[Show abstract][Hide abstract] ABSTRACT: Pelvic magnetic resonance imaging (MRI) is accurate in identifying perianal fistulas. The exact visualization of fistulous tracts and concomitant abscesses determine the type of treatment. To improve the detection of perianal fistulas, we studied digital subtraction MR-fistulography for tissue differentiation based on signal intensity measurements.
This study included 75 patients with the clinical diagnosis of perianal fistula. All patients were analyzed by a thin-slice, high-resolution, fast low-angle shot 3-dimensional sequence in the axial plane before and after intravenous injection of gadobenate dimeglumine, followed by image subtraction. Operator-defined regions of interest were used to calculate signal intensities of the inflamed fibrous walls of fistulas, the common femoral artery, the internal and external sphincter muscles, and the gluteus muscle. The fistulas were classified according to Parks classification.
Based on signal intensity measurements in 75 patients with perianal fistulas, diagnosed by digital subtraction MR-fistulography, a significant differentiation between fistulous tracts and anatomic structures was possible. MRI identified 116 perianal fistulas (34 intersphincteric, 33 transsphincteric, 10 suprasphincteric, and 39 extrasphincteric) and 35 abscesses.
Digital subtraction MR-fistulography is a new, promising, noninvasive imaging technique for the detection of perianal fistulas and abscesses.
[Show abstract][Hide abstract] ABSTRACT: The (dis-)advantages of preoperative chemoradiation in patients with esophageal cancer (EC) are still controversial as data are lacking showing a clear cut benefit. Therefore, data of neoadjuvant therapy of our hospital have been analyzed. Since 1994 102 patients with an EC (33 % adenocarcinoma, 67 % squamous cell cancer, scc) were operated after receiving preoperative chemoradiation (36 Gy radiation, 1.8 Gy/day for 4 weeks, 500 mg/m (2) 5-FU for 4 weeks and 20 mg/m (2) Cisplatin, day 1-5, week 1 and 4). Operation was performed usually 8-10 weeks after treatment start. In 11.7 % of patients with an adenocarcinoma a complete pathological response (CR, pT0N0M0) was observed and a pT0 stage in 20.6 %. 38.2 % of these patients were staged as pN0. Postoperative morbidity was observed in 66 % (anastomotic leakage in 20 %, recurrent nerve palsy in 23 %). In-hospital mortality was 5.9 %. 5-year survival was calculated as 30.5 %, in patients wit a CR 66 %.26.5 % of patients with a scc revealed a CR. However no effect at all was observed in 32 % of these patients. 56 % were staged as pN0. Postoperative morbidity was observed in 87 % (anastomotic leakage in 16 %, recurrent nerve palsy in 32 %). In-hospital mortality was 11.8 %. 5-year survival was calculated as 19.2 %, in patients with a CR 45 %. The impact of pN stage was significant (p = 0.0052). These results underline the benefit of neoadjuvant therapy in patients with a CR. Further on, a pN0 stage is an important prognostic indicator. However, it remains open, whether neoadjuvant therapy leads to a downstaging of lymph node involvement, as histological confirmation in clinically positive lymph node is seldom performed prospectively.
Zentralblatt für Chirurgie 11/2004; 129(5):350-5. · 0.69 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Conflicting results of preoperative radiochemotherapy in patients with esophageal cancer have been obtained; only patients with a complete pathological response seem to benefit from this therapy. However, there is evidence that preoperative radiochemotherapy leads to considerable postoperative morbidity. Therefore, postoperative morbidity was retrospectively investigated in 82 patients with an esophageal cancer who received preoperative radiochemotherapy.
One hundred twenty-two consecutively operated on patients were included (1991 to 2001). Preoperative radiochemotherapy was initiated in 1994 for cT >1, cNx, cM0 regardless of histology (n = 82); 36 Gy was applied (1.8 Gy daily, days 1 to 5, weeks 1 to 4), concurrently 5-fluorouracil (500 mg/m(2) days 1 to 5, weeks 1 to 4), and cisplatin (20 mg/m(2) days 1 to 5, weeks 1 and 4). Postoperative morbidity was categorized as surgery- and nonsurgery-related morbidity. Survival was calculated by the Kaplan-Meier method. Results were stratified into histology and compared with patients who were operated on only (n = 40).
