidity, short- and long-term outcome, cost effectiveness and maintenance of quality of life. METHODS: On the basis of randomized clinical trials, minimal access surgery results in reduced postoperative pain, reduced early postoperative analgetic medication, reduced frequency of systemic inflammatory response syndrome and systemic complications, early restoration of normal bowel function, and minimalization of wounds and skin scars. Among the well-established laparoscopic procedures, laparoscopic cholecystectomy has been convincingly demonstrated as superior to open cholecystectomy on the basis of controlled clinical trials. Superior benefit in favor of laparoscopic hernia repair has been demonstrated only regarding a lower level of pain, a higher level of physical activity, and earlier return to work. However, in terms of operating time and costs, open repair without mesh has benefits. Laparoscopic appendectomy offers benefits in terms of pain reduction, faster postoperative recovery, and lower incidence of wound infections, but has major drawbacks with regard to longer operating time, higher local complication rates, and significantly higher costs for total hospitalization. A cost study group concluded from a randomized clinical trial that only minimal short-term quality-of-life benefits were found for laparoscopically assisted colon resection, as compared with standard open colectomy, for colon cancer. On the basis of controlled clinical trials, there is only a little doubt that the laparoscopic approach is currently the operative treatment of choice for gastroesophageal reflux compliance. Endoscopic intraluminal techniques are increasingly important for minimalization of surgical treatment. For ulcer bleedings, endoscopic treatment is the established first choice. A major old and new challenge for GI tract surgeons is the intraluminal endoscopic approach to lesions. For neoplastic lesion in the esophagus (> 2 cm, mucosa restricted), Barrett's epithelium, early gastric cancer, adenoma of the ampulla of Vater, T1+, TIM lesion of the large bowel, T1 cancer of the rectum, intraluminal endoscopic treatment methods are increasingly replacing open surgical resection or even a laparoscopic technique. The surgeon must be aware that many of the local surgical complications, particularly those of GI tract anastomoses, are managed by endoscopic techniques. CONCLUSIONS: The GI tract surgeon must accumulate competent endoscopic experience. His responsibility for GI diseases focuses on surgical treatment using minimal access surgical techniques including surgical endoscopy in preoperative, intraoperative, and postoperative settings. This major assignment is a challenge not only for GI tract surgeons in the near future.
Clinical Trials as Topic↗
Endoscopic mucosal resection for advanced non-polypoid colorectal adenoma and early stage carcinoma.
PURPOSE: Endoscopic mucosal resection (EMR) techniques were evaluated in the treatment of flat and sessile colorectal neoplasm. PATIENTS AND METHODS: Fifty-seven patients (32 female, 25 male) with non-polypoid colorectal lesions (n = 71, size >or= 10 mm) were included in the study. Tumor location, shape, size, and depth (in malignant lesions) were determined by endoscopy and endoscopic ultrasound. EMR was performed using snare resection, endoscopic aspiration mucosectomy, or EMR using a cap-fitted endoscope. RESULTS: Lesion size ranged from 10 to 50 mm. Complete resection was achieved in 59 of 61 benign and 6 of 8 malignant tumors. Thirty-five tumors were excised in one segment and 34 tumors in piecemeal technique. Pathological examination of neoplasm treated by EMR showed adenoma in 61 and early-stage carcinoma in 8 cases. Because of the non-lifting sign, 2 of 71 tumors were not treated endoscopically and referred to surgical resection revealing a T2 adenocarcinoma in both cases. Resection was incomplete in 2 of 61 adenomas with histological positive resection margin. Complications occurred in 2 patients, with 1 bleeding treated endoscopically and 1 perforation treated by surgery. Local recurrence was observed in 2 of 59 completely resected adenomas and in none of 6 early-stage carcinomas during a mean follow-up of 18 months (range 6 to 30 months). CONCLUSION: Advanced non-polypoid colorectal adenomas and early-stage carcinomas can be safely and effectively resected by endoscopic mucosal resection.
Adenoma↗
Interaction of fibronectin and aggregation substance promotes adherence of Enterococcus faecalis to human colon.
