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ABSTRACT: In this study we examined the feasibility of portal vein embolization (PVE) by using the Amplatzer Vascular Plug (AVP-II). We measured the time of vessel occlusion after plug deployment and changes in plug length and diameter within 4 weeks of PVE.
In 10 consecutive patients (4 women, age 64 +/- 10 yrs, 48 - 82 yrs) an ipsilateral PVE of the right portal vein was performed prior to intended hemihepatectomy. After embolization with microparticles, the right portal vein was occluded using an AVP-II. We measured the time of complete vessel occlusion by angiography. Follow-up with computed tomography (CT) was performed within 72 h and after 4 weeks.
PVE was performed in all 10 patients without acute complications. Complete vessel occlusion was achieved in 9.7 +/- 5.1 min (range 1 - 21 min). On follow-up CT we found enhanced arterial vascularization of the embolized liver segments in 5 / 5 patients within 72 hours and in 6 / 10 patients after 4 weeks. The plug showed a contraction of 20 +/- 9 % and a dilatation of 23 +/- 13 %. Thus, the AVP-II dilated to 94 +/- 8 % (78 - 100 %) of its nominal diameter. The plug diameter was significantly larger in men compared to women (17 +/- 1.7 mm vs. 14 +/- 1.4 mm, p < 0.02). We did not observe any recanalization or migration of the device. The volume of the left liver lobe increased significantly by 27 % (p < 0.001) after 4 weeks.
PVE with the AVP-II is a feasible and effective method. The AVP-II can dilate within 4 weeks up to its nominal diameter dependent on the grade of oversizing. Dilatation of the diameter is associated with a shortening in length.
RöFo - Fortschritte auf dem Gebiet der R 06/2010; 182(6):501-6. · 2.76 Impact Factor
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ABSTRACT: Controversies exist about the management of esophageal perforation in order to eliminate the septic focus. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 12-year period, in order to characterize optimal treatment options in this severe disease. Between May 1996 and May 2008, 44 patients (30 men, 14 women; median age 67 years) with esophageal perforation were treated in our department. Etiology, diagnostic procedures, time interval between clinical presentation and treatment, therapeutic management, and outcome were analyzed retro- or prospectively for each patient. Iatrogenic injury was the most frequent cause of esophageal perforation (n= 28), followed by spontaneous (n= 9) and traumatic (n= 4) esophageal rupture (in three patients, the reasons were not determinable). Eight patients (18%) underwent conservative treatment with cessation of oral intake, antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, esophagectomy with delayed reconstruction in 14 patients, and resection of the distal esophagus and gastrectomy in one patient. In case of iatrogenic perforation, conservative or interventional therapy was performed each in 50% of the patients; 89% of the patients with a Boerhaave syndrome underwent surgery. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death occurred in the 25 patients with a diagnostic interval less than 24 hours, whereas the mortality rate in the group (n= 16 patients) with a diagnostic interval of more than 24 hours was 19% (P= 0.053). In three patients, the diagnostic interval was not determinable retrospectively. An individualized therapy depending on etiology, diagnostic delay, and septic status leads to a low mortality of esophageal perforation.
Diseases of the Esophagus 10/2009; 23(3):185-90. · 1.81 Impact Factor
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ABSTRACT: Leiomyomas are rare esophageal disorders, although among the benign esophageal neoplasms, they are the most common. Multiple leiomyomas are distinguished from esophageal leiomyomatosis, an extremely rare condition, which is associated with Alport syndrome, showing deletions and rearrangements of the COL4A5/COL4A6 gene. There are only a few reports of diffuse multilocular lesions. A 19-year-old man presented with upper gastrointestinal bleeding and diffuse abdominal pain. On endoscopy multiple nodules covered with intact mucosa were present, the largest tumor arising from the gastro-esophageal border infiltrating the cardia. Barium swallow demonstrated narrowing of the middle and lower esophagus with the upper third of the stomach filled by the tumor. Thorax and abdominal CT scans revealed infiltration of almost the total aboral esophagus by the tumor with compression of left and right bronchi. The infiltration reached the whole lesser curvature of the stomach. Endosonography showed multiple encapsulated nodules. Due to the extended tumor growth with infiltration of the upper third of the stomach, a total esophago-gastrectomy with reconstruction by colon interposition was performed. On histopathological examination multiple esophageal leiomyomas with infiltration of the proximal third of the stomach was shown. Immunohistochemically the tumor stained positive for desmin and sm-actin and negative for CD34 and c-kit. Genetic analysis ruled out a deletion of the COL4A5/COL4A6 locus on chromosome X that is linked with Alport syndrome-diffuse leiomyomatosis. Extended mutations in the COL4A5 gene, associated with Alport syndrome, to the COL4A6 gene, are required for the development of leiomyomatosis. In young patients with diffuse multinodular infiltration by encapsulated tumors, esophageal leiomyomatosis should be considered. If the proximal third of the stomach is infiltrated by the tumor an extended resection is necessary. Reconstruction procedures include colon interposition.
