Showing papers by "J. R. Siewert published in 1999"

Stented versus nonstented pancreaticojejunostomy after pancreatoduodenectomy: a prospective study.

Abstract: OBJECTIVE: To compare morbidity and mortality rates of stented versus nonstented pancreaticojejunostomy after partial pancreatoduodenectomy. BACKGROUND DATA: Despite a marked reduction in the mortality rate after partial pancreatoduodenectomy in recent years, leakage of the pancreaticojejunostomy still occurs in 5% to 25% of patients and remains the major source of complications. METHODS: The authors compared the morbidity and mortality rates of 85 consecutive patients who had a partial pancreatoduodenectomy with (n = 44) or without (n = 41) temporary stented external drainage of the pancreatic duct between 1994 and 1997. RESULTS: A pancreatic fistula was diagnosed in 3 of the 44 patients (6.8%) with stents versus 12 of the 41 patients (29.3%) without stents. Surgical reintervention was necessary in 1 of the 3 patients with a pancreatic fistula in the stented group and 3 of the 12 patients with a pancreatic fistula in the nonstented group. There were two deaths after surgery, both in the nonstented group. The median hospital stay after surgery was 13 days in patients with stents and 29 days in patients without stents. CONCLUSION: In this nonrandomized prospective observational study, temporary external drainage of the pancreatic duct with a PVC tube significantly reduced the leakage rate of the pancreaticojejunostomy as well as the duration of hospital stay after partial pancreatoduodenectomy. Although promising, these observations require confirmation by further studies.

Selective defects of T lymphocyte function in patients with lethal intraabdominal infection

Abstract: Background: In recent models, compensatory antiinflammatory immune reactions triggered in response to systemic inflammation were considered important for the outcome of sepsis. The present study investigated T-cell functions in patients with postoperative sepsis due to intra-abdominal infection. Methods: Peripheral T cells were purified from 32 sepsis patients and 41 healthy controls. Proliferation and production of interferon (IFN)-γ, interleukin (IL)-2, IL-4, tumor necrosis factor (TNF), and IL-10 were stimulated by cross-linking of CD3 and CD28. Results: T-cell proliferation and production of IL-2 and TNF were severely suppressed in patients with lethal intraabdominal infection as compared with survivors and healthy controls. Sepsis survivors showed normal T-cell proliferation and IL-2 release, whereas secretion of TNF was reduced. However, TNF suppression in survivors was less severe than in nonsurviving patients. Defective T-cell functions were observed at the onset of sepsis and persisted throughout the entire observation period. T-cell production of IL-4 and IL-10 was not affected by postoperative intraabdominal infection. Conclusions: Defective T-cell proliferation and secretion of IL-2 and TNF correlate with sepsis mortality, thus indicating an important role of T cells for the immune defense against postoperative infection. Immune defects were evident at the onset of sepsis, suggesting that immunosuppression may develop as a primary response to sepsis without preceding immune hyperactivity.

Downregulation of T helper type 1 immune response and altered pro-inflammatory and anti-inflammatory T cell cytokine balance following conventional but not laparoscopic surgery.

Abstract: Background: The clinical advantages of laparoscopic procedures result from a minimized surgical trauma. The present study was performed to investigate immunosupression following laparoscopic operations as compared with open surgery. Our analysis focused on the T cell secretion of cytokines that regulate the critical balance of either T helper type-1 (Th1)- and Th2-mediated immune responses on pro- and anti-inflammatory activities. Methods: In a prospective study, immunological data of 26 patients submitted to laparoscopic cholecystectomy (LCE) and 17 patients undergoing conventional cholecystectomy (CCE) for symptomatic cholecystolithiasis were compared. Patients with acute cholecystitis and patients developing postoperative complications or receiving immunosuppressive medication were excluded. Production of interferon (IFN)-γ, interleukin (IL)-2, IL-4, tumor necrosis factor (TNF)-α, and IL-10 by isolated T cells stimulated by cross-linking of CD3 and CD28 was evaluated preoperatively as well as on postoperative days 1 and 6 or 7. Cytokines were measured by immunoenzymometric assay. Results: IFN-γ, TNF-α, and IL-2 production by T cells decreased significantly by 48.3%, 36.6%, and 36.8%, respectively, on postoperative day 1 after CCE, but not after LCE. These results indicate severe suppression of Th1-type and pro-inflammatory cytokines after the open operation. In contrast, IL-4 and IL-10 did not show significant changes in either group suggesting that Th2 cell response and anti-inflammatory activity remained normal. Conclusions: The present study shows that open, but not laparoscopic cholecystectomy is associated with a marked suppression of T lymphocytes functions as indicated by deregulation of both the Th1/Th2 and the pro-/anti-inflammatory cytokine balance. The results therefore suggest that downregulation of Th1 cell–mediated immune response and pro-inflammatory activity of T cells is a hallmark of open, but not laparoscopic surgery.

