Specially designed instruments for laparoscopic surgery with a pneumoperitoneum are expensive and delicate, and surgeons are initially not familiar with their handling. Beside restrictions of the surgeon's intraabdominal range of motion they lead to a loss of tactile sensation. In gasless laparoscopic procedures not only special laparoscopic instruments, but the standard conventional instruments, used in open surgery, can also be employed with simple valveless trocars. Still using these instruments can put up some difficulties, because ergonomic factors were not considered in their development. With regard to the instrument's length, shape and joint-position we developed a special instrument-set under the ergonomic criteria of gasless laparoscopy.

Equipment Design↗

PubMed1996

[Ludwig Rehn (1849-1930) and his importance in the development of modern surgery].

The unusual course of Ludwig Rehn's professional development directed him from a general practitioner close to Frankfurt am Main to his convocation as first Professor in ordinary for surgery to the Frankfurt University, which was newly established in 1914. Among his numerous publications, especially the following contributed immensely to the development of modern surgery: in 1884, he already described the healing of patients with Graves' disease by subtotal resection of the goiter; in 1885 he first described the high prevalence of bladder tumors in workers of an aniline factory; in 1886, he managed the first successful heart-suture after a stab-incision of the right ventricle; in 1897, he already performed an operation at the thoracal oesophagus, with an access via the posterior mediastinum; in 1920, he established the operative treatment (pericardectomy) of patients with a calcified pericarditis (armour heart).

General Surgery↗

PubMed1996

[Changes in the spectrum of the health provision contract and their effects on education, graduate education, research, quality of treatment and continuing development of surgery].

The legal "contract for patient care" issued by the Federal Government for all hospitals interferes with graduate medical education (approbation order), postgraduate surgical training, the KMK paper for new structures and financing of university medicine, health politics of the Physicians Parliament and the Legal Health System, guidelines for surgical practice, internal and external quality measurement, and, last but not least, with clinical research in surgery. The different effects are outlined in detail.

Cost Control↗

PubMed1995

Effects of proinflammatory cytokines on cultivated primary human hepatocytes. Fluorometric measurement of intercellular adhesion molecule-1 and human leukocyte antigen-A, -B, -C, and -DR expression.

Expression of adhesion molecules and human leukocyte antigens on the surface of hepatocytes (HC) may play an important role in the immune reaction in different types of infectious and noninfectious hepatitis, liver graft rejection, and autoimmune liver diseases. The aim of this study was to evaluate the influence of the proinflammatory cytokines IFN-alpha, IFN-gamma, and IL-1 alpha on the expression of intercellular adhesion molecule-1 (ICAM-1) and HLA-A, -B, -C, and -DR on highly purified primary human HC in cell culture. Expression was assessed by semiquantitative measurement of HC in cell culture by means of computer-aided fluorometry after immunofluorescent labeling. Avidin-biotin-immunoperoxidase staining was applied on parallel cultures to evaluate cell purity (> 99%) and to confirm the results obtained by fluorometry. ICAM-1 was expressed constitutively on untreated HC in vitro. Stimulation of HC with IFN-gamma and IL-1 alpha for 24 hr resulted in an increase of ICAM-1 expression. Cultured HC were moderately HLA-A, -B, and -C positive, but HLA-DR negative. Stimulation of HC with 500 U/ml IFN-gamma for 72 hr resulted in an increase of HLA-A, -B, -C, and -DR expression, whereas stimulation with 10 U/ml IL-1 alpha for 72 hr had no influence. By using 5000 U/ml IFN-alpha for 72 hr, we achieved an increase of HLA-A, -B, and -C expression; effects on the other tested antigens were not significant. In contrast to endothelial cells and transformed human hepatocytic cell lines, ICAM-1 on HC was changed more intensively by IFN-gamma than by IL-1 alpha. Furthermore, the results reveal differences in HLA and ICAM-1 expression between HC in vivo and in vitro.