Diseases of the Esophagus 02/2006; 19(6):504-8. · 1.81 Impact Factor
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ABSTRACT: The formation of a gastric tube is associated with partial devascularisation of the stomach and impaired tissue perfusion in the anastomotic region. The aim of the study was to gain data on the time interval of microcirculatory recovery of the normal gastric conduit.
Twenty-nine out of 49 consecutive patients who had undergone oesophagectomy and reconstruction with a gastric tube and intrathoracic oesophagogastrostomy were selected. Inclusion criterion was an uncomplicated postoperative course. After the patients' admission to ICU, continuous measurement of mucosal pCO(2) (pCO(2)I) was commenced, with the use of recirculating gas analysis with a TONOCAP device. pCO(2)I values (in mmHg and kPa) were recorded hourly and related to the arterial pCO(2) (DeltapCO(2) = pCO(2)I - pCO(2)a). In addition, mean arterial pressure (MAP), cardiac output (CO) and systemic vascular resistance (SVR) were measured by pulse contour analysis.
pCO(2)I was monitored over an average period of 79 h (total 2,288 measurements). The mean DeltapCO(2) before extubation was 12.4 mmHg (1.7 kPa) +/- 8.7 SD (1.2 kPa). After extubation, there was an increase in DeltapCO(2) values in all 29 patients. The peak DeltapCO(2) of 27.4 mmHg (3.7 kPa) +/- 12.6 SD (1.7 kPa) was observed 18 h after extubation. This was followed by a steady decline in DeltapCO(2) values that almost reached baseline DeltapCO(2) values after 4 days of monitoring. Changes in DeltapCO(2) did not correlate with changes in MAP, CO and SVR.
High levels of pCO(2)I indicate an impaired postoperative microcirculation in normal gastric tubes. After initial deterioration, gastric microcirculation takes approximately 4 days to recovery. These data are important for the implementation of ischaemic conditioning prior to gastric tube formation and gastric pull-up.
Langenbeck s Archives of Surgery 09/2004; 389(4):267-71. · 1.81 Impact Factor
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ABSTRACT: Intestinal transplantation is the only curative form of treatment for fulminant short bowel syndrome. Results have been hampered by frequent rejection episodes as well as technical and infectious complications. We report the first case of complete small bowel transplantation performed at our institution. A 37-year-old male patient suffered from massive gut infarction due to a superior mesenteric artery embolus from a thrombus in the descending aorta resulting from hereditary protein S and C deficiency. The primary surgery resulted in a duodenocolostomy requiring total parenteral nutrition. The course was further complicated by multiple central line infections and pre-renal kidney failure induced by dehydration. After 17 months, we performed a cadaveric small bowel transplant using systemic venous drainage. The ileum was anastomosed end-to-end to the recipient ascending colon. The proximal jejunum was used to create a jejunostomy, with an end-to-side duodenojejunostomy. Immunosuppression consisted of a single-administration of antithymocyte globulin (ATG), tacrolimus, mycophenolate mofetil (MMF), and methylprednisolone given enterally from day 1. Biopsies of the upper jejunum showed no signs of rejection. The graft was monitored via capsule video endoscopy after 9 weeks and appeared normal. The patient was discharged on day 35, completely on an enteral diet and gaining weight with a good quality of life. Oral valganciclovir was given for the cytomegalovirus prophylaxis infection (donor-positive, recipient-negative constellation), with no clinical or serologic signs of infection. The early course after small bowel transplantation using a quadruple regimen was clinically successful. The use of video-capsules allows for noninvasive visual monitoring of bowel segments that cannot be reached endoscopically.
Transplantation Proceedings 04/2004; 36(2):340-2. · 1.00 Impact Factor
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ABSTRACT: To study prospectively a cohort of patients in the first year after liver transplantation (LTx) with respect to their subjective experiences and their clinical condition.
Sixteen non-selected, consecutive patients (9 male) of the Clinic of Visceral Surgery of Cologne University were interviewed between 4 and 12 months after orthotopic LTx by narrative interviews. The interviews were audiotaped and transcribed according to standard international rules. We analysed the content of the interviews according to Grounded Theory and performed an ideal type analysis based on case comparison.
