Laparoscopic partial splenectomy.
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Carcinoma, Papillary↗
Biomedical subjects
Markus Schäfer
Publications and source records attributed to Markus Schäfer.
Postoperative bezoar ileus after early enteral feeding.
Postoperative enteral nutrition is a widely accepted route of application for nutrition formulas due to a low complication rate, a good acceptance by patients. and a favorable cost-effectiveness. We report three cases of bezoar ileus after early postoperative enteral nutrition, using a fine needle jejunostomy (FNJ) in two cases and a nasoduodenal tube in one case. A male patient who underwent gastric resection for a gastrointestinal stroma tumor and was nourished through an fine needle jejunostomy developed an acute abdomen on the seventh postoperative day. Surgical exploration revealed a mechanical ileus caused by denaturated nutrition formula distal to the catheter tip. The second case, a female patient, underwent gastric resection for a gastric cancer and on the fourth postoperative day developed acute onset of abdominal pain. Intraoperative findings were the same as described in the first case. The third case, a male patient with necrotizing cholecystitis, underwent open cholecystectomy. Postoperative enteral feeding was performed using a nasoduodenal tube. He developed a small bowel obstruction on the 17th postoperative day that was caused by an intraluminal bezoar. In conclusion, bezoar formation represents an underestimated complication of postoperative enteral feeding. Acute onset of abdominal pain and the development of small bowel obstruction are the main clinical symptoms of this severe complication. The pathogenesis of bezoar formation remains unclear.
Adult↗
Pancreatic cancer in cystic fibrosis after bilateral lung transplantation.
Cystic fibrosis (CF) is the most common lethal genetic disease affecting 1 in 2500 white patients. Chronic obstructive lung disease and pancreatic insufficiency are the main clinical manifestations of CF. Lung transplantation has become a treatment option for advanced pulmonary disease during the last decade. On the other hand, there is evidence from large cohort studies that CF and immunosuppression are risk factors for pancreatic cancer. Here, we report the case of an 18-year-old female patient with CF and bilateral lung transplantation who underwent Whipple procedure for pancreatic adenocarcinoma at the age of 12 years. Because of growth retardation, the patient underwent a 2-year period of growth hormone treatment before the diagnosis of pancreatic cancer. This case should sensitize physicians to be aware of the increased risk for pancreatic cancer in CF patients especially in those after lung transplantation with immunosuppression and prolonged survival.
Adenocarcinoma↗
Evidence-based treatment of acute pancreatitis: a look at established paradigms.
BACKGROUND: The management of acute pancreatitis (AP) is still based on speculative and unproven paradigms in many centers. Therefore, we performed an evidence-based analysis to assess the best available treatment. METHODS: A comprehensive Medline and Cochrane Library search was performed evaluating the indication and timing of interventional and surgical approaches, and the value of aprotinin, lexipafant, gabexate mesylate, and octreotide treatment. Each study was ranked according to the evidence-based methodology of Sackett; whenever feasible, we performed new meta-analyses using the random-effects model. Recommendations were based on the available level of evidence (A=large randomized; B=small randomized; C=prospective trial). RESULTS: None of the evaluated medical treatments is recommended (level A). Patients with AP should receive early enteral nutrition (level B). While mild biliary AP is best treated by primary cholecystectomy (level B), patients with severe biliary AP require emergency endoscopic papillotomy followed by interval cholecystectomy (level A). Patients with necrotizing AP should receive imipenem or meropenem prophylaxis to decrease the risk of infected necrosis and mortality (level A). Sterile necrosis per se is not an indication for surgery (level C), and not all patients with infected necrosis require immediate surgery (level B). In general, early necrosectomy should be avoided (level B), and single necrosectomy with postoperative lavage should be preferred over "open-packing" because of fewer complications with comparable mortality rates (level C). CONCLUSIONS: While providing new insights into key aspects of AP management, this evidence-based analysis highlights the need for further clinical trials, particularly regarding the indications for antibiotic prophylaxis and surgery.
Acute Disease↗
Fatal esophageal perforation caused by invasive candidiasis.
