Showing papers by "J. R. Siewert published in 1997"

Distinct mechanisms of immunosuppression as a consequence of major surgery.

Abstract: Altered host defense mechanisms after major surgery or trauma are considered important for the development of infectious complications and sepsis. In the present study, we demonstrate that major surgery results in a severe defect of T-lymphocyte proliferation and cytokine secretion in response to coligation of the antigen receptor complex and CD28. During the early postoperative course, reduced cytokine secretion was observed for interleukin-2 (IL-2), gamma interferon, and tumor necrosis factor alpha, which are associated with the Th1 phenotype of helper T lymphocytes, and for IL-4, the index cytokine of Th2 cells. During the late postoperative course, T-cell cytokine secretion increased to normal levels. Production of the anti-inflammatory cytokine IL-10 was altered, with different kinetics being selectively elevated during the late postoperative course. In contrast, the capacity of peripheral blood monocytes to present bacterial superantigens and to stimulate T-cell proliferation was normal or enhanced after surgery despite a significant loss of cell surface HLA-DR molecules. Thus, the level of major histocompatibility complex class II protein expression does not appear to predict the antigen-presenting capacity of monocytes obtained from surgical patients with uneventful postoperative recovery. Secretion of IL-1beta and IL-10 by endotoxin-stimulated peripheral blood monocytes was increased at different time points after surgery. Major surgery therefore results in a distinct pattern of immune defects with a predominant defect in the T-cell response to T-cell receptor- and CD28 coreceptor-mediated signals rather than an impaired monocyte antigen-presenting capacity. Suppression of T-cell effector functions during the early phase of the postoperative course may define a state of impaired defense against pathogens and increased susceptibility to infection and septic complications.

Early adenocarcinoma in Barrett's oesophagus

Abstract: Background The results of surgical treatment in 41 patients with early adenocarcinoma of the oesophagus were analysed retrospectively. Methods The treatment of choice was transhiatal radical subtotal oesophagectomy (n = 38); in three patients with adenocarcinoma in the mid or upper thoracic portion of the oesophagus, right transthoracic en bloc oesophagectomy was performed. Results One patient died within 30 days and another within 90 days (4.8 per cent). All tumours were resected completely. Multicentricity of adenocarcinoma in Barrett's oesophagus was detected in six cases and high-grade dysplasia in 28. Some 31 patients had infiltration of the submucosa, whereas in ten, carcinoma was limited to the mucosa. No patient with mucosal adenocarcinoma had lymph node metastases, whereas five of the 31 with submucosal infiltration showed lymph node involvement. The 5-year survival rate of the total group of 41 patients, including postoperative mortality, was 83 per cent. All ten patients with adenocarcinoma limited to the mucosa (pT 1a ) were alive at 5 years; of 31 with submucosal infiltration (pT 1b ) 79 per cent survived to 5 years (P not significant). Patients without lymph node metastasis had a 5-year survival rate of 81 per cent, compared with 50 per cent for those in the pN 1 category (P not significant). Conclusion Oesophagectomy for early oesophageal adenocarcinoma is safe and leads to a favourable long-term prognosis.

Significance of lymph node involvement at the hepatic hilum in the resection of colorectal liver metastases

Abstract: Background The indication for surgical resection of colorectal liver metastases should be guided by technical feasibility and expected prognostic benefit. The aim of the present study was to analyse the frequency and prognostic significance of lymph node involvement of the hepatoduodenal ligament in the resection of colorectal liver metastases. Methods Aseries of 126 prospectively documented patients who underwent hepatectomy for metastases of colorectal carcinoma was analysed. The prognostic factors of patients with complete resection (R0) of the metastases were studied by multivariate analysis. Results R0 resection was achieved in 94 per cent. The 30-day mortality rate was 2 per cent. In all patients, lymph nodes were excised from the hepatoduodenal ligament, and histological evaluation demonstrated tumour infiltration in 28 per cent of the patients. Multivariate analysis revealed nodal involvement of the hepatoduodenal ligament (P< 0·0001) and synchronous or metachronous appearance of liver metastases (P < 0.005) as independent prognostic factors. The 3- and 5-year survival rates were 3 and 0 per cent for lymph node-positive patients compared with 48 and 22 per cent respectively for the node-negative group. Conclusion Infiltration of lymph nodes in the hepatoduodenal ligament is the most important prognostic factor following R0 resection of colorectal liver metastases.

Boerhaave's syndrome: analysis of the literature and report of 18 new cases.