Pretherapeutic laparoscopic staging in advanced gastric carcinoma.

Abstract: Background and Study Aims: Direct visualization of the abdominal cavity by laparoscopy prior to multimodal treatment may be capable of improving the diagnostic precision of gastric cancer staging. The aim of this study was to evaluate whether diagnostic laparoscopy can influence treatment strategies in gastric cancer staged T3 and T4 by preoperative diagnostic tests. Patients and Methods: Extended diagnostic laparoscopy (EDL) was carried out in 111 patients with advanced gastric cancer staged T3 or T4 by computed tomography (CT) and endoluminal ultrasound (EUS). On Lauren's classification of gastric cancer, 46% of the lesions were of the intestinal type and 54% of the nonintestinal type. EDL was carried out with the patients under general anesthesia, and included visual inspection of the abdomen, with surgical exploration of initially inaccessible regions, laparoscopic ultrasound examination, peritoneal lavage, and biopsies. The information provided by laparoscopy was classified as 1) no additional information, 2) important additional findings independent of the tumor stage, 3) downgrading of the tumor to a more favorable stage, and 4) upgrading of the tumor to a less favorable stage. The results of EDL were then compared with those obtained by sonography, CT and EUS in combination. Results: EDL was performed successfully in 107 patients. In 56 of the 111 patients (50.5 %), no additional findings were obtained. In 5.4% of cases, additional unforeseen information was found, not connected with the tumor but altering the management. EDL altered the preoperative diagnosis in 51 of the 111 patients (46.0 %), leading to changes in management in 45 of them (40.5 %). EUS provided additional information in eight cases (7.2 % of the whole group, or 15.7 % of those in whom the diagnosis had to be changed). Four metastases were detected using EDL. It was possible to rule out peritoneal spread in four patients, but it was newly detected in 26. Conclusions: Additional information by EDL about the tumor stage in gastric cancer led to a modification of the therapeutic strategy in 40% of patients, in spite of earlier comprehensive diagnostic work-up using modern imaging procedures. EDL should therefore be mandatory if neoadjuvant treatment is planned, in order to avoid either undertreatment or overtreatment of this type of tumor.

Surgical resection for cancer of the cardia.

Abstract: From the pathogenic and therapeutic point of view, adenocarcinomas of the esophagogastric junction (AEG) should be classified into adenocarcinoma of the distal esophagus (Type I), true carcinoma of the cardia (Type II), and subcardial carcinoma (Type III). This classification can be easily performed by summarizing the information available from contrast radiography, endoscopy, and intra-operative findings; it allows comparison of data between various centers and facilitates the choice of surgical therapy. A complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of any surgical approach to adenocarcinoma of the esophagogastric junction. In patients with potentially resectable, true carcinoma of the cardia (AEG Type II), this can be achieved by a total gastrectomy with transhiatal resection of the distal esophagus and en bloc removal of the lymphatic drainage in the lower posterior mediastinum and along the celiac axis and superior border of the pancreas. This approach is associated with lower morbidity and provides equal long-term survival as compared to the more radical transmediastinal or abdominothoracic esophagogastrectomy. Whether a routine splenectomy for lymphadenectomy in the splenic hilus offers a survival benefit in these patients is questionable. In patients with early tumors staged as uT1 on pre-operative endosonography, a limited resection of the proximal stomach, cardia, and distal esophagus with interposition of a pedicled isoperistaltic jejunal segment appears justified since this procedure allows a complete tumor removal with adequate lymphadenctomy and offers excellent functional results. Multimodal therapy with pre-operative polychemotherapy or combined radio-chemotherapy appears to offer a significant survival benefit in patients with locally advanced tumors. With this tailored approach, extensive pre-operative staging becomes mandatory for an adequate selection of the appropriate therapeutic concept.

