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Biomedical subjects

J Mössner

Publications and source records attributed to J Mössner.

At least 37 records · Page 2Linked to original sources
PubMed2005

Malignant oesophago-pleuro-pericardial fistula in a patient with oesophageal carcinoma.

Pericardial and cardiac fistulae secondary to oesophageal or gastric tumours are a rare complication. We report about a 50-year-old male patient with a 10-month history of distal oesophageal carcinoma with lung and liver metastases who was referred to our hospital after 6 cycles of palliative chemotherapy at the beginning of March 2004. The patient presented with dysphagia, dyspnea, tachycardia, and hypotension. Purulent pericardial and bilateral pleural effusion was diagnosed, and the patient was treated with antibiotics, repeated pleurocentesis and pericardial drainage with daily polihexanide lavage. Oesophagogastroduodenoscopy, Peritrast swallow and computed tomographic scans of chest revealed a malignant oesophago-pleuro-pericardial fistula. A total of three coated, expandable metal stents were inserted into the oesophagus, which sealed successfully the fistula. Unfortunately, the patient succumbed to his carcinoma three months later.

Esophageal Fistula↗
PubMed2005

[Current diagnostics and therapy for carcinomas of the biliary tree and gallbladder].

Carcinoma of the biliary tree are rare tumours of the gastrointestinal tract with a rising incidence during the last years. Biliary neoplasms are classified into intra- and extrahepatic cholangiocarcinoma (Klatskin tumour, middle and distal extrahepatic tumours), gallbladder cancer, and ampullary carcinoma. Transformation of normal into malignant bile duct tissue requires a chain of consecutive gene mutations, similar to the adenoma-dysplasia-carcinoma-sequence in colon cancer. Abdominal ultrasound, combined non-invasive magnetic resonance cholangiography/tomography (MRC/MRT), and facultatively endoscopic retrograde cholangiography (ERC) for unclear diagnosis, represent the gold standard for primary diagnosis. For ampullary carcinoma, endosonography and endoscopic biopsy are the diagnostic tools of choice. Cure is attainable only by formal curative radical surgical resection. Increasing surgical radicality within the last years enabled clearly improved 5-year survival rates. In contrast, there has been no clinical benefit for adjuvant and neoadjuvant therapies. For palliation, bile duct stenting and photodynamic therapy are established methods. Radio- and chemotherapy should be reserved for clinical studies. New therapeutic approaches include brachytherapy, the use of modern chemotherapeutics, COX-2- and tyrosine kinase-receptor-inhibitors.

Algorithms↗
PubMed2005

[Is 18F-FDG-PET suitable for therapy monitoring after palliative photodynamic therapy of non-resectable hilar cholangiocarcinoma?].

BACKGROUND: If existing biliary drainage is insufficient, photodynamic therapy (PDT, laser treatment after application of a photosensitizer) is an already established adjunct to palliative therapy for progressing hilar cholangiocarcinoma (Klatskin tumours), since it prolongs survival and improves quality of life. Experimental studies of other tumour entities showed that (18)F-FDG-PET ( (18)F-fluorodeosxyglucose-positron emission tomography) may play a role in monitoring tumour response to PDT. Furthermore, previous studies have revealed a high accuracy of this method for the detection of hilar cholangiocarcinoma. Therefore, the aim of the present study was to investigate the feasibility of (18)F-FDG-PET as a follow-up screening method in patients with hilar cholangiocarcinoma who underwent PDT. PATIENTS AND METHODS: 10 patients were examined by (18)F-FDG-PET before and 4 - 6 weeks after PDT. The following parameters were evaluated: maximum and mean SUV in the tumour, the ratio of maximum SUV in the tumour and mean SUV in the liver, the vital tumour volume, as well as bilirubin and CA 19 - 9 levels. RESULTS: All tumours were detected by (18)F-FDG-PET. Within a period of 4 - 6 weeks after PDT the cholestasis parameter bilirubin decreased significantly. However, SUV-associated parameters did not show a significant change after treatment while the estimated vital tumour volume even increased. DISCUSSION: PDT does not effect a relevant reduction of tumour mass in non-resectable hilar cholangiocarcinoma. However, PDT leads to a significant reduction of cholestasis. If (18)F-FDG-PET is suitable for monitoring the effect of new palliative therapeutic approaches, like brachytherapy, the use of modern chemotherapeuticals, COX-2 and receptor-tyrosine kinase inhibitors, perhaps also in combination with PDT, has to be further investigated.

