Biomedical subjects
Publications and source records attributed to K Rückauer.
Benign neoplasms of the ovary originating from epithelial tissue are common tumors in adult women. They are, however, rarely seen in children or adolescent girls. Here the authors present a case of an ovarian mucinous cystadenoma in a premenarchal girl. To our knowledge, there are only 5 other cases reported in the literature.
The introduction of proton pump inhibitors (PPI) and laparoscopic fundoplication in the treatment of gastroesophageal reflux disease offered an opportunity for definitive healing. The indication for surgery is the failure of medical treatment, recurrence of symptoms following conservative treatment, severe side effects of the medication, and the patient's wish to stop taking drugs. The laparoscopic treatment has a low rate of complications. Apart from temporary dysphagia (30%), rapid satiety, increased flatulence and suppressed eructation are possible undesirable sequelae. Intra-operative bleeding and organ perforation (1%) are major feared occurrences. The rate of conversion to open surgery is 5.8%, and the mortality rate is 0.1%. Persistent dysphagia in 3.4% may be caused by a slipped cuff. A revision procedure is necessary in 0.7% of the patients. Patient satisfaction with the results of the operation ranges between 87 and 100%.
BACKGROUND: The overall survival rate for patients with an esophageal cancer remains poor. As a consequence, preoperative chemoradiation was introduced for patients with tumor stage T >1 M0 regardless of tumor histology or localization. However, factors predicting response to this therapy pretherapeutically are largely unknown. METHODS: Clinical results of preoperative chemoradiation were investigated. The rates of proliferation and apoptosis were determined in pretherapeutic tumor samples and correlated with tumor response and long-term survival after surgery. RESULTS: A complete tumor response due to chemoradiation (n = 42; cervically localized tumors excluded) was achieved in 11 patients (26%) after resection. Five-year survival rate was significantly improved in these patients compared with those who did not respond to chemoradiation (48% versus 5.5%; P = 0.003). Chemoradiation was performed without benefit in 43%. Perioperative hospital mortality rate was 14.3% in all patients. No correlation of apoptosis with response to chemoradiation or postoperative long-term survival was observed. However, there was a clear correlation between the proliferation rate as determined by MIB-1 immunohistology. Five-year survival rate of patients with a proliferation index (PI) >/=39% was 38% compared with 0% in tumors with a PI <39%. Tumors with a PI >/=39% responded to chemoradiation in 71.4%, but 100% of tumors with a PI <39% did not. Mean survival time of these patients was 33 months and 11 months, respectively (P = 0.015). CONCLUSIONS: The results indicate that the PI may be used for stratification of patients treatment prior surgery. However, these results need further validation in larger patient numbers in the search for factors indicating response pretherapeutically to preoperative chemoradiation in esophageal cancer.
BACKGROUND: Various handles are available for use in minimally invasive surgery. Nonergonomic positioning of the hand and fingers can lead to pressure areas, nerve irritation, and rapid fatigue. This study was designed to compare the ergonomic efficiency of several different handles, along with the concepts underlying them, in an attempt to find the best one for laparoscopic surgery. We also consider whether the position of the surgeon in relation to the patient and the posture of the surgeon have any influence on the use of the handles. METHOD: A ring handle positioned in-line (the Microsurge/Vygon 01-1007), an axial handle (the Aesculap PM-953), a shank handle (the Wilo 25.00), and a functional model of a new ergonomic multifunctional handle (the MFEHG Schafreuter) were tested and evaluated by 15 volunteers during an objective test using a transparent pelvitrainer with the left and right hand in a frontal and left and right lateral positions. Our analysis was based on their subjective answers to a questionnaire developed from ergonomic checklists and the semiquantitative observations of the test leader about their posture during testing. RESULTS: There were no significant differences in the results of the objective tests. Subjectively, the shank handle was preferred by most test persons, followed by the functional model for the right hand and the axial handle for the left hand; the ring handle positioned in-line scored poorly for both right and left hands. Arm movements were greater in the latter than in the frontal position. CONCLUSIONS: A clear recommendation for any one of the three currently available handles cannot be given. The results obtained with a simple model of a multifunctional handle were highly promising, and it may be possible to extend it to a real multifunctional instrument.
