[Electron microscopy change in the peritoneum after laparoscopic operations].
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Biopsy↗
Biomedical subjects
A Encke
Publications and source records attributed to A Encke.
[Use of normal human hepatocytes in a hybrid organ system].
Using the bioreactor model developed by J. Gerlach, we examined the potential of normal human hepatocytes for application in bioartificial liver devices. From normal human donor livers 1.5 x 10(8) hepatocytes were isolated. Hepatocytes were perfused in a woven multi-compartment capillary system in serum-free culture medium containing ammoniachloride over a period of 2 weeks. These cells demonstrated a well differentiated ultrastructure with formation of junctional complexes and bile canaliculi between adjacent cells. During reactor run, a constant albumin synthesis with levels above 11 mg/ml and maintenance of urea production and lignocaine metabolism (MEGX-test) were detected. These initial results indicate that normal human hepatocytes express typical morphology and ultrastructure and are able to keep differentiated functions in suitable perfusion models. Combination of the distinct human liver cell populations might enable promotion of further specific functions (clotting factors) and induction of liver cell proliferation.
Cell Survival↗
Intraoperative gamma probe detection of neuroendocrine tumors.
UNLABELLED: Previous studies of the intraoperative use of a handheld gamma probe to localize metastases and primary tumors of colorectal cancer have shown improved assessment of tumor spread and changes in surgical management based on added information gained by radioimmunoguided surgery. We conducted a prospective study to determine whether intraoperative radiodetection is able to reveal microscopic and occult disease of neuroendocrine tumors [medullary thyroid carcinomas (MTCs), gastroenteropancreatic (GEP) tumors]. METHODS: After the injection of 180 MBq [111In-diethylenetriaminepentaacetic acid (DTPA)-D-Phe1]pentetreotide and/or 500 MBq 99mTc-dimercaptosuccinic acid (DMSA) (both for double-nuclide scintigraphy), preoperative somatostatin receptor imaging (12 patients with GEP tumors) and double-nuclide scintigraphy (10 patients with relapsing MTCs were performed. The results were combined with the information obtained from conventional imaging modalities (CT and sonography). Intraoperative radiodetection was performed 24 hr after administration of [111In-DTPA-D-Phe1]pentetreotide or 4 hr after the injection of 99mTc-DMSA using a handheld gamma probe. RESULTS: Intraoperative gamma counting localized 70 somatostatin receptor-positive lesions of GEP tumors, whereas preoperative receptor imaging visualized 74%, surgical palpation visualized 44% and radiological imaging modalities localized only 43%. In 10 patients with recurrent MTCs, the surgeon was successful in localizing and removing 30 tumor lesions using the gamma probe. Twenty-seven of 30 lesions demonstrated tumor involvement, whereas 3 lesions were false-positive (lymphadenitis). Double-nuclide scintigraphy revealed 67% (Octreoscan, 7 of 20; 99mTc-DMSA, 13 of 20), surgical palpation revealed 60% and conventional imaging methods (CT, sonography) revealed only 50% of all lesions detected intraoperatively by the handheld gamma probe. The smallest lesion identified by the handheld probe (not palpated by the surgeon) was a lymph node metastasis (5-mm diameter). CONCLUSION: The preliminary data show that intraoperative handheld gamma probe detection of microscopic and occult endocrine tumors is feasible and more sensitive than external scintigraphy and conventional imaging.
Carcinoma, Medullary↗
[The common surgical heritage].
The mutual and dreadful history of Poland and Germany has left behind wounds and scars on both sides. This session is dedicated to the common surgical heritage and joint development of the presence and future. Important pioneering contributions of German surgery were achieved at the University of Breslau (Wroclaw), especially by Johann von Mikulicz-Radecki and his associate Ferdinand Sauerbruch. Our Polish colleagues have further developed the surgical tradition in Poland since World War II.
General Surgery↗
[Development and importance of surgical oncology in Germany].
