Biomedical subjects
Publications and source records attributed to J Fahlke.
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INTRODUCTION: Based on the fact that pancreatic carcinoma is still associated with poor outcome, the aim of the study was to determine frequency of early tumor cell dissemination using immunohistology in lymph nodes classified as tumor-free by conventional histopathology. METHODS: Fifteen patients with ductal pancreatic carcinoma and 10 patients with carcinoma of the papilla of Vater underwent radical tumor resection (resection status R0, tumor staging pTxpN0M0). In total, 229 lymph nodes classified as tumor-free by histopathology were investigated for disseminated tumor cells using antibodies against cytokeratin and CA19-9. As control, 81 lymph nodes obtained from patients with chronic pancreatitis were analyzed. RESULTS: In 55 of 229 lymph nodes (26.3%), cytokeratin-positive, disseminated tumor cells were detected. Cytokeratin-positive cells were found in at least one resected lymph node of each patient with ductal carcinoma of the pancreatic head (100%), whereas in patients with carcinoma of the papilla of Vater, no disseminated tumor cells were detected using the antibody against cytokeratin. Similarly, there was no detection of tumor cells (false-positive) in patients with chronic pancreatitis. In contrast, CA19-9 antigen was detectable in resected lymph nodes of each of the 25 carcinoma patients (pancreatic carcinoma and carcinoma of the papilla of Vater). Interestingly, 52 of 81 lymph nodes (64.2%) from the control group (chronic pancreatitis) were false-positive. CONCLUSION: Detection of disseminated tumor cells in lymph nodes using an antibody against cytokeratin is specific and suitable while use of an antibody against CA19-9 is not recommendable because of the high rate of false-positive results. The results may indicate that ductal pancreatic carcinoma generates early dissemination of tumor cells into lymph nodes. This may be one explanation for the poor outcome of this carcinoma compared with that of the carcinoma of the papilla of Vater (14 versus 48 months P < 0.05).
In the course of reconstruction of peripheral arterial occlusion processes, two gelatin-coated Dacron grafts and one collagen-coated Dacron patch were implanted in a 52-year-old male patient. Eight days following low-dose heparinization (5 days prior to surgery, 3 days postoperatively) with unfractionated heparin, with no clinical symptoms present, a dramatic isolated thrombocyte depression occurred, from 212 Gpt/l prior to surgery to 14 Gpt/l on postoperative day 3. Laboratory tests verified an HIT type II [heparin-induced platelet aggregation assay (HIPAA) and ELISA]. Despite immediate discontinuation of heparin and commencement of an anticoagulant therapy with Revasc and Refludan, an 8-week thrombocyte depression occurred which was eliminated only temporarily by administration of gammaglobulin. The specific antibody tests turned out positive for more than 5 months. Having ruled out other causes of thrombocytopenia, we assume that the case presented was either due to an interaction not elucidated to date or triggered by the grafts (gelatin/collagen/Dacron). The manufacturers of the grafts have disputed a heparinoid action.
BACKGROUND: Poor treatment results obtained with palliative chemotherapy for advanced gastric cancer indicate the need for new effective and well-tolerated regimens. PATIENTS AND METHODS: Forty-three patients with locally advanced or metastatic gastric cancer were enrolled in a phase II study to evaluate the efficacy and safety of combination chemotherapy with doxetacel 75 mg/m2 and cisplatin 75 mg/m2 given every three weeks. RESULTS: Thirty-nine patients were evaluable for response. Four achieved a complete response and twelve a partial response, for an overall response rate of 37.2% (16 of 43 patients; 95% confidence interval (CI): 22.98-53.72). Median time to progression was 6.1 months and median overall survival 10.4 months. Forty-two percent of all patients were still alive at one year and twelve percent at two years. The major toxicity was leukopenia which reached grade 3-4 in 18.6% (n = 8) of the patients. However, no febrile neutropenia occurred. Non-haematological toxicities were usually mild to moderate. Grade 3 toxicities included diarrhea (9% of the patients), nausea and vomiting (7%), and alopecia (7%). Severe ototoxicity with or without peripheral neuropathy developed after completion of chemotherapy in two patients. CONCLUSIONS: These results suggest that the combination of docetaxel and cisplatin has moderate toxicity and is an effective regimen for the treatment of advanced gastric cancer, both with regard to response rate and survival.
Simultaneous treatment of Salmonella typhimurium-induced symptomatic abdominal aortic aneurysm with associated spondylitis. Bacterially infected aneurysms associated with local spondylitis, while representing a potentially fatal clinical picture, are an operative challenge for vascular surgeons and orthopaedic surgeons alike. In this context, the concurrent occurrence of an infection with Salmonella typhimurium as a causative agent is a rare observation. The case report gives an outline of the simultaneous vascular and orthopaedic surgical procedure. The subrenal mycotic aneurysm was removed in a first step. The continuity of the aorta was restored centrally through an autogenic aortic graft with caudal anastomosis to a dacron vascular prosthetic tube. Initially, the latter was chosen of excessive length so as to facilitate the orthopaedic surgeon's approach. Upon completion of stabilising surgery of the vertebral column, the dacron tube was reduced in length as necessary and the surgical area was enclosed with an omentum majus plastic mesh. No complications were noted during the 18-month follow-up period.