In children with short-bowel syndrome and the need for long-term parenteral nutrition, hepatic dysfunction is a multifactorial phenomenon that has not been completely understood. Alterations in gut motility lead to intraluminal stasis which is thought to be a major etiologic factor for bacterial overgrowth and subsequent cholestasis, especially when the ileocecal valve is absent. We report on two infants with short-bowel syndrome caused by gastroschisis and intestinal atresia. The intestinal lengths after resection were 18 and 55 cm. Long-term parenteral nutrition (PN) was obligatory due to intestinal shortness in the first patient and dilatation of the preatretic bowel segment with ineffective peristalsis in the second patient. Despite multiple trials of enteral nutrition and medical therapy for gut decontamination and stimulation of bowel motility, hepatopathy developed in both patients in a similar period of time and to about the same degree. At the age of 4 and 6 weeks, respectively, increasing bilirubin values were measured. Deterioration of liver function and thrombocytopenia at the age of 3 to 4 months led to the diagnosis of acute cytomegalovirus (CMV) infection. Treatment with ganciclovir followed. Both patients died of acute liver failure at the age of 7 and 9 months, respectively. Additional hepatic injury secondary to CMV infection might have contributed to the rapid deterioration of liver disease. Screening for further hepatotoxic factors, especially infectious etiologies, is therefore recommended in children with short-bowel syndrome. Liver transplantation should be considered early in cases of progressive hepatic dysfunction.
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Three patients suffering from extensive cavernous lymphangiomatosis are presented here. They were examined by MRI using RARE-MR hydrography (rapid acquisition with relaxation enhancement) as well as conventional spin-echo sequences. RARE sequences, which depict each fluid-filled lymphatic space, can be used for screening. RARE-sequences help to shorten investigation time, particularly in cases involving the skeleton. The imaging strategy can be changed according to the results of this sequence. It may be performed prior to spin-echo sequences and facilitates follow-up investigations. RARE sequences distinguish between lymphangiomatosis and hemangiomatosis, or a combination of the two.
We report a retrospective analysis of 61 patients admitted during the years 1974 to 1992 after having recently swallowed a corrosive agent. Within 24 hours, the localisation, severity and extent of the injury had been determined by endoscopy. In 13 patients the injury was restricted to the oropharynx, and in 48 it involved esophagus, stomach and duodenum. Fourteen had sustained a second degree injury, and 16 a third degree injury. Out of five patients with third degree injuries who were treated by operation within the first three days, two survived. Two patients operated upon for complications after 10 days of conservative treatment died. The total mortality was 21%, but 56% for those who had received a third degree injury. Thirteen patients developed a stenosis (27% of those with gastroesophageal lesions). Esophageal strictures were dilatated with bougies, but stomach stenoses were treated by resection. Of the 12 patients treated by dilatation, 4 sustained perforations and 4 of them were free of symptoms for a considerable period of time (more than 4 years).
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We have recently shown that ERCP is the most useful technique for detecting a biliary origin of acute pancreatitis and can be done without side effects. We now report on a second series of 50 patients with acute pancreatitis in whom ERCP, computed tomography (CT), ultrasound (US), and clinical and laboratory assessment were performed within the first 24 to 48 hours of hospitalization. A score for ERCP, CT and US was used to assess the severity of the disease. Patients were followed up until discharge or death and their condition classified according to outcome as mild (less than or equal to 1 complication), severe (greater than 1 complication) or fatal. ERCP was superior in detecting choledochal stones (ERCP 100%, US 25%, CT 50%) and dilated intrahepatic ducts (ERCP 75%, US 75%, CT 37%) but not gallbladder stones (ERCP 70%, US 100%, CT 60%). When the ERCP severity score was calculated there was no relevant difference between patients thereafter having a mild course (0.66 +/- 0.91, range 0-3), a severe course (1.3 +/- 0.80, range 0-3), or a fatal outcome (1.0 +/- 1.1, range 0-3). In contrast, the CT score was different in all three groups (mild: 3.0 +/- 1.9; severe: 5.3 +/- 3.2; lethal: 6.3 +/- 3.1) as was the US score (mild: 1.5 +/- 1.3; severe: 3.2 +/- 2.3; lethal: 4.4 +/- 1.4). It is concluded from these results that ERCP is of value in defining the origin of acute pancreatitis. When a biliary origin is detected this can lead to immediate treatment using endoscopic sphincterotomy.(ABSTRACT TRUNCATED AT 250 WORDS)
The usefulness of surgical treatment of inflammatory bowel disease is determined by the results that can be achieved. In Crohn's disease, in addition to minimal resections, non-resective procedures such as stricturoplasty, are also available for the treatment of acute and chronic complications. The operative treatment of peri-anal Crohn's lesions is determined by the acute or chronic complications that develop. Ulcerative colitis can be cured by complete removal of the colorectal mucosa, and malignant degeneration thus avoided. Continence-preserving colectomy with proctomucosectomy and ileo-anal pouch anastomosis obviates the need for a permanent ileostomy.