Abstract: Postemetic spontaneous rupture of the esophagus is an intrathoracic disaster which is generally lethal if untreated. The tragedy seems to strike more often than commonly suspected. The current literature review focuses on publications since 1980 and includes the retrospective review of 18 additional patients treated in our hospital for spontaneous rupture of the esophagus. Frequently, a wide variety of unspecific symptoms has led to the mistaken diagnosis of an acute abdomen, pancreatitis or cardiac arrest. About 40% of the patients with spontaneous rupture of the esophagus presented a history of alcoholism or heavy drinking and 41% suffered from gastroduodenal ulcer disease. Pain (83%) and vomiting (79%) often associated with dyspnea (39%) and shock (32%) are the major symptoms. This unspecific symptomatology delayed the correct diagnosis of the Boerhaave's syndrome and resulted in a significant complication rate. The mortality rate associated with Boerhaave's syndrome was 50% from the first successful surgical repair in 1947 by Barrett to 1980. After 1980, however, the mortality rate dropped to 31%, because of earlier diagnosis, surgical repair and improvement in intensive care. When surgery is delayed, the prognosis of patients with spontaneous rupture of the esophagus is in general severe.

Efficacy and Safety of a Low-Molecular-Weight Heparin and Standard Unfractionated Heparin for Prophylaxis of Postoperative Venous Thromboembolism: European Multicenter Trial

Abstract: p = 003); wound hematoma occurred in 29 (44%) of the LMWH group compared with 55 (77%) in those in the UFH group for an RR of 057 (95% CI 037–088; p = 001) This study confirmed that a very low dose of 1750 anti-Xa IU daily of this new LMWH is as effective as 10,000 IU of UFH for preventing postoperative deep vein thrombosis At this dose its administration is associated with a significant reduction in the risk of bleeding including wound hematoma

Assessment of non-acid esophageal reflux: comparison between long-term reflux aspiration test and fiberoptic bilirubin monitoring.

Abstract: Reflux esophagitis may result from the action of both acid and non-acid agents. The aim of this study was to test a new system able to measure the quantity of the bilirubin contained in the esophageal lumen. The analysis of esophageal reflux composition was conducted in two phases. In the first bile and pancreatic enzyme, concentration of 136 fluid samples obtained with ambulatory esophageal long-term reflux aspiration test were measured. For the second, the total bilirubin content of each sample was measured in vitro with a fiberoptic probe (Bilitec 2000, Synetics Medical Inc., Sweden). Studies were performed on 48 subjects: 43 patients with esophageal reflux and five healthy volunteers. The results of both techniques were then compared. Higher concentration of bile and pancreatic enzymes were found in esophageal fluid samples of patients with endoscopic esophagitis. Bile and pancreatic enzyme concentrations of esophageal fluid samples were higher in patients after gastrectomy compared to patients with intact stomachs. There was a significant correlation between the total bilirubin concentration of fluid specimens and the fiberoptic probe reading of bilirubin (r = 0.72, P < 0.001). The presence of bilirubin and bile acids within the esophageal refluxate can be determined reliably with continuous fiberoptic measurement. The correlation between total bilirubin content and the concentrations of pancreatic enzymes contained in the esophageal refluxate suggests that bilirubin is a good tracer for non-acid, duodenal or intestinal reflux in the esophagus.

Laparoscopic gastrojejunostomy and endoscopic biliary stent placement for palliation of incurable gastric outlet obstruction with cholestasis

Abstract: Background: For patients with incurable malignant gastric outlet obstruction and cholestasis, laparoscopic gastrojejunostomy combined with endoscopic biliary stent placement seems to offer a minimally invasive palliation.

Barrett's cancer: Indications, extent, and results of surgical resection

Abstract: In the Western world, the prevalence of Barrett's carcinoma, i.e., adenocarcinoma of the distal esophagus arising from specialized columnar epithelial metaplasia, has risen dramatically in the past two decades. High-grade dysplasia in the columnar epithelium has been identified as the precursor of malignant carcinoma. Whether an esophagectomy should be performed in patients with high-grade dysplasia remains controversial. Surgical resection is the mainstay of therapy in patients with invasive adenocarcinoma who are fit for surgery. Complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of any surgical approach to adenocarcinoma of the distal esophagus. In patients with tumors located in the distal esophagus, this can be achieved by a radical transhiatal esophagectomy and proximal gastric resection with en bloc removal of the lymphatic drainage in the lower posterior mediastinum and along the celiac axis. Early adenocarcinoma can be cured by this approach. The value of multimodality therapy in patients with advanced tumors needs to be confirmed in well-designed randomized prospective trials.

