[Report on the membership meeting of the Westphalia Area Society of BDC 19 October 2005].
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General Surgery↗
Biomedical subjects
D Löhlein
Publications and source records attributed to D Löhlein.
[Sentinel lymph node excision (SLNE) and positron emission tomography in the staging of stage I-II melanoma patients].
BACKGROUND AND OBJECTIVE: Sentinel lymph node excision (SLNE) and positron emission tomography (PET) were evaluated in the staging of 51 Stage I and II melanoma patients (staged according to the guidelines of the German Dermatological Society). PATIENTS/METHODS AND RESULTS: Tumor thickness ranged from 1.0 mm to 6.0 mm (median: 1.5 mm; mean: 2.07 mm). At least one sentinel lymph node (SLN) was excised in all patients; 80 SLN were excised from 69 lymphatic drainage areas. Positive SLN were detected in 6 patients (11.8%). Additional positive lymph nodes were not detected in any of these patients in the following complete lymph node dissection of the affected lymph node basin. Preoperative PET was performed in 40 patients and did not detect any of the micrometastases that were subsequently found by SLNE. During the follow up of 7-40 months (mean 21.9 months) 3 patients experienced tumor progression; 2 of 3 had a positive SLN. CONCLUSIONS: According to the current literature SLNE is recommended in primary tumors greater than 1 mm thickness. PET cannot be expected to give additional information in the staging of stage I-II patients.
Adult↗
[The de-epithelialized turnover flap for defect coverage iin the area over the Achilles tendon and over the lateral malleolar region].
The deepithelialized "turn-over-flap" is a reversed dermis flap. The pedicle of the flap remains intact. The mobile upper part of the flap is turned over the defect and the pedicle itself. A mesh graft covers both, the flap and the donor side. Two case reports will present the principles of the flap design and the clinical outcome of a patient with a defect over the lateral malleolar region and a patient with a defect over the Achilles tendon.
Adult↗
[Small intestinal transit with radio-opaque markers to localize intermittent small bowel obstruction] .
AIM: In difficult diagnostic cases of partial small bowel obstruction, radiopaque, non-digestible markers were used to challenge and localize the site of obstruction. MATERIAL AND METHOD: 32 patients (19 female, 13 male, 3-80 years) were examined. Each patient received 20 4-mm radiopaque markers orally. Abdominal radiographs were obtained at 4-8 h intervals. Mechanical obstruction was defined as the clustering of at least 3 markers for 4 hours or longer. The transit of radiopaque markers was compared to plain radiography, ultrasound, barium meal, computed tomography, enteroclysis and operative findings. RESULTS: 18 of 32 patients showed small bowel clustering suggestive of obstruction. Diagnostic agreement was found in 12 of 14 cases with ultrasound, in 7 of 13 cases with plain radiography and in 3 of 6 cases with enteroclysis. 13 of the 18 patients with clustering had surgery. All of them (13/13) had adhesions with the need of resection. CONCLUSION: This investigation is an alternative diagnostic method for the decision between conservative and surgical treatment in cases of intermittent partial small bowel obstruction.
Adolescent↗
Noninvasive whole-body electrical bioimpedance cardiac output and invasive thermodilution cardiac output in high-risk surgical patients.
OBJECTIVE: To evaluate the reliability of whole-body impedance cardiography with two electrodes on either both wrists or one wrist and one ankle for the measurement of cardiac output compared with the thermodilution method. DESIGN: Prospective, clinical investigation SETTING: Surgical intensive care unit of a university-affiliated community hospital. PATIENTS: Simultaneous cardiac output measurements by noninvasive whole-body impedance cardiography (nCO) and invasive thermodilution (thCO) in 22 high-risk surgical patients scheduled for extended surgery requiring perioperative pulmonary artery catheter monitoring. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 109 sets of measurements consisting of 455 single comparison measurements between nCO and thCO were included in the analysis. The mean cardiac output difference between the two methods was 1.62 L/min with limits of agreement (2 SD) of +/- 4.64 L/min. The inter-measurement variance was slightly higher for nCO. The correlation coefficient between nCO and thCO was r2 = 0.061 (p < .001) for single measurements and r2 = 0.083 (p < .002) for sets of three to six measurements. The two most predictive factors for between-method differences were the absolute thCO value (r2 = 0.13; p < .001) and whether or not a continuous nitroglycerin infusion was used (p < .05, Student's t-test). CONCLUSIONS: Agreement between whole-body impedance cardiography and thermodilution in the measurement of cardiac output was unsatisfactory. Factors that can explain these differences are differences between the populations used for calibration of nCO and the study population, the influence of changing peripheral perfusion, and the effect of a supranormal hemodynamic state on the bioimpedance signal. Whole-body impedance cardiography cannot be recommended for assessing the hemodynamic state of high-risk surgical patients as studied in this investigation.
