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J R Siewert

Publications and source records attributed to J R Siewert.

At least 19 recordsLinked to original sources
PubMed1992

[Laparoscopic cholecystectomy: ERCP as standard preoperative diagnostic technique].

In a prospective study 250 patients with proven cholelithiasis and clinical, biochemical and ultrasound indications for laparoscopic cholecystectomy (LC) underwent endoscopic retrograde cholangiography (ERCP) and (if bile-duct stones had been shown) endoscopic papillotomy (EPT). The biliary system was demonstrated in 229 patients (91.6%). Biliary tract stones were confirmed in 18 of 68 patients in whom they had been suspected clinically. In addition, ERCP revealed small stones in the bile-duct in eight of 154 patients with normal biochemical results and unremarkable ultrasound imaging, and in seven patients bile-duct anomalies which required EPT or open cholecystectomy. However, in retrospect five of the patients with cystic duct anomalies could have been treated by LC. The complication rate of ERCP/EPT was 3.2%. It is concluded from these results that, in view of the cost and potential risk to the patient, ERCP before LC can be limited to patients suspected of having bile-duct stones, even though small stones may be missed.

Adolescent↗
PubMed1992

Radical surgical procedure improves survival time in patients with recurrent ovarian cancer.

BACKGROUND: There is plenty of evidence that survival time associated with advanced ovarian cancer is predominantly related to the amount of residual tumor after primary operation. However, there are only few and inconclusive reports concerning the effect of second debulking procedures on survival time after relapse. METHODS: To evaluate the effect of radical second operation, 30 patients with clinically diagnosed relapses had second operations after a median recurrence-free interval of 16 months. Considerable efforts were made to resect all tumor tissue. Complete resection was achieved in 14 of 39 (47%) patients, and residual tumors smaller than 2 cm remained in 12 (40%) patients. In 19 (63%) patients, intestinal resections were necessary. Operation time, blood units needed, hospital stay, and complication rates were comparable to those associated with primary debulking procedures. RESULTS: Survival time after second operation was closely correlated with the residual tumor remaining after second surgical procedure and also with the length of the recurrence-free interval. Patients with complete resections had significantly longer survival times than those with residual tumors of less than 2 cm (median, 29 months versus 9 months; P = 0.004). Patients with a recurrence-free interval of more than 12 months had a longer survival time than those with a shorter disease-free time (median, 29 months versus 8 months; P = 0.002). Postoperative treatment also was shown to influence survival time, whereas grade of the tumor (P = 0.74), age of the patient (P = 0.87), and initial FIGO stage (P = 0.58) had no influence on survival time after second operation. Multivariate analysis (Cox regression) revealed that residual tumor after second surgical procedure (relative risk, 4.7) was the most important independent variable predicting survival time after second surgical procedure. Recurrence-free interval (relative risk, 2.7) and postoperative (second-line) treatment (relative risk, 3.0) were equally potent variables. Residual tumor after primary operation, was almost significant (P = 0.06) in the univariate analysis, but was canceled in the multivariate setting by the recurrence-free interval. Again, FIGO stage, grade of the tumor, and patient age had no predictive value. CONCLUSIONS: The authors conclude that radical surgical procedure can prolong survival times in patients with recurrent ovarian cancer. Patients who had a complete resection of cancer tissue in the primary operation or those who experienced a disease-free interval of more than 12 months after primary operation are most likely to benefit from second operation in recurrent ovarian cancer. Radical surgical procedure should be offered to these patients to enhance efficacy of second-line chemotherapy, which is of limited value in bulky recurrent disease.

Adult↗
PubMed1992

[The endosonographic staging of pancreatic carcinoma].

Endoscopic ultrasound (EUS), conventional ultrasound (US), computed tomography (CT) and angiography were compared in their assessment of local resectability in 35 consecutive patients (19 men, 16 women; mean age 49.8 [42-821] years) with non-metastatic carcinoma of the pancreas. The findings were made prospectively and independently of each other. EUS proved to be superior to transabdominal US and to CT in the diagnosis of tumour infiltration of the portal and splenic veins. For the portal vein the sensitivity was 93% by EUS, 14% by US and 36% by CT. Corresponding figures for the splenic vein were 92%, 39% and 69%. EUS was markedly superior to angiography in the diagnosis of portal vein involvement (sensitivity of 93% and 36%, respectively), but the two methods had similar sensitivity regarding splenic vein infiltration (92 and 100%). Tumour involvement of the coeliac trunk was diagnosed with higher sensitivity angiographically (86%) than by EUS (57%), CT (71%) or US (29%). Regarding T and N staging, EUS was superior to both US and CT. These data indicate that EUS is the most accurate method for local tumour staging of potentially resectable pancreatic carcinoma. It can replace angiography in the diagnosis of portal vein infiltration.