We report the course of 2 patients with ruptured aneurysms of the iliac artery admitted in hemorrhagic shock which were treated successfully. These 2 cases demonstrate that a rupture of a retrogradely perfused aneurysm as a late complication of aortobifemoral bypass grafting is possible even after 10 years. Wether these aneurysms are causally connected with the peripheral run-off remains unclear. In our opinion, these 2 examples underline the importance of long-term follow up after resection of abdominal aortic aneurysms with femoral end to side bypass anastomoses. The goal is the early detection and therapy of metachronous iliac aneurysms before rupture.
PURPOSE: To report the endovascular repair of concomitant aneurysms of the abdominal aorta and both internal iliac arteries. CASE REPORT: A 72-year-old man with a 5.5-cm abdominal aortic aneurysm (AAA) extending to the right common iliac artery also presented with separate aneurysms of both internal iliac arteries. The patient refused conventional surgery, so an endovascular strategy was devised. Initially, the iliac aneurysms were sequentially coil embolized, allowing several weeks to elapse between the embolization sessions to encourage collateral development. A bifurcated Talent endograft was inserted successfully 8 months after the initial intervention; no evidence of endoleaks or mesenteric ischemia has been seen over a 1-year follow-up. CONCLUSIONS: This case illustrates the feasibility of inducing collateralization prior to endovascular AAA repair that would jeopardize internal iliac artery circulation bilaterally. Sequential embolization of the internal iliac arteries over several months initiates this response, paving the way for eventual endovascular repair of the primary aortic aneurysm.
The incidence and etiology of iatrogen vascular injuries have changed during the last years due to the fact that many vascular procedures, including invasive catheter procedures, minimally invasive interventions and osteosynthetic operations are more frequently performed. 66 patients who were treated between 1993 and 1997 were retrospectively analysed. The most common cause of surgical repair were lesions after catheter procedures (n = 47; 71.2%) followed by various other causes (traumatology n = 6, orthopedics n = 5, gynecology n = 4, general surgery n = 4). In patients with complicated catheterizations and need for acute vascular-surgical repair, the limb could only be preserved in 12 of 21 cases (57.1%). Vascular lesions on account of other operative specialities finally required an amputation in 3 patients. One patient in this group died. Besides the seriousness of injury one main reason for an unfavourable outcome was a delayed diagnosis with subsequent exceeding of the ischemic tolerance in 18 patients (27.3%). Some rare and serious complications are especially discussed.
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In a prospective clinical trial we treated 27 patients with metastatic colorectal carcinoma a continuous 24-h high-dose regimen of 2.6 g/m2 5-fluoroucil and 500 mg/m2 folinic acid per week for 6 weeks. To evaluate the effect of amifostine, a selective cyto- and radioprotector, in reducing chemotherapy-related mucositis, 740 mg/m2 amifostine was administered before chemotherapy, and the results were compared to 15 patients without amifostine treatment. In the amifostine group the dose was reduced or treatment was stopped because of mucositis observed in 6 of the 12 patients, while 13 of the 15 control patients could not be treated according to the treatment plan. The incidence of gastrointestinal side effects of WHO grade III or higher was reduced in the amifostine group, with no mucositis of this severity, versus 3 of 15 in the control group. The response rate was identical in the two treatment arms (33.3%).
While laparoscopic cholecystectomy has become the procedure of choice for the elective treatment of symptomatic cholecystolithiasis the question whether patients with acute cholecystitis should be operated laparoscopically or conventionally is still debated. Nevertheless, more and more surgeons tend to use the laparoscopic approach even in patients with acute cholecystitis. Of 1006 laparoscopic cholecystectomies performed at our hospital 42 were done for acute cholecystitis. Conversion to an open procedure was necessary in only one patient because of severe inflammatory changes. The overall mortality was zero. The average age was 45.9 years for all patients and 50.4 years for those with acute cholecystitis. The average operating time in patients with acute cholecystitis was 81 minutes compared to 62 minutes in patients who underwent elective laparoscopic cholecystectomy. The complication rate and the average hospitalization time did not differ significantly between the two groups. Our own data as well as the data retrieved from the literature seem to indicate that laparoscopic cholecystectomy is superior to the open procedure in the treatment of acute cholecystitis. Prerequisite is that the operation is performed less than 72 hours after the onset of the symptoms by an experienced operating team and the readiness to convert to open procedure if necessary. Under those circumstances laparoscopic cholecystectomy seems to be the treatment of choice for acute cholecystitis.
