Biomedical subjects
Publications and source records attributed to H Lippert.
Kuzmak's adjustable gastric banding procedure is well established and has proven to be efficacious in obese patients. After gastric banding we observed a good weight loss and an improvement in metabolic syndrome diseases. Therefore we were able to reduce the dosage of preoperative medication in patients with diabetes or hypertension.
Pancreatic cancer has a very poor prognosis despite surgical resection or chemotherapy. For patients with a pancreatic cancer stage III or IV, locoregional or systemic chemotherapy is often the only chance for treatment. In our opinion, locoregional treatment is currently the best concept.
Inappropriate trypsinogen activation is discussed as an early intracellular event in the secretagogue-induced model of acute pancreatitis. However, the mechanisms by which trypsinogen is activated are not well characterized. In the present work, trypsinogen activation was studied in intact acinar cells using bis-(CBZ-arginyl)-Rhodamine 110 [(CBZ-Arg)2-Rho 110] as a cell-permeant substrate for trypsin and also independently via the formation of trypsinogen activation peptide (TAP). Preincubation with 10 nM caerulein increased the Rho 110-substrate cleavage more than threefold. This proteolytic activity was fully sensitive to a benzamidine (BA)-type serine protease inhibitor. The appearance of enzymatic activity was paralleled by the formation of TAP. The lack of effect of the high-molecular soybean trypsin inhibitor indicates an intracellular substrate cleavage. The cathepsin B inhibitor CA-074 prevented neither the caerulein-induced formation of TAP nor the (CBZ-Arg)2-Rho 110-cleaving activity. BA inhibited the Rho 110-substrate cleavage and significantly reduced the TAP formation. These results show that trypsinogen activation in caerulein-hyperstimulated acinar cells may occur independently of the activity of cathepsin B. On the contrary, the effect of BA suggests the role of a serine protease in trypsinogen activation.
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Hamartomas are rare benign tumors appearing very often without any symptoms. In case of diagnostic detection the operative exploration is indicated for a correct histological diagnosis and resection. In this report we describe a very rare case of mesenterial hamartoma. During the late postoperative course a refilling chylothorax and chylous ascites occurred. With total parenteral nutrition, excluding short- and long-chain fatty acids, chylous leakage was successfully treated. The chylous exudation was stopped totally; only intraabdominally did minimal ascites persist. The therapy was continued by a oral Ceres diet nutrition. The conservative therapy involving total parenteral nutrition permitted us to avoid the peritoneovenous Le Veen shunt and the associated complications.
Infectious complications are the leading cause of death in acute pancreatitis. Individual factors of immune defence could be of significance, whether or not a patient develops a severe course with infectious complications. In a prospective 5-year trial including 72 patients, we investigated 29 cellular and humoral markers of the body's defence system for their potential to indicate the severity and course of acute pancreatitis. Complement factors C3 and C4 as well as immunoglobulins IgG, IgM and IgA were normal, in general. Measurable levels of IL-1 alpha, IL-1 beta, IL-2 and sIL-2R could be detected only occasionally. Values of alpha 1-AT, TNF-alpha, TNF alpha-Rp75, neopterin, sICAM-1, IL-8, IL-1RA and sIL-6R did not correlate with a severe course. Due to the high magnitude of increase, CRP, IL-6 and granulocyte elastase were the best indicators of the inflammatory process. Delayed-type hypersensitivity response was the only early predictor of a severe course. It was superior over other cellular markers such as monocyte count or CD4+/CD8+ ratio. In vitro function of polymorphonuclear granulocytes (PMN) was not adequate to the severity of the disease already during the first week of illness. During further course, PMN motility and capacities to produce reactive oxygen species even worsened. The compromized PMN function could explain the frequent development of infectious complications in patients suffering from severe pancreatitis. These results should encourage new concepts of infection prophylaxis using stimulants of cellular defence.
Surgery of colorectal cancer is suited for assurance of surgical quality. The R0-resection rate in 1927 operations for colorectal cancer was 74.4%. The postoperative mortality was 7.1%. Wound suppuration occurred after surgery of the colon in 6.5%, after surgery of rectal cancer in 9.9% of the cases. In 68.6% of pT4-tumors we found lymphoid metastasis, in 19.3% around the trunk of the inferior mesenteric artery. For compilation of comparative data the quality assurance in colorectal surgery should be realised every 3 to 5 years.
Laparoscopic transperitoneal and endoscopic extraperitoneal adrenalectomy are two safe options in minimally invasive surgery associated with a very low morbidity. Comparative studies with the conventional access to the adrenal gland demonstrated the advantages of the endoscopic technique. The anterior transperitoneal approach yields a better exposure of the anatomic structures and allows the surgeon to orient himself more easily, while at the same time he may perform additional laparoscopic maneuvers. In two cases of bilateral pheochromocytoma a bilateral laparoscopic adrenalectomy was performed simultaneously by employing the transperitoneal approach. The duration of surgery was approximately 210 and 270 min, respectively, with an intraoperative blood loss of about 350 and 400 ml. There were no complications following this procedure. Already on the 1st postoperative day, the patients could be fully mobilized. Furthermore, immunological data obtained perioperatively support the minimal invasiveness of this technique.