Adult↗
[Esophageal carcinoma: surgical treatment concepts; access and resectability].
The resectability of oesophageal cancer depends very much on the tumour's localisation and extent. Maintenance of a proximal safety margin of at least 5 cm, and closeness to the posterior tracheal wall, only rarely allow primary resection of high thoracic or intracervical oesophageal cancer above the bifurcation. A possible alternative in this situation is combined radiochemotherapy. If the tumour responds to this therapy and there are no distant metastases, secondary resection frequently remains possible. On the other hand, in the distal oesophagus below the tracheal bifurcation, without involvement of the bronchial system, primary resection is often possible, and in this case infiltrated contiguous structures such as the pericardium and the crura of the diaphragm can also be resected. The extent of the lymphadenectomy is controversial at present. However, as part of an en bloc resection it should today include at least complete dissection of the posterior mediastinum and the upper abdomen (2-field lymphadenectomy). Additional cervical lymphadenectomy (3-field lymphadenectomy) can be recommended in high intrathoracic and cervical oesophageal cancer despite high morbidity, since this reduces the rate of loco-regional recurrences and thus improves the long-term prognosis. Mortality following oesophageal resection probably ranges around 5% today. Postoperative morbidity remains relatively high at over 50%. A reduction in morbidity demands not only competent surgical management and intensive care, but also, in particular, improved selection of patients and their specific preoperative preparation.
Combined Modality Therapy↗
Preoperative assessment of mortality risk in hepatic resection by clinical variables: a multivariate analysis.
Hepatic resection is a chance for cure for primary and secondary liver tumors and a variety of benign diseases. Despite advances in surgical technique and patient care, preoperative and postoperative morbidity in patients undergoing liver resection remains high. Because a high morbidity represents a risk factor contributing to a fatal outcome of the surgical procedure, our study aimed to investigate the contribution of different risk factors to a fatal outcome and if mortality can be predicted by the presence of certain risk factors. Two hundred fifty-seven patients undergoing hepatic resection (curative and palliative) were analyzed preoperatively, immediately after surgery, and 10 days after surgery for 60 potential risk factors. Survivors (n = 238) and nonsurvivors (n = 19) were compared univariately. The analysis identified 14 variables to differentiate between groups. These variables were processed by multivariate logistic regression analysis. Three models to estimate 30-day mortality were identified, tested for statistical accuracy, and assessed for their receiver-operated characteristics (ROCs). The variables in the multivariate models were as follows: preoperatively, age, number of comorbid factors, and presence of cirrhosis; immediately after surgery, age, number of comorbid factors, and percentage of resected liver; and 10 days after surgery, age, hours of ventilation, and number of adverse events. Goodness of fit was 0. 863, 0.912, and 0.966, respectively. Areas under the ROC curves were 83.6%, 85.7%, and 98.0%. The specificity (probability to identify survivors correctly) was greater than 90% for all models, although sensitivity (probability to identify nonsurvivors correctly) was greater than 90% only for 10 days after surgery. We conclude that logistic regression is appropriate to assess the importance of risk factors in the course of hepatic resection and to identify patient groups at high risk.
Female↗
[The Dufourmentel flap-plasty for treatment of chronic pilonidal sinus].
Thirty-seven patients with chronic sinus pilonidalis were treated after total excision by Dufourmentel flap. We saw seroma complications in three and wound infections in two cases. Patients stayed in hospital 6.3 days on an average and were able to work after 2.5 weeks. The method is easy to use. We have not seen a return to sinus problems in any of this cases.
Abscess↗
Statistical pattern detection in univariate time series of intensive care on-line monitoring data.
