Biomedical subjects
T Junginger
Publications and source records attributed to T Junginger.
[Non-parasitic liver cysts: laparoscopic and conventional fenestration].
From 1992 till 1997 10 patients with solitary non-parasitic liver cysts were treated by laparoscopically fenestration of the cysts. The size of the cysts varied between 8 and 16 cm (median 13.5). Conversion to laparotomy was required in one patient because of intraoperative bleeding. In nine patients the laparoscopic procedure was finished successfully. In these cases we observed no intraoperative complications (9/10), intraoperative blood loss amounted up to 100 ml. Median operative time amounted to 82.5 minutes (55-155). No postoperative complications were observed. In two patients a cystadenoma was proven by postoperative histology, in both cases a liver resection was performed. During a median follow-up of 33 (2-43) months 2 of 7 patients treated with laparoscopically fenestration developed a recurrence (28%).
A collective review of the world literature on hepatic cryotherapy.
Published results of hepatic cryotherapy are now available for almost 900 patients. Its safety is well established and its clinical role in treating patients with unresectable hepatoma or liver metastases from colorectal carcinoma is well supported by tumour marker and survival data; the results in the treatment of neuroendocrine liver metastases are promising. Its role as an alternative to liver resection is not yet well supported by long-term data. Although different adjuvant treatment protocols have been used following the cryotherapy of colorectal liver metastases, the effect of adjuvant treatment on recurrence or survival has not been assessed in prospective studies. Laparoscopic hepatic cryotherapy is feasible in selected patients with suitable tumour locations. However, the proportion of patients who might be usefully treated with this technique is not yet well established. The mechanisms of tissue destruction by freezing are reviewed.
[Pigmented villonodular synovitis of the shoulder joint].
A 16-year-old student presented with painful swelling over the left proximal humerus. Magnetic resonance imaging showed a malignant-looking soft tissue mass of 7.5 x 6 x 4 cm invading the shoulder capsule. The patient did not remember initially a shoulder trauma, through postoperatively he reported a distortion trauma of the affected shoulder after a mountain bike accident. Intraoperatively we found two tumors infiltrating the axillary vessel and nerve structures originating from the shoulder joint capsule. Quick examination of the tissue revealed to signs of malignancy, further pathohistologic examination showed a local pigmented villonodular synovitis. Unusual is the clinical presentation of the lesion over the proximal humerus, leading us preoperatively to neglect the possibility of tumor origin from the shoulder capsule, especially since the patient didn't have any complaints or functional deficits of the shoulder joint.
[Surgery of extensive retroperitoneal soft tissue sarcoma].
For retroperitoneal soft-tissue tumours the only treatment capable of having an impact on the course of the disease still is complete surgical resection. Therefore, the pre- and intraoperative assessment of resectability is of particular interest. MRT imaging has gained importance for preoperative imaging. Distant metastases and infiltration of non-resectable vascular or neural structures preclude resection. In approximately two thirds of patients with retroperitoneal soft-tissue tumors complete resection with clear margins (R0 resection) is feasible. The histological differentiation of the tumor is the most important predictor of prognosis following resection. For patients with non-resectable tumors new adjuvant and neo-adjuvant treatments are currently being reconsidered in an EORTC trial.
[Intensive care medicine from the viewpoint of patients, their family and nursing personnel].
We wanted to know how our intensive care unit would be graded by the patients, their family members and the staff, as well as the impression that intensive care medicine made on them. A total of 82% of the patients and 90% of the family members were of the opinion that they owed their lives to intensive care medicine, and 100% of the patients and 96% of family members deemed intensive care medicine significant. The patients and their family members judged the medical and nursing care, the medical technology, the care of basic needs and their accommodation altogether positive. The nursing staff held a contrary opinion and were more critical. Competent explanation and transmission of information represented the most important factor in forming a positive opinion of intensive care medicine.
[Multicenter phase II study of the Liver Metastases Study Group of weekly intra-arterial 24-hour high dose therapy with 5-FU and folinic acid (FA) in liver metastases of colorectal tumors].