Nine patients (56.25 %) had a mental disorder according to ICD-10. Patients' subjective experiences of the transplantation could be grouped into five ideal types: the successful, the grateful, the help-seeking, the vulnerable, and the special patient. These ideal types were found to be of a dimensional pattern when re-assessed at single-case level, i. e. individual patients fulfilled criteria of these ideal types to different degrees.
Our patients perceive LTx predominantly as successful therapy for terminal liver disease. They use different coping strategies to come to terms with the considerable impact of transplantation. Each strategy implies specific risk profiles which have to be kept in mind when dealing clinically with LTx patients.
Zentralblatt für Chirurgie 11/2003; 128(10):842-8. · 1.02 Impact Factor
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ABSTRACT: The formation of a gastric tube for esophageal replacement requires partial devascularization of the stomach and induces microcirculatory changes in the anastomotic region of the gastric fundus. The additional influence of celiac trunk stenosis on anastomotic healing has not been investigated. In total, 23 patients with an esophageal carcinoma underwent transthoracic esophagectomy. Reconstruction was performed by a gastric tube (x22) with cervical or thoracic esophagogastrostomy or colon interposition (x1). All patients had a selective mesenterico-celiacography preoperatively via puncture of the right femoral artery. Preoperative cardiovascular and pulmonary risk factors were assessed. Angiographic findings were correlated to postoperative anastomotic leakage of esophagogastrostomy (x22). In seven out of 23 patients (30.4%), a stenosis of the celiac trunk could be demonstrated (x3 stenosis of 50%, x4 stenosis > 80%). Except for one patient with an additional stenosis of the superior mesenteric artery of > 80%, none of the patients with celiac trunk stenosis developed a postoperative anastomotic leakage of the esophagogastrostomy. Coronary artery disease was the only preoperative risk factor to predict a stenosis of the celiac trunk. Isolated stenosis of the celiac trunk does not seem to impair circulation of the gastric tube.
Diseases of the Esophagus 01/2002; 15(3):232-6. · 1.81 Impact Factor
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ABSTRACT: The formation of a gastric tube after esophagectomy with ligation of the left gastric artery and resection of the lesser curvature is associated with microcirculatory changes, especially in the anastomotic region of the fundus. This influences the healing of the esophagogastrostomy. The presented prospective protocol was designed to assess continuous tonometry as a tool to demonstrate microcirculatory changes during gastric tube formation. In 15 patients with esophageal carcinoma, pCO2 of the gastric mucosa (pCO2i) was measured intraoperatively during formation of a gastric tube. This was done by a nasogastric tube with a silicon balloon connected to a Tonocap recirculating gas analyser. pCO2i measurements were compared for a period of 90 min before and after ligation of the left gastric artery and correlated to the corresponding end expiratory pCO2 (pCO2e). In 14 of 15 patients examined (93.3%), an increase of pCO2i after ligation of the left gastric artery was demonstrated. pCO2i (mean+/-SD) before ligation of the left gastric artery (87 measurements: 40.6+/-7.5 mmHg; range, 29-67 mmHg) was significantly lower (P<0.001) compared to the mean pCO2i after ligation of the left gastric artery (88 measurements: 49.1+/-10.2 mmHg; range, 31-79 mmHg). Continuous tonometry is a valid method to detect changes in mucosal pCO2 during gastric tube formation and should be assessed to monitor the gastric interposition graft during the postoperative course.
Langenbeck s Archives of Surgery 08/2001; 386(5):324-7. · 1.81 Impact Factor
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ABSTRACT: To investigate concentrations of phosphorus-containing metabolites in human transplanted kidney in vivo by quantitative 31P MR spectroscopy (MRS) using surface coils and to compare the obtained values with previous data.
In 5 patients with well-functioning transplanted kidneys, 31P spectra were obtained with the three-dimensional localization image-selected in vivo spectroscopy technique applying a protocol for quantitative spectroscopy using surface coils. Relaxation corrected signal intensities determined by time domain fitting were used to derive absolute molar concentrations for phosphate-containing metabolites.
Little or no phosphocreatine in all spectra verified the absence of muscle contamination, confirming proper volume localization. The mean concentrations in the transplanted kidneys were as follows: ATP 1.60 +/- 0.26 mmol/ 1, PDE 2.14 +/- 0.91 mmol/l, Pi 0.66 +/- 0.25 mmol/l, PME 2.32+ /- 0.50 mmol/l. These values are consistent with previously reported values determined by other techniques.
The non-invasive determination of absolute metabolite concentrations in human kidney using MRS supplements the use of signal intensity ratios to detect pathologic changes in the energy metabolism of transplanted kidneys.
