Biomedical subjects
Publications and source records attributed to S Truong.
Based on the data of 56 patients undergoing elective cholecystectomy the value of subhepatic drainage is evaluated in a randomized controlled clinical trial. The design of the study and the perioperative management of the patients are described in detail and the results analyzed according to clinical course, blood tests and abdominal ultrasound.
The "postcholecystectomy syndrome" was originally defined by Pribram as a pure functional disturbance after cholecystectomy. Today it has become a melting pot of various postoperative syndromes of mostly obscure origin. It's incidence is said to be 26-40%, but surgically treatable lesions of the biliary system amount only 1.5%. Functional consequences for biliary excretion are rare because the loss of the gallbladder reservoir is substituted in part by the biliary tree.
A case of carcinoma arising in a posterior pharyngeal pulsion diverticulum is reported. The radiologic work-up included computed tomography and magnetic resonance. Both these modern cross-sectional imaging methods allow conclusive differentiation of filling defects, which is known to be difficult in many cases with conventional imaging techniques. Filling defects due to carcinoma are easily recognized and differentiated from those caused by inspissated food debris as they are enhanced following i.v. administration of contrast medium. In addition, the depth of infiltration can be established.
Between October 1988 and July 1989 100 consecutive patients with suspected appendicitis were seen at the surgical clinic, University Hospital of Aachen. All patients underwent ultrasonographic examination corresponding to a prospective study protocol in order to determine the value of ultrasound for the diagnosis of acute appendicitis. The sonographic findings were correlated with the histologic diagnosis or the clinical course, respectively. We found a sensitivity of 100% for appendiceal mass, of 88% for phlegmonous appendicitis and of 25% for catarrhal appendicitis. The overall sensitivity was 49% and the overall specificity rate was 97%. The overall accuracy rate was 64%. The predictive value of a positive test was 97% and the predictive value of a negative finding was 46%. The morphologic changes during the progress of inflammation of the appendix and their sonographic visualisation were discussed. A differentiated concept was developed to integrate the sonographic findings in the therapeutic decision.
From 65 patients with 73 abscesses 38 were treated by operation and 27 by PCD. The mean duration of drainage was 6.8 days (OP) and 7.4 days (PCD) respectively. In the surgical group 2 patients needed reintervention and 1 died due to sepsis. In the PCD group 1 patient had to be operated on because of insufficient drainage and 1 died after perforation of the colon. With modern techniques of imaging (Ultrasound, CT) PCD is a useful tool in the therapeutic regimen of intraabdominal abscesses. PCD has to be considered as definitive treatment or preparation for surgical eradication. Above all indication to PCD depends on localization and cause of the abscess.
Unusual sonographic behavior of intussusception is demonstrated in 4 cases. The results of 54 well-documented cases have shown two possible deviations from the normal sonographic pattern of an intussusception. The first was a highly reflective target sign, and the second a loss of regular sonographic structure in a tumor-like mass.
Forty seven patients with suspected malignant disease (mainly colorectal cancer) were studied with 111In labelled F(ab')2 fragments of an anti-CEA monoclonal antibody (BW 431/31). The kinetic data revealed a long whole body retention of the label (62% after 4 days) and a rapid blood clearance (77% within 24 h, 89% within 48 h) leading to an early positive tumour contrast 24 h p.i. and optimal scintigrams 48 h p.i. Diagnostic results were promising in local recurrences of colorectal cancer (8/10 positive = 80%) though false positive findings in patients with inflammatory bowel disease occurred probably due to cross-reaction with a human granulocyte antigen. Liver metastases and tumours neighbouring liver and spleen were often missed (10/27 = 37%) because of high nonspecific uptake in these organs. Thus BW 431/31 proved to be a suitable compound for radioimmunodetection, however, further improvements to optimize tumour affinity and specificity of the antibody are mandatory.
