Biomedical subjects
Publications and source records attributed to J Funovics.
A case of an early cancer of the stomach is reported, in which the development of the lesion could be followed by repeated biopsies. Because of a high cardial risk of the patient, the tumor was resected as late as 23 months after the first diagnosis. During this time the lesion changed from a borderline lesion into an early cancer with penetration into the submucosa.
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In a randomised study the influence of 3 different amino acids (AA) solutions on nitrogen balance, plasma protein synthesis, and plasma and urine AA pattern was investigated in postoperative (p.o.) cancer patients. The patients in group I received a balanced AA solution designed especially for p.o. patients with 10 percent branched chain amino acids (BCAA), those in group II a solution with 60 percent BCAA and those in group III a solution with 67 percent alanine. All patients received the same amount of nitrogen (0.16 g/kg BW/day) and energy (2.p.o. day: 80 kJ/kg BW/day; 3.-5. p.o. day: 160 kJ/kg BW/day) with a 3:1 ratio of carbohydrate to fat calories. No difference was observed between the three groups for mean daily nitrogen balances, however, the cumulative nitrogen balance of group I (-4.5 +/- 3.6 g) was significantly (p less than 0.05) improved compared to group II (-12.2 +/- 4.2 g). The p.o. decreased concentrations of short-life plasma proteins (prealbumin, transferrin, retinol-binding protein) increased until the end of the study period without any statistic differences between the three groups. On the 2nd p.o. day especially the gluconeogenetic AA were decreased in all patients, but were nearly normal in all patients on the 5th p.o. day. In conclusion the increased administration of BCAA neither improved nitrogen retention nor plasma protein synthesis and does not seem advantageous in the postoperative total parenteral nutrition.
Thoracic endoscopic sympathectomy (TES) is a short surgical procedure used for the treatment of axillary and palmar hyperhydrosis. It involves creation of tension pneumothorax, lateral and head-up position and necessitates minimal lung excursions during breathing, so that a special anaesthetic technique is required. In six otherwise healthy patients an endobronchial double lumen tube was used for one-lung ventilation with intravenous anaesthesia and muscular relaxation, and circulatory response, FE CO2 and blood gases were monitored in order to compare this anaesthetic technique to conventional endotracheal intubation in previous patients. Some difficulties with inserting and securing the double lumen tube were encountered, but were far outweighed by the advantages of stable circulation, physiological blood gas values and easy access to a calm surgical field.
The resection of thoracic oesophageal cancer by blunt finger-dissection and stripping is a further palliative procedure at the disposal of the surgeon. This method represents an alternative to intubation or bypass without resection. The advantages are the better functional results and at least palliative removal of the tumour. This method should be used, however, if there is the possibility of carrying out radical resection from the oncological point of view, with the aim of curing the patient. The technical details are described and the indications and results discussed on the basis of six case reports.
The nutritional status and skin reactivity of 82 cancer patients were determined before surgery and compared with the postoperative complication rate. The nutritional status of 47 patients was evaluated by weight, height, weight-loss, arm muscle circumference, triceps skin-fold measurements, serum albumin, pre-albumin, retinolbinding protein, tranferrin, and cholinesterase. In 35 patients protein catabolism was assessed by the urea production rate (catabolism greater than 15 g/d). Immunity was assessed by the total lymphocyte count and a skin reactivity test. Using these criteria, 55% of the patients were malnourished. Curative operations could only be carried out in 17.4% of the malnourished, but in 50% of the normally nourished patients (P less than 0.0001). Postoperative complications were increased in malnourished patients (47%) when compared with normally nourished patients (20%, P less than 0.05). In anergic and malnourished cancer patients no curative surgical treatment was possible. Due to the increased postoperative complication rate in malnourished cancer patients, nutritional assessment, including the determination of cellular immunity should be performed after admission.
Eighteen cases of operated ulcerative colitis are described. In 15 cases ileorectal anastomosis was performed. In one case, the rectum had to be excised because of a massive rectal haemorrhage; in another case, the anastomosis had to be separated Hartmann's operation) because of a dehiscence of the anastomosis. A re-examination of 13 patients shows full continence in 12 cases; one patient was incontinent with regard to flatus. The Karnofsky Index shows 100 in 10 patients, and 90 in 3 patients. The sigmoidoscopy reveals normal rectal mucosa in 6 patients, a moderate colitis in 5 patients and a severe colitis in 2 patients. There are only two indications for rectal excision in our opinion: uncontrollable rectal haemorrhage and carcinoma (dysplasia).