Bile Duct Neoplasms↗
PubMed2005

Are endoscopic antireflux therapies cost-effective compared with laparoscopic fundoplication?

BACKGROUND AND STUDY AIMS: A number of endoscopic antireflux therapies (EATs) have emerged as potential nonmedical treatment options for patients with gastroesophageal reflux disease (GERD). Concerns about clinical efficacy and costs have given rise to debate about their role in GERD management. The costs of laparoscopic fundoplication (LF) were compared with the costs of EAT when used in a sequential strategy that reserves the option of LF for EAT failure. METHODS: A simple mathematical criterion of direct medical costs was applied. Published articles concerning EAT were reviewed to assess its effectiveness, durability and costs, in order to estimate the parameters of the model. The costs of EAT and LF were evaluated from the perspective of a German third-party payer. Only direct medical costs were considered. RESULTS: Assuming that EAT has no impact on potential LF later on, the outcome of both strategies (LF, or EAT first with LF in case of failure of EAT) is identical and preference is a simple question of costs. The sequential strategy in nonmedical GERD treatment would be preferable if the long-term relief rate with EAT exceeds the ratio of the cost of EAT to the cost of LF. Long-term success rates of EAT do not exceed 0.65. At current prices EAT is clearly not cost-effective in Germany. CONCLUSION: Our simple criterion indicates that EAT would only be cost-effective and beneficial in a sequential strategy if the costs of EAT were to be decreased to around 30 % of current retail prices. However, long-term studies and randomized controlled trials are necessary to finally determine the role of EAT in GERD treatment, and the preference may change in either direction.

Cost-Benefit Analysis↗
PubMed2005

Developments in the inhibition of gastric acid secretion.

Understanding the physiology of gastric acid secretion and the pathophysiology of acid-related diseases (e.g. gastrooesophageal reflux and peptic ulcer) has led to the development of numerous ways to decrease acid exposure. Pharmacologically one can try to neutralize secreted acid by antacids, prevent stimulation of the parietal cell, improve mucosal defences and block the functioning of the proton pump. Proton pump inhibitors (PPIs) inhibit the final step of acid secretion, and are currently the most potent acid inhibitors. Major therapeutic improvement within the PPI class appears unlikely, as agents in this class share similar chemistry, mode of action, and pharmacokinetic profiles. New approaches that block acid secretion are now being developed. Gastrin (CCK2) receptor antagonists and potassium-competitive acid blockers (P-CABs) are in clinical development.

Acetylcholine↗
PubMed2004

[Pancreatico-pleural fistula in chronic pancreatitis with necrosis of the pancreatic tail].

HISTORY AND CLINICAL FINDINGS: A 68-year-old male was admitted to the hospital with progressive dyspnea and thoracic pain radiating to the shoulder, back and upper abdomen. The patients medical history included hypertension, diabetes and chronic pancreatitis with splenic vein thrombosis. INVESTIGATIONS: Laboratory findings showed no signs of myocardial infarction, but pronounced inflammation. The ECG was normal. Chest X-ray revealed a massive left-side pleural effusion with partial lung atelectasis. An abdominal CT-scan showed no signs of acute pancreatitis. Puncture of the pleural effusion revealed elevated amylase and lipase. ERCP showed pancreatic duct stenosis, partial necrosis of the pancreatic body and peripancreatic necrosis with a pancreatico-pleural fistula. TREATMENT AND CLINICAL COURSE: After ballon-dilatation of the constricted pancreatic duct, a plastic stent and a nasopancreatic drain were inserted into the necrosis and into the fistula. Drainage and antibiotic therapy led to regression of the necrosis within 3 weeks. With external pleural drainage and octreotide therapy almost complete regression of the pleural effusion and closure of the pancreatico-pleural fistula could be achieved within 3 weeks. CONCLUSION: Complications of chronic pancreatitis such as necrosis and fistulas are rare, but important differential diagnoses in patients with chronic pancreatitis and chest pain. A combination of transpapillary or transgastral endoscopic drainage procedures and pleural drainage, sometimes with additional octreotide therapy is the treatment of choice.

