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Biomedical subjects

M Trede

Publications and source records attributed to M Trede.

At least 37 records · Page 2Linked to original sources
PubMed1997

Ultrafast magnetic resonance imaging improves the staging of pancreatic tumors.

OBJECTIVE: This prospective study was undertaken to evaluate the accuracy of a noninvasive "all-in-one" staging method in predicting surgical resectability in patients with pancreatic or periampullary tumors. SUMMARY BACKGROUND DATA: Despite progress in imaging techniques, accurate staging and correct prediction of resectability remains one of the chief problems in the management of pancreatic tumors. Staging algorithms designed to separate operable from inoperable patients to save the latter an unnecessary laparotomy are becoming increasingly complex, expensive, time-consuming, invasive, and not without risks for the patient. METHODS: Between August 1996 and February 1997, 58 consecutive patients referred for operation of a pancreatic or periampullary tumor were examined clinically and by 5 staging methods: 1) percutaneous ultrasonography (US); 2) ultrafast magnetic resonance imaging (UMRI); 3) dual-phase helical computed tomography (CT); 4) selective visceral angiography; and 5) endoscopic cholangiopancreatography (ERCP). The assessment of resectability by each procedure was verified by surgical exploration and histologic examination. RESULTS: The study comprised 40 male and 18 female patients with a median age of 63 years. Thirty-five lesions were located in the pancreatic head (60%), 11 in the body (19%), and 1 in the tail of the gland (2%); there were 9 tumors of the ampulla (16%) and 2 of the distal common duct (3%). All five staging methods were completed in 36 patients. For reasons ranging from metallic implants to contrast medium allergy or because investigations already had been performed elsewhere, US was completed in 57 (98%), UMRI in 54 (93%), CT in 49 (84%), angiography in 48 (83%), and ERCP in 49 (84%) of these 58 patients. Signs of unresectability found were vascular involvement in 22 (38%), extrapancreatic tumor spread in 16 (26%), liver metastases in 10 (17%), lymph node involvement in 6 (10%), and peritoneal nodules in only 2 patients (3%). These findings were collated with those of surgical exploration in 47 patients (81 %) and percutaneous biopsy in 5 (9%); such invasive verification was deemed unnecessary and therefore unethical in 6 clearly inoperable patients (10%). In assessing the four main signs of unresectability (extrapancreatic tumor spread, liver metastases, lymph node involvement, and vascular invasion), the overall accuracy of UMRI was 95.7%, 93.5%, 80.4%, as compared to 85.1%, 87.2%, 76.6% for US and 74.4%, 87.2%, 69.2% for CT. In assessing vascular invasion, the sensitivity, specificity, and overall accuracy of angiography were 42.9%, 100%, and 68.8%, respectively. There were 3 complications (12.5%) after 24 resections, 5 in 17 palliative procedures, and none after 6 explorations only. The hospital stay was 14 days after resection, 13 after palliative bypass, and 6 after exploration alone. There was no operative or hospital mortality in these 58 cases. CONCLUSIONS: Although it is by no means 100% accurate, UMRI is equal or even superior to all other staging methods. It probably will replace most of these, because it provides an "all-in-one" investigation avoiding endoscopy, vascular cannulation, allergic reactions, and x-radiation. But because even UMRI is not perfect, the final verdict on resectability of a tumor still will depend on surgical exploration in some cases.

Adult↗
PubMed1997

[Postoperative follow-up in patients with partial Whipple duodenopancreatectomy for chronic pancreatitis].