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The metabolic profiles of 14 patients with prolonged abdominal sepsis were analysed on the second day after laparotomy. The profiles of survivors were compared with those of non-survivors who died one to five days after the time of evaluation due to uncontrollable multiple organ failure. In the non-surviving patients plasma glucose and glucagon levels were significantly higher than in surviving patients. The plasma concentrations of phosphoserine, cysteine, valine, phenylalanine, and 3-methylhistidine were found to be significantly increased in non-survivors and their muscle tissue showed significantly decreased concentrations of glutamine, proline and lysine with increases in valine and leucine. A correct classification of non-survivors and survivors could be obtained from the plasma and muscle amino acid concentrations, the highest discriminant power being from muscle glutamine. In severe sepsis metabolic changes correlate with the outcome of the patients, and amino acid metabolism seems to be characterised by low concentrations of muscle glutamine and high levels of the branched chain amino acids possibly indicating an inhibited intracellular glutamine formation in muscle tissue.
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Four patients with fulminant hepatic failure had extracorporal hemoperfusion. In selecting the patients, the following criteria were applied: Potential reversibility of the liver disease, prothrombin time under 10%, neurological coma stage III-IV. In total 11 treatments (9 treatments using baboon and 2 treatments using human livers) were performed lasting from 3 to 60 hours. One patient improved immediately after perfusion. 3 patients died; at post mortem severe oedema of the brain and acute yellow atrophy of the liver without tendency to regeneration was observed in these patients.
The possible role of poly(C)RNase serum activity and CEA serum level for early detection and differentiation of pancreatic carcinoma and its specificity and valuability were critically analyzed: Serum RNase (median, min-max) with polycytidin as substrate was determined in 13 "normal" patients (14.6 E/ml, 4.3--29.8 E/ml), 16 patients with pancreatic cancer (T3 or metastases) (17.6 E/ml, 6--49-9 E/ml), 15 patients with chronic pancreatitis (9.5 E/ml, 4.9--26.5 E/ml), 7 patients with acute pancreatitis (14.2 E/ml, 5.5--67.3 ng/ml), and 13 patients with other types of malignomas (15 E/ml, 4.3--42.5 E/ml). Serum CEA level was evaluated in 18 "normal" patients (1.15 ng/ml, 0--4.3 ng/ml), 12 patients with pancreatic carcinoma (T3 or metastases) (6.5 mg/ml, 2--456.5 ng/ml), 13 patients with chronic pancreatitis (2.3 ng/ml, 0--8.5 ng/ml), 8 patients with acute pancreatitis (2.7 ng/ml, 0.1--4.6 ng/ml) and 5 patients without operative verification of suspected pancreatic carcinoma (0.9 ng/ml, 0--1.7 ng/ml). The serum RNase activity in pancreatic cancer patients did not show any significant increase in comparison to the other groups, and these patients could not be distinguished from those with the other diseases when excluding other factors influencing serum RNase level such as: Renal insufficiency, nutrition, age, sex. Their CEA level was significantly higher in comparison to the other groups (p less than 0.05). Using 2.5 ng/ml as the limit, the sensitivity was found to be 80% (10/12 of pancreatic carcinomas positive) and the specificity being 70.5% (31/44 of other groups without malignant diseases negative). The presented study and data in the literature show that poly (C) RNase measurement is not useful in early detection of pancreatic carcinoma, but the CEA test could be helpful in the differential diagnosis of pancreatic diseases due to its specificity (70.5%) and seems to be valuable in detection of residual and in monitoring for recurrent pancreatic carcinoma in view of its sensitivity and correlation with the stage of cancer.
UNLABELLED: An alanine infusion (90 mg/kg/h) for eight hours was administered to seven patients after cholecystectomy in order to investigate the influence of elevated plasma alanine levels on the postoperative metabolism. The following metabolites and hormone concentrations were analysed in plasma: glucose, urea, free fatty acids, ketone bodies, amino acids, insulin and glucagon. Compared to the pre-infusion values on the 1. postoperative day after an overnight fasting, the following changes were monitored. The plasma glucose concentrations reached a maximum after four hours of infusion (p less than 0.05). Of the amino acids, significant elevated levels were found for alanine (300%, p less than 0.001), glutamine (36%, p less than 0.05), and alpha-aminobutyrate (61%, p less than 0.01). The free fatty acids and ketone bodies concentrations decreased immediately after the onset of the infusion of alanine (p less than 0.05), the increased again during the last four hours of infusion. The secretion of insulin and also the secretion of glucagon were stimulated by the increased alanine levels. The stimulation of insulin reached a maximum after only five minutes, but the glucagon levels increased continuously until the end of the infusion. During the administration of alanine a nitrogen homeostasis was achieved, which was a significant improvement (p less than 0.001) when compared to saline infusions before and after the alanine infusion. CONCLUSIONS: (1) Postoperative increased plasma levels of alanine stimulate gluconeogenesis and reduce the plasma levels of lipolytic metabolites. The induced stimulation of insulin and glucagon is dependent on the duration of the alanine infusion for during extended infusion of alanine the insulin stimulation diminishes while the glucagon secretion continuously increases. (2) Alanine is a potent anabolic substrate in the immediate postoperative situation.