Adult↗
PubMed1992

[The quality of life after total gastrectomy for stomach carcinoma. Esophagojejunal plication with pouch versus esophagojejunostomy without pouch].

A group of 178 patients with total gastrectomy for gastric carcinoma were divided into two groups matched for sex, age, tumour stage and follow-up interval (29 pairs, 46 men and 12 women; mean age 63.4 [39-74] years) according to the type of reconstruction performed, oesophagojejunal plication with pouch or simple oesophagojejunostomy without pouch. Those with left-extended gastrectomy, follow-up period of 9 months or less, and local recurrence or metastasis were excluded. Quality of life was evaluated by means of three standardized questionnaires sent to all the patients: (1) general physical complaints; (2) satisfaction with life; and (3) psychosocial burden. Patients with pouch reconstruction declared more favourable results in 90 of the 94 questions contained in the questionnaire (96%) than the patients without pouch. Patients in the former group also had significantly fewer general physical complaints (P less than or equal to 0.05) and were significantly more satisfied with life (P less than or equal to 0.05) than those without pouch. Correlation analysis for the entire group (n = 58) indicated significant relationships especially between quality of life and postoperative nutrition and body weight. Technical surgical problems of total gastrectomy having largely been solved, the question of quality of life must increasingly determine the choice of treatment.

Anastomosis, Surgical↗
PubMed1992

Pylorus-preserving versus standard pancreatico-duodenectomy: an analysis of 110 pancreatic and periampullary carcinomas.

Pylorus-preserving pancreaticoduodenectomy (PPPD) has received increasing attention as a physiological alternative to the standard pancreaticoduodenectomy (PD) in patients with adenocarcinoma of the pancreatic head or the periampullary region. We evaluated mortality, morbidity and survival in 110 patients with pancreatic carcinoma (n = 53) or periampullary carcinoma (n = 57). In each group 31 patients underwent PD, the remainder PPPD. There were no differences in age, sex and tumour stage (UICC 1987) between patients undergoing PPPD or PD. Median follow-up was 24 months. There were no significant differences in mortality and morbidity rates between procedures. The mode of resection had no influence on survival in patients with periampullary carcinoma. Patients with pancreatic carcinoma who underwent PD had a significantly better survival rate compared with those who underwent PPPD (P less than or equal to 0.05). This was particularly so in patients with stage III tumours (P = 0.007). These data suggest that in patients with ductal carcinoma of the head of the pancreas, PD provides better survival than PPPD. However, PPPD appears to achieve equivalent results to PD in patients with periampullary carcinoma.

Adenocarcinoma↗
PubMed1992

Preoperative assessment of lymph node metastases in patients with gastric cancer: evaluation of the Maruyama computer program.

The probability of survival of patients with gastric cancer depends upon depth of wall penetration by the primary tumour and metastatic lymph node burden. Radical lymphadenectomy may lead to prolonged survival but with increased morbidity. A computer program from Maruyama, National Cancer Centre, Tokyo enables evaluation of individual survival time and infiltration of lymph nodes. This analysis was applied to a German population. Computer-aided predictions were determined retrospectively using the prognostic factors of sex, age, Borrmann classification, histology, depth of wall penetration, location and diameter of the tumour. Data were collected from 222 patients at the Technical University of Munich (median age 66 years, sex ratio (M:F) 2:1), who had been operated on (72 per cent total gastrectomy, 28 per cent subtotal gastrectomy) for gastric cancer. The predicted results were compared with the postoperative pathological findings. The prediction of node metastases was highly accurate (lymph nodes 13-16, 96 per cent; 7-12, 89 per cent; 1-6, 82 per cent). These computer predictions may provide perioperative information of therapeutic value.

Aged↗
PubMed1992

[Prognostic factors in diffuse peritonitis].

In order to evaluate their prognostic relevance for survival 46 variables were submitted to univariate as well as multivariate analysis in a group of 184 patients with diffuse peritonitis. In the univariate analysis a significant correlation with the outcome was found for the following parameters: age greater than or equal to 70 years, preexisting hepatic or cardiac disease, no eradication of the primary source of infection at first laparotomy for peritonitis, cardiovascular instability, respiratory failure, hyperbilirubinemia, thrombocytopenia, elevated serum creatinine and diminished creatinine clearance at the beginning and proof of pseudomonas aeruginosa in the peritoneal exsudate and of candida albicans in the blood culture during the course of the peritonitis. In the multivariate analysis the surgical eradication of the primary source of infection at the first laparotomy for peritonitis, serum creatinine at the beginning of peritonitis, age greater than or equal to 70 years and a preexisting hepatic disease proved to be the independent variables with significant prognostic relevance for survival of the patients.

