Biomedical subjects
M Rothmund
Publications and source records attributed to M Rothmund.
[Diagnostic localization of insulinoma. Experiences with 25 patients with solitary tumors].
OBJECTIVE: The most effective way to localize the mostly small ( < 2 cm), benign and solitary insulinomas is still under discussion. Especially the evaluation of the different preoperative localization methods is not clarified. The aim of our study was to support the ongoing discussion in that matter. PATIENTS AND METHODS: In total 25 patients have been included in our study since 1987. All showed sporadic insulinomas and underwent surgery. The following preoperative localization methods had been used: ultrasonography (US): 25 patients, computed tomography (CT): 23 patients, somatostatin receptor scintigraphy (SRS): four patients since 1990, angiography: six patients, endosonography (ES): five patients since 1995, selective portal venous sampling (PVS): two patients, magnetic resonance imaging (MRI): four patients since 1993. All 25 patients underwent a bidigital palpation in combination with intraoperative ultrasonography (IOUS). Four of the 25 patients were reoperated and had a prior unsuccessful operation elsewhere. RESULTS: Preoperatively 19 of 25 insulinomas were localized (76%). The following sensitivity rates had been found: ultrasonography: 56%, computed tomography: 43%, endosonography: 100%, angiography: 66%, magnetic resonance imaging: 25%, selective portal venous sampling: 100%, somatostatin receptor scintigraphy: 0%. All 25 insulinomas were detected during operation, 100% by palpation in combination with intraoperative ultrasonography and 92% by palpation on its own. CONCLUSION: After an insulinoma is biochemically proven and after exclusion of a malignant metastasizing tumor by ultrasonography, all patients should be operated on. Intraoperative ultrasonography should be performed in any case. As other preoperative localization methods did not prove a convincing cost-utility-relation, one should not consider the usage of these methods before the initial operations. Before re-operations one should consider the use of costly pre-operative methods to localize insulinomas. Here endosonography and selective portal venous sampling are recommended as the first procedures of choice.
Symptom reporting in cancer patients: the role of negative affect and experienced social stigma.
BACKGROUND: Recent research suggests that patients' appraisal of somatic symptoms is more closely related to emotional variables (particularly negative affect) than to their actual health as determined by external criteria. METHODS: Sixty surgical cancer patients who at the time of a routine follow-up examination filled out the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire-C30, which included a positive/negative affect scale and a scale tapping into experienced social stigma. Patients' health status was determined in two ways: the examining physician gave a global judgement on a standardized scale at the end of the examination, and an additional two external physicians later rated the patients based on the findings listed in the medical record. RESULTS: Patients' reports of somatic symptoms were strongly correlated with two measures of negative affect (r = 0.75 and r = 0.65, respectively) and with experienced social stigma (r = 0.51). In contrast, the correlations between reported symptoms and the examining or external physicians' ratings were considerably weaker (r = 0.31 and r = 0.19). According to a multiple linear regression with 6 predictors, negative affect was the best single predictor of symptom reporting (beta = 0.68; P < 0.001) and global quality of life (beta = 0.48; P < 0.001). Factor analysis yielded a dimension of somatopsychosocial distress that accounted for 44.1% of the variance and is comprised of reported symptoms (factor loading = 0.86), negative affect (0.90 and 0.82), experienced social stigma (0.74), and global quality of life (0.70). Physicians' ratings and positive affect constituted two additional separate factors. CONCLUSIONS: Cancer patients' reporting of somatic symptoms by means of a standardized quality of life questionnaire is closely related to emotional and social distress and is not equivalent to health status as determined from a clinical perspective. Researchers and practitioners have to be aware of this fact when interpreting quality of life data. Furthermore, negative affect deserves attention as an important signal for intervention in tumor follow-up programs.
Value of somatostatin receptor scintigraphy for preoperative localization of carcinoids.
Most carcinoid primary tumors are small and do not cause symptoms until complications (e.g. intestinal obstruction) or symptoms and signs of the carcinoid syndrome occur. Therefore in most cases an assessment of the primary tumor and its metastases must be performed. To determine the value of somatostatin receptor scintigraphy (SRS) for localizing carcinoid tumors, we compared the results of SRS with those obtained with computed tomography (CT) and ultrasonography (US) in 22 patients who had not undergone surgery for removal of the primary tumor. We could not find an advantage of SRS over CT and US for detecting the primary lesions. Tumors > 2 cm in diameter were regularly detected using all methods. SRS was not superior to CT or US for the detection of liver metastases. SRS showed the liver metastases in 16 of 18 patients, whereas CT and US detected liver metastases in all patients. For localization of extrahepatic abdominal and extraabdominal metastases (lymph nodes, bone), whole-body SRS showed an advantage over CT and US. We conclude that SRS is not superior to CT or US for localization of primary carcinoid tumors or liver metastases, although it did prove successful for visualizing extrahepatic and extraabdominal tumor spread. Additionally, SRS is useful for identifying receptor-positive metastases that may be treated by somatostatin analogs. Thus SRS should be performed in patients with a known carcinoid tumor, except those with an appendiceal carcinoid measuring < 1 cm in diameter.
