Biomedical subjects
Publications and source records attributed to K H Muhrer.
About 1-2% of all tumors are found in the mediastinum. Any space-occupying swelling of the mediastinum has to be exstirpated. Even if a carcinoma cannot be completely removed, the tumor mass should be reduced as much as possible. The operation must not be delayed by any diagnostic uncertainties.
263 patients with severe thoracic trauma were treated between 1961 and 1977. In 219 cases, most of them being traffic accidents, the injury was caused by blunt trauma. 80% were thoracic emergencies. Injuries of the mediastinal organs were observed in 26 cases. Even the slightest suspicion of injuries of the airways demands bronchoscopy. In case of rupture early surgical intervention gives the best results. 3 of 7 patients with tracheo-bronchial rupture were saved. Complete rupture of the large vessels of the myocardium leads to fatal bleeding. Partial rupture can be survived. Angiography gives proof of dissecting aneurysm. 2 of our patients with traumatic aneurysms of the aorta have survived after resection of the aneurysm and interposition of a prosthesis. Massive bleeding into the pericardium causes shock and high venous pressure in most cases. In 2 cases of traumatic valve insufficiency a Björk-Shiley-valve could be implanted sucessfuly. Perforating thoracic injuries have been observed in 44 of our patients; 7 died. Besides surgical wound care and intravenous fluids, Bülau's drainage is often the only treatment necessary. While intraabdominal lesions require immediate laparotomy, lesions of the lung generally do not demand thoracotomy. However, whenever there is suspicion of injury to the mediastinal organs immediate surgery has to be performed.
Congenital cysts of the esophagus are rare tumors of the mediastinum. They are classified as foregut-cysts. Most of them are found accidentally on routine chest X-ray. They are seldom diagnosed preoperatively. Exstirpation of the cysts presents no major problems. Five patients with congenital esophageal cysts are presented.
263 persons with chest injuries were treated over a period of 16 years. 47 had performating chest injuries, in the remaining cases it was a blunt trauma. Prompt recognition of a life-endangering situation (cardiac tamponade, tension pneumothorax, mediastinal emphysema, massive haemothorax) is essential; radiological and laboratory diagnostic methods play a secondary role. The most effective emergency treatment is intercostal continuous suction; in many cases it is the only one needed. A haemothorax must be evacuated completely because of the risk of complications and fibrin formation. Thoracotomy is rarely, and surgical removal of lung tissue hardly ever, indicated. 30 persons needed emergency thoracotomy. Accompanying intraabdominal injuries, mostly rupture of the diaphragm and spleen, were observed in 45 patients. Late sequels were lung abscesses, posttraumatic cysts, pleural empyema and adhesions, atelectases. Decortication, if indicated, should be performed at an early stage.
10% of chest traumata are accompanied by injuries to the mediastinal organs. Since rupture of a bronchus may be masked by additional intrathoracic injuries any suspicion of such lesion must be verified by bronchoscopy. Symptoms of a shock condition after traumatization of the precordial region point to damage to the heart the extent of which may range from a slight disturbance of cardiac function (commotio cordis) to laceration of cardiac tissue and rupture of the myocardium. Enlargement of the mediastinum after a sufficiently forceful chest trauma should be examined by visualization of the aortic arch to elucidate its aetiology and exclude an aortic aneurysm. The mortality of chest trauma involving the mediastinal structures is 35%. This fairly high figure is partly attributable to severe accompanying injuries.
Primary or secondary implantation of the Erlangen magnetic stoma seal in case of colostomy or ileostomy is technically simple, although it requires a critical selection of patients and careful surgical technique. The best follow-up of the operated cases should be in the special protological clinics in the hands of stoma therapists. About 15% of the cases meet local complications and therefore the magnet-ring is explanted. An ideal continence is not always achieved. We hope that these patients can be better helped with magnetic stoma seal through further development.
1. After jejunoileostomy patients rapidly loose body weight. This loss of weight may turn out to be too small in cases where there is a reflux. 2. There is a direct relationship between the rapidity of the loss of body weight and the duration of gastro-intestinal passage. The shorter the duration of passage, the quicker the patient's loss of body weight. 3. Duration of passage remains approximately constant during the first 9 months after jejunoileostomy as shown by the evaluation of 52 patients. From the 15th month onward the duration of passage rises significantly and reaches 2-3 times its initial value from the 18th month onward. Simultaneously, a cessation of the loss of body weight is to be observed owing to an adaptation to the malabsorption.
Studies on intraabdominal infections have been difficult to compare in the past due to a missing system of classification for peritonitis. According to a recently developed classification system, secondary peritonitis, including spontaneous acute peritonitis, postoperative peritonitis and posttraumatic peritonitis, is the most common complication of severe intraabdominal infections. In several studies the mortality rate of postoperative peritonitis was still between 60% and 79%. Scoring systems were developed, some of them with the idea to predict mortality in peritonitis. Although the APACHE II score cannot predict the outcome of peritonitis in an individual patient, it is a reliable, valid and objective system for risk stratification in intraabdominal infections. Local trauma or bacterial contamination is responsible for an acute phase reaction, which involves the release of certain cytokines such as TNF-alpha, interleukin-1 (IL-1) and interleukin-6 (IL-6). The IL-6 seems to play an important role in the mechanism of the acute phase reaction, acting on hepatocytes to release acute phase proteins (e.g. CRP). Preliminary results of investigations of IL-6 levels in peritonitis indicate a possible role for IL-6 as a predictor of the outcome of peritonitis.
Since 1985, 150 patients with pancreatic ductal adenocarcinoma have been treated with the monoclonal antibody BW 494 in four different multicentric trials in Germany. The antibody recognizes a human pancreatic cancer associated antigen and mediates an antibody dependent cellular cytotoxicity (ADCC) in vitro, when human mononuclear cells are coincubated as effector cells. In patients with at advanced unresectable pancreatic cancer there where two phase-I-studies finished in 1987 and 1989, respectively, and one uncontrolled phase-II-study finished in 1988. In 1987, we started a controlled randomized trial in patients with resectable (Whipple) pancreatic cancer, which will be finished in 1990. There were no major side effects if the intravenous antibody application was restricted to a 10-d treatment protocol (up to 370 mg given in 10 different dosages). Human anti-mouse-antibodies could be demonstrated in all patients investigated for within 4 wk after immunotherapy. In patients with advanced pancreatic cancer (n = 87), monoclonal antibody treatment did not induce significant response rates. There was stable disease in 1/3 to 1/2 of the patients lasting three months or longer. Therapeutic success may be expected in patients with minor tumor burden.
Illumination of unstained 9 microns cryosections of lung tissue with 365 nm results in visible fluorescence light with a maximum intensity at about 460 nm. These fluorescence tomographical studies can be used for detecting carcinoma of the lung. The fluorescence pattern obtained can be matched nicely with histological findings. Since it takes less than 5 min for getting the fluorescence images, the fluorescence tomographical technique might be used in addition to established methods for determining the histology of a biopsy sample.