Aged↗
PubMed1992

Interaction of gastroesophageal reflux and esophageal motility. Evaluation by ambulatory 24-hour manometry and pH-metry.

The present study addresses the question of whether esophageal motility shortly before, during, and after gastroesophageal reflux (GER) is different in patients with GER disease and healthy controls. Twenty-four-hour continuous recordings of intraesophageal pressures and pH were performed in 12 unselected patients with clinically proven GER disease and in 11 volunteers using a new ambulatory and digital recording device. All GER episodes in each studied subject were classified according to their associated motility pattern shortly before (induction period) and during (response period) GER. More GER episodes were analyzed in patients than in volunteers (median: 41 vs 26, P less than 0.05), and a total of 917 GER episodes (593 in patients, 324 in volunteers) was recorded. During the induction period patients more often had irregular esophageal contractions (median: 23% vs 13%, P less than 0.05) and less often had a peristaltic sequence (median: 6% vs 21%) than normals. No difference between patients and controls existed when comparing the frequency of negative pressure peaks or common cavity phenomena shortly before GER. During the response period peristaltic motility in patients was decreased (median: 10% vs 47%, P less than 0.05). We conclude that: (1) GER events in GER patients are more often associated with irregular esophageal contractions than in healthy controls; (2) GER patients present with a diminished, if any, esophageal peristalsis during GER; and (3) combined ambulatory manometry and pH-metry provides clinically useful information on the individual pathogenesis of GER disease, which is superior to the information retrieved by pH-metry alone.

Adult↗
PubMed1992

Vicryl-scarf-induced scarring around esophagogastric junction as treatment of esophageal reflux disease. An experimental study in the dog.

A ringlike structure around the cardia has proven to be sufficient in preventing gastroesophageal reflux, as seen with the Angelchick prosthesis. To avoid the insertion of a nonabsorbable foreign body, a scarring was induced by implanting a Vicryl scarf around the esophagogastric junction. Reflux disease was induced in 18 dogs by circular cardiomyomectomy. In 12 dogs, a Vicryl scarf was laid around the cardia; six dogs served as controls. All of the dogs in the control group either died or had to be sacrificed due to severe reflux esophagitis. All animals receiving the scarf survived the entire duration of the experiment. Endoscopically, only one case of temporary reflux esophagitis could be detected. Long-term pH-metry demonstrated complete reflux suppression after the third postoperative month. Radiographically, esophagogastric transit was always unimpaired. On autopsy, the scarf was found to have changed into a slim scarring after the sixth postoperative month and then remained unaltered. We conclude that inducing scarring around the cardia is as effective in reflux prevention as the silicone ring.

Animals↗
PubMed1992

Vascular anatomy of the gastric tube used for esophageal reconstruction.

This study investigates the actual, as contrasted with the presumed, blood supply of the greater curvature gastric tube commonly used to reconstruct the gullet after esophagogastrectomy. Arterial and venous corrosion casts of this tube were created in 30 cadavers and demonstrated the following: (1) The right gastroepiploic artery is the exclusive conduit of blood in the pedicle. (2) The contribution of the right gastric artery is negligible. (3) Although tributaries of the left gastroepiploic artery are distributed over the central portion of the tube, the connection between the right and left gastroepiploic vessels is minute. (4) The blood supply of the cranial 20% of the greater curvature tube is through a microscopic network of capillaries and arterioles. These findings constitute an anatomical argument for extremely gentle handling of the stomach throughout its mobilization, during construction and positioning of the tube, and during the anastomosis.

Adult↗
PubMed1992

Staging of pancreatic and ampullary carcinoma by endoscopic ultrasonography. Comparison with conventional sonography, computed tomography, and angiography.

In a prospective study, endoscopic ultrasonography was compared with transabdominal ultrasonography, computed tomography, and angiography in 60 consecutive patients with pancreatic (n = 46) and ampullary (n = 14) cancer considered to be candidates for surgery. The diagnostic value of these imaging procedures in determining local resectability was assessed. The diagnosis of ampullopancreatic malignancy was made by operation (n = 40) or puncture/biopsy (n = 20). In the 40 patients who underwent surgery, endoscopic ultrasonography was significantly superior to abdominal ultrasonography and computed tomography in determining tumor size and extent and lymph node metastases of pancreatic and ampullary cancer. Furthermore, involvement of the portal venous system as judged by histopathology or surgical exploration was correctly assessed by endoscopic ultrasonography in 95%, whereas angiography (85%), computed tomography (75%) and abdominal ultrasonography (55%) were less sensitive. Of 11 cases of portal venous infiltration found at surgery, endoscopic ultrasonography correctly predicted 10, abdominal ultrasonography only 1, computed tomography 4, and angiography 5 (P less than 0.05 for all three comparisons). Twenty patients did not undergo surgery for different reasons: of those, 9 patients were excluded from operation because of portal venous involvement as shown by angiography. Endoscopic ultrasonography detected portal venous invasion in all these cases. In contrast to the venous system, arterial encasement was less reliably detected by endoscopic ultrasonography. In conclusion, endoscopic ultrasonography is the most effective single imaging procedure for local tumor staging in pancreatic and ampullary cancer. Thus, endoscopic ultrasonography will improve the assessment of tumor resectability and further decrease the need for explorative laparotomy.