Acta Radiologica 12/2000; 41(6):634-41. · 1.37 Impact Factor
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ABSTRACT: This is the first report of palliative percutaneous treatment of a malignant duodenal stenosis due to cancer of the pancreatic head with Palmaz stents. A 65-year-old male with a malignant tumour of the pancreatic head developed an abscess with fistular communication to the cutis. In the subsequent course of the disease, tumour growth led to a severe duodenal stenosis. To dilate the tumorous stenosis, three Palmaz stents were introduced coaxially into the duodenum percutaneously, via the preexisting fistula. A technique to pass an almost 90 degrees kink is described. Symptomatic malignant duodenal stenosis was treated by insertion of three Palmaz stents. Due to their accurately controlled passive expansion at the level of the stenosis, and the resulting good adaptation to the individual anatomical situation, they were suitable for application in the duodenum.
European Radiology 02/1999; 9(6):1142-4. · 3.22 Impact Factor
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ABSTRACT: Volume-selective 31P-MR spectra were obtained from 37 patients using a whole-body MR scanner in combination with surface coils and a modified ISIS sequence. The quantitative evaluation took place by line fitting to the signal in the time domain using a non-linear procedure. The following signal intensities were determined: PME, PDE, Pi, gamma-, alpha-, beta-ATP and pH. 1024 excitations were averaged to achieve an adequate signal-to-noise ratio (10.0 +/- 3.3), measurements lasting 34 minutes on average. The mean measured volume was 174 +/- 52.4 ml. Contamination by muscle tissue could be excluded based on the absence of phosphocreatinine signal in the spectra. Contamination by fatty tissue was excluded by visualisation. A reduction in the value of the Pi/alpha-ATP ratio as a function of time was observed due to the regeneration process following reperfusion injury. In transplant rejection (n = 7) a significant rise in Pi/alpha-ATP ratio was seen compared to the control group (n = 20) (0.4 +/- 0.16 vs. 0.22 +/- 0.11, p < 0.01), the calculated difference in pH was significant as well. In cases of acute tubular necrosis a reduced value fore the PME/PDE ratio was observed (0.65 +/- 0.1 vs. 0.96 +/- 0.5, p < 0.04). Acute tubular necrosis could be differentiated from rejection by difference in pH (6.93 +/- 0.1 vs. 7.14 +/- 0.19, p < 0.04).
Langenbecks Archiv für Chirurgie. Supplement. Kongressband. Deutsche Gesellschaft für Chirurgie. Kongress 01/1998; 115(Suppl I):155-9.
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ABSTRACT: For evaluation of the prognostic relevance of p53 expression in gastric cancer, the immunohistochemical tissue status of 133 primary gastric cancer patients was investigated for p53 expression and the association between p53 tissue status and clinicopathological parameters was analyzed. P53 immunoreactivity was detected in the nuclei of cancer cells in 35 cases (26.3%). The nuclear p53 immunoreaction was closely associated with tumor location, lymph node metastasis, and curability. Tumors with positive p53 stain reactions frequently metastasized to lymph nodes (metastatic rate: 91.4%) in contrast to tumors with negative p53 stain reactivity (71.4%, P = 0.021). Immunohistochemical analysis of primary gastric cancer appears to be an accurate and simple method of screening for p53 expression. In combination with common prognostic parameters, determination of p53 tissue status might help to detect prognostically unfavorable subgroups of gastric cancer patients.
Digestive Diseases and Sciences 01/1998; 42(12):2463-7. · 2.12 Impact Factor
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The European Journal of Surgery 02/1997; 163(1):73-6.
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ABSTRACT: A modified method of access to the upper thoracic spine is presented based on a case report. The third and fourth thoracic vertebral bodies can be reached by partial upper sternotomy. This approach takes the local anatomic situation into account, thus avoiding the typical complications of complete sternotomy and reducing the postoperative pain. Closure was done using biodegradable sutures, achieving satisfactory stabilisation and a low rate of complications. In only 4 of 130 cases (3%) did a superficial wound infection occur. There was no case of deep infection, osteomyelitis or dehiscence of the sternum.
Der Unfallchirurg 01/1997; 99(12):986-8. · 0.61 Impact Factor
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ABSTRACT: A modified method of access to the upper thoracic spine is presented based on a case report. The third and fourth thoracic
vertebral bodies can be reached by partial upper sternotomy. This approach takes the local anatomic situation into account,
thus avoiding the typical complications of complete sternotomy and reducing the postoperative pain. Closure was done using
biodegradable sutures, achieving satisfactory stabilisation and a low rate of complications. In only 4 of 130 cases (3%) did
a superficial wound infection occur. There was no case of deep infection, osteomyelitis or dehiscence of the sternum.