Aged↗
PubMed2004

The role of acid suppression in patients with endoscopy-negative reflux disease: the effect of treatment with esomeprazole or omeprazole.

BACKGROUND: Patients with endoscopy-negative reflux disease have reflux symptoms, mainly heartburn, but not mucosal breaks characteristic of erosive oesophagitis. Standard-dose proton pump inhibitors can provide symptom relief in endoscopy-negative reflux disease but the effect of greater acid suppression has not been studied. AIM: To test the hypothesis that esomeprazole produces heartburn resolution in a greater proportion of patients with ENRD than omeprazole. METHODS: Three multi-centre randomized, controlled, double-blind, 4-week acute treatment studies were conducted in endoscopy-negative reflux disease patients. In study A (n = 1282), patients received either esomeprazole 40 mg, esomeprazole 20 mg or omeprazole 20 mg daily; in studies B (n = 693) and C (n = 670) patients received either esomeprazole 40 mg or omeprazole 20 mg (B), and esomeprazole 20 mg or omeprazole 20 mg (C), respectively. RESULTS: Resolution of heartburn at 4 weeks (no heartburn symptoms during the last 7 days) was achieved in similar proportions of patients in each treatment arm in study A (esomeprazole 40 mg, 56.7%; esomeprazole 20 mg, 60.5%; omeprazole 20 mg, 58.1%), study B (esomeprazole 40 mg, 70.3%; omeprazole 20 mg, 67.9%) and study C (esomeprazole 20 mg, 61.9%; omeprazole 20 mg, 59.6%). There were no significant differences between treatment groups within each study. CONCLUSIONS: More than 60% of endoscopy-negative reflux disease patients reported heartburn resolution but, after 4 weeks of therapy, these proportions did not differ significantly between treatments.

Adult↗
PubMed2004

[Pyogenic liver abscess in chronic alcoholic pancreatitis].

HISTORY AND ADMISSION FINDINGS: A 44-year-old patient was transferred for further treatment of pyogenic liver abscess and a severe attack of a chronic pancreatitis for strong upper right quadrant abdominal pain and recurring fever. INVESTIGATIONS: Laboratory results revealed a significant inflammatory constellation. Abdominal ultrasound was performed which showed a big pyogenic abscess in the right lobe of the liver. Escherichia coli and Enterococcus faecalis could be isolated from abscess aspirates. Endoscopic retrograde cholangiography (ERC) without access of the pancreatic duct showed stenosis of the Ductus hepatocholedochus which was treated with a biliary endoprothesis. DIAGNOSIS, TREATMENT AND COURSE: Antibiotic treatment and percutaneous drainage led to complete remission of the abscess. A few days after discharge the patient returned with identical clinical symptoms. Abdominal ultrasound showed recurrence of the abscess. Because of excessively high pancreatic amylase in aspirated abscess material the patient underwent endoscopic retrograde cholangiopancreaticography (ERCP). There, a pancreatico-hepatic fistula was seen, probably the result of necrosis caused by a severe acute attack of the chronic pancreatitis. After insertion of a naso-fistular drainage, continous rinse and appropriate antibiotic therapy both abscess and fistula completely disappeared without recurrence. CONCLUSION: The rare case of a pancreatic fistula should be considered when a pyogenic liver abscess follows an episode of acute pancreatitis or attack of chronic pancreatitis. Determination of pancreatic amylase in aspired abscess material can be an important step towards correct diagnosis.

Adult↗
PubMed2004

[26-year-old patient with ulcerative colitis and anemia].

A 26-year-old patient was admitted to the hospital because of severe anemia and exacerbation of ulcerative colitis. Laboratory tests revealed a hemolytic anemia and elevated parameters of acute phase reaction. Ten months ago an autoimmune hemolytic anemia was diagnosed. Three months before admission splenectomy was performed due to ongoing hemolytic exacerbations despite treatment with corticosteroids. Anemia is a common problem of inflammatory bowel disease. The association of autoimmune hemolytic anemia and ulcerative colitis presented in this case report is a rare complication of ulcerative colitis. The autoimmune hemolytic anemia is often refractory to corticosteroids. Immunosuppressive treatment with azathioprine induced a sustained remission in our patient, thereby a total colectomy could be avoided.