[Malignant tumors of the hepatic bifurcation--results of surgical therapy and prognostic factors]

Abstract: Vom 1. 1. 1986 bis zum 31. 12. 1994 wurden in der Chirurgischen Klinik 45 Patienten mit Hepaticusgabelcarcinom operiert. Es handelte sich im Sinne der Bismuth-Klassifikation (1992) um 7 Typ-I-, 4 Typ-II-, 22 Typ-III- und 12 Typ-IV-Tumore. Bei 31 der 45 Patienten (68,9 %) wurden in primar kurativer Intention folgende Operationen durchgefuhrt: Hepaticusgabelresektion: n = 9 (29 %), Hepaticusgabelresektion mit hilarer Leberteilresektion: n = 7 (22,6 %), Hepaticusgabelresektion mit linker Hemihepatektomie: n = 10 (32,3 %), Lebertransplantation: n = 5 (16,1 %). Bei den ubrigen 14 Patienten erfolgten primar palliative (n = 6) bzw. rein diagnostische (n = 8) Eingriffe. Die Klinikletalitat aller Patienten betrug 2/45 (4,2 %). Die endgultige Histologie ergab bei 17/31 (54,8 %) der Resektate eine R0-Situation, in den ubrigen Fallen war eine R1/Rx-Resektion (n = 14) erfolgt. 1-, 2- und 5-Jahres-Uberlebensraten lagen fur die 31 resezierten Patienten bei 75,4, 53,9 und 24,5 % (medianes Uberleben:729 Tage), und bei 30,8, 10,3 und 0 % (medianes Uberleben:153 Tage) fur die rein palliative Behandlungsgruppe. Ein statistisch signifikanter Einflus auf das Uberleben konnte fur den nodalen Status (N0/N1) und den Residualtumorstatus (R0/R1 und R2) nachgewiesen werden.

Klassifikation der neuroendokrinen Tumoren des Gastrointestinaltrakts und des Pankreas und ihre therapeutische Relevanz

Abstract: In der vorliegenden Arbeit wird unter Einbeziehung der aktuellen Klassifikation der neuroendokrinen Tumoren des Gastrointestinaltrakts und des Pankreas eine stadiengerechte Therapie vorgeschlagen Grundsatzlich wird fur alle neuroendokrinen Tumoren eine primare chirurgische Therapie empfohlen, auch bereits bei bestehender Metastasierung Besondere Bedeutung hat insbesondere bei Tumoren des oberen Gastrointestinaltrakts und des Pankreas eine adaquate praoperative klinische und pathohistologische Diagnostik Wir haben versucht die therapeutischen Richtlinien analog der Klassifikation zu vereinfachen und zu prazisieren Es wird in vielen Fallen jedoch unabdingbar sein, eine enge Kooperation zwischen Gastroenterologen, Chirurgen und Pathologen zu pflegen, um im individuellen Fall die adaquate Therapie zu finden

Incidence and prognostic significance of epithelioid cell reactions and microcarcinoses in regional lymph nodes in stomach carcinoma

Abstract: The frequency and prognostic relevance of sarcoid-like lesions and microcarcinosis in regional lymph nodes in gastric cancer (n = 113; pT1-3, pN0-1, pM0, R0) were investigated; the prognostic value was compared with pT and pN stage, grading and Lauren's tumor classification with Cox's multivariate regression-model. Sarcoid like lesions were found in 34% of the cases (n = 113). Statistical analysis did not indicate that they had any prognostic value or showed whether or not microcarcinosis or metastasis was present; they were independent of pT stage, histological tumor type, tumor grading, and the clinical course of disease. Microcarcinosis (defined as scattered carcinoma cells within lymph node sinuses or pulp without adjacent stromal reaction) was revealed by immunohistochemistry in 90% of pN0 cases; the presence of 3 or more tumor cells per lymph node section in over 10% of sampled lymph nodes per case carried a significant prognostic value. In microcarcinosis without evidence of metastasis, the number of tumor cells and the number of involved lymph nodes are of prognostic value. In pN1 cases microcarcinosis was found as well as the metastases in 97% and had no additional prognostic value. Microcarcinosis alone has a different significance from lymph node metastasis for prognosis.

Massive intrahepatic hemorrhage as first manifestation of polyarteritis nodosa.

Abstract: A case of an acute abdomen caused by a massive intrahepatic hemorrhage in a 77-year old man is presented. The hemorrhage was the first manifestation of an underlying polyarteritis nodosa which had not been diagnosed prior to the event. The diagnosis was suspected after a preoperatively performed angiography, surgical treatment was required to control the bleeding. This case demonstrates the differential diagnosis of acute intrahepatic hemorrhage which includes rare causes of vasculitis.