This prospective multicenter trial was performed to determine the response rate, toxicity and applicability of continuous 24 h hepatic arterial infusion of high-dose 5-FU and folinic acid. An improved response rate (60.5% in non-pretreated patients) was however associated with many systemic side-effects (340/509), mainly nausea and diarrhea. Therefore this treatment should be applied only in selected patients in specialized centers.
[Diameter of metastases is decisive for local treatment outcome of cryotherapy of colorectal liver metastases].
In a retrospective analysis we aimed to assess the incidence of local recurrence at the cryosite as well as possible prognostic indicators for the disease-free interval at the cryosite following hepatic cryotherapy for non-resectable colorectal metastases. At a median follow-up of 22 months, 66 of 85 patients had developed tumor recurrence, involving local recurrence at the cryosite in 28 patients, with cryoablated metastases of > 3 cm being associated with shorter disease-free intervals at the cryosite. Improvements in probe placement and monitoring of the freezing process are required to allow successful treatment of large liver metastases.
[Diagnosis and therapy of primary stomach lymphoma. Consensus of the Surgical Working Group for Oncology, the Working Group for Medical Oncology and the Working Group for Radiologic Oncology].
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Bile duct warmer in hepatic cryosurgery--a pig liver model.
Freezing of the common bile duct resulted in injury, stenosis, or perforation of the bile duct in a dog model. Biliary cutaneous fistulas and bile leaks are reported as complications of hepatic cryosurgery in man. In an ex vivo pig liver model we compared freezing close to the bile duct with and without warming the bile duct with warmed saline solution via an inserted catheter ("bile duct warmer"). The recorded temperatures at the outer wall of the bile duct were -50 degrees C after 10 min of freezing without and 5. 8 degrees C with the use of the warmer (P < 0.001, two-way ANOVA). The bile duct warmer system may be a simple and inexpensive device in reducing perioperative morbidity after hepatic cryosurgery of hepatic liver lesions close to a bile duct.
Clinicopathologic study for the assessment of resection for ampullary carcinoma.
In a prospective observational study including 34 patients with carcinoma of the ampulla of Vater, postoperative morbidity, mortality, and long-term survival were analyzed to determine the surgical procedure of choice. Surgically related postoperative complications were observed in 35.4% of patients after pancreatic resection. No patient died within the first 30 days postoperatively, and in-hospital mortality was 3%. Lymph node metastases were associated only with moderate or undifferentiated tumors larger than 0.6 cm in diameter that infiltrated beyond the ampulla of Vater. The median follow-up time was 4.3 years. The 5-year survival rate for the 31 patients undergoing radical resection was 62.7%. Multivariate analysis (including the covariates depth of tumor infiltration, lymph node metastases, and the ratio of metastatic to dissected lymph nodes) demonstrated that only this ratio exerted an independent influence on the prognosis (p = 0.001). The present series demonstrates that radical resection of ampullary cancer is the procedure of choice even in elderly patients. The most important factor influencing the survival rate is the extent of the lymph node dissection. The histopathologic investigation of our pancreatoduodenectomy specimens demonstrates clearly that local excision of ampullary cancer may be indicated only in high risk patients with a pT1, well differentiated tumor smaller than 0.6 cm in diameter.
[Prospective observational study of surgical therapy of renal hyperparathyroidism].
A prospective long-term follow-up study in patients who had had surgical therapy for renal hyperparathyroidism was launched to investigate the results of surgical treatment and to evaluate possible correlations between preoperative laboratory values and the course of symptoms. From August 1987 to December 1995, 79 patients underwent surgery for renal hyperparathyroidism. It was the first neck exploration for 72 patients. Total parathyroidectomy with autotransplantation to a forearm was our preferred procedure (n = 67). The postoperative course of all patients is know. We carried out one to nine reexaminations (median 4) in 74 of 79 patients. The follow-up period ranged from 1 month to 5 years with a median of 18 months. After the operation transient hypocalcaemia occurred in 84.4% of patients. Postoperative hypocalcaemia correlated negatively with the preoperative levels of alkaline phosphatase and intact parathyroid hormone. Within the first month after surgery 60% of the preoperatively affected patients completely recovered from pruritus, whereas the skeletal syndrome took longer to disappear. One year after surgery 75% of the patients with pruritus and 79% of those with skeletal syndrome had became asymptomatic. After total parathyroidectomy with autotransplantation, patients with preoperatively elevated concentrations of alkaline phosphatase (> 200 U/I) experienced faster relief from joint pain than patients with preoperatively normal concentrations (P = 0.0297). To date 4.5% of the patients developed recurrent hyperparathyroidism after total parathyroidectomy with autotransplantation. Morbidity of surgery for renal hyperparathyroidism is influenced by patients' risk factors. Postoperative hypocalcaemia correlates negatively with the grade of renal osteopathy at the time of operation. Preoperative concentrations of alkaline phosphatase influence the rapidity of the relief from joint pain.