OBJECTIVES: To determine how different mathematical time series approaches can be implemented for the detection of qualitative patterns in physiologic monitoring data, and which of these approaches could be suitable as a basis for future bedside time series analysis. DESIGN: Off-line time series analysis. SETTING: Surgical intensive care unit of a teaching hospital. PATIENTS: 19 patients requiring hemodynamic monitoring with a pulmonary artery catheter. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Hemodynamic data were acquired in 1-min intervals from a clinical information system and exported into statistical software for further analysis. Altogether, 134 time series for heart rate, mean arterial pressure, and mean pulmonary artery pressure were visually classified by a senior intensivist into five patterns: no change, outlier, temporary level change, permanent level change, and trend. The same series were analyzed with low-order autoregressive (AR) models and with phase space (PS) models. The resulting classifications from both models were compared to the initial classification. Outliers and level changes were detected in most instances with both methods. Trend detection could only be done indirectly. Both methods were more sensitive to pattern changes than they were clinically relevant. Especially with outlier detection, 95% confidence intervals were too close. AR models require direct user interaction, whereas PS models offer opportunities for fully automated time series analysis in this context. CONCLUSION: Statistical patterns in univariate intensive care time series can reliably be detected with AR models and with PS models. For most bedside problems both methods are too sensitive. AR models are highly interactive, and both methods require that users have an explicit knowledge of statistics. While AR models and PS models can be extremely useful in the scientific off-line analysis, routine bedside clinical use cannot yet be recommended.
Aged↗
[Report on the membership meeting of the Regional Westphalia Society of the BDC 12 November 1997 in Dortmund].
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Ambulatory Surgical Procedures↗
[What is the risk of resection of the right hepatic artery in resection of central bile duct carcinoma?].
Between 1990 and 1994 we performed tumor resection on 21 patients with a cholangiocarcinoma of the porta hepatic. In 5 cases a segmental resection/ligature of the patent right hepatic artery was performed. The postoperative course of recovery in these 5 patients was compared to that of the other 16 patients. We found no significant differences in either the postoperative course of recovery or the laboratory parameters of the two groups. There was no clinical liver necrosis or bile duct necrosis (which would have manifested itself as a leak in the anastomosis) in either group. On the basis of our experience, segmental resection/ligature of the right hepatic artery as part of a radical cholangiocarcinoma resection is possible provided that the right portal vein is patent.
Bile Duct Neoplasms↗
[Transoral video-endoscopic esophago-diverticulotomy of Zenker's diverticulum with the Endo-GIA device].
The transoral endoscopic staple-assisted esophagodiverticulotomy is a new technique for the treatment of Zenker's diverticulum. In the period of July and August 1997, four older high-risk patients underwent this new technique with good results. To assess the value of this technique long-term follow-up studies as well as comparative trials will be needed.
Aged↗
[Acute intrahepatic bleeding in a male patient with focal nodular hyperplasia].
HISTORY AND CLINICAL FINDINGS: A 45-year-old man had acute bouts of pain in the right lower thorax with radiation to the mid-thorax and upper abdomen. For 3 years he was known to have coronary heart disease, for 4 years arterial hypertension and for 8 months, as an accidentally discovered finding, a liver cyst 2.5 cm in diameter, as well as an inhomogeneous focal lesion, demonstrable only by sonography, lying dorsally and close to the diaphragm in the right lobe of the liver, 3.0 x 3.5 cm which was not detected by computed tomography or magnetic resonance imaging. Physical examination at admission detected epigastric pain on pressure but no other abnormalities. INVESTIGATIONS: Sonography showed the inhomogeneous hepatic lesion now to be 6.0 x 7.5 cm. Computed tomography demonstrated a space-occupying mass, 7.5 cm in diameter, dorsal to the hepatic cyst, partly hypo-, partly hyper-dense with marginal spotty enhancement after contrast-medium injection. TREATMENT AND COURSE: As acute bleeding into the focal hepatic lesion was suspected, a laparotomy was performed and liver segments VII and VIII resected. On inspection there was a sharply demarcated yellowish-white tumor with a central haemorrhagic softening. Histology revealed focal nodular hyperplasia (FNH) without signs of malignancy. CONCLUSION: In the case of a known but not definitively diagnosed focal hepatic lesion, acute upper abdominal pain can be a sign of acute bleeding into the lesion.
Acute Disease↗
[Is splenectomy "en principe" necessary for radical gastrectomy with systematic lymphadenectomy?].
SUMMARY: In order to screen the necessity of splenectomy "en principe" we evaluated all patients suffering from gastric carcinoma between Jan. 1988--Apr. 1993 retrospectively. In total a group of 318 patients were treated and from these 261 patients were operated (resection rate 82%). In 30% of the patients (77 pat.) we performed a subtotal distal gastrectomy and in 70% (184 pat.) a radical gastrectomy with a D 2-lymphadenectomy. The splenectomy rate in the group of gastrectomy was 94% (173 pat.). In total 13% of the lymph nodes of the hilus of the spleen were infiltrated and an additional metastasis of the spleen was found in 1%. In carcinomas located at the minor curvature 13% had an infiltration of the lymph node station 10, in carcinomas located at the greater curvature in 17% and in carcinomas with a diffuse tumor growth in 10% respectively. Patients with a tumor located in the proximal stomach had an infiltration of the lymph nodes in 14% and in carcinomas of the antrum in 7% respectively. None of the patients having a UICC stage I/II had an infiltration of the lymph nodes at the hilus of the spleen, but 25% of the patients having a UICC stage III/IV. 2 patients from the latter group had an additional metastasis of the spleen. CONCLUSION: The indication of splenectomy is given only in advanced proximal tumor locations, especially in tumors of the greater curvature. In the early tumor stages and in the distal locations of gastric carcinoma it might be useful to perform a selective lymph node dissection of the hilus of the spleen in order to increase the completeness of the radical gastrectomy.