Using a new model of a reversible pancreatic fistula which allows the long-term-investigation under nearly physiological conditions on the unrestrained dog, we tested the effect of somatostatin (50 micrograms), calcitonin (4 micrograms), glucagon (1 microgram), and prostaglandin E1 (150 micrograms) on the exocrine pancreatic function in 45 experiments over a period of 13 h: SST inhibits the basal as well as the secretin or CCK-stimulated secretion: calcitonin shows inhibition of the stimulated secretion only; glucagon blocks the secretin-stimulated pancreatic function; and PGE1 reduces the bicarbonate concentration and trypsin output in secretin stimulation, but in one of the two series it stimulates the basal secretion.
Levels of free amino acids were analysed in plasma and muscle tissue of nine patients with acute hemorrhagic necrotising pancreatitis and compared with date from healthy volunteers. In the patient group the concentrations of threonine, serine, glutamine (p less than 0.001) and tyrosine (p less than 0.01) in plasma were found to be significantly lower than in the volunteers group, while increased plasma levels were found for 3-met-histidine (p less than 0.05). In muscle tissue the cytoplasmatic levels of glutamate, glutamine and histidine (p less than 0.001) and also of lysine, ornithine and arginine (p less than 0.,01) showed decreased concentrations. However tyrosine and phenylalanine had increased intracellular concentrations (p less than 0.05). It is concluded that (1) the patients in this study had a severely disturbed amino acid metabolism with extremely reduced levels of free glutamine in muscle tissue and (2) that the disturbed amino acid metabolism results from an acute catabolic situation of the patients, in which the reduced levels of free amino acids may indicate an impaired nutritional state.
1. 20 patients before surgery received enteral nutrition for three days (12 g nitrogen, 1800 Kcal). Nitrogen and urea excretions in urine during the second and third day were determined. Eleven patients had a negative nitrogen balance (-2,7 and -2,4 g/day). In these patients urea production rates were 21,1 and 20,1 g/day. An urea production rate exceeding 15 g urea/day is probable an indication for a protein catabolism. The reason for this catabolic state seems to be a decreased protein utilisation (49 and 47 percent) as the result of a metabolic stress situation. This metabolic stress was determined according the stress index (Bistrian). The patients were in a stress situation comparable to postoperative stress (+3,7 and +3,9). The determination of urea production rate and catabolic index seems a suitable tool for defining a catabolic state. 2. 3-met-histidine excretion in urine were measured in seven patients postoperatively. In different periods saline or aminoacids solutions (5% alanine) were infused. During alanine administration protein (+49%)--and 3-met-histidine excretions (+50%) increased. It is not possible to state a catabolic situation out of the 3-met-histidine excretion, because an increased excretion may result from a stimulated protein synthesis in muscle tissue or from an increased muscleprotein wasting. 3. Free amino acid pools in plasma and muscle tissue were analysed in patients with severe illness of liver and pancreas. The free amino acid pattern differed from healthy volunteers. In patients with liver disease significantly increased concentrations of phenylalanine, tyrosine and methionine were found. In patients with acute pancreatitis highly abnormal pattern of intracellular amino acids occurred with decreased concentrations of glutamine, cysteine, histidine, lysine, arginine and ornithine. The highly significant decreased concentrations of glutamine (p less than 0,01) indicate a catabolic situation of these patients. A quantification of the severity of the catabolic state out of amino acid concentrations is not possible.
Seven patients undergoing cholcystektomy received a 5 pevcent solution of alanine (90 mg/kg/h) during a period of 8 hours on the 1. postoperative day. Stimulation of gluconeogenesis was observed with increase of glucose from 5,9 +/- 0,2 to 6,3 +/- 0,2 mmol/l. Initially the level of ketone bodies decreased (acetoacetate 70 +/- 23 to 17 +/- 6 mumol/l) but again increased to start values during infusion of alanine. Insulin increased twofold from 7,6 +/- 1,4 microU/ml to 14,6 +/- 4,0, and had a constant level during infusion as did glucagon, which increased from 561 +/- 70 to 608 +/- 74 pg/ml. Nitrogen balance during infusionsperiod was almost zero (0,04 +/- 0,09 g/h minus) showing a significant difference to balances calculated from periods before and after infusion of alanine (0,57 +/- 0,07 and 0,53 +/- 0,06 g/h deficit respectively). Direct influence on peripheral glucose alanine cycle and increased gluconeogenetic substrate seem to be responsible for the nitrogen sparing effect of alanine.
In 38 preoperative patients the production of urea was estimated and the cell-mediated immunity was measured. 10 patients were catabolic and had negative skin tests, all of them were inoperable. 15 patients were catabolic and had positive skin tests five patients were inoperable. 12 patients were not catabolic and had positive skin tests, two were inoperable. One female patient was not catabolic and had negative skin tests, but was operable. The catabolic state can be assessed by the urea production rate and you can give prognostic and therapeutical references in correlation with the delayed hypersensitivity.