BACKGROUND AND AIM: Physicians and surgeons essentially agree today that chronic pancreatitis must primarily be treated conservatively. The aim of surgery in chronic pancreatitis is the treatment of symptoms. Surgical treatment cannot be a causal therapy for chronic pancreatitis. If surgery is indicated at all. Whipple's operation is considered to be the gold standard. PATIENTS AND METHODS: Between 1973 and 1992, out of a total of 700 patients referred to the surgery University Department in Mannheim with the express purpose of having an operation for chronic pancreatitis, duodenopancreatectomy (Whipple's operation) was performed in 110 cases. 58 of these patients were followed up postoperatively and the results have been compared with preoperative findings. RESULTS: All patients returned to full or only slightly impaired activity. 60% took up work again, 40% retired after the operation with a mean age of 49 years. 38 patients (66%) were totally free of pain, 13 patients (22%) had less pain than preoperatively and only seven (12%) often need analgesics postoperatively because of abdominal pain. Preoperatively there has been a history of long-standing excessive alcohol use in 32 (55%) patients, in the postoperative period there was a significant reduction to only three (5%) patients. 40 patients clinically examined were in a sufficient nutritional condition. Exocrine function of the pancreas (stool chymotrypsin and fluorescein dilaurate test) showed an insufficiency in 20 (71%) of 28 cases. The preoperative exocrine function of the pancreas was not examined in most cases. Examination of endocrine function showed diabetes mellitus treated with insulin occurring preoperatively in six (10%) patients and in 21 (36%) patients postoperatively. CONCLUSION: As chronic pancreatitis very often is concentrated in the head of the pancreas, Whipple's operation seems to be a good procedure for pain relief and concerning late results of life quality and socioeconomic situation.

Adult↗
PubMed1997

[Guidelines in therapy of pancreatic carcinoma].

The definition of guidelines as merely describing a "corridor of action" and the existence of numerous up-to-date textbooks on the subject raises the question as to their purpose and necessity. This paper provides a critical commentary on existing guidelines. Above all it points out that the sections on preoperative diagnosis and palliative surgery require amendments barely 8 months after publication of the guidelines. Thus while the compilation of guidelines is laudable, it is both expensive and time-consuming, and this problem is potentiated by the need for constant amendment.

Humans↗
PubMed1996

[Immune paralysis in acute pancreatitis--HLA-DR antigen expression on CD14+DR+ monocytes].

UNLABELLED: Determination of the prognosis in acute cases of pancreatitis, particularly in its serious and necrotizing form, still presents problems. Patients require intensive care and suffer from severe septic complications that do not correlate with pancreatic enzyme levels (amylase lipase). METHOD: Thirty-one patients with acute pancreatitis were examined: group 1 -- necrotizing pancreatitis (lethal outcome n = 7); group 2 -- necrotizing pancreatitis (surviving n = 12); group 3 edematous pancreatitis (surviving n = 12). For 11 consecutive days after admission to a clinical ward, flow cytometric check-ups were carried out daily on all patients. The antigen-presenting system HLA-DR antigen expression on monocytes and C-reactive protein were examined. RESULTS: When groups 1 and 2 were compared with group 3, HLA-DR values on monocytes were significantly different following the third day after admission (P < 0.01). Comparison of groups 1 and 2 were significant from the third day of observation (P < 0.001). During all 11 days of observation, patients in group 1 remained in immune paralysis (HLA-DR expression on monocytes CD14+DR+20% antigen density). All of these patients had infected necroses. Patients in group 2 overcame their immune paralysis. HLA-DR depression of monocytes and a long-standing high C-reactive protein level are almost certain predictors of a fatal outcome in cases with severe pancreatitis. A routine passage cytometric check/FACS to determine the activity of monocytes (HLA-DR) is of prognostic significance.

Adult↗
PubMed1996

[Surgical therapy of pancreatic diseases].

When a decision must be made about inflammatory versus malignant diseases of the pancreas, close interdisciplinary cooperation is required, especially with the radiologist. The tash of improving contemporary strategies in the therapy of pancreatic diseases is a challenge for internists, radiologists and surgeons alike. The first encouraging results of this collaboration have now emerged. Nonetheless, when considering the current hospital settings, it is mandatory to continue the ongoing dialogue to optimize the procedures for diagnosing pancreas disease according to the motto less is more and adjust them according to the clinical requirements.

Acute Disease↗
PubMed1996

Completion pancreatectomy for surgical complications after pancreaticoduodenectomy.