In a retrospective analysis the diagnostic procedure was evaluated in patients with acute lower gastrointestinal bleeding. Bleeding sources were localized distally to the ligament of Treitz in 233 patients (1979-1988). Patients with hemorrhoidal bleeding were not included. Following exclusion of an upper gastrointestinal bleeding the diagnostic procedure was initiated with a recto-/colonoscopy. Lesions were detected in 77% of the treated patients (n = 136). Angiography localized the bleeding in 68%, in combination with colonoscopy the identification of the bleeding source reached 86.5% in the treated patients. Following scintigraphy the bleeding source was determined in 89.7% of these patients. The sensitivity of colonoscopy (0.93) was superior to the angiography (0.78) and to the scintigraphy (0.75). Apart from neoplasms and adenomas angiodysplasia and Meckel's diverticula were the most common sources of the bleeding in patients who underwent operation. In 61 patients endoscopic therapy was performed, however, 6.5% of these patients had to be operated on later because of persistent bleeding. All together 79 patients underwent operation, 31 for bleeding and 48 for other reasons. 12 patients died, 6 of them were operated on for the bleeding, the other for neoplasms.
Experimental studies have shown that interleukin-6 induces all major acute-phase proteins in the liver, including C-reactive protein. In 50 patients with acute pancreatitis, the serum concentrations of interleukin-6 and C-reactive protein were determined daily during the first week of hospitalization. Patients were divided into three groups according to clinical criteria: mild pancreatitis (less than or equal to 1 complication; n = 25), severe pancreatitis (greater than or equal to 2 complications; n = 15), and lethal outcome (n = 10). Patients with mild disease showed initially slightly elevated levels of interleukin-6 (22.0 +/- 9.8 U/mL) that decreased to low levels within 4 days (5.0 +/- 1.0 U/mL). In patients with severe pancreatitis, serum concentrations of interleukin-6 were initially clearly elevated (35.0 +/- 7.5 U/mL) and remained slightly elevated until day 7 (13.0 +/- 2.0 U/mL). Patients with lethal outcome had markedly elevated initial interleukin-6 concentrations (61.0 +/- 15.0 U/mL) that decreased but were still elevated at day 7 (26.0 +/- 2.5 U/mL). In all three groups, C-reactive protein concentrations followed the course of interleukin-6 concentrations by 1 day. There was a positive correlation between maximal interleukin 6 concentrations and maximal increases in the serum concentrations of C-reactive protein (r = 0.66). At days 1 and 2, increased (greater than 15 U/mL) interleukin-6 concentrations (positive predictive value, 91%; negative predictive value, 82%) predicted a severe or lethal course of the disease more accurately than elevated [greater than 0.10 g/L (greater than 10 mg/dL)] C-reactive protein concentrations (positive predictive value, 67%; negative predictive value, 79%). In conclusion, elevated serum concentrations of interleukin-6 followed by increased levels of C-reactive protein reflect the severity of acute pancreatitis.