Karl Heinrich Bauer (1890-1978) must be considered the Nestor of surgical oncology in Germany (mutation hypothesis 1928, monograph "Das Krebsproblem" 1949, German Cancer Research Institution (DKFZ) in Heidelberg 1964). The biological understanding of tumor disease has influenced the standardization of surgical procedures and has integrated these into a multimodal oncological concept, including neoadjuvant and adjuvant radio- and chemotherapy. Guidelines and consensus recommendations for the diagnosis and treatment of solid tumors have been established. Laparoscopic oncological surgery is under discussion and should be restricted to prospective trials.
General Surgery↗
[Prospective study of spontaneous medical utilization of antibiotics on the normal surgical ward--rationale and economic aspects].
For 8 months, the spontaneous behaviour of the surgeons concerning the use of antibiotics (AB) was studied. The study focused on the indication itself, the chosen substance, the method of drug administration, and the treatment duration. It was evaluated whether the use of AB was rational and what the economic consequences of inadequate use of AB are. Of a total of 1168 pts 21.1% received AB, 88% of them i.v. The intention of AB treatment was therapy in 56.3%, and prophylaxis in 43.7% beside the regular perioperative single shot regimen. More than every second AB prescription was irrational. More rational behaviour (indication, therapy once daily, sequential therapy, no postoperative prophylaxis, less i.v. AB) by the prescribing surgeons would have led to a saving of more than 60% of the total costs of DM 215,000 without any loss of antiinfective efficacy. Moreover, a more rational use of AB would mean prevention of infectious hospitalism and would save a lot of staff time.
Anti-Bacterial Agents↗
[Clinical value of somatostatin receptor scintigraphy. Studies of pre- and intraoperative localization of gastrointestinal and pancreatic tumors].
BACKGROUND: [111In-DTPA-D-Phe1]-pentetreotide scintigraphy is able to detect neuroendocrine tumors not shown by radiological methods. PATIENTS AND METHODS: In 270 patients with neuroendocrine gastroenteropancreatic tumors (GEP tumors) 400 somatostatin receptor scintigraphies were performed. 70 patients (38 female, 32 male, aged 28 to 74 [56 +/- 12.6] years) underwent surgery and follow-up over 2 years. The aim of the present study was the comparison of preoperative somatostatin receptor scintigraphy with radiological methods (sonography, CT) and intraoperative localization of GEP tumors with a hand-held gamma-probe. RESULTS: Somatostatin receptor scintigraphy was successful in localizing primary tumors in all patients. Liver- and lymph node metastases could be visualized with a sensitivity of 94 and 95 percent. In 7 patients 35 lesions could be identified by intraoperative tumor localization using a hand held gamma probe. Radiological methods identified only 11, surgical palpation 15 and preoperative somatostatin receptor scintigraphy 27 lesions. CONCLUSION: Somatostatin receptor scintigraphy improves detection of small and occult GEP tumors. Intraoperative probe counting with a hand-held gamma probe can identify tumors even when they are small and impalpable, but receptor positive.
Adult↗
[Surgery in patients treated with anticoagulation during emergency and elective interventions].
Patients under oral anticoagulation with coumarin derivatives have a variable perioperative thromboembolic risk which necessitates continuation of their thromboembolic prophylaxis during elective and emergency surgery. Because of their better handling unfractionated heparin and low-molecular-weight heparins are used most often for this purpose. The overlapping effect of coumarin and heparin therapy requires a close daily monitoring of the clotting inhibition (partial thromboplastin time, thromboplastin time, thrombin time). In elective surgery coumarin therapy is interrupted 2-3 days preoperatively; in emergency cases vitamin K or fresh frozen plasma have to be substituted. Patients under heparin therapy or prophylaxis are easier to handle, because the effect of heparin disappears in a few hours after stopping the treatment. In the immediate postoperative phase the heparin application is interrupted for 6 h because of increased bleeding risk. It is important to take into account additional risk factors like the underlying disease, disturbances of platelet function, liver diseases and renal insufficiency.