Adult↗
PubMed2004

[Conservative and interventional endoscopic therapy of biliary tract carcinoma].

Endoscopic therapy is central to the palliative treatment of bile duct carcinoma. In obstructive jaundice, biliary drainage has few complications and relieves symptoms reliably. It can prevent further complications and is indispensable to the treatment of cholangitis. The principal drawback of biliary stents is stent occlusion and cholangitis. Prophylactic antibiotics were not proven to be effective. Technical details concerning material, number and location of stents await further clarification. Photodynamic therapy is an emerging adjunct to palliative therapy of biliary cancer. Preoperative biliary drainage in obstructive jaundice is not warranted as a routine intervention. It may be indicated, though, as preoperative bridging or to allow liver function to recover before major hepatic surgery. Finally, stenting of postoperative bile duct stenosis is gaining increasing acceptance.

Biliary Tract Neoplasms↗
PubMed2004

[Best supportive care of pancreatic carcinoma].

The incidence of pancreatic cancer is about 10,000 cases a year in Germany. The role of surgery as a curative modality is limited. The 5-year survival for all stages remains less than 5%. Pain, cachexia, jaundice, nausea, fatigue and depression are frequent symptoms which reduce the quality of life for affected patients. Therefore, amelioration of symptoms is a major goal of palliative care. Chemotherapy may yield a moderate survival benefit. Gemcitabine is the drug of choice in metastatic pancreatic cancer. In locally advanced disease, radiochemotherapy can be considered. Different treatment strategies against molecular targets are currently tested in clinical trials.

Adenocarcinoma↗
PubMed2004

[Unclear liver fibrosis in a 42-year-old patient with polycythemia vera].

A 42-year-old patient was admitted to hospital because of ascites and polyglobulia. Laboratory tests revealed reduced liver function and a significant elevation of all three hematopoietic cell lines. Liver fibrosis and polycythemia vera were diagnosed by histologic examination. The most frequent causes for liver fibrosis were serologically excluded. Ultrasound combined with Doppler imaging revealed an obstruction of the right hepatic vein, which was indicative of Budd-Chiari syndrome. BCS can occur under fulminant and nonfulminant conditions, which can result in progressive damage of the liver. Phlebotomy and combined therapy with low-dose aspirin and anagrelide achieved permanent reduction of the elevated blood parameters. In the follow-up the patient's clinical course was stable without hepatic decompensation.

Adult↗
PubMed2004

Endoluminal gastroplication: what are the predictors of outcome?

BACKGROUND: Endoluminal gastroplication (EndoCinch) has emerged as an endoscopic anti-reflux therapy, but predictive factors for symptom relief have not been established. The aim of this study was to evaluate the major determinants to predict outcome in patients treated with EndoCinch. METHODS: A total of 53 consecutive patients, treated with EndoCinch at a single center were included in this prospective study. Inclusion criteria were symptoms of chronic heartburn, dependency on proton-pump inhibitors, documented pathological esophageal acid exposure, and a hiatal hernia smaller than 3 cm in length. All patients underwent endoscopy, 24-h pH monitoring, esophageal manometry, barium esophagram, and a detailed questionnaire regarding their symptoms before treatment. Patients were stratified into a responder and a non-responder group using a questionnaire at 3-month follow-up. A multivariate analysis was performed. RESULTS: The success rate was 64% (34/53 patients). Three variables weresignificantly predictive for successful endoscopic anti-reflux treatment at the multivariate level: presence of typical symptoms (P=0.01), complete symptom relief with acid suppressive therapy (P=0.01), and normal lower esophageal sphincter pressure (P = 0.04). Not predictive of outcome were age, body mass index, esophagitis, other manometric findings, hiatal hernia size, or pathological level of pH <4/24 h. Barium esophagram did not add any additional predictive information. CONCLUSIONS: Since no single factor can predict outcome after EndoCinch, a careful patient selection is mandatory to maximize the success rate. The ideal candidate for EndoCinch is a gastroesophageal (GERD) patient with a normal lower esophageal sphincter pressure, whose typical symptoms completely resolved with acid suppressive therapy.

Adult↗