Immunocytochemically detected free peritoneal tumour cells (FPTC) are a strong prognostic factor in gastric carcinoma.

Abstract: Immunocytochemically detected free peritoneal tumour cells (FPTC) are a strong prognostic factor in gastric carcinoma

Lymph-node dissection in squamous cell esophageal cancer -- who benefits?

Abstract: A complete tumor removal with an adequate safety margin in all three dimensions (the oral margin, the aboral margins and the tumor bed) must be the primary aim of any surgical approach to esophageal cancer. The same goal has to be achieved in the area of the lymphatic drainage. The safety margin of lymphadenectomy can be estimated by the so-called lymph-node ratio, i.e., the ratio between the number of positive nodes and removed nodes. Several studies have shown that, for esophageal carcinoma, a lymph-node ratio below 0.2 constitutes an independent prognostic factor. Although controlled trials are still lacking, these data suggest that extensive lymphadenectomy may thus improve the prognosis in patients at an early stage of lymphatic spread, i.e., patients with only lymph-node 'microinvolvement' or patients with a limited number of positive regional nodes on standard histopathologic assessment. In practice, this requires, as a minimum, a two-field lymphadenectomy. In patients with more advanced lymphatic metastases, two-field lymphadenectomy does not improve the prognosis and can only result in a reduction of local recurrences. A more extensive lymphadenectomy, i.e., three-field lymph-node dissection, increases the risk and morbidity of the surgical procedure, while a prognostic gain, if any, appears to be limited to a subgroup of patients with proximal tumors and less than five involved lymph nodes. Since, in the Western world, these patients are usually submitted to multimodal therapeutic protocols, extended three-field lymphadenectomy can currently not be recommended as standard therapy.

Micrometastases in bone marrow: prognostic indicators for pancreatic cancer.

Abstract: Minimal residual disease in patients with operable pancreatic carcinoma is frequently missed by current noninvasive tumour staging. We applied an immunocytochemical cytokeratin assay that allows identification of individual pancreatic carcinoma cells disseminated to bone marrow. Prior to therapy, bone marrow was aspirated from the upper iliac crest of 48 patients with ductal adenocarcinoma of the pancreas at various disease stages and an age-matched control group of 33 noncarcinoma patients. Tumor cells in cytologic bone marrow preparations were detected with monoclonal antibodies (mAbs) CK2, KL1, and A45-B/B3 to epithelial cytokeratins (CK) using the alkaline phosphatase antialkaline phosphatase method. CK-positive cells were found in 14 (48.4%) of 31 cancer patients treated with curative intent and in 10 (58.8%) of 18 patients with extended disease. The overall frequency of these cells was 1 to 83 per 5x10(5) mononuclear cells with no significant differences between patients at different tumor stages and lymph node involvement. After a median follow-up of 22.8 months (range 3-48 months), 6 (40.0%) of 15 patients who underwent complete surgical resection but had tumor cells in bone marrow presented with distant metastasis and 7 (46.7%) had local relapse compared to none of 12 corresponding patients without such cells (p<0.05). Univariate survival analyses revealed that the presence of CK-positive cells was predictive of reduced overall survival. In conclusion, anticytokeratin mAbs are reliable probes for the immunocytochemical detection of single pancreatic cancer cells disseminated to bone marrow. Thus the described technique may help identify patients with pancreatic cancer and at potentially high risk of early metastatic relapse. The results promise to be of important assistance for determining prognosis and the consequences in therapy of early stage pancreatic cancer.

Adenocarcinoma of the esophago-gastric junction.