Cells, Cultured↗

PubMed1995

Gasless laparoscopy in abdominal surgery.

Pneumoperitoneum, as a necessary precondition of laparoscopic procedures, represents a restriction of the surgeon's freedom of movement and can lead to rare but typical complications. We describe our first experiences with laparoscopic surgery without using pneumoperitoneum. Under direct vision and digital control a fan-formed wall retractor, which is attached to an electric lift arm, is introduced into the abdominal cavity. After raising the abdominal wall, the scope is introduced through the same access and the laparoscopic procedure can be started without the technical and physiopathological problems which may occur using a pneumoperitoneum. In this gasless laparoscopic procedure, simple valveless trocars and instruments can be used. Furthermore, an unlimited suction can be obtained without a loss of exposure. During anesthesia, neither increased ventilation nor increased ventilation pressure is necessary, and the surgeon has increased freedom of action. Not only special laparoscopic instruments, but the conventional instruments, used in open surgery, can also be employed in gasless laparoscopy. In this way we performed gasless laparoscopic surgery on 54 patients: cholecystectomy (n = 37), abdominal exploration for NSAP (n = 5) or tumor staging (n = 4), fenestration of liver cysts (n = 5), and appendectomy (n = 3). We did observe three wound infections as related complications. Six times, we had to change the surgical procedure. Compared to the traditional procedure with a CO2 pneumoperitoneum, the results of the first gasless procedures demonstrate potential advantages.

Abdomen↗

PubMed1995

In vitro inhibition of human cytomegalovirus replication in human foreskin fibroblasts and endothelial cells by ascorbic acid 2-phosphate.

Antiviral activity of L-ascorbic acid-2-phosphate (ASC-2P), a long-acting derivative of L-ascorbic acid, against several human cytomegalovirus (CMV) strains was examined in cultures of human foreskin fibroblasts (HFF) and endothelial cells (EC). ASC-2P at concentrations ranging from 0.2 to 2 mM had no effect on the number of cells expressing 72 kDa CMV immediate early antigen (IEA) while it inhibited expression of 68 kDa late antigen (LA) in infected cultures of both cell types (30% and 55% reduction for EC and HFF, respectively). In HFF cells, virus yield was reduced up to 4-fold, when ASC-2P was added after CMV infection. Antiviral effects were significantly increased in cultures pretreated with ASC-2P. In HFF and EC pretreated for three subcultures (18 days) with 0.2 mM ASC-2P, a significant reduction of cells expressing IEA (75% and 80% reduction in EC and HFF, respectively) and LA (92% and 90% reduction for EC and HFF, respectively) was observed. Pretreatment for three subcultures with ASC-2P inhibited virus yield 50- to 100-fold in EC and 100- to 1000-fold in HFF. The continuous presence of ASC-2P was not required for its antiviral activity. A significantly higher reduction of virus replication with ganciclovir and foscarnet was obtained in ASC-2P pretreated cells than in untreated controls. The results showed that ASC-2P provides L-ascorbic acid with long-lasting antiviral activity against CMV. ASC-2P may be of benefit for the adjunctive treatment of CMV infection.

Antigens, Viral↗

PubMed1995

Lymphocytes induce enhanced expression of HLA class I antigens on cytomegalovirus-infected syngeneic human endothelial cells.

Human cytomegalovirus (HCMV) infection has been associated with enhanced expression of HLA antigens on the endothelium and with cellular infiltrates within the graft following human organ transplantation. We investigated the interactions between human cytomegalovirus-infected cultured endothelial cells and cocultured syngeneic as well as allogeneic lymphocytes. Our objective was to find out whether cocultured lymphocytes elicit HCMV-mediated immune responses. In this report we focus on the modified expression of HLA antigens on the surface membrane of human umbilical vein endothelial cells (HUVECs). Endothelial expression of HLA class I and II antigens was measured by means of flow cytometry. Cocultures of HCMV-infected HUVECs with unprimed autologous PBLs led to virus-specific lymphocyte response, resulting in enhanced expression of HLA class I on HUVECs. This effect was only observed when lymphocytes were added to HUVECs during the very early phase after virus inoculation and was due to the stimulation of the CD8+ T-cell subpopulation. The modification of endothelial HLA expression was not observed in transwell cocultures, indicating the importance of cellular contact between endothelial cells and lymphocytes to elicit this effect. We conclude that HCMV-infected endothelial cells may induce virus-specific responses of unprimed syngeneic lymphocytes that lead to upregulated HLA class I expression on the endothelium. This pathway might be of important relevance for graft rejection crises after transplantation.