Surgical relevance of diagnostic imaging techniques in pretherapeutic staging of carcinoma of the esophagus, stomach, colon and rectum

Abstract: The increasing spectrum of therapeutic options for tumors of the gastrointestinal tract has resulted in a refinement of the pretherapeutic diagnostic strategies. The diagnostic approach in surgical institutions that are focused on primary surgical resection will therefore be much less sophisticated than in institutions who propose a selective therapeutic approach based on the pretherapeutic tumor stage and prognostic parameters. Pretherapeutic assessment of the depth of tumor infiltration, i. e. the T-category, is essential because most further diagnostic and therapeutic decisions are based on this information. This can today be achieved with a high degree of accuracy by endoscopy and endoscopic ultrasonography. Early T-stages (T1–2) are usually an indication for primary surgical resection and, after exclusion of distant metastases, no further diagnostic studies are required. In patients with locally advanced esophageal, gastric or rectum tumors (T3–4) multimodal therapeutic concepts should be considered. This usually requires additional diagnostic studies. None of the available diagnostic imaging modalities today allows satisfactory pretherapeutic assessment of lymph node metastases. The assumed nodular status should therefore currently not influence therapeutic decisions. Essential is, however, the assessment of distant metastases, since the documentation of distant tumor spread will change the therapeutic approach to a palliative situation. Detailed histologic and molecular-biologic assessment of tumor characteristics is growing in importance. This not only provides therapeutically relevant information regarding tumor grading, but opens the door towards a modern molecular diagnostic approach. It can be expected that in the near future a vast amount of relevant prognostic information can be obtained from endoscopic tumor biopsies, which may soon alter our therapeutic concepts.

Interventionelle Therapie des intraabdominellen Abszesses: Ergebnisse und Grenzen

Abstract: In d em Zeitraum 6/92–12/96 wurde der postoperative Verlauf von 2985 Pat. nach viszeral-chirurgischen Eingriffen prospektiv analysiert. Bei 144 Pat. (4,8%) wurden intraabdominelle Abszesse CT-gezielt punktiert. Bei 123 Pat. (85,4%) war die percutane Abszes-Drainage (PAD) erfolgreich - diese Pat. musten nicht reoperiert werden. 21 Pat. (14,6%) musten reoperiert werden wegen fistelassoziierten Abszesse bei ausgedehnter Insuffizienz (8 Pat.), subphrenischen Abszessen mit Pankreasbeteiligung (5 Pat.), nicht drainagefahigem Nekrosematerial (3 Pat.), multiplen Abszessen (3 Pat.) und Persistieren der Abszeshohle (2 Pat.). Die punktionsbedingte Komplikationsrate lag bei 5,5%, die punktionsbedingte Letalitat bei 0,7%.

Mikrosatelliteninstabilität und positive Familienanamnese bei Patienten mit Magenkarzinom

Abstract: Hereditare Aspekte von Tumorerkrankungen gewinnen im Rahmen molekulargenetischer Untersuchungen zunehmende Bedeutung. Die molekularbiologische Charakterisierung des „Hereditaren nicht-polyposen colorektalen Carzinomsyndroms“ (HNPCC) durch einen DNA-Reparaturgendefekt war Anlas fur Untersuchungen anderer Tumoren auf DNA-Reparaturgendefekte, um eine Beteiligung dieser an der Onkogenese zu evaluieren. Somatische Mutationen und Keimbahnmutationen in DNA-Reparaturgenen (hMLH1, hMSH2, hPMS1, hPMS2, GTBP) fuhren unter anderem zu einer erhohten Replikationsfehlerrate innerhalb kurzer repetitiver, hochgradig polymorpher, im gesamten Genom aller Spezies verbreiteter DNA-Sequenzen, den sogenannten Mikrosatelliten. Eine derartige Mikrosatelliteninstabilitat (MSI) ist somit charakterisiert durch das Auftreten von Langenalterationen in diesen Sequenzen in Tumoren. In unserer ersten Untersuchung zur Inzidenz einer MSI bei Magenkarzinomen konnte diese in 24% der untersuchten Tumoren nachgewiesen werden, wobei auch ein Bezug zur Tumorfamilienanamnese erkennbar war (1). Eine Mutationsanalyse des DNA-Reparaturgens hMLH1 bei bisher 10 Tumoren mit Mikrosatelliteninstabilitat zeigte lediglich eine Missense-Mutation (2).