[Results of endoscopic, retroperitoneal adrenalectomy with special reference to the intraoperative course].
In 20 patients the hemodynamic and ventilatory data during endoscopic retroperitoneal adrenalectomy were checked retrospectively to analyze the hemodynamic and ventilatory effects of a pneumoretroperitoneum. After insufflation of CO2 into the retroperitoneal space we observed an increase in systolic blood pressure [median 180 mm Hg ([130-200)]. Analyzing the ventilatory parameters we noted that the minute ventilation had to be increased by a median value of 4.25 I (0.4-13) to reduce the increased carbon dioxide levels during CO2 insufflation. After insufflation of CO2 into the retroperitoneal space we observed no major complications. We therefore believe that retroperitoneal endoscopic adrenalectomy is also indicated in patients with cardiac or pulmonary diseases.
[Repeat interventions in metastases].
Between 1985 and 1994, 262 patients with metastases underwent resectional treatment in the Department for General and Abdominal Surgery of the University of Mainz. Twenty-seven patients with recurrent metastases were treated with repeat resections. The records of these 27 patients were reviewed and analyzed. After 42 repeat resections, 4 of 27 patients (14.8%) developed complications. Three of 27 patients died in the postoperative period (11.1%). For patients with R0 resection of metastases from colorectal primaries the median survival time was 69 months after resection of the primary tumor (n = 16), 38 months after the first resection of metastases (n = 15), and 25 months after the second resection of metastases (n = 15). After the last repeat resection of metastases in each patient, median survival was 25 months in patients with R0 resection (n = 11), compared to 7 months following R1/2 resection (n = 5) (P = 0.007). Disease-free survival following first R0 resection of colorectal metastases (n = 15), was not significantly different from disease-free survival following repeated R0 resection of colorectal metastases (n = 21). Patients with repeat resection of colorectal liver metastases (n = 9) had longer disease-free survival (median 18 months) than patients with repeat resection of colorectal metastases in organs other than liver or lungs (median 4 months; n = 4) (P = 0.005). Repeat resections for metastases are characterized by low operative risk and a prognostic benefit for highly selected patients.
[Laparoscopic cholecystectomy in high risk patients].
As opposed to the advantages of laparoscopic cholecystectomy, patients with cardiopulmonary impairment may be endangered by the haemodynamic and respiratory effects of the pneumoperitoneum. Between June 1990 and December 1995, laparoscopic cholecystectomies were performed in 19 high-risk patients (ASA IV) and 465 patients with a lower operative risk (ASA I-III). Out of 484 patients, 24 (5%) suffered intraoperative cardiopulmonary complications. Three belonged to the high-risk group (15.8%) and 21 to the lower risk groups (4.5%). General postoperative complications occurred in 14 cases (2.9%), whereby patients of the ASA IV group were, again, concerned more often [15.8% (n = 3) of ASA IV versus 2.4% (n = 11) of ASA I-III]. The number of days spent in hospital was 7.6 +/- 4.96 days in the high-risk group versus 4.8 +/- 2.23 days in groups ASA I-III. The evaluation as a high-risk patient indicates an elevation of the perioperative rate of complications in laparoscopic cholecystectomy; however, it is not basically a contraindication for this operative method.
[Abrikossoff granular cell tumor: a rare tumor of the esophagus].
