Biomedical subjects
Publications and source records attributed to W Hohenberger.
Isolated limb reperfusion in patients with locoregional recurrence after previous isolated limb perfusion achieves local tumor control in a high percentage of cases. One of the main aims of the repeat procedure is limb salvage, which was possible in 96% of our patients. Complication rate of reperfusion is acceptably low.
BACKGROUND: Glucocorticoids are an effective treatment of ulcerative colitis. The occurrence of steroid side effects depends on dosage and duration of steroid treatment. It may be a high as 80%. A rare side effect of glucocorticoid therapy is steroid induced myopathia. There exists an acute and a chronic form of steroid induced myopathia. Chronic steroid myopathia affects mainly the proximal musculature of the lower and upper extremities and leads to proximal muscle weakness. Histologically, an atrophy of type IIb-muscle fibers can be found. Chronic steroid myopathia occurs after prolonged treatment with higher doses of glucocorticoids. CASE REPORT: The case report describes a 25 year old male patient with left-sided ulcerative colitis who developed chronic steroid myopathia after several months of glucocorticoid treatment. After switching from systemic steroids to budesonide the symptoms of myopathia disappeared. Left-sided ulcerative colitis remained in remission. CONCLUSION: The case documents the disappearance of a severe steroid side effect after switching from a systemic steroid to budesonide.
New diagnostic and prognostic markers are needed in colorectal cancer. They can be found by differential analysis at DNA, RNA or protein level. The accuracy of phenotypic comparisons of tumor and normal tissues depends on the purity of the samples. We present an effective method to identify and isolate proteins that are differentially expressed under altered conditions, and a two-dimensional reference protein map of the normal human colonic epithelium. Normal colonic mucosa, primary tumors and liver metastases were prepared in the operating room. After washing in an ice-cold medium containing protease inhibitors, crypts were isolated by mechanical preparation without using metalloproteinases. Epithelial cells were then selected using Ber-EP4 Dynabeads. The samples were denaturated before processing for immobilized pH gradient two-dimensional polyacrylamide gel electrophoresis according to SWISS-2DPAGE standards. The samples contained more than 95% epithelial cells as confirmed by fluorescence-activated cell sorting using pan-anticytokeratin antibodies. Cell surfaces were not damaged, as assessed by scanning electronic microscope. A protein reference map of the normal colonic epithelium was defined. Using gel matching, N-terminal sequencing and/or immunoblotting techniques, 60 polypeptides - including proteins specifically expressed in colorectal epithelium - have now been identified. This reproducible method of sample preparation permits the comparison of protein patterns found in various pathological states with the present reference map (http://www.expasy.ch). Some of these patterns might provide diagnostic or prognostic markers, or even molecular targets for therapy in the future.
Explore the source record for details and available documents.
Oncological problems associated with laparoscopic colorectal surgery with curative intent include port site metastases, inadequate radicality, seeding of tumour cells through unprotected recovery of the surgical specimen, faulty surgical technique, and failure to observe the technical and/or oncological limitations applicable to certain tumour sites. Investigations so far reported reveal a preponderance of mechanical pathogenesis of port site metastases caused by the contamination of trocar entry ports by tumour cells borne on instruments, trocars and resected material. This suggests that appropriate precautionary measures could resolve the problem. It appears that the CO2 pneumoperitoneum plays only a minor role in the development of port site metastases. Owing to a lack of long-term data, the oncological radicality of laparosopic resections for colorectal carcinoma cannot be assessed; merely a few reports on the number of lymph nodes removed during such operations have been published. Nevertheless, it would appear that fewer lymph nodes were removed than with comparable conventional surgery. However, a more accurate analysis needs to take account of the fact that the indication for laparoscopic surgery is determined by the size and location of the tumour. The many potential pitfalls and hazards of oncological laparoscopic surgery make it mandatory that such interventions should be done only within the framework of prospective clinical studies covering limited indications. Randomized prospective studies to cover all tumour stages and sites cannot be recommended.