Anticoagulants↗
Historical evolution of inguinal hernia repair.
When analyzing original articles since the sixteenth century, it becomes apparent that all surgical techniques for repair of the inguinal hernial orifice can be traced back to two simple repair principles. The first is reinforcement of the anterior wall of the inguinal canal and tightening of the external inguinal ring (Stromayr 1559, Purmann 1694, Czerny 1877), and the second is reinforcement of the posterior wall of the inguinal canal and the tightening of the internal inguinal ring, either externally (Lucas-Championnière 1881, Bassini 1889, Lotheissen 1898, McVay 1942, Shouldice 1945, Lichtenstein 1987, Stoppa 1989) or via an intraabdominal approach by laparotomy (Tait 1891) or laparoscopically (Ger 1990, Velez and Klein 1990). We have tried to provide a systematic order to the diverse procedures of surgery of inguinal hernias according to their repair principles. We also point out their historical development.
General Surgery↗
Cultured human biliary epithelial cells induce allogeneic lymphocyte activation in vitro: possible relevance in liver transplant rejection.
The biliary epithelium is a major target for allograft-directed immune responses during rejection crises after liver transplantation. This paper deals with in vitro studies on the immunogenetic potential of cultured biliary epithelial cells (BECs) to elicit an allogeneic cellular immune response. Therefore, BECs were cocultured with syngeneic and allogeneic lymphocytes in order to study lymphocyte activation. The respective lymphocytes [3H]thymidine incorporation was a measure for the proliferative activity. While syngeneic peripheral blood lymphocytes (PBL) never exhibited BEC-induced proliferation allogeneic PBL were significantly (P < 0.05) activated in all experiments (n = 6). In experiments with purified subpopulations CD8+ cells but not CD4+ cells proved to be activated by BECs. In time kinetics (n = 5) the maximum of the BEC-induced proliferation was on day 9 while the endothelial cell-induced proliferation was found to be 2 days earlier on day 7 after onset of the experiments (P < 0.05). BEC-induced proliferation was accompanied by induced IL-2 secretion (> 300 pg/ml) by activated lymphocytes as determined by ELISA. Stimulation of BECs with 500 U/ml interferon-gamma, 1000 U/ml interferon-alpha or blocking expression of HLA molecules on the surface membrane of BECs by monoclonal antibodies did not alter BEC-induced allogeneic lymphocyte proliferation. Monoclonal antibodies against CD8+ but not CD4+ suppressed proliferative activity of PBL and CD8+ cells by 40 and 45%, respectively. Overall, these results provide evidence that BECs may induce CD8+ lymphocyte activation in vivo and therefore might play a crucial role in triggering immune responses related to liver transplant rejection episodes.
Antibodies, Monoclonal↗
Long-term results of operation for carcinoma of the stomach in T1/T2 stages: critical evaluation of the concept of early carcinoma of the stomach.
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Carcinoma↗
[Dissent over standards in adjuvant management of colon carcinoma].
Since 5-fluorouracil (5-FU) plus levamisole substantially reduces the recurrence rate and improves survival in adjuvantly treated patients with curative resected stage III colon cancer this combination has been considered the standard therapy. Shortly thereafter folinic acid modulated 5-FU-therapy also demonstrated adjuvant efficacy compared to surgery alone. Therefore various schedules of folinic acid modulated 5-FU-therapy were compared with the standard regimen (5-FU/levamisole). Randomized multicentric studies revealed: In three of four studies 5-FU/FA is superior to 5-FU/levamisole. Treatment duration of 6 months for 5-FU/FA is similar to 12 months 5-FU/Levamisole. No benefit is obtained for 5-FU/FA by additional levamisole. The effect of regional (portal vein or intraperitoneal) treatment is controversial discussed, but combination of the treatment with systemic chemotherapy versus 5-FU/levamisole demonstrated slightly increased therapeutic efficacy. Immunotherapy with autologous tumor cell-BCG or monoclonal antibody treatment improved survival and is currently investigated in studies with conventional systemic treatment and combined chemoimmunotherapy. Beside treatment in studies patients with colon cancer stage III should be offered adjuvant chemotherapy with 5-FU/FA. Further improvements and adjuvant treatment protocols for stage II carcinoma have to be investigated in studies.