Using percutaneous-transhepatic cholangioscopy with a guided small calibre, cholangioscope (3.5 mm) in patients with obstructive jaundice it is possible to perform biopsies under visual control or to look for the exact intraductal extension of a tumor with only little stain on the patient. The access may be via a puncture of the right or the left hepatic duct. Since 1987 we have used this method 61 times in 45 patients. Some 32 patients suffered from malignancy of the bile duct. Of 13 patients with benign obstruction we performed a bougienage in 8. The other 5 patients were treated by stone extraction.
Complexes of granulocyte elastase and alpha 1-antitrypsin are markers for granulocyte activation. In 75 patients with acute pancreatitis these complexes were immunologically determined daily in plasma during the first week of hospitalization. Patients were classified into three groups: mild pancreatitis (I, less than or equal to 1 complication, N = 34), severe pancreatitis (II, greater than or equal to 2 complications, N = 29), lethal outcome (III, N = 12). Initially, granulocyte elastase (mean +/- SEM) was lower in group I (348 +/- 39 micrograms/liter) as compared to groups II (897 +/- 183 micrograms/l) and III (799 +/- 244 micrograms/liter), P less than 0.001 for I vs II + III. Initial elastase concentrations greater than 400 micrograms/liter were consistent with a severe or fatal course of the disease but did not distinguish between severe and lethal pancreatitis. In patients with mild or severe disease, mean elastase concentrations decreased continuously during the following days (197 +/- 15 micrograms/liter in mild cases, 325 +/- 30 micrograms/liter in severe cases at day 7). In patients with lethal disease, however, mean elastase concentrations even increased at day 2 and remained higher than 700 micrograms/liter during the observation period. At days 1 and 2 the predictive value for severe or lethal disease of raised (greater than 400 micrograms/liter) elastase concentrations [positive predictive value (PPV) 82%, negative predictive value (NPV) 81%] was better than that of elevated (greater than 100 mg/liter) C-reactive protein (PPV 73%, NPV 73%), elevated (greater than 4.0 g/liter) alpha 1-antitrypsin (PPV 59%, NPV 50%), or decreased (less than 1.5 g/liter) alpha 2-macroglobulin (PPV 82%, NPV 67%).(ABSTRACT TRUNCATED AT 250 WORDS)
Computed tomography-guided fine-needle biopsies of the pancreas were performed in 54 patients. In 46/54 biopsies, the material obtained permitted a histological diagnosis despite the small external needle diameter of only 0.95 mm. The only complication was due to laceration of an artery of the transverse mesocolon. The prevalence of malignant tumors was 67%. Adenocarcinoma was diagnosed in more than 80% of all biopsies; rare findings were malignant carcinoid or centroblastic lymphoma. Benign tumors included mucinous adenocystoma and serous microcystic adenoma. Within the group of patients where pathologic-anatomic evaluation was possible, the sensitivity of fine-needle biopsy for malignant tumors was 87% and the specificity 100%. A positive needle biopsy diagnosis for a malignant tumor reduces the number of exploratory laparotomies needed and is helpful in the planning of surgery.
Tight peritoneal adherence of the stomach to the abdominal wall as a prerequisite of percutaneous gastrostomy can be achieved by a newly developed cannula. It serves for puncture and fixation of the gastric wall. Thus, percutaneous gastrostomy can be established safely even in instances of an endoscopically nonaccessible stomach. Further applications of the device for the purpose of intestinopexy and facilitation of endoscopic procedures are being evaluated.
Based on 1099 endoscopic retrograde cholangiopancreatograms (ERCP), 659 examinations conducted in 1973-1980 prior to the introduction of computed tomography (CT) and 440 performed in 1988-1989, the impact of sonography and CT on ERCP is studied. The availability of CT did not cause any significant change in the frequency of and indications for ERCP. The rate of successful ERCP examinations increased from 73.6% to 92%. Complications occurred in 2.3%, and the mortality rate was 0.4% and was similar in both periods. ERCP was the third imaging procedure, being applied after sonography and CT, in most patients. The diagnostic value of ERCP in pancreatic disease is compared with that of sonography and CT in 116 patients with histologically or clinically proven diagnosis. The sensitivity is 79% for ERCP and 78% for CT. Indeterminate findings were recorded in 11% of the ERCP and 8% of the CT examinations; these rates can be decreased by complementary use of both imaging modalities.