In 48 patients who had undergone anterior resection for rectal cancer with straight colorectal reconstruction, clinical and manometric results were correlated with the level of anastomosis. Patients were divided into four groups by anastomotic level: < or = 3, 4-6, 7-9, and > or = 10 cm. Functional outcome with regard to frequency of bowel movements, minor leakage, fecal incontinence. ability to defer stool and to differentiate consistency showed increasing impairment the lower the anastomotic level. Frequency, leakage owing to the inability to defer stool, incontinence for solid stool, inability to discriminate flatus from stool, and incomplete emptying were significantly different (P < 0.05) between the patients with an anastomotic level between 3-6 cm and between 7-9 cm. Manometric data revealed no trend or significant differences among the groups with regard to anal resting pressure and maximal and median squeeze pressure. Rectoanal inhibitory reflex was abolished in 60% of the patients. Clear changes, with a trend toward reduced function with lower anastomotic levels, were seen in the volume that produced a feeling of urgency, maximal tolerable volume, and neorectal compliance (between anastomotic levels 7-9 and > or = 10 cm the differences were significant; P < 0.05). Analysis by length of residual rectum (< 1.5, 1.5-4.0, 4.1-6.5, > 6.5 cm) demonstrated similar findings, suggesting that impaired function after rectal resection is due to reduced function of the neorectum. Thus, as much residual rectum as possible should be preserve without risking cure. If the level of the anastomosis is expected to be below 6 cm, or if the residual rectum is less than 4 cm, the construction of a colon pouch to increase neorectal capacity should be considered.
An important aim of proctocolectomy with ileal pouch-anal anastomosis (IPAA) is to maintain anal continence. Anal sphincter disruption during IPAA is felt to play an important role in loss of continence, which is described in up to 30% of the treated patients in the early postoperative period. Although sphincter function recovers gradually after surgery, some patients stay incontinent. In our investigation of possible parameters involved in preservation of continence after this operative procedure, we focused on changes in anal manometry. We compared these findings with the functional results obtained by questioning the patients and physical examination. Anal manometry was performed with a low-compliance hydraulic perfusion system. All patients underwent a J-pouch procedure with a short rectal cuff for ileoanal reconstruction. We examined 25 patients, 13 underwent operation for the treatment of ulcerative colitis, 12 because of adenomatous polyposis. In the colitis and polyposis group, 28% of the patients reported events of soiling. Three patients (12%) were incontinent. The remaining 15 patients were completely continent. The median time after operation was 58 months, ranging from 12 to 96 months. Comparing the results of anal manometry with standard values of ten age- and gender-matched healthy volunteers, it was found that there was a significant increase in the threshold of balloon awareness and urge to defecate. These sensations were sometimes elicited by pouch contractions. Median pouch-compliance was also clearly elevated in comparison to rectal compliance (P < 0.005). Inhibitory reflexes during balloon inflation could not be evoked in any of the patients. Comparing continent with incontinent patients there were significant differences in balloon awareness, urge to defecate, and stool frequency (P < 0.01, P < 0.01 and P < 0.001, respectively). But in contrast to other publications, we could not find significant differences in anal sphincter length, resting and squeezing, anal canal pressure. Pouch compliance was lowered in incontinent patients and negatively correlated with stool frequency (P < 0.001, r = -0.82). In conclusion, our study indicates that anal sphincter resting pressure alone is not a crucial factor in continence preservation in the long-term after total proctocolectomy and IPAA. Poor pouch-compliance and concomitant higher stool frequencies seem to be related to incontinence in this patient group.
BACKGROUND: Laparoscopic resection for cancer is controversial and port-site metastases are not infrequent. The mechanisms of occurrence of port-site metastases remain unclear. Animal experiments have suggested a role for carbon dioxide (CO2), but port-site metastases also occur after thoracoscopy, where no CO2 is used. The aim of this study was to define the role of CO2 in the seeding of tumor cells in the human patient. METHODS: CO2, instruments, trocars, suction device, and peritoneal washing were examined during 12 staging laparoscopies for pancreatic cancer. The presence, viability, and biological significance of cells were investigated using conventional cytology, polymerase chain reaction (PCR), and restriction fragment length polymorphisms (RFLPs) to detect the presence of a mutant k-ras gene as a genetic marker of cancer cells. RESULTS: Cytology exam of peritoneal washing, instruments, the suction device, and trocars revealed many cells. Tumor cells were detected in 6/12 peritoneal, in 4/12 trocars and 4/11 instruments washings, but not in 12 CO2 samples. The DNA content of CO2 was very low-as assessed by PCR. Mutant DNA was detected by RFLP in four out of 12 aerosols. Six aerosols did not contain any DNA. Two aerosols were borderline. CONCLUSIONS: During staging laparoscopy for pancreatic cancer in humans, CO2 contains only very low levels of free-floating tumor cells, even in the presence of massive peritoneal contamination. These results suggest that the incidence of port-site metastases might be reduced if mechanical contamination of the port sites with instruments or with the specimen can be avoided.