Complete pathological response after preoperative radiochemotherapy was achieved in 22%. An increase in surgery-related morbidity was observed after preoperative radiochemotherapy due to lesion of recurrent nerve (38% versus 12.5%, P = 0.009), as well as a marked difference in pulmonary morbidity (57% versus 37.5%, P = 0.05). The proportion of combined morbidity was increased after preoperative radiochemotherapy (49.4% versus 15%, P = 0.02), which led to a considerable prolongation of postoperative hospital stay (33 versus 21 days median, P = 0.0022). Patients with a longer postoperative hospital stay (>30 days; 43.2%) lived significantly shorter than patients with a shorter postoperative hospital stay (56.8%, P = 0.001). There was no statistical survival benefit in the neoadjuvant treated group. However, calculation of long-term survival revealed a significant survival advantage in patients with squamous cell cancer and a complete pathological response compared with patients without response (median 642 days versus 302, P = 0.026).
Perioperative morbidity was significantly increased after preoperative radiochemotherapy. Long-term survival was clearly affected by the length of postoperative stay. Therefore, we need better patient selection for application of preoperative radiochemotherapy.
The American Journal of Surgery 02/2004; 187(1):64-8. · 2.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In a 36-year-old male with ileocolic Crohn's disease (CD) no long-lasting remission was obtained by treatment with corticosteroids, mesalazine, azathioprine and antibiotics. Surgical interventions due to relapsing fistulae and abscesses resulted in the removal of >1.5 m of small bowel and left only 40 cm of large bowel. In July 2000, a new fistula and abscess developed. The combination of corticosteroids, mesalazine, ciprofloxacin, metronidazol, azathioprine, formula diet and anti-TNF-alpha antibody largely reduced clinical activity, and resection of fistula and abscess were successful. Despite clinical remission, histology showed activity in the small bowel and the colon. In March 2001, stem cell mobilization chemotherapy with cyclophosphamide was performed. It induced an endoscopic remission for 9 months, which was maintained on azathioprine and corticosteroids. After relapse, in March 2002, high-dose chemotherapy with cyclophosphamide and reinfusion of T-cell-depleted autologous peripheral CD34+ blood stem cells were performed. This led to a complete clinical, endoscopical and histological remission for 9 months without any treatment. Thereafter, endoscopy showed initial aphthous lesions with minimal histological signs of inflammation. The patient is asymptomatic, but low-dose prednisolone and methotrexate are prophylactically given. Immunoablative chemotherapy followed by autologous peripheral blood stem cell transplantation may be a beneficial therapeutic option in complicated refractory CD.
Bone Marrow Transplantation 09/2003; 32(3):337-40. · 3.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mitogen activated protein kinases (MAPKs) play a central role in the regulation of both cell growth and differentiation. They are involved in signal transduction of oncogenes and growth factors. The role of MAPK in colonic carcinoma is unknown.
To establish whether the expression and activity of p42/44 MAPKs are altered in colorectal tumours as compared with normal mucosa.
The expression and activity of p42/p44 MAPK were investigated in 22 colorectal carcinomas, four adenomas, and the corresponding normal colorectal mucosa by the use of western blotting, immunoprecipitation, and in vitro kinase assays.
After immunoprecipitation with an antibody specific for p42 MAPK, we found significant inactivation of p42 MAPK in colonic carcinomas as well as in adenomas, whereas most sample pairs showed only minor differences in p42 MAPK expression. Investigation of MAPK with an antibody capable of detecting both p42 and p44 MAPK showed a slight but significant decrease in p44 MAPK content in malignant tissues. With this antibody, only minor alterations in MAPK activity and no correlation with p42 MAPK activity were found.
Inactivation of p42 MAPK could be associated with colonic carcinogenesis.