Significant complications continue to occur in a minority of patients undergoing pancreaticoduodenectomy; these frequently have fatal consequences. Analysis of 458 patients undergoing the Whipple procedure in this institution from 1972 to 1994 revealed that 16 patients with malignant periampullary tumours (ampullary, eight; pancreatic, seven; bile duct, one), and one patient with chronic pancreatitis subsequently required completion pancreatectomy. Postoperative difficulties after pancreaticoduodenectomy and indications for re-exploration were multifactorial: leakage (n = 8), pancreatitis (n = 7), bleeding (n = 1), and a delayed report of cancer at the margin of the pancreatic transection (n = 1). Completion pancreatectomy was often difficult (mean operating time 2.7 h, mean estimated blood loss 1897 ml). There was considerable significant postoperative morbidity (41 per cent) and mortality (24 per cent) after completion pancreatectomy. Patients who survived completion pancreatectomy lived a mean of nearly 4 years (range 4 months to 9.7 years, median 2.6 years). Tumour recurrence led to death in ten of 13 patients. Three patients remain alive and free of recurrence each more than 8 years after resection. Re-exploration and subsequent completion pancreatectomy after pancreaticoduodenectomy is rarely necessary, but if clinical manifestations occur secondary to failure of the pancreaticojejunostomy, early surgical intervention may maximize survival.

Adenocarcinoma↗
PubMed1996

[Geriatric tumor surgery--change in the patient sample].

The comparison of our surgical tumor patients over 65 years of age treated in 1973-1974 or 1993-1994 showed the following results: increased average age and more patients with a greater unfavorable preoperative risk profile, an increase in colorectal tumors, a decrease in gastric carcinomas, no changes in tumor stages, more frequent sphincter-preserving operations for rectal tumors, an increase in the curative resection rate, lower mortality and shorter hospital stays. A curative resection of a malignant tumor is justified in the majority of elderly patients and should be performed considering the post-operative quality of life.

Aged↗
PubMed1996

[Surgical therapy of pancreatic carcinoma in elderly patients over 70].

Between October 1972 and December 1994, 519 pancreatic resections were performed at the Chirurgische Universitätsklinik Mannheim, 372 for pancreatic carcinoma. Of 328 patients who underwent a partial duodenopancreatectomy for cancer, 45 patients were older than 70 years: only in one case a partial duodenopancreatectomy was performed for chronic pancreatitis. In comparison to all patients the perioperative morbidity increased to 39.1% (21.5% vs. 39.1%). The perioperative mortality of all patients was 1.9%, the mortality of patients older than 70 years was 4.3%. The mean survival time of 28 patients who died subsequently was 30.6 (5-96) months. Despite increased perioperative morbidity and mortality, the patient's age is not considered to be a limiting factor to an attempt at curative resection of pancreatic or periampullary cancer.

Aged↗
PubMed1996

[Results of colorectal carcinoma surgery in elderly patients].

Between 1972 and 1995, 4434 operations for colorectal carcinoma were performed at the University Clinic of Mannheim. The increasing average age of the patients resulted in a higher lethality rate due to more emergency operations and concomitant failure of other organs. But the prognosis of patients over 70 years old can be compared with younger patients when hospital lethality is not considered. Thus the aim of treatment in older patients is also R0-resection, avoidance of emergency operations, optimum treatment of concomitant failure of other organs and multiple operations in extreme emergency cases.

Aged↗
PubMed1996

[Is diagnostic laparoscopy a reliable addition to preoperative staging of pancreatic carcinoma?].

Over the last decade several authors proposed adopting diagnostic laparoscopy as an early diagnostic routine method in the staging of pancreatic carcinoma to prevent exploratory laparotomy. In our hospital only 11.6% of all patients who underwent explorative laparotomy would have benefitted from diagnostic laparoscopy. Therefore, we do not recommend diagnostic laparoscopy as a routine method to assess resectability of pancreatic carcinoma?

Angiography↗
PubMed1996

[Extensive palliative carcinoma operation--is it really worthwhile? What are the aims?].

This question can be approached from 3 viewpoints. 1. Economics. Here it becomes clear that calculations of cost-effectiveness-important as they are-are meaningless for any individual case. 2. Internal quality control found 138 patients (out of a total of 1200 oncological procedures performed in 1993/94) who had extensive palliative cancer operations. With an overall operative mortality of 9.4%, 59 were still alive after a mean follow-up period of 15 months; among the 49 who could be reached 60% rated their quality of life to be "satisfactory" to "very good". However, in the end, quality control figures are of little help for the individual case. 3. Selected individual case histories concerning surgery for metastases make it abundantly clear that the answer to the title's question must be found a new by each individual patient and his surgeon.