Total gastrectomy (GX) in humans is frequently followed by osteopenia, but the details are unclear. The present investigations in the rat were aimed at elucidating its pathogenesis. Seventeen weeks after GX, we evaluated Ca, Mg and P metabolism as well as bone parameters, including fluorochrome-based bone histomorphometry. In GX rats, fecal Mg was increased, but intestinal absorption of P, Ca, and Mg was within normal limits, as was the urinary excretion of Ca, Mg, hydroxyproline and the pyridinium cross-links. In contrast, urinary P as well as cyclic AMP were significantly increased. In serum of GX rats, gastrin and 25-hydroxyvitamin D (25-OHD) were decreased, and Ca, Mg, P, parathyroid hormone (PTH), calcitonin, and the bone marker osteocalcin were normal, whereas 1,25-dihydroxyvitamin D [1,25(OH)2D] was significantly increased. GX rats had significantly reduced bone density and mineral content, severe high-turnover osteopenia, characterized by normal width but significantly decreased maturation time of osteoid, increased bone formation rate, and increased numbers of osteoclasts. We concluded that after GX (1) there is high-turnover osteopenia with normal mineralization and other histomorphometric features resembling those seen in states with hyperphosphaturia and subsequent hypervitaminosis D; (2) normal serum PTH levels and several indirect indicators of parathyroid gland function argue against the presence of (secondary) hyperparathyroidism, whereas increased bone mobilization due to elevated 1,25(OH)2D explains the maintenance of homeostasis of serum minerals, especially Ca, at the expense of bone mineral; (3) a complex interplay of mineral-metabolic effectors exists, among which low 25-OHD-PTH-independent renal phosphate losses, and high 1,25(OH)2D are prominent features. The presented animal model is recommended for future research in this area.
OBJECTIVE: To find out if there is an association between the acute phase response preoperatively and the development of postoperative infective complications. DESIGN: Prospective open study. SETTING: Teaching hospital Germany. SUBJECTS: 229 patients who were to undergo major abdominal operations. INTERVENTIONS: Measurements of serum concentrations of interleukin 6 (IL-6), alpha-1-antitrypsin, C-reactive protein (CRP), albumin, and prealbumin. MAIN OUTCOME MEASURES: Abnormal values of substances measured. RESULTS: Serum concentrations of IL-6, alpha-1-antitrypsin and CRP were raised, and those of albumin and prealbumin were reduced in 5% to 14% of patients. 25 (11%) developed major complications, of whom 9 (4%) died. 9 Patients (4%) had a severe systemic inflammatory response caused by infective complications that did not result from technical failure of the operative technique. Of these 9 patients, 7 (78%) already had signs of an increased acute phase response before operation that was significantly different from the incidence among patients who recovered without complications (21/204. p < 0.001) CONCLUSION: These data suggest that if there are signs of an acute phase response preoperatively the patient's response to operation and infection during the postoperative period may be adversely affected.
In the literature the question as to what constitutes the most suitable faecal diversion procedure continues to be controversial. Between 1989 and 1994 at the Surgical Department of the University of Erlangen a total of 464 patients received intestinal stomas for a wide range of different indications. Of these procedures 41.6% (n = 193) were temporary diversion stomas (ileum n = 170, transverse colon n = 16, jejunum n = 4, sigmoid n = 2, ascending colon n = 1). Subsequently, 7.8% of the loop ileostomies and 9.7% of the loop colostomies needed revision for early or late complications. After reversal surgery none of the loop colostomies, but 2.5% of the loop ileostomies, developed complications needing operative treatment. On the basis of our own experience and the data reported in the literature it may be stated that both loop ileostomy and loop colostomy are effective faecal diversion procedures which, with appropriate bowel preparation and a meticulous surgical technique, can be reversed with a low incidence of complications. Both procedures, however, require careful preoperative planning, operative technique and care if complications are to be avoided. Used simply for the creation of a stoma, the laparoscopic approach offers certain advantages.