Chemotherapy, Adjuvant↗
[Pre- and intraoperative localization of neuroendocrine tumors].
Previous studies of the intraoperative use of a hand-held gamma probe to localize metastases and primary tumors of colorectal cancer have shown improved assessment of tumor spread and changes in surgical management based on added information gained by radioimmunoguided surgery. Following the injection of 180 MBq [111In-DTPA-D-Phe1]-pentetreotide and/or 500 MBq 99mTc-dimercaptosuccinic acid (both for dual-radionuclide scintigraphy) preoperative somatostatin receptor imaging [11 patients with GEP tumors] and dual-radionuclide scintigraphy. (8 patients with relapsing medullary thyroid carcinomas) was performed. One patient with a metastasizing pheochromocytoma underwent 123]-MIBg scintigraphy. Results were combined with the information obtained from conventional imaging modalities. Intraoperative radiodetection was performed 24 hours after administration of [111In-DTPA-D-Phe1]-pentetreotide or 4 hours following the injection of 99mTc(V)DMSA using a hand-held gamma probe (Tec Probe 2000. Stratec, FRG). Intraoperative gamma counting localized 39 somatostatin receptor positive lesions of GEP tumors whereas preoperative receptor imaging visualized 81%, surgical palpation 41% and radiological imaging modalities localized only 31%. In 8 patients with recurrent medullary thyroid carcinoma the surgeon was successful in localizing and removing 18 tumor lesions by the help of the gamma probe. Dual-radionuclide scintigraphy revealed 77% (Octreoscan 5/18; 99mTc-V-DMSA 9/18), surgical palpation 55% and conventional imaging methods (CT, sonography) only 38% of all lesions detected intraoperatively by the hand-held gamma probe. In summary, this preliminary data show that intraoperative hand-held gamma probe detection of microscopic and occult endocrine tumors is feasible and more sensitive than external scintigraphy and conventional imaging.
Adrenal Gland Neoplasms↗
[Victor Schmieden (1874-1945) and his contribution to the development of modern surgery].
Victor Schmieden (1874-1945) was the second Professor on ordinary for surgery (1919-1945) at the Frankfurt University, which was newly established in 1914. Among his numerous publications, especially the following contributed to the development of modern surgery: in 1915 during the first world war he proposed the operative treatment (laparotomy) of abdominal shot-wounds, in 1920 he established the operative treatment (pericardectomy) of patients with a calcified pericarditis (armour heart). In 1926 he described the adenomas (polyps) of the colon as a precursor of colorectal cancer (dysplasia-carcinoma sequence) and proposed total colectomy to patients with polyposis coli.
General Surgery↗
[Evaluation models for therapy planning/standardization exemplified by infection].
Models of evaluation in therapeutic management pathways (practice guidelines, clinical algorithms) are demanded today, both by public health research and health policy. However, practical achievements are lacking. To overcome this controversy, the Lucerne Study Group on Sepsis Research was founded to develop guidelines in accordance with a series of official groups. It was shown that there was no agreement between the providers and the daily users. However, every surgeon has a firm, personal view about sepsis.
Algorithms↗
[Initial experiences with the modular retraction system (VarioLift) for laparoscopic surgery without pneumoperitoneum].
The VarioLift system is an alternative method for abdominal wall lifting to create sufficient intra-abdominal space and adequate laparoscopic exposure to the operating field. The installation of a CO2 pneumoperitoneum is not necessary, which means that technical disadvantages, systemic and local physiological effects, or complications related to gas insufflation are not relevant when this method is used. The surgeon is allowed to combine the advantages of endoscopic surgery, such as magnified video-endoscopic visualisation, with well-known open surgical techniques to create a symbiosis of prove methods.