[Show abstract][Hide abstract] ABSTRACT: Auch wenn konservative Maßnahmen in der Behandlung chronisch entzündlicher Darmerkrankungen den Vorrang haben, werden bei
vielen Patienten chirurgische Eingriffe notwendig. Wegen des unterschiedlichen chirurgischen Vorgehens ist präoperativ eine
möglichst sorgfältige differenzierende Diagnostik hinsichtlich des Vorliegens eines M. Crohn bzw. einer Colitis ulcerosa erwünscht,
was allerdings in 10-15% der Fälle nicht gelingt.
Über die chirurgischen Interventionen und ihre Indikationen sowie Komplikationen berichtet die folgende Arbeit. Dabei wird
auch über die neuerdings häufiger ausgeführten minimalinvasiven Techniken der laparaskopischen Chirurgie referiert, die dann
angewendet werden können, wenn akute Obstruktion, Perforation oder toxische Dilatation zuvor ausgeschlossen worden sind.
Für operative Maßnahmen chronisch entzündlicher Darmerkrankungen stellt das Alter keinen limitierenden Faktor dar. Wundheilungsstörungen
zählen zu den häufigsten Frühkomplikationen, als Spätkomplikationen nach restaurativer Proktokolektomie werden Stromakomplikationen
und die Pouchitis beobachtet, die sogar bei ungestörter Pouchfunktion auftreten kann und deren Genese ungeklärt ist. Die Rezidivraten
nach chirurgischer Intervention bei Morbus Crohn und Colitis ulcerosa sind je nach Schweregrad der Erkrankung und elektiver
Operation teilweise hoch; auch dies wird differenziert erläutert.
Der Internist 09/1998; 39(10):1041-1047. · 0.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Rectal continence preservation became feasible in treatment of cancer of the lower third of the rectum based upon technical evolutions and better understanding of tumor biology. Absolutely necessary precondition is correct preoperative staging. Operative strategy is determined by tumor stage, localization, grade and continence function. In most cases the total mesorectal excision leads to tumor-free circumferential resection margins. Distal safety margins are assured by intraoperative frozen sections. Restorative approaches are contraindicated in case of sphincter infiltration. If continence function is impaired preoperatively, restorative procedures lead to a worse functional result. The local recurrence remains the most important problem in rectal cancer surgery. Safety in resection is achieved by total mesorectal excision. The presence of distal satellite metastasis or lymph node metastasis bear a certain risk for local recurrence after partial resections of middle or upper third rectal cancer. Local resection in T1-Tumors with G1- or G2-Grading may produce comparable results.
Langenbecks Archiv für Chirurgie. Supplement. Kongressband. Deutsche Gesellschaft für Chirurgie. Kongress 02/1998; 115:454-8.
[Show abstract][Hide abstract] ABSTRACT: An overview of frequency, diagnosis, classification and therapy of perianal fistula in Crohn's disease is presented. There is a positive correlation with the extent of intestinal disease. The fistula as primary manifestation can present problems of differential diagnosis. Crohn fistulas may persist for an extended period of time without discomfort and complaints. Surgical treatment should be individualized for any given form of fistula. Hemorrhoidectomy in Crohn's disease associated with perianal fistulas should be avoided. Transspincteric and recto-vaginal fistulas can be treated by peranal mucosal flap with good results. In summary, neither therapeutic nihilism nor hyperactivity is justified.
[Show abstract][Hide abstract] ABSTRACT: The aim of diagnostic procedures following abdominal injuries is rapid assessment of the necessity for surgical intervention and specification of the organ lesion, thus reducing the number of negative laparotomies. The extent of the diagnostic approach must be reduced in unstable patients. Sonography is the standard procedure in stable as well as in unstable patients, both in the initial period and the subsequent follow-up. CT-scan is complementary to sonography in detecting organ lesions. Sonographically guided puncture has replaced diagnostic peritoneal lavage. Laparoscopy following blunt abdominal injuries is not useful; however, it may be helpful following penetrating abdominal trauma.
Langenbecks Archiv für Chirurgie. Supplement. Kongressband. Deutsche Gesellschaft für Chirurgie. Kongress 01/1997; 114:406-9.