PURPOSE: To report the percutaneous endovascular management of popliteal artery lesions with a new polytetrafluoroethylene (PTFE) stent-graft. METHODS AND RESULTS: Three patients have undergone endovascular treatment in the popliteal region owing to: (1) an iatrogenic false aneurysm with arteriovenous fistula, (2) entrapment syndrome, and (3) an isolated arterial aneurysm. In each case, arterial occlusion was treated initially with thrombolysis. The underlying vascular lesions then were stented using the new Hemobahn endograft, a nitinol stent covered internally with PTFE. Each percutaneous procedure was completed successfully without major complications. During early follow-up (6 to 7 months), no signs of intimal hyperplasia, occlusion, or stent migration have been observed. CONCLUSIONS: Based on these early experiences, percutaneous treatment of stenotic and aneurysmal lesions in the popliteal artery using the Hemobahn endograft appears feasible and effective. Further experience and longer follow-up are required to evaluate this new prosthesis.
The surgical strategies in the treatment of operable breast cancer have changed basically within the last decades. Today the therapy of breast cancer is indicated by the individualization of the procedure in which the extent of the operative intervention is determined in first line in dependence of the clinical and histopathological results and the wishes of the patients. The current surgical strategies are indicated by a further reduction of radicalness in the operative procedure and a patient obtained strategy adapted to the individual risk. Goals of the reduction of the radicalness are discussed at the example of the extend of minimal tumor free margins and the technique of the "sentinel lymph node detection". The use of Van-Nuys classification is described as an example for an individual risc adapted strategy in the surgical treatment of breast cancer. Furthermore is discussed the significance of the extensive intraductal component, of lymphatic and blood vessel invasion and the patient's age for estimating the risk of of local recurrence after breast preserving therapy. Besides of all efforts there are still limits in reducing surgical radicalness of the therapy of breast cancer. That has to be taken into account in an adequate therapeutical concept.
Recommendations for adjuvant treatment of patients with breast cancer are given based on the International Consensus panel of adjuvant Therapy of Breast Cancer in St. Gallen in 1998. Possible therapeutical options (antihormonal therapy, chemotherapy with CMF or EC/AC) are discussed in dependence on the risc of recurrence. Problems of individual therapeutical strategies are discussed additionally.
Pancreatic cancer has a very poor prognosis despite surgical resection or chemotherapy. For patients with a pancreatic cancer stage III or IV, locoregional or systemic chemotherapy is often the only chance for treatment. In our opinion, locoregional treatment is currently the best concept.
Laparoscopic transperitoneal and endoscopic extraperitoneal adrenalectomy are two safe options in minimally invasive surgery associated with very low morbidity. The anterior transperitoneal approach we prefer yields a better exposure of the anatomic structures and allows the surgeon to orient himself more easily. In addition, various other laparoscopic maneuvers may be performed synchronously. We report on our own experience with eight laparoscopic transperitoneal adrenalectomies performed in four cases unilaterally and in two additional cases bilaterally during April, 1996, and January, 1997, in six patients aged 20 to 56 years. The indications were in four cases pheochromocytoma (operated on bilaterally in two cases), and in the remaining two cases adrenal Cushing's syndrome. The duration of surgery was approximately 240 min for bilateral adrenalectomy and 166 min for unilateral adrenalectomy, respectively, with an intraoperative blood loss of about 50 to 400 ml. Except for haematoma of the abdominal wall there were no other postoperative complications. The serum levels of interleukin 6 and 10 underline the minimal invasiveness of this technique, since there were only small increases of interleukin 6 and interleukin 10.
The role of hypothermic storage of rat kidneys on lipid peroxidation compared to its effect on mitochondrial respiratory parameters has been investigated. Rat kidneys were flushed with cold solutions of isotonic sodium chloride; Euro-Collins'; preservation solution containing histidine buffer, tryptophane, and alpha-ketoglutarate (HTK); or hypertonic citrate and then stored for 20 hr at 4 degrees C. After storage, the endogenous contents of malondialdehyde as well as the chemically (by Fe2+/ascorbic acid) and enzymatically (by Fe3+/ADP/NADPH) induced generation of malondialdehyde were measured in cortical homogenates and partly in mitochondria and microsomes by the thiobarbituric-acid reaction. Compared to the values measured in fresh, unstored kidneys, the levels of malondialdehyde were significantly higher in kidneys preserved in solutions of isotonic sodium chloride or HTK. This stimulating effect of the HTK solution on the generation of lipid peroxidation products could also be established when homogenate was incubated with this solution. Euro-Collins' and hypertonic citrate solution did not change the endogenous contents of malondialdehyde in kidneys during hypothermic storage. Both the chemically and enzymatically induced lipid peroxidation increased after hypothermic storage of kidneys in all solutions investigated. No direct relationship between the contents of malondialdehyde and respiratory mitochondrial parameters was detectable. The results demonstrate that the extent of lipid peroxidation does not correlate with preservation effectiveness.