Der Unfallchirurg 04/1996; 99(12):986-988. · 0.61 Impact Factor
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ABSTRACT: The clinical and long-term results encountered from July 1983 to December 1992 are subject of this study. Contrary to other (transanal and transabdominal) surgical treatments the endorectal system permits therapeutic local excisions of large, rectal adenomas and early rectal carcinomas of the "low-risk" type within the entire rectum with minimal morbidity. A superior or comparable rate of adenoma recurrence (4.8%, n = 228) as well as a more favourable operative result (complication rate 3.9%; lethality 0.6%; n = 348) can be achieved with the transanal endoscopic microsurgery. Under palliative conditions, transanal endoscopic surgery is more effective than other conservative treatments in cases of circumscribed, non-stenotic carcinomas of the rectum. Thorough surgical training is required in order to successfully practice transanal endoscopic surgery.
Der Chirurg 03/1996; 67(2):139-44. · 0.70 Impact Factor
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ABSTRACT: In a prospective study the results of surgery for gastric carcinoma were analysed comparing patients under 70 years of age (n = 384) and patients over 70 years of age. The surgical treatment for gastric cancer resulted in increased mortality in patients over 70 years of age due to severe risk factors. Optimization of anociassociation and stageoriented cancer treatment may further prolong survival of patients over 70 years of age with this malignancy.
Langenbecks Archiv für Chirurgie. Supplement. Kongressband. Deutsche Gesellschaft für Chirurgie. Kongress 02/1996; 113:483-5.
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ABSTRACT: The purpose of this retrospective study was to analyze the development of malignancies after renal transplantation. 633 renal graft recipients with an organ function longer than 1 year were followed up over a mean period of 67.6 +/- 48.7 months. Only 12 recipients received grafts from living-related donors. 38 recipients (6.0%) exhibited cancer of either the skin, the genitourinary system, the bronchial system, the female breast, or the colon. All tumors were de novo malignancies. The number of patients developing a tumor was significantly higher in the cyclosporine-treated group than in patients with conventional immunosuppression. 15 patients died within a mean survival time of 7.7 +/- 12.1 months. The frequency of disorders makes it necessary for organ transplant recipients to have routine examinations both before and at regular intervals after transplantation. This includes examination of the patient's skin, native kidneys and cervical smears for females.
Urologia Internationalis 02/1996; 57(1):21-6. · 0.99 Impact Factor
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ABSTRACT: The clinical and long-term results of 286 cases encountered from 1983 to 1993 in our Department of Surgery regarding the local excision of large, sessile rectal adenomas (> 2 cm2) by the endoscopic surgical method and the influence of this selected series of adenomas on age, sex, size, grade of dysplasia, and architecture are subjects of this study. Histologically proven rectal carcinomas as well as non-neoplastic polyps were excluded from this trial. Early postoperative complications amounted to 3.4%. The 1-year and 5-year recurrence rates +/- SE of adenomas were 1.2 +/- 0.7% and 7.0 +/- 1.9%, respectively. Remarkably, there was no significant relationship between the histological type of the adenoma and the grade of dysplasia nor between the size and grade of dysplasia. However, there was a significant relationship between the size and histological type of the adenoma (P < 0.01). With the endoscopic minimal-invasive system, we are able to achieve a superior rate of recurrence compared to any other local treatment as well as a more favorable operative result compared to extensive surgical procedures.
Surgical Endoscopy 11/1995; 9(10):1106-12. · 4.01 Impact Factor
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ABSTRACT: To analyse the development of malignancies of the genito-urinary system after renal transplantation.
A total of 868 renal graft recipients were followed up over a mean period of 41.8 +/- 45 months. Fifteen patients received grafts from living related donors and 853 were transplanted with kidneys from cadavers.
Twelve patients (1.4%) exhibited cancer of the genito-urinary system: 11 tumours were de novo malignancies. One small renal carcinoma was transplanted from a living related donor. The incidence of tumours of the genito-urinary system was 34 in 100,000 patient years in the patients treated with cyclosporin and 32 in 100,000 patient years in the conventional therapy group. Four patients died within a mean survival time of 14.4 months. Comparison of our results with sex- and age-specific incidence rates in a reference population showed an increase in malignant tumours of the genitourinary system by a factor of 7.3 in males and 11.2 in females.
The frequency of disorders after transplantation necessitates routine examinations in organ transplanted recipients both before and at regular intervals after transplantation, including the patient's native kidneys and cervical smears in females.
British Journal of Urology 06/1995; 75(5):572-7.