This in vitro study investigates the interaction between aggregation substance (AS), a virulence factor of Enterococcus faecalis, and colonic mucosal fibronectin in normal colon and colon from patients with Crohn's disease. Fibronectin was found to be overexpressed in Crohn's disease compared to normal colon. Compared to E. faecalis OG1X:pAM944 (AS-negative), E. faecalis OG1X:pAM721 (expressing AS) showed a significantly enhanced adhesion to human colonic mucosa in normal colon and in colon from patients with Crohn's disease. Double-staining of fibronectin and AS-positive enterococci showed that colocalization of bacteria and fibronectin was significantly more frequent in Crohn's disease than in normal colon. Preincubation of bacteria with soluble fibronectin caused a significant reduction in the adherence to fibronectin. In conclusion, the interaction between AS and fibronectin plays is an important factor that mediates adhesion of Enterococcus faecalis to colonic mucosa. This might be one of the mechanisms responsible for bacterial translocation of Enterococcus faecalis.
Bacterial Adhesion↗
Serum amyloid A is a better early predictor of severity than C-reactive protein in acute pancreatitis.
BACKGROUND: Serum amyloid A (SAA) is an early and sensitive marker of the extent of tissue trauma and inflammation. The aim of this study was to compare the early prognostic accuracy of SAA with that of serum C-reactive protein (CRP) in acute pancreatitis. METHODS: In a prospective multicentre trial, plasma SAA and CRP levels were measured in patients with severe and mild acute pancreatitis, and in a control group with acute abdominal pain. Plasma samples were collected on admission and at 6-h intervals for 48 h, every 12 h between 48 and 72 h, then daily for 5 days. Plasma SAA was measured by a new enzyme-linked immunosorbent assay and CRP was measured by immunoturbidometry. RESULTS: There were 137 patients with mild and 35 with severe acute pancreatitis, and 74 control patients. SAA levels were significantly higher in patients with severe acute pancreatitis than in those with mild acute pancreatitis, on admission, at 24 h or less after symptom onset, and subsequently. Whereas plasma CRP concentration was also significantly higher in patients with severe acute pancreatitis on admission, it failed to distinguish mild from severe acute pancreatitis until 30-36 h after symptom onset. SAA levels predicted severity (sensitivity 67 per cent, specificity 70 per cent, negative predictive value 89 per cent, mean(s.d.) area under curve 0.7(0.05)) significantly better than CRP (57 per cent, 60 per cent, 84 per cent, 0.59(0.06) respectively) on admission (P = 0.02) and at 24 h following symptom onset (area under curve 0.65(0.09) versus 0.58(0.09) respectively; P < or = 0.02). CONCLUSION: Plasma SAA concentration is an early marker of severity in acute pancreatitis and is superior to CRP estimation on hospital admission and at 24 h or less after symptom onset. This study suggests that plasma SAA concentration is clinically useful, with the potential to replace CRP in the management of acute pancreatitis.
Abdominal Pain↗
Regional chemotherapy of nonresectable colorectal liver metastases with mitoxantrone, 5-fluorouracil, folinic acid, and mitomycin C may prolong survival.
BACKGROUND: Regional chemotherapy of isolated, nonresectable colorectal liver metastases (CRLMs) by hepatic artery infusion (HAI) has the advantages of high response rates and the possibility of downstaging and resection of CRLMs. 5-Fluorodeoxyuridine (5-FUDR) has been the drug studied in most Phase II and III trials. The meta-analysis of the Phase III trials comparing HAI with systemic or supportive therapy confirmed an advantage for response and even survival for HAI. Hepatic artery infusion with 5-FUDR, however, is hepatotoxic, inducing sclerosing cholangitis (SC). The authors have introduced 5-fluorouracil (5-FU) with folinic acid for HAI and found equal effectivity but no SC when compared with HAI with 5-FUDR. Now, they report a new combination chemotherapy protocol based on HAI with 5-FU with FA and on in vitro Phase II studies suggesting mitoxantrone and mitomycin C as active drugs for HAI in CRLM. PATIENTS AND METHODS Between February 1993 and August 2000, 63 patients with CRLM were treated with HAI using mitoxantrone, 5-FU with FA, and mitomycin C (MFFM) via port catheters with a protocol planing up to 11 cycles of treatment. Toxicity and response were analyzed according to World Health Organization (WHO) criteria, and survival was analyzed according to Kaplan-Meier. All patients were treated with more than two HAI cycles. RESULTS: The objective response rate (complete remission and partial remission) was 54% and primary intrahepatic progression (progressive disease) occurred in 4.8%, whereas in 41.3% of the patients the intrahepatic disease was evaluated as no change. Median survival times from the first diagnosis of CRLM or start of HAI were 25.7 months and 23.7 months, respectively, and 7 patients lived longer than 40 months. Grade 3 toxicity according to WHO occurred in 34.9%, and Grade 4 occurred in 3.2%. No toxic death or SC occurred. CONCLUSIONS: Our new HAI protocol with MFFM seems to be superior to HAI with 5-FUDR, 5-FU with FA, and systemic chemotherapy with 5-FU and FA at acceptable toxicity. Currently, HAI with MFFM is compared with systemic chemotherapy using 5-FU and FA intravenously in a randomized Phase III trial.