Cost-Benefit Analysis↗
PubMed1995

Protein metabolism in human colon carcinomas: in vivo investigations using a modified tracer technique with L-[1-13C]leucine.

To quantify the protein anabolism of tumors it is not sufficient simply to determine the level of protein synthesis. The decisive factor is the net balance. This is the first attempt to establish this parameter in human tumors in vivo. Intraoperative tumor leucine/protein metabolism was studied in 15 patients with resectable malignant colon tumors using a balance model and L[1-13C]leucine as the tracer substance. Comparative measurements were also carried out simultaneously for peripheral tissue (forearm); in addition, protein kinetics parameters were established for the whole body using a proven two-pool model (with the same tracer as above). In view of the frequently conflicting data on amino acid metabolism in tumors, the tumoral and peripheral exchange rates of 20 amino acids were also determined. In tumors, essential and branched-chain amino acid uptakes were found to be 1.68 +/- 0.59 (SE) and 1.52 +/- 0.23 mumol/100 g tissue/min, respectively; in peripheral tissue there was overall an amino acid release [-0.11 +/- 0.06 and -0.05 +/- 0.04 mumol/100 g/min; in either case P < 0.01 (tumor versus periphery)]. Tracer analyses yielded a net retention for the tumors but a protein loss for peripheral tissue (8.941 +/- 3.113 versus -0.557 +/- 0.53 g/kg/24 h; P < 0.01) and for the whole body (-0.363 +/- 0.04 g/kg/24 h). The tumors were divided into two prognostic groups on the basis of their histology. Significant differences were found between the two groups in terms of the net retention rate for 10 amino acids, including leucine; retention was elevated in tumors with an unfavorable prognosis, possibly due to a higher amino acid requirement because of more rapid growth or for export processes (mucus production). The protein balance model used here has proved satisfactory for our purposes and could also be used to directly evaluate dietary measures (e.g., adjuvant parenteral nutrition in connection with chemotherapy).

Aged↗
PubMed1995

[Adrenal incidentaloma].

Asymptomatic adrenal tumors are discovered more and more frequently with improving quality of diagnostic imaging. Treatment of these tumors, described as incidentalomas is controversial and depends on the one hand on the size of the tumor and on the other hand on morphological appearance in diagnostic imaging. In the literature a tumor size over 3 cm is in general regarded as an indication for operation, based on findings of Copeland et al. where the size of the tumor was correlated with malignancy. In the Department of Surgery in Mannheim 28 operations on adrenal incidentalomas have been performed between 1973-1993. In three patients a carcinoma was found. Four of the removed tumors each of them benign had a diameter smaller than three centimeters. An operation seems to be justified under certain conditions, even in small tumors, because potentially malignant tumors can undergo early and radical surgery. A general recommendation for treatment of the above mentioned tumors, depending only on size and morphology in diagnostic imaging, seems to be difficult. The decision for surgical therapy needs to be evaluated individually for every patient.

Adrenal Gland Neoplasms↗
PubMed1995

[Long-term survival after surgical therapy of T4 colorectal carcinomas].

Between 1972 and 1990, 456 patients with locally advanced colorectal carcinomas (tumor stage T4) were operated. In 187 cases the operation was extended by multivisceral resection and in 269 patients a conventional resection was performed. The rate of curative R0-resections was 74.9% for the extended resection group compared to 66.2% for the conventional group. The postoperative mortality after extended resection was 4.9% (2.9% conventional resection). Analyses of long-term results showed a 5-year survival for all R0-resected cases of 52.1% +/- 4.1. Further evaluation of additional lymph-node involvement in T4 colorectal tumors revealed significant differences in 5-year survival: 64.8% T4N0; 27.9% T4N1,2; 9.2% T4N3 for conventional R0-resection and 59.9% T4N0; 23.2% T4N1,2; 6.6% T4N3 for extended R0-resection. After curative resection (R0) the presence or absence of intraoperative tumor-cell dissemination could be identified as a significant prognostic factor. In all cases of T4 colorectal carcinomas-especially for N1-3-an adjuvant treatment after conventional or extended R0-resection is recommended.

Adult↗