Abstract: BACKGROUND: The border between the esophagus and stomach gives rise to many discrepancies in the current literature regarding the etiology, classification and surgical treatment of adenocarcinoma arising at the esophago-gastric junction. We have consequently used the AEG-criteria (adenocarcinoma of the esophago-gastric junction) for classification and have based the selection of the surgical approach on the anatomic topographic subclassification. METHODS: In the following we report an analysis of a large and homogeneously classified population of 1602 consecutive patients with adenocarcinoma of the esophago-gastric junction, with an emphasis on the surgical approach, the pattern of lymphatic spread, the outcome after surgical treatment and the prognostic factors. Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor subclassifiations. RESULTS: The study confirms the marked differences in sex distribution, associated specialized intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, lymphatic spread, and stage between the three tumor entities. The degree of resection and lymph node status were the dominating independent prognostic factors by multivariate analysis. The data show no significant differences of long-term survival after abdomino-thoracic esophagectomy and extended total gastrectomy in these patients. CONCLUSION: The classification of adenocarcinomas of the esophago-gastric junction in three types, AEG type I, type II and type III shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are associated with good long-term prognosis. Better surgical management and standardized procedures will improve the outcome also of patients who need to undergo more radical surgery, i.e. abdomino-thoracic esophagectomy.

The role of surgery in the treatment of liver metastases for colorectal cancer patients.

Abstract: BACKGROUND/AIMS: Liver metastases deriving from colorectal cancer can be treated with curative intention in a select number of patients. Controversy does, however, persist pertaining to the impact of adjuvant treatment strategies. The aim of this study is to elucidate upon the various treatment modalities for patients suffering from liver metastases of colorectal primary tumor as well as to provide a rationale for surgical and adjuvant treatment. METHODOLOGY: From November 1987 to September 1998, a total of 449 consecutive patients suffering from liver metastases deriving from a colorectal cancer were documented at our institution in a protective study. Prognostic factors providing the most beneficial outcome (whether with surgical and/or adjuvant treatment modalities) were analyzed by univariate and multivariate analysis. RESULTS: Whenever possible, curative (R0) surgical resection of colorectal liver metastases provides the most benefit to the patient. Multivariate analysis revealed tumor infiltration of the lymph nodes of the hepatoduodenal ligament and metachronous occurrence of liver metastases as most independent factors related to survival. CONCLUSIONS: Adjuvant post-operative chemotherapy fails to significantly improve survival following resection of liver metastases when compared to the liver resection only group. In patients with unresectable metastases, regional arterial chemotherapy did not improve survival significantly when compared with systemic chemotherapy.

Endoscopic stapling diverticulostomy for Zenker's diverticulum

Abstract: Endoscopic stapling diverticulostomy (ESD) using an endostapler is a modification of the standard endoscopic treatment of Zenker's diverticulum (ZD). It is characterized by complete myotomy of the upper esophageal sphincter, with division of the common wall between diverticulum and esophagus, followed by immediate simultaneous closure of the divided edges with the staples. ESD was performed on 21 patients with ZD between January 1996 and October 1997. The results were then evaluated. Operation time averaged 22 min. Wide opening of the diverticulum and excellent hemostasis were achieved. All of the patients but one, who died postoperatively of myocardial infarction, resumed oral intake without any evidence of cervical sepsis or mediastinitis. Complete relief of dysphagia was achieved in all 20 patients. Hospital stay averaged 4.7 days (range, 2-7 days). The patients were followed up after ESD for a median time period of 12 months. No relapses were recorded. ESD is an effective endoscopic treatment for ZD that entails a low risk of complications and requires only a short period of hospitalization.

Transcutaneous electrogastrography: a non-invasive method to evaluate post-operative gastric disorders?