Adult↗
Efficacy of oral ofloxacin for single-dose perioperative prophylaxis in general surgery--a controlled randomized clinical study.
BACKGROUND: Perioperative antibiotic prophylaxis surely reduces surgical infection rate. Pharmacokinetic data of oral ofloxacin in combination with its antibacterial spectrum suggest effective protection against perioperative infection. In addition, costs, adverse effects, and induction of microbial resistance are low. Therefore we performed a controlled randomized study comparing oral and intravenous single dose prophylaxis. METHODS: A total of 61 patients undergoing colonic or pancreatic resection randomly received either a single dose standard intravenous prophylaxis or ofloxacin 400 mg and metronidazole 500 mg orally 2 h before surgery. Postoperative infections were recorded for 3 weeks. RESULTS: Groups were very well comparable regarding age, overweight, concomitant disease, type and duration of surgery, blood loss, and volume support. Infectious complications occurred in 14.8% after parenteral and 3.3% after enteral antibiotic prophylaxis. There was no difference in post-operative hospital stay. CONCLUSION: The data demonstrate that single-dose oral ofloxacin is at least as effective as a standard intravenous prophylaxis in patients with colonic or pancreatic resection. It offers significant advantages regarding costs and ease of administration.
Administration, Oral↗
Reduced membranous and ectopic cytoplasmic expression of beta -catenin correlate with cyclin D1 overexpression and poor prognosis in pancreatic cancer.
Beta-catenin is a component of the E-cadherin-catenin cell adhesion complex. It plays also a role in intracellular signaling and can function as an oncogene when it binds to the T-cell factor 4 (Tcf4)-binding site in the promoter region of cyclin D1 and transactivates genes after translocation to the nucleus. We evaluated the immunohistochemical expression pattern of beta-catenin in relationship with cyclin D1 overexpression, tumor grade, clinicopathologic parameters and patients' survival in 43 ductal adenocarcinomas of the pancreas and 5 normal pancreatic tissues. We were able to show that, both reduced membranous beta-catenin expression (25 of 43, 58.1%) and accumulation of beta-catenin in the cytoplasm (28 of 43, 65.1%) correlated significantly with cyclin D1 overexpression (both p < 0.0005). Furthermore, we could show a clear correlation between reduced membranous expression and ectopic cytoplasmic expression of beta-catenin (p < 0.0005). Among patients with carcinomas showing no cytoplasmic expression, the 1-year survival was 86.6% whereas among patients with carcinomas showing cytoplasmic expression only 35.7% survived 1 year (p < 0.01). Co-precipitation experiments revealed reduced beta-catenin bound to the E-cadherin-catenin complex in pancreatic tumor tissues compared with normal pancreatic tissues. These results suggest that beta-catenin may be involved in the tumorigenesis of pancreatic cancer and exhibited its effects mainly by the transactivation of cyclin D1.
Adult↗
Immunogenicity of recombinant GA733-2E antigen (CO17-1A, EGP, KS1-4, KSA, Ep-CAM) in gastro-intestinal carcinoma patients.