Surgical management for carcinoid tumors of small bowel, appendix, colon, and rectum.
Carcinoid tumors occur most frequently in the gastrointestinal tract. Despite their ability to produce hormones, most of the midgut and hindgut carcinoids covered in this study are clinically silent, and the diagnosis is often not made before emergency surgery or evaluation for liver metastases. Because the rate of lymph node involvement and the prognosis of carcinoid tumors depend on their site and size, surgery refers to these two factors too. Lymph node metastases are most commonly found with small bowel carcinoids (20-45%), providing the rationale for an extended resection including the adjacent lymph node drainage area. Carcinoid tumors of the appendix < 1 cm in diameter rarely metastasize, simply requiring appendectomy for treatment. Lesions > 2 cm should be treated by right hemicolectomy because of their approximately 30% risk of lymph node metastases. Resection should always be done for carcinoid tumors of the colon resection as for adenocarcinomas. Rectal carcinoids < 2 cm rarely metastasize, directing the conclusion that for these smaller lesions local excision is sufficient; for lesions >2 cm a standard cancer resection should be performed provided distant metastases are absent. In general, the younger the patient or the larger the primary tumor, the more aggressive the treatment should be.
Duration of antibiotic treatment in surgical infections of the abdomen. Introduction--the different ways to reach consensus.
The many interrelated issues concerning administration of antibiotics following operations for abdominal contamination and infection were a powerful impetus to create this Discussion Forum in The European Journal of Surgery, which focuses on the duration of administration-a previously neglected topic. The guidelines presented herein are not based on previous randomised trials alone, nor are they prescribed by dictatorship of one person. Instead, they are proposed by a steering committee in the form of a table and are confirmed by consensus of many experts. The science of consensus has to be recognized in surgery. The Discussion Forum offers written judgements that provide more details than the usual Consensus Development Conference statements. It can be used for a nominal group process organized by sepsis trial groups and may be of value for a consensus-based treatment of individual patients.
Prospective evaluation of different diagnostic techniques for the detection of liver metastases at the time of primary resection of colorectal carcinoma.
OBJECTIVE: To evaluate preoperative and operative methods of detecting liver metastases in patients undergoing primary resection for colorectal carcinoma. DESIGN: Prospective, open study. SETTING: Teaching hospital, Germany. SUBJECTS: 51 Patients with confirmed primary colorectal carcinoma. INTERVENTIONS: Computed tomography during arterial portography (CT-AP), percutaneous ultrasonography (US), operative palpation and examination of the liver, operative US, and computed tomography (CT) follow-up 6-12 months postoperatively. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive value, and accuracy. RESULTS: Overall accuracy was worst for CT during portography, because of the diagnosis of many false positive lesions. Exploration and palpation of the liver had the highest sensitivity (83%) and specificity (100%), and operative US did not give any useful additional information. CONCLUSIONS: Preoperative percutaneous US is recommended as the best non-invasive screening test; otherwise careful inspection and palpation during operation are sufficient for the evaluation of the liver during primary resection for colorectal carcinoma.
Carcinoid tumors--introduction.
Explore the source record for details and available documents.
Management of leucopenic sepsis.
Explore the source record for details and available documents.
Clinical and surgical aspects of double adenoma in patients with primary hyperparathyroidism.
The incidence of double parathyroid adenoma in 277 prospectively documented patients suffering from primary hyperparathyroidism was 5.4 per cent (15 patients). Patients with double adenoma were all symptomatic and had a significantly higher parathyroid hormone (PTH) level and tumour weight than those with a solitary adenoma or four-gland hyperplasia. In 11 patients the adenomas were located bilaterally. Bilateral neck exploration must be performed routinely to deal successfully with this condition at initial operation. In six patients one enlarged gland was found in the thymus or posterior mediastinum. These locations should be explored, especially in patients with high PTH levels, in those in whom all four parathyroid glands cannot be detected or if only one small adenoma is found. In all such patients, selective resection of the enlarged parathyroid glands resulted in normocalcaemia (median follow-up 3.5 years). Selective resection of the pathological glands is the treatment of choice.