In the present case of a granular cell tumor an abdomino-thoracal resection of the esophagus was performed in a 41-year-old patient after preoperative diagnosis had suggested esophageal cancer. Granular cell tumors (Abrikossoff's tumor) of the esophagus are rather rare tumors of neuroectodermal benign histogenesis. Diagnosis can be obtained by endoscopic and histological study and immunohistochemical forceps biopsy. Because of the peculiar histological feature of the tumor, it can be mistaken for an squamous cell carcinoma.
[Influence of the number of dissected lymph nodes on local recurrence of rectal carcinomas. A staging effect].
In 386 patients with rectal carcinoma of UICC stage I-III operated on between 1 January 1985 and 31 December 1995 we investigated the influence of the number of dissected lymph nodes on tumor stage and local recurrence retrospectively. We found a significant correlation between the number of lymph nodes dissected and the number of detected lymph node metastases. Following this result we found an increase in UICC stage III (P = 0.013) and pTx pN2 tumors (P = 0.000) in correlation with the number of dissected lymph nodes. Significantly lower rates of local recurrence were found only in UICC stage I and UICC stage II. Overall and in a multivariate analysis the number of dissected lymph nodes had no influence on local recurrence. It was shown that lower local recurrence rates in UICC stage I and II did not depend on therapeutic benefit but on stage migration because of more exact tumor staging. The influence of other surgical factors, especially total mesorectal excision, remains to be discussed.
[Liver metabolism during cold ischemic incubation in UW solution in the rat model].
Simple cold storage of livers for transplantation activates glycolysis due to lack of oxygen. Energy derived from glycolysis may be critical for cell survival and liver cell death may occur once glycolysis is inhibited in the liver due to accumulation of end products or lack of substrates (glycogen). The relationship between cell death (lactate dehydrogenase, LDH release), anaerobic glycolysis (lactate production), and glycogen content of liver tissue was studied during cold incubation of liver slices in UW solution. Rat livers slices from male Sprague Dawley rats were incubated at 4 degrees C in UW solution, with continuous gentle shaking, under conditions of chemical hypoxia (KCN, 5 mM). The rate of lactate production, LDH release-ATP and glycogen content were measured spectrophotometrically and by HPLC. Lactate increased nearly linearly for the first 48 h of incubation; total lactate which had accumulated after 48 h was 33.9 +/- 0.81 mumol/g and at 96 h nearly the same, 31.3 +/- 1.2 mumol/g. Glycolysis stopped, apparently, because of the depletion of liver slice glycogen which was initially 228.8 +/- 1.7 mumol/g wet wt. It decreased to 34.7 +/- 2.7 mumol/g at 48 h and to 18.7 +/- 1.1 mumol/g at 72 h and remained at this level for the next 24 h. An increased leakage of LDH occurred once glycogen metabolism (and accumulation) ceased. LDH release could be stimulated after only a few hours of cold incubation of liver tissue slices by adding glycolysis inhibitor (iodoacetic acid) to the medium. After 24 h. LDH release was 24.4 +/- 1.8% and increased to 52.8 +/- 5.2% (P < 0.05, Student's t-text) with iodoacetic acid. Adding a glycolytic substrate (fructose, 10 mM) to the medium maintained lactate production for 96 h. The stimulation of glycolysis by fructose also reduced cell death: LDH release was significantly lower at 72- and 96-h incubation (P < 0.001, two-way ANOVA). The ATP content was significantly higher with fructose (P < 0.001). Adding glucose (20 mM) and fructose (10 mM) in combination resulted in prolonged cell survival, significantly delayed glycogen depletion and significantly higher ATP content at 48 and 72 h (two-way ANOVA). Livers from rats who had fasted for 24 h demonstrated the same LDH release at 48 h when incubated with glucose (20 mM) and fructose (10 mM). In conclusion, LDH leakage from hypoxic cold-stored liver slices is related to anaerobic glycolysis. Anaerobic glycolysis appears to continue slowly under hypothermia and provides sufficient energy for maintenance of cell viability. A stimulation of glycolysis in the cold is possible by fructose and results in prolonged cell survival under hypothermic conditions. Glycogen depletion can be slowed down by combining glucose and fructose.