Targeting the GA733 antigen (also known as CO17-1A, EGP, KS1-4, KSA, Ep-CAM) by monoclonal antibody CO17-1A or anti-idiotypic antibodies mimicking the CO17-1A or GA733 epitope has induced prolonged survival and specific immune responses to the antigen, respectively, in colorectal cancer (CRC) patients. In pre-clinical studies in mice and rabbits, recombinant baculovirus-derived GA733-2E antigen was superior to anti-idiotypic antibodies at modulating specific immune responses. Our aim was to evaluate the immunogenicity and potential toxicity of alum-precipitated GA733-2E in a phase I trial in patients with resected CRC or pancreatic cancer. Six patients with advanced pancreatic carcinoma and 6 with CRC Dukes' stage A, B or C received between 4 and 7 doses of alum-precipitated GA733-2E at 50, 200 or 800 microg/dose at monthly intervals. Antibody binding to GA733-2E or antigen-positive CRC cells was determined, as were antigen-specific proliferative, cytolytic T-lymphocyte and delayed-type hypersensitivity responses. Six of the 12 patients developed antigen-specific humoral immune responses after immunotherapy, and 8 developed cellular immune responses. The overall immune response rate, including patients with humoral and/or cellular immune responses, was 83%. Median overall survival of the CRC and pancreatic cancer patients was 39.8 and 11.2 months, respectively. Following 18 years of single-epitope targeting of the GA733 antigen, immunization of patients against multiple epitopes of the antigen frequently induces an immune response in the absence of significant toxicity, despite relatively widespread expression of this antigen on normal epithelial cells.
Aged↗
Inhibition of caspase-1 induces cell death in pancreatic carcinoma cells and potentially modulates expression levels of bcl-2 family proteins.
Caspase-1 (interleukin-1beta-converting enzyme) is reported to play an important role in the regulation of apoptosis. We investigated the inhibition of caspase-1 by the cell permeable caspase-1 inhibitor Ac-AAVALLPAVLLALLAP-YVAD.CHO in pancreatic carcinoma cells. Inhibition of caspase-1 induced a non-apoptotic/"necrotic-like" cell death in AsPC-1, BxPC-3, MiaPaCa-2 and Panc-1 cells. Expression levels of bcl-2 and bax were up-regulated in caspase-1 inhibitor-treated cells while that of bcl-x(L) remained unaltered. Our observations support our previous findings that caspase-1 is potentially involved in anti-apoptotic processes in pancreatic carcinoma.
Apoptosis↗
[Surgical therapy of alveolar echinococcosis and long-term outcome].
INTRODUCTION: The incidence of alveolar echinococcosis (AE) is low, and studies and progress reports with regard to surgical procedures are rare. METHODS: Retrospective analysis of surgical therapy of AE and its long-term results between 1983 and 2000 by evaluating medical records and questionnaires. SETTING: German university hospital within the endemic area. RESULTS: Twenty-five surgical procedures were performed in 19 patients with AE (12x partial resection of the liver, 3 of them with additional extrahepatic resection; 3x just extrahepatic resection, 4x bilidigestive anastomosis, 5x exploratory laparotomy, 1x bypass procedure). Fifteen patients were operated on the first time with that diagnosis, four due to a relapse. Seven surgical procedures were estimated to be curative, whereas 18 were palliative, because the parasitic mass could not be resected in toto. One patient died from persistent systemic sepsis as a consequence of microbial superinvasion of a splenic parasitic mass. Morbidity was 28%. All patients had additional medical treatment and periodic follow-up. Three of seven patients estimated for curative surgery developed a relapse. One of the patients discharged following palliative surgery died 13 years after diagnosis with liver insufficiency. Advances in conservative and interventional treatments have greatly improved the prognosis of the disease. CONCLUSION: Curative surgery for AE is feasible only in a minority of patients, because frequently the disease has already spread widely when diagnosed. The minimum distance between the lesion and the cut surface should be 2 cm. Taking the advances in conservative treatment into consideration, the benefit of palliative surgery is uncertain and today there is no evidence for prolonged survival by palliative surgical procedures. Palliative surgery should therefore be reserved for cases with complications that could not be managed by conservative and interventional treatment.
Adult↗