Instrumental lesions, spontaneous rupture, and trauma cause most esophageal perforations. Transmural fungal infection is extremely rare, although Candida may be detected in as many as 25% of normal esophagus. In this report we present a case of fatal esophageal perforation due to transmural Candida infection in a 76-year-old woman. The patient died from septic shock and multiorgan failure, despite esophageal resection and systemic antifungal therapy. Pathogenetic aspects and treatment strategies are discussed.
Aged↗
Positron emission tomography/computed tomography influences on the management of resectable pancreatic cancer and its cost-effectiveness.
OBJECTIVE: We sought to determine the impact of positron emission tomography/computed tomography (PET/CT) on the management of presumed resectable pancreatic cancer and to assess the cost of this new staging procedure. SUMMARY BACKGROUND DATA: PET using 18F-fluorodeoxyglucose (FDG) is increasingly used for the staging of pancreatic cancer, but anatomic information is limited. Integrated PET/CT enables optimal anatomic delineation of PET findings and identification of FDG-negative lesions on computed tomography (CT) images and might improve preoperative staging. MATERIAL AND METHODS: Patients with suspected pancreatic cancer who had a PET/CT between June 2001 to April 2004 were entered into a prospective database. Routine staging included abdominal CT, chest x-ray, and CA 19-9 measurement. FDG-PET/CT was conducted according to a standardized protocol, and findings were confirmed by histology. Cost benefit analysis was performed based on charged cost of PET/CT and pancreatic resection and included the time frame of staging and surgery. RESULTS: Fifty-nine patients with a median age of 61 years (range, 40-80 years) were included in this analysis. Fifty-one patients had lesions in the head and 8 in the tail of the pancreas. The positive and negative predictive values for pancreatic cancer were 91% and 64%, respectively. PET/CT detected additional distant metastases in 5 and synchronous rectal cancer in 2 patients. PET/CT findings changed the management in 16% of patients with pancreatic cancer deemed resectable after routine staging (P = 0.031) and was cost saving. CONCLUSIONS: PET/CT represents an important staging procedure prior to pancreatic resection for cancer, since it significantly improves patient selection and is cost-effective.
Adenocarcinoma↗
Reduced hepatic glycogen stores in patients with liver cirrhosis.
BACKGROUND: Patients with alcoholic liver cirrhosis have reduced hepatic glycogen stores but the mechanisms leading to this finding are not clear. METHODS: We therefore determined the hepatic glycogen content in patients with alcoholic (n = 9) or biliary cirrhosis (n = 8), and in control patients undergoing liver surgery (n = 14). All patients were in the postabsorptive state. In addition, we performed a morphometric analysis of the livers, and measured activities and mRNA expression of several enzymes involved in glycogen metabolism. Cirrhotic and control patients were similar regarding age and body weight. RESULTS: Cirrhotic patients had a reduced glycogen content per gram liver wet weight (17 +/- 11 versus 45 +/- 17 mg/g, P < 0.05), per milliliter hepatocytes (28 +/- 16 versus 52 +/- 21 mg/ml, P < 0.05) and per liver (28 +/- 17 versus 64 +/- 22 g, P < 0.05), the reduction being observed in both patients with alcoholic or biliary cirrhosis. Liver histology confirmed these findings and revealed that the decrease in liver glycogen in cirrhotic patients was not homogeneous across cirrhotic lobules. Activities of glycogen synthase and phosphorylase (total activity and active form) were not different between cirrhotic and control patients, whereas hepatic mRNA expression was decreased in cirrhotics by approximately 50%. The activity of glucokinase was decreased in cirrhotic as compared in control patients (0.06 +/- 0.30 versus 0.42 +/- 0.21 U/ml hepatocytes, P < 0.05), the reduction being observed in both patients with alcoholic or biliary cirrhosis. CONCLUSIONS: We conclude that patients with alcoholic or biliary cirrhosis have decreased hepatic glycogen stores per volume of hepatocytes and per liver. Decreased activity of glucokinase may represent an important mechanism leading to this finding.
3-Hydroxybutyric Acid↗
Hepatic and skeletal muscle glycogen metabolism in rats with short-term cholestasis.