Equipment Design↗
[Research and ethics in emergency medicine. Findings of a workshop].
Prerequisites for experimental study designs are extremely difficult to realise under prehospital emergency conditions. Results obtained in animal experiments always need validation with prehospital or in hospital patient studies. Investigations related to emergency medicine are, however, an ethical obligation on behalf of the patient. A retrospective analysis of the available literature should be considered a prerequisite for prospective randomised and controlled studies. Frequently, a pilot study or feasibility trial needs to precede the actual study. Informed consent must be obtained for all patient studies. However, under emergency conditions informed consent cannot always be obtained due to unconsciousness, etc. Nevertheless, the following principles should be observed: (a) randomised studies are essential, even in emergency medicine; (b) they are ethically acceptable if the treatment provided for the study group is at least equivalent to the therapy for the control group; (c) only these preconditions guarantee that the patient always receives treatment in accordance with the standard of treatment. If the patient is unconscious or otherwise unable to give informed consent, the principle of deferred consent is acceptable. The deferred consent principle should be carefully documented. A prospective randomized study represents the gold standard for an investigation, even under emergency conditions. There are different principles of randomization: telephone or telefax randomisation, etc. Emergency medicine investigations need to be completed within a reasonable time frame which should, as a rule, not exceed 2 years. Otherwise, too many items might change without being noted. Curative treatment and the intention to treat are terms employed by ethics committees. If an investigation does not bear in itself additional risk factors, it does not necessarily have to be brought before the ethics committee. If, however, for example, the effect of obtaining blood samples is investigated separately for research purposes, the patient needs to be informed and sign the respective agreement. In Germany the ethics committees have agreed to accept their respective decisions. For multicentre and multinational studies, however, the ethics committees also need to accept decisions made by non-German ethics committees. Not all therapeutic principles can serve as the basis of prospective randomized studies because they need to be considered the present standard of care (e.g., endotracheal intubation, etc.). Nevertheless, the feasibility of a study should be assessed according to the 1-3 rating proposed by the American Heart Association. In principle, the overall emergency physician protocol does not fulfill scientific requirements. For all studies, particularly in the prehospital setting, an independent observer should be involved for documentation purposes. Scores can be of importance for investigating different treatment regimens. Biases in emergency medicine studies focus on the variability of EMS, personnel qualifications, etc. This is in part why it is extremely difficult to prove efficacy and efficiency in emergency medicine. The results of emergency medicine investigations should be published in suitable journals, i.e., journals with a reasonable rating.
Emergency Medicine↗
Experiences with percutaneous endoscopic gastrostomy.
Today the procedure of choice for long-term enteral tube feeding in patients with prolonged swallowing difficulties or inabilities is percutaneous endoscopic gastrostomy (PEG). The primary indications are head and neck cancers, neurologic dysphagia, cancer cachexia, and obstruction of the esophagus and pharynx with enough space for an endoscopic procedure. This technique requires no general anesthesia and is possible in patients with contraindications to surgical gastrostomy. Between September 1994 and April 1995 a total of 115 patients underwent PEG placement attempts. We employed the pull-technique with 15-Freka PEG tubes. The average procedure time, including esophagogastroduodenoscopy, was 17 minutes. In nine cases PEG insertion was impossible owing to severe obstruction of the esophagus. In 46 (40%) patients local abdominal pains started on the first or second postoperative day; 7 of these patients required surgical consultation, and no further intervention was needed. In only one patient was there a serious complication that required surgical intervention: a presumed perforation that turned out to have no correlate upon review. All patients received single-shot antibiotic prophylaxis; and only in those patients with abdominal symptoms do we recommend a prolonged antibiosis. The abdominal symptoms reported were due to a slight leak of gastric fluid causing a topical peritonitis, which required no further treatment. In our experience PEG is a useful alternative to surgical gastrostomy. The simplicity of this procedure leads to low complication rates, short hospitalization, and is possible on an outpatient basis. It is cost-efficient and has a much better psychological tolerance than nasogastric tubes.
Adult↗