Gastrectomy↗
[Comparison of liver resection with sequential transarterial chemoembolization in stage pT3 or pT4 hepatocellular carcinoma].
Between January 1990 and January 1996, 39 consecutive patients with histologically improved pT3 or pT4 HCC tumors underwent curative resection (n = 19) or sequential transarterial chemoembolization (n = 20) with a median time interval of 7 weeks up to six times with an emulsion of Lipiodol, Epirubicin and Cisplatin. The 30-day mortality rate for all sessions of TA was 3.8% vs. 21.8% in the resection group (p < 0.05); the cumulative survival rate for the embolization group at 6, 12, 18 and 24 months was 72.3%, 50.1%, 41.2%, 35.4% vs. 42.1%, 31.6%, 31.6% and 14.2% following resection, which cannot be considered statistically significant. Patients with T3 and T4 HCC, treated with sequential embolization or resection, seem to have a comparable survival time.
Carcinoma, Hepatocellular↗
[Treatment of postoperative lung failure with prone positioning].
Of forty-three consecutive patients with severe adult respiratory distress syndrome (ARDS) treated in the prone position pulmonary function improved significantly in 39 patients during the first 12 h in prone position. Changes were most pronounced in patients with high QS/QT, as well as in patients in the early stages of ARDS. Twenty-eight patients could be weaned from the ventilator, and 22 patients were able to leave the hospital. These results suggest that prone position has an important role in the overall therapeutic approach to ARDS and should be used as early as possible.
Abdomen↗
Repeated administration of recombinant human insulin-like growth factor-I in patients after gastric surgery. Effect on metabolic and hormonal patterns.
OBJECTIVE: The primary objective of this investigation was to evaluate the anticatabolic effects of repeated subcutaneous administration of recombinant human insulin-like growth factor-I (rhlGF-I) in patients after gastric surgery. SUMMARY BACKGROUND DATA: The anabolic and protein-sparing effects of growth hormone are primarily mediated by IGF-I. Malnutrition and catabolic states result in increasing blood levels of growth hormone and decreasing levels of IGF-I. Experimental data showed that exogenous IGF-I could attenuate or reverse catabolism. METHODS: After giving their written informed consent, 38 male and female patients undergoing gastrectomy (age 40-75 years, body mass index 17-30 kg/m2) were treated with 80 micrograms/kg body weight rhlGF-I or placebo in a prospective, randomized, double-blind study for 5 consecutive days. Patients received a standardized total parenteral nutritional regimen with 3 g/kg body weight glucose and 0.1 g/kg body weight nitrogen. Nitrogen balance and 3-methylhistidine excretion were measured daily. Hormone profiles (IGF-I, IGFBP1, IGFBP3, cortisol, insulin, glucagon, triiodothyronine [T3], levothyroxine [T4], and thyroxine-binding globulin) were taken.
Adult↗
[Surgical therapy of esophageal cancer--early results].
PATIENTS AND METHOD: A prospective study was undertaken in 230 patients with carcinoma of the esophagus and of the cardia with infiltration of the distal oesophageal part from 1988 to 1993. RESULTS: According to postoperative UICC-classification 3% of patients had stage 0, 43% stage I/II and 54% stage III/IV. 162/230 were resected (resection rate 70.4%). 55% (89/162) of resected patients had thoracoabdominocervical, 38% (62) thoracoabdominal and 8% (11) transhiatal esophagectomy. Rate of anastomotic break-down was 1.9% (3/162). Clinical mortality decreased from 32% in 1988/89 to 11% in 1990/91 to at least 0% in 1992/93 (total 13%). CONCLUSION: Control of the postoperative phase is of decisive importance in decreasing mortality after esophageal resection, while surgical-technical problems seem to be solved. Esophagectomy is possible even as palliative measure in the presence of low mortality.
Adenocarcinoma↗