CD8-Positive T-Lymphocytes↗

PubMed1995

Effects of desferrioxamine on human cytomegalovirus replication and expression of HLA antigens and adhesion molecules in human vascular endothelial cells.

Desferrioxamine (DFO), commonly used in therapy as a chelator of ferric ion in disorders of iron overload, is a potent inhibitor of human cytomegalovirus (HCMV) replication in cultured fibroblast cells. Moreover, DFO has immunomodulatory activity both in vitro and in vivo. We studied DFO effects on HCMV replication in cultured human endothelial cells and on the expression of several cell surface molecules, which mediate interactions of endothelial cells with other cell types in the immune system. The concentrations of DFO required for 50% reduction in the number of endothelial cells expressing HCMV late antigen, ranged for several HCMV strains from 5.2 to 8.8 microM. DFO concentrations ranging from 5 to 40 microM inhibited cellular DNA synthesis in a dose-dependent manner without any significant effects on the cell viability. DFO at 10 microM concentration suppressed expression of intercellular adhesion molecule-1 (ICAM-1) and endothelial leucocyte adhesion molecule-1 (ELAM-1), while it had no significant effect on the expression of vascular cell adhesion molecule-1 (VCAM-1). Expression of HLA class I and class II was not influenced by DFO treatment. The results showed that DFO is both effective in inhibition of HCMV replication and expression of ICAM-1 and ELAM-1 in endothelial cells, a combination that warrants attention to its potential use to prevent HCMV-induced allograft rejection in transplant recipients.

Cell Adhesion Molecules↗

PubMed1995

Adenocarcinoma of the gastric antrum: does D2 total gastrectomy with splenectomy improve prognosis compared to D1 subtotal gastrectomy? A long-term survival analysis with emphasis on Lauren classification.

AIMS: The purpose of this retrospective study was to evaluate whether a more radical resection, including total gastrectomy (TG), D2 lymphadenectomy and splenectomy, or subtotal gastrectomy (SG), improves the prognosis of patients with an adenocarcinoma located on the distal third of the stomach. PATIENTS AND METHODS: Seventy-four consecutive patients with an antral carcinoma underwent gastric resection. Forty-three had a TG and 31 an SG. D2 lymph node dissection was carried out in 70% of all patients (30/43) and 100% (21/21) of patients with curative resection in the TG group, whereas in the SG group the patients had only a standard D1 lymph node dissection. Splenectomy was carried out in 84% (36/43) of patients in the TG group, whereas in the SG group the spleen was preserved in all patients. Follow-up was complete for 100% of the patients, with a median follow-up time of 74 months. MAIN END-POINTS OF INTEREST: Overall survival rates, mortality and morbidity rates. RESULTS: The postoperative 30-day mortality rate was 7% in the TG group and 3.2% in the SG group. The overall morbidity rate was increased from 19% after SG to 37% after TG. There was no microscopic evidence of involvement of proximal resection margins in any of 31 subtotal resected gastric specimens. Lymph node metastases to the splenic hilus (no. 10 nodes) or along the splenic artery (no. 11 nodes) were not found in any of 36 patients who underwent splenectomy and lymphadenectomy. The 5- or 10-year survival rates did not differ significantly between both groups. Analysis of survival showed no significant difference between the TG and SG groups when related to subgroups of patients with curative resection (UICC-RO resection), nodal status (pN), tumour depth (pT-category), tumour stage (pTNM), or Lauren classification (intestinal or diffuse type of carcinoma). The survival rates for patients with curative resection after 5 or 10 years were 58% in the TG group and 66% or 51% in SG group, respectively (P = 0.66). CONCLUSION: Since D2 total gastrectomy carried an increased overall morbidity risk and did not improve survival in patients with intestinal or diffuse type carcinoma, it seems that with regard to luminal gastric resection, SG is the treatment of choice for carcinomas located in the distal third of the stomach. Whether extensive radical D2 lymphadenectomy should be routinely performed in addition to SG is still controversial.The spleen should be preserved in most cases.