Abstract: BACKGROUND/AIMS With the development of high-performance computer programs, transcutaneous electrogastrography has experienced a renaissance in the last few years and is widely recommended as a non-invasive diagnostic tool to evaluate functional gastric disorders. We assessed the clinical value of electrogastrography in symptomatic and asymptomatic patients after a variety of procedures of the upper gastrointestinal (GI) tract. METHODOLOGY Electrogastrography tracings were recorded with a commercially available data logger using a recording frequency of 4 Hz. A standard meal was given between a 60 min preprandial and a 60 min postprandial period. The following parameters were analyzed pre- and postprandially utilizing Fourier and spectral analysis: Regular gastric activity (2-4 cycles/minute), bradygastria (0.5-2 cycles/minute), tachygastria (4-9 cycles/minute), dominant frequency and power of the dominant frequency. Nineteen asymptomatic healthy volunteers served as a control group. Forty-nine patients, who had undergone upper intestinal surgery, were included in the study (cholecystectomy n = 10, Nissen fundoplication n = 10, subtotal gastrectomy n = 8, truncal vagotomy, and gastric pull-up as esophageal replacement n = 6). Twenty of these patients complained of epigastric symptoms post-operatively, while 12 of these 20 patients also had a scintigraphic gastric emptying study with Tc99m labeled semisolid meal. RESULTS Preprandial gastric electric activity was between 2 and 4 cycles/minute in 60-90% of the study time in healthy volunteers. In all study groups the prevalence and power of normal electric activity increased significantly after the test meal (p < 0.001). After cholecystectomy, Nissen fundoplication, subtotal gastrectomy or vagotomy and gastric pull-up pre- and postprandial gastric electric activity showed a greater variability compared to normal volunteers (p < 0.05), but no typical electrogastrography pattern could be identified for the different surgical procedures. There was no significant difference in the electrogastrography pattern between asymptomatic and symptomatic patients and patients with normal or abnormal scintigraphic gastric emptying curves. CONCLUSIONS There is no specific electrogastrography pattern to differentiate between typical surgical procedures or epigastric symptoms. To date, electrogastrography does not contribute to the diagnosis and analysis of gastric motility disorders after upper intestinal surgery.

Traditionelle extraluminale Operation des Zenker-Divertikels

Abstract: Die klassische chirurgische Behandlung des Zenker-Divertikels umfast die Abtragung des Divertikels und die cervicale Myotomie. Bei sehr kleinen Divertikeln ist die alleinige Myotomie ausreichend. Die Komplikationsrate des Eingriffs ist akzeptabel; die langfristigen funktionellen Ergebnisse sind mit einer Erfolgswahrscheinlichkeit von 90 % uber 5 Jahre gut. Trotz der zunehmenden Bedeutung alternativer Verfahren wird die konventionelle extraluminale Operation das Verfahren der Wahl bei Divertikeln der Stadien I–III bleiben.

Moderne Diagnostik des stumpfen Bauchtraumas

Abstract: Mortalitat und Morbiditat des stumpfen Bauchtraumas hangen direkt von der rechtzeitigen, korrekten Diagnosestellung ab. Da in der uberwiegend Zahl der Falle Begleitverletzungen vorliegen und die Patienten haufig nicht (mehr) kommunikations- bzw. kooperationsfahig sind, ist die klinische Diagnostik unzuverlassig. Bezuglich der weiteren, bildgebenden Diagnostik wurde das praktische Vorgehen in den letzten Jahren vereinfacht und weitgehend vereinheitlicht: Initial erfolgt die Ultraschalldiagnostik des Abdomens. Bei Patienten, die aufgrund eines Blutverlusts in das Abdomen kreislaufinstabil geworden sind, kann diese Ursache immer sonographisch entdeckt und damit gleichzeitig die Indikation zur Notfalllaparotomie gestellt werden. Bei kreislaufstabilen Patienten wird zur weiteren Feindiagnostik des Abdomens bei nicht ganz eindeutigem Ultraschallbefund die computertomographische Untersuchung (CT) des Abdomens angeschlossen. Vom Nachweis direkter oder indirekter Zeichen einer Lasion hangt das weitere Vorgehen ab und kann u. a. die Angiographie (Leber, Milz, Niere, Mesenterialwurzel, V. cava), die endoskopisch-retrograde Cholangio-Pankreateographie (ERCP) (Leber, Gallenwege Pankreas) bzw. die Punktion von freier intraabdominaler Flussigkeit umfassen, wodurch Verletzungen von Hohlorganen diagnostiziert werden konnen. Die heute recht zuverlassige computertomographische Diagnostik des stumpfen Bauchtraumas stellt daruberhinaus eine wesentliche Voraussetzung fur die heute immer deutlichere Tendenz zur konservativen Behandlung von Parenchymlasionen beim stumpfen Bauchtrauma dar. Da die Moglichkeit der Ultraschalldiagnostik heute praktisch in jedem Versorgungskrankenhaus gegeben ist und die sonographische Diagnostik fester Bestandteil der chirurgischen Ausbildung ist, sind konkurriende Verfahren wie die diagnostische Peritoneallavage praktisch bedeutungslos geworden. Auch die diagnostische Laparoskopie hat – im Ggs. zum Perforationstrauma – keinen aktuellen Stellenwert.