[Intraoperative injury to the spleen--organ preservation at any price?].
Explore the source record for details and available documents.
Influence of somatostatin to biochemical parameters in patients with primary hyperparathyroidism.
Somatostatin (SRIF) is effective in the nonoperative management of a variety endocrine tumors. A potential role of SRIF for treatment of patients with primary hyperparathyroidism (pHPT) has been suggested. In a controlled, prospective, triple-blinded, randomized clinical trial, the somatostatin analogue octreotide (SMS 201-995, Sandostatin) was evaluated in 40 patients with well documented pHPT. Amongst other biochemical parameters, serum calcium and-phosphate and levels of parathyroid hormone, calcitonin, and osteocalcin as well as octreotide were assessed before and for 4 hours after a single iv. application of 200 micrograms ocreotide or placebo. SRIF-receptor autoradiography was performed in parathyroid tissue samples. Baseline values revealed a constellation of biochemical parameters typically found in pHPT. Following 200 micrograms octreotide, no significant changes in any of the biochemical parameters investigated for were observed. Multivariate analysis was performed to identify patient subpopulations in which any given combination of laboratory parameters changed in response to either drug or placebo. However, no 'responders' to octreotide were identified. 45% of patients receiving octreotide, reported side effects. Parathyroid tissue samples were negative for SRIF-receptor expression. It is concluded that a single dose iv. application of octreotide does not result in appreciable changes of biochemical parameters relevant in pHPT and carries a high rate of side effects. Furthermore, absence of SRIF-receptors in parathyroid tissue from patients with pHPT, together with lack of octreotide effects, suggests that somatostatin-analogues may not be effective in the non-operative therapy of pHPT.
Influence of ceruletid on gallbladder contraction: a possible prophylaxis of acute acalculous cholecystitis in intensive care patients?
The purpose of this study was to investigate the utility of repeated applications of ceruletid to reduce gallbladder volume and its feasibility as a means of prophylaxis of acute acalculous cholecystitis in intensive care patients. First, a dose-response curve of ceruletid was obtained in 20 mechanically ventilated patients of a surgical intensive care unit (SICU) not receiving enteral nutrition. An effective dose of ceruletid, defined by a 50% reduction of gallbladder volume was established and subsequently studied in 40 mechanically ventilated SICU patients on total parenteral nutrition in a prospective, randomized, controlled, triple-blind trial. Gallbladder volume, sludge formation and side effects were evaluated. A dose of 1.5 micrograms/kg body weight ceruletid was established as the effective dose, causing 50% reduction of gallbladder volume in all patients studied and reduction of gallbladder sludge in 95%. In 67.5% of patients side effects were observed, requiring therapeutic intervention in 68%. It is concluded that ceruletid is effective in stimulating gallbladder contraction and reducing sludge formation in severely ill patients on intensive care units. Its routine use as prophylaxis of acute acalculous cholecystitis, however, may be limited by the nature, severity and frequency of side effects.
"Human pancreas-specific protein" (procarboxypeptidase B): a valuable marker in pancreatitis?
Human pancreas-specific protein (PASP) has been characterized previously as a serum marker for pancreatitis. It was then identified as pancreatic procarboxypeptidase B (PCB). The aim of the present study was to verify the usefulness of PASP (PCB) as a serum marker in patients with acute (n = 20) and chronic (n = 12) pancreatitis and in those following endoscopic retrograde cholangiopancreaticography (ERCP) (n = 44). Serum PASP values were analyzed by radioimmunoassay, with a range of normal values between 15 and 111 ng/ml. Between April 1992 and September 1992, 20 subjects (19-86 years of age) with acute pancreatitis (alcoholic, 8; biliary, 8; other, 4) were studied. We found edematous pancreatitis in 17 cases and severe hemorrhagic pancreatitis in three cases. At admission, peak levels of PASP (average value, 1,976 +/- 329 ng/ml), pancreatic isoamylase (942 +/- 151 U/L) and lipase (2,946 +/- 534 U/L) were detected in 15 of 20, 16 of 20, and 12 of 20 cases, respectively. The etiology of the pancreatitis had no influence on the PASP values. Furthermore, 10 patients with alcoholic and two patients with nonalcoholic chronic pancreatitis (29-67 years of age) were studied. The average peak level of PASP was 1,229 +/- 434 ng/ml. In this group, PASP paralleled the time course of amylase and lipase. Maximal PASP, amylase, and lipase levels were found in 11 of 12, nine of 12, and five of 12 patients, respectively, on the day of admission. ERCP was performed in 44 patients (36-87 years of age), demonstrating common bile duct stones in 16 and bile or pancreatic ductal tumors in 15 cases.(ABSTRACT TRUNCATED AT 250 WORDS)
Liver segmentectomy as anatomically precise resections. An experimental study in sheep.