A disturbed energy metabolism in pancreatic acinar cells is discussed as factor contributing to the development of acute pancreatitis (AP). In this study, we investigated to what extent the mitochondrial ATP producing capacity is impaired in the pancreatic tissue of rats with experimental AP. For preparation of mitochondria from rat pancreas, routine isolation procedures (tissue homogenization and differential centrifugation) were applied. Mitochondria were isolated from rats with edematous pancreatitis produced by hyperstimulation with caerulein, and from rats with mild necrotizing acute pancreatitis. The latter form of AP was induced by a temporary occlusion of the biliary pancreatic duct accompanied by a simultaneous intravenous injection of caerulein plus secretin and an intraabdominal administration of ethanol. As functional parameters of oxidative phosphorylation, the respiration rate, the mitochondrial membrane potential, and the activity of the complex I of the respiratory chain were determined. Mitochondria from rats with caerulein AP showed an enhanced respiration (61% vs. saline control) and a diminished membrane potential (-17 mV) if respiring with succinate in the non-phosphorylating state. This indicates an increased proton leak across the mitochondrial inner membrane. In the mild necrotizing AP, mitochondria were characterized by a decreased respiration with NAD(+)-linked substrates (-33% vs. sham-operated animals). This inhibition of respiration was confirmed by the reduced activity measured for the NADH-cytochrome c reductase (-32%). In both models of experimental AP the potency of mitochondria to produce ATP was significantly diminished. The stronger impairment of mitochondrial functions were found in the necrotizing form of AP. Reactive oxygen species may lead to the observed alterations--to the enhanced permeability of the mitochondrial inner membrane as well as to the inhibition of the complex I of the respiratory chain.
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Laparoscopic transperitoneal and endoscopic extraperitoneal adrenalectomy are two safe options in minimally invasive surgery associated with very low morbidity. The anterior transperitoneal approach we prefer yields a better exposure of the anatomic structures and allows the surgeon to orient himself more easily. In addition, various other laparoscopic maneuvers may be performed synchronously. We report on our own experience with eight laparoscopic transperitoneal adrenalectomies performed in four cases unilaterally and in two additional cases bilaterally during April, 1996, and January, 1997, in six patients aged 20 to 56 years. The indications were in four cases pheochromocytoma (operated on bilaterally in two cases), and in the remaining two cases adrenal Cushing's syndrome. The duration of surgery was approximately 240 min for bilateral adrenalectomy and 166 min for unilateral adrenalectomy, respectively, with an intraoperative blood loss of about 50 to 400 ml. Except for haematoma of the abdominal wall there were no other postoperative complications. The serum levels of interleukin 6 and 10 underline the minimal invasiveness of this technique, since there were only small increases of interleukin 6 and interleukin 10.
Preoperative evaluation before cholecystectomy includes detailed history of the disease and blood chemistry. Hepatobiliary ultrasonography is the main noninvasive preoperative investigation. The decision to evaluate the common bile duct for stones prior to planned laparoscopic cholecystectomy by ERC may be prompted by clinical suspicion or evidence of jaundice, recent pancreatitis, or a dilated common duct on sonography. Preoperative ERC has the advantage of allowing the simultaneous treatment of duct stones. Intraoperative cholangiography should be available.
It has been verified that laparoscopic appendectomy increases safety. The indications for laparoscopic appendectomy depend on the surgeon's confidence in diagnosis, his skills and the stage of appendicitis. The complications could be prevented by placement of open trocars and (dividing the mesoappendix and appendix with sutures, clips or staples. Electrosurgery should never be used. Bipolar electrosurgery should be limited to 20 Watt power for 5 s. The appendix is removed either though a trocar or in a specimen bag.
Carcinoid tumors are very rarely seen. We have treated 10 patients with carcinoid tumors in the last 4 years. We used arterial chemo-embolisation, embolisation, hepatic arterial ligature and a drug therapy with octreotide and interferon alpha after the resection of the primary tumor.
The postoperative finding of gallbladder cancer after laparoscopic cholecystectomy is unavoidable. Because of the special technique, tumor dissemination with serious consequences is seen more frequently than after open cholecystectomy. For prevention, the general use of saving bags and a reduced indication in cases of advanced inflammation and high-risk groups is discussed.
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In the period of time between September 1, 1991 and August 31, 1993 a total of 1927 patients at 22 East German hospitals were operated for colorectal carcinoma. In anticipation of quality assuring aspects these surgeries were registered and interpreted. An application of a constant classification (pTNM, R-classification) at this was essential. The resection rates of 87.3% on the colon (R0-resections 74.4%) and of 83.1% on the rectum (R0-resection 70.8%) were established in total patient group. Preoperative measures and technique of surgery were also registered. The rate of the colonic anastomosis insufficiencies was about 3.2%, resp. of the rectum 8.2%. Wound suppurations occurred after surgery of the colon in 6.5% of the cases, resp. the rectum in 9.9%. The postoperative mortality was 7.1% in the overall patient group. The practical realization and the efficiency of studies for quality assurance is pointed out.
Differential diagnosis of uncertain swelling of the neck has a limited number of possibilities. Thyreoideal processes, lymphatic adenomatosis and abscesses are in most of these cases prevent. However, vascular diseases should be also considered. It is current practice to perform a sonography, completed by computertomography for establishing a diagnosis. If vascular disease is suspected also an angiography is indicated. During the diagnostic procedure we discovered a major aneurysm of the left external carotid artery. The aneurysm was resected and vascular continuity restored by PTFE patchplasty. In case of tumorous processes of the neck extracranial aneurysms of the carotid artery have to be included into the differential diagnosis in order to guarantee adequate therapy.