[Show abstract][Hide abstract] ABSTRACT: In this retrospective trial, we examined 215 patients with bowel lesions following abdominal injuries. We analyzed the diagnostic procedures, the time to diagnosis, the subsequent surgical therapy, and complications. The diagnosis of bowel lesions remains a diagnostic challenge. All apparative diagnostic procedures (sonography, CT-scan, lavage, laparoscopy, X-ray) fail to diagnose bowel lesions. In our trial, most patients showed clinical signs of peritonitis leading to diagnosis. Ultrasonographically guided puncture was important, if clinical signs remained unclear. This study underlines the importance of repeated clinical examination for early diagnosis and treatment of bowel injury.
Langenbecks Archiv für Chirurgie. Supplement. Kongressband. Deutsche Gesellschaft für Chirurgie. Kongress 01/1997; 114:1244-6.
[Show abstract][Hide abstract] ABSTRACT: Diagnosis of diaphragmatic rupture is often missed after blunt thoracic and abdominal injuries because diaphragmatic injury does not play an important role beside severe injuries of intrabdominal and/or thoracic organs. Between 1976 and 1993, 141 patients were treated for traumatic injury of the diaphragm. In 42 patients with penetrating injuries following stab or shot wounds diaphragmatic lesions were diagnosed by the emergent surgical therapy. 99 had diaphragmatic tears from blunt thoracic or abdominal trauma by accidents. 14 of 99 patients sustained isolated diaphragmatic rupture, in 85 the rupture was combined with other injuries, 24 had fractures of the pelvic ring. Preoperatively the following diagnostic procedures were performed: chest radiograph in 99 patients, abdomen radiograph in 75, contrast radiographs in 34, angiography in 9, sonography in 74 and computed tomography in 48. Sensitivity and specificity of these diagnostic methods depend on the dimension of intrathoracic prolaps of abdominal organs. The sensitivity of contrast radiographs ranged from 72-78%. With the additional experience of ultrasonography since 1985 the sensitivity came up to 82%. In 11 patients additional diaphragmatic rupture was diagnosed by laparotomy indicated by liver and/or splenic rupture. Therapy of diaphragmatic injury was performed in 83 patients within 4 days, in 9 within 4 months and in 7 later than one year. For diaphragmatic repair 87 patients underwent laparotomy and 12 thoracotomy. Local complications were found in 13 patients (13.1%). 19 patients (19.2%) died postoperatively due to accompanying injuries.
Zentralblatt für Chirurgie 02/1996; 121(1):24-9. · 0.69 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The coinfusion of tauroursodeoxycholate (TUDC) prevents taurolithocholate (TLC) -induced cholestasis. 23-Methyl-ursodeoxycholate (MUDC) is a side-chain derivative of ursodeoxycholate (UDC). If conjugation with taurine is important for the protective effect of UDC, the MUDC may not be as able as TUDC to prevent TLC-induced cholestasis since it is poorly amidated by the liver. To answer this question, isolated livers of adult Sprague-Dawley rats were coinfused with MUDC (UDC, TUDC) and TLC. After 15 min, inflow rates of the bile acids were doubled. In further experiments taurine in excess was added to the coinfused bile acids. The uptake of bile acids was >90% in all groups, irrespective of whether they were perfused alone or in combination. Single perfusion of TLC caused a rapid decrease in bile flow. UDC and MUDC were hypercholeretic; TUDC moderately choleretic. During coinfusion experiments, TUDC not only completely abolished cholestasis but in addition increased bile flow and biliary bile acid secretion. UDC did prevent TLC cholestasis at the lower inflow rates. At high inflow rates, bile flow decreased significantly. Addition of taurine to this bile acid combination did not significantly improve the anticholestatic effect of UDC. At low and high infusion rates of MUDC, cholestasis induced by TLC was reduced very little. Cumulative bile flow over 30 min fell by approximately 70% as compared to that of singly perfused MUDC. Addition of taurine to the coinfused MUDC/TLC slightly, but less significantly, improved the anticholestatic effect of MUDC. Since MUDC is by far less protective than UDC (and TUDC) despite similar physiochemical properties, it is concluded that taurine conjugation of UDC seems to be a prerequisite to prevent TLC-induced cholestasis. The results imply that treatment of cholestatic liver diseases with taurine-conjugated UDC might be more appropriate than with unconjugated UDC in cases where taurine conjugation is defective or where taurine depletion has occurred.