OBJECTIVE: To assess a new technique of anatomically precise hepatic segmental resection and to compare the degree of precision and biochemical profiles with results after traditional segmental resection and a sham operation. DESIGN: Experimental study. SETTING: University hospital, Germany. MATERIAL: 50 sheep (10 each had segments II, III, and IV removed by the new technique, and 10 each were studied in the traditional resection and sham operated groups). INTERVENTIONS: Operative ultrasonography and injection of methylene blue to identify segmental boundaries. In traditional operations boundaries were identified only from knowledge of the surface structure of the liver. MAIN OUTCOME MEASURES: Degree of precision, duration of operation, blood loss, mortality, transaminase activities and liver function tests. RESULTS: Anatomically precise segmentectomies were achieved in 6/9 (67%) for segment II, 6/9 (67%) for segment III, and 4/8 (50%) for segment IV. Using the traditional technique (segment III only) there was only 1/10 anatomically precise resections, together with 5 perisegmentectomies and 4 incomplete resections (p < 0.02). The operations for anatomically precise resection lasted significantly longer, but resection time was similar. Blood loss, survival, and transaminase activities were similar for the two groups, but the margin of necrosis at the cut edge was significantly less in anatomically precise resections. CONCLUSION: Anatomically precise hepatic resections are technically feasible with the use of intraoperative ultrasonography and selective staining of the segment(s) to be removed with methylene blue. Although it takes longer, there are no detrimental consequences compared with the considerably less accurate traditional technique.
[Iodine-induced hyperthyroidism in metastatic thyroid carcinoma].
A 75-year-old man with nodular goitre (for the preceding 2 years treated with 75 micrograms/dl L-thyroxine) complained of pain over the left hip: on auscultation an arterial flow murmur was audible over the hip. The radiograph demonstrated extensive osteolysis in the flat part of the ilium. Search for the primary tumour, including two pelvic angiographs, was unsuccessful. Examination of a biopsy from the right ilium revealed a metastasis from a highly differentiated follicular thyroid carcinoma, which could not be demonstrated scintigraphically because of a reduced 99mTc-pertechnetate and 123I-iodine uptake, the result of the L-thyroxine administration. A thyrotoxic crisis occurred 2 days after the second angiography (free thyroxine 3.17 ng/dl, triiodothyronine 219 ng/dl, thyroglobulin > 250 ng/ml). Treatment with thiamazole (40 mg/d) and perchlorate (1 g/d) reduced the concentration of peripheral thyroid hormone, but the patient's general condition improved only slowly. As a result, radioiodine treatment could not be started until 9 months later. He died a further 9 months later from septicaemia originating from the metastasis.
[Combined kidney and pancreas transplantation in late-stage diabetes].
Explore the source record for details and available documents.
[Routine intravenous urography before colorectal resections?].
The value of preoperative intravenous urography (IVU) to prevent iatrogenic damage to the urogenital tract was investigated in a series of 236 females and 188 males (mean age 54 [5-87] years) who underwent an operation on the colon or rectum between April 1988 and March 1992. The operations were: 101 right and 49 left hemicolectomies, 125 sigmoid resections, 74 anterior rectum resections, 58 abdomino-perineal rectum amputations and 17 total colectomies. Preoperative IVU was performed in 279 patients (65.8%), while in 145 (34.2%) urgency of the operation or intolerance to contrast medium prevented the procedure being done. The results were abnormal in 75 of the 279 IVUs (26.9%). Of the latter, only 19 (6.8%) of the abnormalities were related to the colorectal disease (renal obstruction due to tumour: 9, malignant invasion of the bladder: 5, ureter displacement: 5). Other diagnostic procedures had given abnormal results in six patients, although the preoperative IVU had been unremarkable. Iatrogenic damage to a ureter occurred in only one patient: the IVU had been normal. No ureteral damage occurred in any of the patients who had not had an IVU. These data indicate that the decisive factor in preventing intraoperative damage to a ureter is not a preoperative IVU but careful intraoperative dissection and visualization of the ureter. There is, therefore, no need for routine preoperative IVU in these cases.