Adult↗
PubMed1992

Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy.

Preoperative cholangiography and subsequent removal of bile duct stones may increase the efficacy of laparoscopic cholecystectomy and reduce the rate of conversion to open cholecystectomy. Since there is little data on the incidence of choledocholithiasis in this group of patients, we undertook a prospective study on the routine performance of ERC in 288 patients selected for laparoscopic cholecystectomy. ERC succeeded in 264 of the 288 patients (91.7%) and showed a normal bile duct system in 227 (86.0%). Atypical bile duct anatomy was seen in eight patients. Open cholecystectomy was performed in seven of them but was judged to be absolutely necessary in only two cases (one patient each with Caroli syndrome and Mirizzi syndrome). ERC also revealed bile duct stones in 29 of 264 patients (11.0%) which had not been suspected on the basis of clinical, laboratory and ultrasonographic findings in nine cases (3.4%). EPT succeeded in all of the 29 patients with choledocholithiasis but open cholecystectomy was subsequently performed in four patients due to incomplete bile duct clearance (n = 3) or temporary bleeding after EPT (n = 1). The rate of ERC/EPT-related morbidity was 2.8%. It is concluded from a risk-benefit analysis in these patients that ERC should be restricted to patients with suspected bile duct stones. Following this strategy, small ductal concrements and bile duct abnormalities will be missed in 6.4% of cases but the clinical relevance of these findings is still unclear. In patients with combined gallbladder and common bile duct stones, preoperative EPT plus subsequent laparoscopic cholecystectomy appears to be an effective and time-saving therapeutic regimen which should be compared with open cholecystectomy plus common bile duct exploration in future studies.

Bile Duct Diseases↗
PubMed1992

Postoperative pulmonary complication rate and long-term changes in respiratory function following esophagectomy with esophagogastrostomy.

Upper abdominal surgery has a high incidence of postoperative respiratory complications. Although operations involving a thoracic as well as an upper abdominal incision as encountered in esophageal surgery are likely to be associated with an even higher complication rate and perhaps permanent alterations of respiratory function, only a few studies have addressed this problem. We evaluated the postoperative course of patients undergoing thoracoabdominal esophagectomy with esophagogastrostomy. Twenty patients were evaluated, of whom 10 (50%) developed respiratory complications as defined by our criteria, which were the simultaneous occurrence of rectal temperature over 38 degrees C on the first postoperative day and radiographic evidence of pulmonary infiltration. Although there is no general consensus regarding the diagnostic criteria of a postoperative pulmonary complication, we were able to validate the clinical relevance of our definition by showing that these patients suffered from a more severe and more prolonged impairment of global oxygen exchange than those who did not fulfill the criteria. They also required a longer period of respiratory support (median duration of intubation 12 vs. 3 days, P less than 0.005). A comparison of the preoperative pulmonary function with that determined at least 6 months after the operation showed that only vital capacity (VC) and total lung capacity (TLC) were significantly (P less than 0.05) reduced following the operation, but not to a clinically relevant degree (VC-6%, TLC-7%).

Adolescent↗
PubMed1992

[Analysis of prognosis-associated factors in pancreatic head and peri-ampullary cancer].

Between 1982-1990 we treated 461 patients with adenocarcinoma of the pancreas or the periampullary region. 125 (68 ductal pancreatic and 57 periampullary carcinomas) of these patients (27.1%) underwent resection. Hospital lethality was 3.6% (n = 4). Distribution of pT stages (UICC 1987) and frequency of complete resection (R0 vs. R1/R2) were significantly different between the periampullary and pancreatic tumors. This appeared to be due to the high frequency of pT1/2 periampullary tumors (49.2%) as compared to the prognostically equivalent pT1 tumors of the pancreas (1.9%). The absence of lymph node metastases significantly improved survival of periampullary tumors. This was not observed in tumors of the head of the pancreas. This data indicate that the poor prognosis of ductal pancreatic compared to periampullary cancer is primarily caused by their advanced stage at the time of diagnosis. In addition current resection techniques only inadequately respect the complex lymphatic drainage of the head of the pancreas.

Adenocarcinoma↗