Digestive Diseases and Sciences 02/1996; 41(2):250-5. · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In an experimental study in monkeys, liver fibrosis development after segmental bile duct obstruction was investigated and correlated with the aminoterminal propeptide of type III procollagen (PIIINP).
Segmental bile duct obstruction was produced by ligation and section of the left hepatic bile duct in all monkeys. Fibrosis induction was examined by intravenous leukotriene C4 (LTC4, 5 nmol/kg) application, endogenous LT-production stimulated by endotoxin (LPS,salmonella abortus equi, 50 ng/kg), fibrosis inhibition by dexamethasone (1 mg/kg) intramuscularly and subsequent endogenous LT-production stimulation by LPS (50 ng/kg). Ligated and unligated liver lobe biopsies were taken 3, 7 and 12 weeks after ligation. All portal areas were measured morphometrically. PIIINP was measured by a specific radioimmunoassay each week and correlated with the morphometric results.
Bile duct obstruction leads to secondary sclerosing cholangitis with bile duct vanishing and subsequent biliary cirrhosis combined with perivenous sclerosis and cavernous transformation of the terminal vein. The collagen concentration increased in the nonligated lobe from mean +/-SEM 1.05 +/- 0.03% to 1.53 +/- 0.19% only after LTC4 and with no difference in the other groups. In the ligated lobe collagen concentration increased significantly in all groups continuously from 1.05 +/- 0.03% up to: controls 6.1 +/- 0.9%, dexamethasone 5.9 +/- 0.8%, LPS 8.2 +/- 0.8%, LTC4 9.075 +/- 1.4%. PIIINP concentration rose within 6 weeks in the controls with hepatic bile duct obstruction from 34.43 +/- 15 ng/ml up to 57 +/- 13.27 ng/ml, after dexamethasone to 48.5 +/- 18.23 ng/ml, after LPS to 57 +/- 13.27 ng/ml, after LTC4 to 80.25 +/- 16.04 ng/ml. After 12 weeks, PIIINP decreased in the controls resp. after dexamethasone to 41.25 +/- 6.94 ng/ml resp. 33.5 +/- 7.72 ng/ml and increased after LPS resp. LTC4 up to 64.25 +/- 17.07 ng/ml resp.104 +/- 22.46 ng/ ml. The correlation of collagen deposition and PIIINP was in the controls r = 0.83, after dexamethasone r = 0.71, after LPS r = 0.83 after LTC4 r = 0.91.
PIIINP determination after segmental bile duct obstruction correlates with collagen deposition and allows evaluation of hepatic fibrosis activity.
[Show abstract][Hide abstract] ABSTRACT: To find out if there was any correlation between the type or number of pathogenic bacteria in peritoneal exudate, the values of various prognostic scores, the inflammatory response, and the outcome, in patients with peritonitis.
Prospective open study.
University hospital, Germany.
51 Consecutive patients with secondary peritonitis.
Laparotomy within 12 hours of admission or within 8 hours of diagnosis in 9 patients with postoperative peritonitis.
Correlation between the severity of the disease (APACHE II score, Septic Severity Score, Mannheim Peritonitis Index, Peritonitis Index Altona II, and outcome), the intraperitoneal and the systemic inflammatory response, intraperitoneal and systemic endotoxin concentrations, and type and number of micro-organisms grown from peritoneal fluid.
Intra-abdominal microbiological findings did not correlate with severity of illness judged by the scoring systems, the later incidence of infective complications, or the final outcome. The presence of intra-abdominal microbes was associated with signs of a systemic inflammatory response (median activation index 3 (range 1-3) compared with 2 (range 1-3)), the length of history (median 52 hours (range 3-72) compared with 16 hours (range 3-56), and local and systemic concentrations of endotoxin (peritoneal exudate: median 4800 EU/ml (range 0.06-136674) compared with 220 EU/ml (range 0.00-1800); plasma: median 0.05 EU/ml (range 0.00-1.32) compared with 0.04 EU/ml (range 0.00-0.13)). The sensitivity of the organisms to the antibiotics given (cefuroxime and metronidazole) did not influence the incidence of later infective complications or the outcome.