Eighty-one immunoscintigraphy (IS) studies in 80 patients with gastrointestinal malignancies were re-evaluated retrospectively to analyze accuracy and clinical impact of the IS findings. Selection of patients was based upon complete diagnostic records and a clinical follow-up of at least 6 months. The 3 antibody preparations used (99m-Tc labelled complete anti-CEA antibodies (BW 431/26), 111-In labelled F(ab')2-fragments against CEA (BW 431/31), and a mixture of 131-I labelled F(ab')2-fragments against CEA and CA 19-9 (IMACIS-1] yielded equal diagnostic sensitivities (65%, range 60-78%) except for liver metastases. These were preferably detected by the 131-I labelled compound. Best results were gained in local recurrencies of gastrointestinal cancer (12/15 true positive = 80%). Among these were 3 out of the 4 lesions which had been exclusively recognized by IS. Thus IS should be applied in patients with suggested local recurrencies and inconclusive outcome of routine diagnostic workup. A widespread and frequent use of IS (e.g. screening of metastases) cannot be advocated since diagnostic results were not convincing and the immunologic risks of IS (development of human anti-mouse antibodies) are still under discussion.
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Gastric surgery is still a major part of routine surgical practice. Diagnostic strategies should be oriented to the surgical consequences and their value for our understanding of pathophysiological connections. Endoscopy, perhaps with biphasic radiography, is mandatory for diagnosis of tumor malignity and localisation. Analysis of secretion is indicated in cases of ulcer recurrence. Postoperative syndromes can be detected and classified by scintigraphic methods. The new procedure of endoscopic ultrasonography seems to offer special benefits for diagnostic problems such as gastric lymphoma and other intramural tumors.
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Based on two cases of splenic cysts diagnosis, indication, and selection of surgical methods are discussed. Ultrasound and computerized axial tomography prove to be the most important diagnostic methods. The indication to operate on cysts with a diameter exceeding 2 cm follows from possible complications. Because of the immunological importance of the spleen and the technical means of today a splenic resection should always be considered.
A clinically developed and prospectively verified therapeutic concept for acute intestinal bleeding is presented in this paper. Emphasis is laid on orthograde lavage likely to enable sooner and more effective use of diagnostic means and to provide optimal conditions for surgical therapy. Prognosis can be further improved by differentiated use of therapeutic endoscopy and early elective surgery. The effectiveness of this new therapeutic concept has been successfully verified on 81 patients, between 1975 and 1986. Lethality amounted to five per cent.
Radioimmunoscintigraphy (RIS) with 111In-and 131I-labelled monoclonal antibodies (MAbs) against CEA and/or CA 19-9 was performed in 83 patients with various gastrointestinal carcinomas. A total of 276 body regions could be examined. The results of planar scintigraphy and SPECT were compared intraindividually. Using 111In-labelled MAbs the sensitivity of RIS was significantly improved by SPECT (88.9 vs. 52.4% with planar scintigraphy, p less than 0.01). For 131I-labelled MAbs the effect was smaller (83.9 vs. 65.6% with planar scintigraphy, n.s.). This finding can be explained by different kinetics and biodistribution of the used MAb preparations. 111In-labelled MAbs with long whole-body retention and rapid blood clearance reveal ideal qualities for SPECT; on the other hand, the short whole-body retention of 131I-labelled MAbs leads to small count rates and therefore long counting times that make delayed SPECT unsuitable in clinical practice.
32 patients suffering from rectal carcinoma were examined by endorectal sonography. The preoperative staging by sonography was compared with digital palpation, colon enema and computertomography of the pelvis. In 90% of the cases the sonographic determination of the grade of invasion was identical to the histopathological examination. The efficiency of local destruction methods of rectal carcinoma (cryotherapy) can be controlled by this method.
Lethality of bleeding peptic ulcer has been reduced to about 15 per cent in recent years by therapeutic endoscopy in combination with differentiated surgical tactics. Intensity and activity of bleeding as well as additional criteria, such as localisation, recurrence of bleeding, and age of the patient, are some of the parameters for surgical indication which are used in decision-making, with due consideration of the spontaneous course. Endoscopic haemostasis should be intensively used to avoid emergency operations and action of early recurrence. Selective early surgery should be performed whenever possible. Surgical techniques should be chosen with two objectives in mind, localised haemostasis and definitive ulcer treatment. Extraluminal and intraluminal ligation and additional vagotomy should be the optional approach to bleeding peptic ulcer. Billroth's I operation should be applied to ventricular ulcer.