Adenocarcinoma↗

PubMed1995

[Adhesion and penetration of human lymphocytes through allogeneic endothelial cells within the scope of organ rejection].

INTRODUCTION: Cellular rejection mechanisms are characterized by the infiltration of sensitized lymphocytes through the donor endothelium into the transplanted organ. The regulation of cellular adhesion molecules by soluble mediators (cytokines) is thought to play a dominant role in this process. In the present study the kinetics of lymphocyte infiltration were examined using a new established in vitro model and compared to the kinetics of adhesion molecule expression. MATERIALS AND METHODS: Peripheral blood lymphocytes (PBL) of healthy volunteers were pipetted to allogeneic endothelial cell (EC) monolayers and binding rates evaluated after different incubation times. Adherent PBL could be distinguished from penetrated PBL by means of a combined phase contrast- / reflection interference contrast - microscope. RESULTS: 30-35% of all pipetted PBL adhered to unstimulated EC maximally. Out of these cells < 10% penetrated through the endothelium ( = maximum penetration). The cytokines alpha-, beta-, gamma-interferon (IFN) or IL-1 did not enhance maximum adhesion, but accelerated this process. However, a 2 hrs prestimulus of EC by these cytokines was necessary to induce acceleration. Maximum penetration was enhanced by alpha-, beta-, gamma-IFN, but not by IL-1, irrespective whether PBL were added together with cytokines to unstimulated EC or to already prestimulated EC. Immunocytochemical and fluorometric analyses of adhesion molecule expression revealed a cytokine induced upregulation or de novo expression of the adhesion antigens ICAM-1, ELAM-1 and VCAM-1 on EC membranes. Interestingly, PBL adhered to EC before upregulation or de novo expression of adhesion molecules was detected. DISCUSSION: The results showed that PBL adhesion and penetration processes were regulated differentially by cytokines. The early phase of PBL attachment to EC seemed not to be influenced by adhesion antigens but by an activation of the lymphocyte cytoskeleton.

Cell Adhesion↗

PubMed1995

[Resection of colorectal liver metastases and adjuvant therapy].

Explore the source record for details and available documents.

Chemotherapy, Adjuvant↗

PubMed1995

[Results of resection and adjuvant therapy of liver metastases of primary colorectal tumors--a review of the literature].

Natural history of patients with colorectal liver metastases is not significantly changed even by curative resection. The majority unfortunately relapse. The results of adjuvant treatment after resection were evaluated by analysis of 17 publications as well as by own data (60 patients). 340 patients were either treated by intraarterial (n = 201), systemic (n = 82), intraportal (n = 29) or intraperitoneal (n = 28) chemoinfusion (5-Fluorouracil or Floxuridine). An alternative approach was the treatment with specific immunotherapy using tumor vaccination (n = 35) or monoclonal antibodies (n = 20). Morbidity of adjuvant treatment includes local (chemical hepatitis, biliary sclerosis) and systemic (diarrhea, stomatitis) side effects. Technical complications could reach a level of up to 50% in case of local administration. With exception of 6 studies no comparison with a resection only group was performed. Despite postulated increase of survival and recurrence free time with historical controls the results of current ongoing studies are needed before general use of adjuvant treatment can be recommended.

Antibodies, Monoclonal↗