Occluding stones left in the stumpf of the cystic duct may account for between 17% and 25% of the cases of post-cholecystectomy syndrome. When acutely inflamed or empyemic gallbladders are removed, an occlusive cystic duct stone must almost always be expected. When performing laparoscopic cholecystectomy, therefore, care must be taken to ensure that any stone occluding the cystic duct are detected and removed. After completely freeing the cystic duct to the point of its junction with the common bile duct, it is carefully "palpated" with a 5 mm forceps for the presence of stones. Any such present are pressed out of the duct through a transverse incision, and retrieved. Bile reflux through the incision in the duct indicates freedom from stones. Finally, intraoperative cholangiography can be performed.
The major factor underlying the seeding of tumor cells during laparoscopy are mechanical, with CO2 playing only a secondary role. The peritoneal wound is of great importance, especially in advanced tumor stages, when cells are present within the abdominal cavity. Most reported port-site metastases were found within the extraction port when no protective measures were taken. Gasless laparoscopy is no solution to the problem, since numerous port-site metastases have been described after thoracoscopy, during which no CO2 is used. The surgeon's role in the seeding of tumor cells is based on tumor perforation, excessive manipulation and replacement of trocars. This presumably explains the large differences (0 and 21%) in the reported incidence of port-site metastases. Prospective studies now show that it is possible to keep the incidence of abdominal wall metastases to about 1%-which is comparable with that seen in open surgery-by the use of a meticulous operating technique and preventive measures.
The inflammatory pericholecystic reaction to acute or subacute cholecystitis results in the involvement in the inflammatory process of connective tissue within the liver bed, with subsequent neovascularization. The inflamed wall of the gallbladder and the surrounding connective tissue also involved in the inflammatory process become fused together thus preventing dissection in this plane. As a result, the gallbladder affected by acute cholecystitis frequently has to be dissected directly out of the liver parenchyma. The resulting diffuse parenchymal bleeding proves difficult to control by cauterization. In addition, there is a danger of postoperative bile leakage occurring. Today, the use of fibrin sealing is accepted practice in the treatment of oozing haemorrhage from the resection surface of the liver following resective surgery, and for the prevention of postoperative biliary fistulae. Using special application systems, the two-component fibrin sealing can now also be employed under video-endoscopic control. Through direct application of the adhesive to the parenchyma in the liver bed using a flexible catheter, diffuse oozing bleeds can be effectively arrested. In addition, coagulation-related parenchymal necroses associated with the development of biliary fistulae can be avoided. The technique of video-endoscopic controlled fibrin sealing is an important method of preventing and controlling complications arising during video-endoscopic surgery.
In the case of acute cholecystitis and chronic cholecystitis of lang standing, the inflammatory changes in Calot's triangle make the risk of damaging the bile duct during laparoscopic cholecystectomy particularly high. In view of the difficult anatomical situation in Calot's triangle, such patho-anatomical conditions when encountered during open surgery best dealt with by anterograde (prograde) dissection of the gallbladder beginning from the fundus and proceeding towards the neck of the gallbladder. Since this approach is considered to be safer and less risky, it should also be adopted during laparoscopic surgery. The advantage is to be seen in the initial dissection far removed from the bile ducts. Despite pronounced inflammatory changes and initial preservation of the cystic artery, the use of modern technologies permit a virtually bloodless procedure. Nevertheless, the difficult anatomical situation makes a high level of readiness to conver mandatory. Should there be any doubt, the open surgical approach is the safer modality.
Abdominal re-operation in patients with recurrent peptic ulcer disease is associated with a high morbidity rate and a mortality rate of 5%. As an alternative procedure, therefore, transthoracic truncal vagotomy was early recommended as a less invasive intervention, and good results can be achieved with it. With the development of minimal invasive surgery, this procedure can now be performed via thoracoscopy and patient stress thus reduced even further. Via a left-sided thoracoscopy, the parietal pleura is incised and a 3-5 cm long segment of the distal oesophagus mobilised and dissected free. Both the posterior and anterior trunks of the vagus nerves are identified and, after applying clips, transected. In order to achieve complete vagotomy, further fine branches have to be searched out and, if found, also divided.
Explore the source record for details and available documents.
Explore the source record for details and available documents.