Intestinale pouches: magenersatz

Abstract: Die Rekonstruktion der Intestinalpassage nach totaler Gastrektomie basiert meist auf einer direkten Oesophagojejunostomie mit End-zu-Seit-Einpflanzung der zufuhrenden Schlinge. Das zweite Rekonstruktionsprinzip beruht auf der Erhaltung der Duodenalpassage. Langzeitprobleme wie Gewichtsverlust und Mangelernahrung fuhrten daruber hinaus zu Uberlegungen, den Magenersatz in Form eines Reservoirs anzulegen. Neben der Reservoirbildung ist klinisch die Vermeidung des intestinooesophagealen Refluxes eine weitere Forderung an die gewahlte Rekonstruktionsform. Als Standardverfahren gilt die Ableitung des Duodenalinhaltes uber eine Roux-Y-End-zu-Seit-Anastomose. Die Interposition einer ausreichend langen Dunndarmschlinge mit Erhaltung der Duodenalpassage wirkt ebenfalls refluxverhutend. Theoretisch von Vorteil ist hierbei die Ankoppelung der Motilitat des Duodenums an das Interponat mit verbesserter Synchronisation der aboral gerichteten Nahrungspassage. Betrachtet man anspruchsvollere Rekonstruktionsverfahren, so ist der derzeitige Stand der Literatur dahingehend zu interpretieren, das die Anlage eines Pouches grundsatzlich der einfachen Oesophagojejunstomie funktionell uberlegen ist. Ob die Duodenalpassage zusatzlich erhalten bleiben soll oder eine Roux-Y-Technik verwendet wird, bleibt nach wie vor in der Diskussion.

Bedeutung des Tumordebulkings bei gastrointestinalen Tumoren

Abstract: Durch das Tumordebulking gastrointestinaler Tumoren soll eine Tumormassenreduktion zur Erhohung der Wirksamkeit nachfolgender Therapiemodalitaten, erfolgen. Bei diesen fortgeschrittenen Carcinomleiden ist eine solche Therapieform mit einer erhohten Morbiditat und Letalitat verbunden. Adjuvante Therapien gelangen fristgerecht nicht zur Anwendung. Ein Langzeituberleben kann dadurch nicht verbessert werden. Fortschritte der biomedizinischen Grundlagenforschung vermogen erste Erklarungsversuche fur dieses Therapieversagen zu geben. Auf ihnen basieren neuere Behandlungskonzepte wie das der neoadjuvanten Therapie lokal fortgeschrittener Tumoren. Die Rate, der zur Verbesserung des Langzeituberlebens notwendigen R0-Resektion, kann dadurch moglicherweise verbessert werden. Erste prospektive, neoadjuvante Studien gastrointestinaler Neoplasien, sind bereits sehr ermutigend.

Die Situation der onkologischen Chirurgie in Deutschland 1998: Aktuelle Umfrageergebnisse

Abstract: Zur Erhebung der Situation der onkologischen Chirurgie in Deutschland wurde im Januar 1998 eine Umfrage an 1979 chirurgischen Kliniken Deutschlands durchgefuhrt. 938 Kliniken nahmen an der Umfrage teil und gaben an, im Fachgebiet der onkologischen Chirurgie tatig zu sein. Bei 72 % der Kliniken liegt der Tatigkeitsanteil zwischen 10 und 30 %. Der Anteil onkologischer Chirurgie korreliert zur Kliniksgrose und ist am hochsten in Universitatskliniken. Die Colon-/Rectumchirurgie ist vor allen anderen Organgebieten mit 93 % aller befragten Kliniken weit fuhrend. 73 % der befragten Kliniken fuhren regelmasig onkologische Magenchirurgie durch. Der Anteil der Kliniken mit Mammachirurgie ist mit 45 % uberraschend hoch. 54,6 % der Kliniken an, neoadjuvante onkologische Therapieverfahren durchzufuhren. Bei adjuvanten Therapieverfahren betragt die Rate sogar 85,2 %. Die apparative Ausstattung der Hauser ist uberwiegend gut. Moderne Moglichkeiten der Netz- und Telekommunikation werden nur unzureichend genutzt. „Second opinion“ findet uberwiegend im eigenen Haus, aber nicht uberregional statt. Die Stellung zu einer Fachkunde „Chirurgische Onkologie“ ist ambivalent: Nur 35,3 % der Klinikchefs befurworten diese. Uber 90 % der befragten Kliniken lehnen eine strukturelle Eigenstandigkeit der onkologischen Chirurgie ab.