These results do not suggest micro-organisms invading the peritoneal cavity and respective antibiotic treatment to be major determinants of the clinical course of peritonitis.
The European Journal of Surgery 08/1995; 161(7):501-8.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to analyze whether partial hepatectomy alters functional liver heterogeneity with respect to bile acid processing. One, 5 and 21 days after liver resection (≈8)% of liver mass) in male Sprague-Dawlye rats (300–400 g), isolated livers were perfused in either the antegrade or the retrograde direction, respectively, with 32 nmol cholate/min per g liver. Uptake, metabolism and biliary secretion kinetics were determined by bolus injection of 14C-cholate. Uptake and biliary recovery (within 30 mn) of cholate were >90% in all groups. One day postresection, liver mass had already doubled and it regenerated to over 80% 5 days after resection. Serum bile acid concentration increased rapidly, peaking 61 h after resection (176.7±28.5 μmol/l) (mean±SEM). Twenty-one days after resection it fell to control values (23.±3.8 μmol/l). T25(T50), the time (min) necessary to excrete 25% (50) of the bile acid load into bile, was strikingly different between periportal and pericentral cells of controls (1.8 vs 5.7 and 3.4 vs 8.1). Five days after resection this difference became smaller (1.4 vs 2.9 and 2.8 vs 5.5) due to accelerated biliary cholate secretion in pericentral cells. Pericentral cells of controls metabolized cholate more extensively to taurocholate (≈83%) and glycocholate (≈13%) than periportal cells of controls (65%, 10%), leading to a 5-fold higher proportion of unmetabolized cholate in periportal than pericentral cells (25% vs 5%). Five days after resection the percentage of taurocholate decreased significantly at the expense of an increased formation of glycocholate. Twenty-one days after resection, bile acid composition came to resemble that of controls. In conclusion, the results demosntrate a reduction of metabolic zonation with regard to bile acid processing after liver resection. Despite accelerated biliary bile acid secretion in pericentral cells of the regenerating liver, overall metabolism was not impaired as compared to controls. This is comparable to weaning rats where functional liver heterogeneity has not yet developed.
Journal of Hepatology 04/1995; · 9.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Bile acid processing in the long-term, bile duct obstructed rat liver was studied ex vivo. Twenty four and 72 h, respectively, after bile duct obstruction the isolated liver was perfused with taurodeoxycholate (16 nmol/min per g liver) the bile duct still being closed. Uptake, metabolism and regurgitation profile were traced by bolus injection of tritium-labeled bile acid; in addition, concurrent histological changes were examined by light- and electron microscopy. Ligation caused dilatation of the intrahepatic ductular branches and increased the serum bile acid concentration to 740 +/- 75 microM (controls: 16 +/- 2.12), reaching its maximum within 24 h. At 16 nmol/min per g liver uptake rate was > 96% in controls and in bile duct obstructed rats. Maximal uptake rates (assessed separately) differed between controls and bile duct obstructed rats (700 nmol/min per g liver vs. 460). Controls excreted more than 80% of labeled bile acid in bile within 10 min after bolus injection. Biliary recovery of label was virtually completed after 30 min. In bile duct obstructed rats excretion of label back to the perfusate effluent (regurgitation) started quantitatively 5 min after bolus application and peaked between 10 and 40 min; after 80 min, effluent recovery was incomplete (about 60% of bolus injected). Biliary bile acids of controls consisted of about 20% taurodeoxycholate-metabolites; bile acids in the perfusate effluent of bile duct obstructed rats of about 55%. The major metabolite in all animal groups was taurocholate; minor metabolites were tauroursocholate, tauro-3 alpha,7 = 0,12 alpha-cholanoic acid and 3-sulfo-taurodeoxycholate. Histologically, inflammation and periportal edema were present after 1 day of bile duct obstruction. After 3 days, marked proliferation of bile ductules was the dominant histological feature. It is concluded that during initial bile duct obstruction, bile acid processing is not altered, although ultrastructural alterations occur early.
Journal of Hepatology 02/1995; 22(2):208-18. · 9.86 Impact Factor