Chirurgische und multimodale Behandlung des pT4-Magenkarzinoms

Abstract: Grundlagen: Die anatomische Lage des Magens zwischen Pankreas, Milz, Colon transversum, Zwerchfell, Leber, Bauchwand, Nebennieren, Dunndarm und Retroperitoneum erklart, das diese Strukturen beim fortgeschrittenen Magenkarzinom infiltriert sein konnen.

Chirurgische Therapie bei Karzinomen des proximalen Magendrittels und des ösophagogastralen Übergangs

Abstract: SummaryDespite the continuing incidence and prevalence of adenocarcinoma of the proximal gastric third and esophago-gastric junction, the classification and optimal therapy of these tumors remains controversial. From the anatomic, pathologic and therapeutic point of view a discrimination of these tumors into those of the gastric fundus, subcardial gastric carcinoma (or adenocarcinoma of the esophago-gastric junction type III according to Siewert, AEG type III), true carcinoma of the gastric cardia (AEG type II) and adenocarcinoma of the distal esophagus (AEG type I) appears logical. A special aspect of tumors of the proximal gastric third is their lymphatic drainage towards the splenic hilum and the left para-aortic lymph nodes. In addition, the proximal gastric third is characterized by a rather large proportion without serosal covering in the area of the major and lesser gastric curvature. Consequently, transmural tumors at this location are frequently assigned the T2 category according to the current UICC criteria, although the true depth of wall penetration and prognosis correspond to that of a more advanced T category.The surgical therapy of choice for tumors of the gastric fundus as well as for subcardial gastric cancers (AEG type III) and true carcinomas of the gastric cardia (AEG type II) is an extended total gastrectomy with resection of the distal esophagus. The optimal extent of lymphadenectomy in these patients includes, at least theoretically, the lymph nodes along the splenic artery, the splenic hilum and the para-aortic lymph nodes at the left renal hilum in addition to the so-called compartments I and II. Since a left pancreatic resection is associated with significant morbidity, a pancreas-preserving splenectomy (PPS) should be performed to complete the lymphadenectomy in the retroperitoneum. The markedly worse prognosis of proximal-third gastric cancer, as compared to more distally located gastric tumors, is due to the current UICC classification which does not take into account the special location and lymphatic drainage of these tumors. A modification of the UICC classification for these tumors appears reasonable. Copyright © 1999 S. Karger GmbH, Freiburg

Nuklear Faktor-кB (NF-кB) als zentraler Modulator der Stickoxid (NO) induzierten intestinalen Inflammation and Stase nach hämorrhagischem Schock

Abstract: Schwerer hamorrhagischer Schock (HS) ist von intestinaler Dysmotilitat begleitet, die zur Darmatonie and funktionellem Ileus fuhrt. Im HS tragt die erhohte Zytokin Produktion zur intestinalen Inflammation und zur reduzierten Muskelkontraktilitat durch die Rekrutierung von polymorphonuklearen Granulozyten (PMN) bei [1]. Wir haben nachgewiesen, das HS zur erhohten Expression der induzierbaren NO Synthase (iNOS) fuhrt [2]. Wahrend der Reperfusionsphase kann induziertes NO in einer cGMP unabhangigen, redox-sensitiven Signalkaskade zur Aktivierung des Transkriptionsfaktors NF-к B fuhren [3]. NF-кB induziert die Expression von Zytokinen, wie z.B. IL-6 and G-CSF, die NF-кB Bindungsstellen in ihrer Promoterregion besitzen. Die Aktivierung von NF-кB stellt daher einen wichtigen Regulator der inflammatorischen Antwort nach HS dar. Unter Verwendung des selektiven iNOS Inhibitors L-N6(1-Iminoethyl)-lysine (L-NIL) uberpruften wir den Einflus der NO induzierten NFкB Aktivierung auf die inflammatorische Antwort and Dysmotilitat nach HS.