BACKGROUND/AIMS: To study the effect of short-term cholestasis on glycogen metabolism. METHODS: Rats were bile duct ligated (BDL) for 4 or 8 days and compared to sham-operated control rats pair-fed to BDL (pair-fed CON) or fed ad libitum (ad libitum-fed CON). RESULTS: Four days after surgery, the hepatic glycogen content was 21.6+/-7.6 mg/g in BDL, 21.2+/-8.5 mg/g in pair-fed CON and 72.9+/-7.7 mg/g in ad libitum-fed CON, respectively. Eight days after surgery, the hepatic glycogen content was reduced in BDL as compared to pair-fed (31.2+/-8.9 vs. 59.1+/-5.4 mg/g) or ad libitum-fed CON (58.3+/-4.7 mg/g). Similar findings were obtained with the glycogen content expressed per ml hepatocytes or per liver. Histological analysis of BDL livers showed that most hepatocytes were affected. As compared to CON, activities and mRNA levels of glycogen synthase and phosphorylase were reduced in BDL, whereas plasma glucagon and endotoxin levels were increased at both time points. In contrast to liver, skeletal muscle glycogen metabolism remained unaffected. CONCLUSIONS: While reduced intake of food explains the decrease in the hepatic glycogen stores in BDL and pair-fed CON 4 days after surgery, reduced glycogen synthesis, possibly related to endotoxinemia, is the most probable cause of the decrease in the hepatic glycogen content in BDL 8 days after surgery.
Acute Disease↗
Impaired ketogenesis is a major mechanism for disturbed hepatic fatty acid metabolism in rats with long-term cholestasis and after relief of biliary obstruction.
BACKGROUND/AIMS: Rats with long-term cholestasis have reduced ketosis of unknown origin. METHODS: Fatty acid metabolism was studied in starved rats with biliary obstruction for 4 weeks (bile duct ligated rats = BDL rats), and 3, 7, 14, 28 and 84 days after reversal of biliary obstruction by Roux-en-Y anastomosis (RY rats), and in sham-operated control rats. RESULTS: BDL rats had reduced beta-hydroxybutyrate concentrations in plasma (0.25 +/- 0.10 vs. 0.75 +/- 0.20 mmol/l) and liver (2.57 +/- 0.20 vs. 4.63 +/- 0.61 micromol/g) which increased after restoring bile flow. Hepatic expression and activity of carnitine palmitoyltransferase I (CPT I) or CPT II were unaffected or decreased in BDL rats, respectively, and increased after restoring bile flow. Oxidative metabolism of different substrates by isolated liver mitochondria and activation of palmitate were reduced in BDL rats and recovered 7-14 days after restoring bile flow. Ketogenesis was decreased in mitochondria from BDL rats and recovered 3 months after restoring bile flow. Both mRNA and protein expression of hydroxymethylglutaryl-coenzyme A synthase (HMG-CoA synthase), the rate-limiting enzyme of ketogenesis, was reduced in livers of BDL rats and increased after reversing biliary obstruction. CONCLUSIONS: In BDL rats, impairment of hepatic fatty acid metabolism is multifactorial. After reversing biliary obstruction, reduced activity of HMG-CoA synthase is the major factor.
Anastomosis, Roux-en-Y↗
Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis.
OBJECTIVE: To review the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis using evidence-based methodology. SUMMARY BACKGROUND DATA: Despite improved results of pancreatoduodenectomy over the recent years, the reputation of the Whipple procedure and its main modifications has remained poor. In addition, the current status of newer modifications of standard pancreatoduodenectomy is still under debate. METHODS: Medline search and manual cross-referencing were performed to identify all relevant articles for classification and analysis according to their quality of evidence. The search was limited to articles published between 1990 and 2001. RESULTS: The mortality rate of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and 3% to 8% for pancreatic cancer. In contrast, overall morbidity rates remain high, ranging between 20% and 70%. Delayed gastric emptying represents almost half of all complications. The overall 5-year survival rate for patients with pancreatic cancer remains poor, ranging between 5% and 15%, with a median survival of 13 to 17 months. Mortality and morbidity are not related to the type of pancreatoduodenectomy; however, patients with pancreatic cancer tend to be at increased risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity rates as standard procedures, but without apparent survival benefits in the long term. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis. CONCLUSIONS: Pancreatoduodenectomy and its main modifications are safe and effective treatment modalities, especially in experienced centers with a high patient volume. For chronic pancreatitis, surgical resection provides major relief of pain and thus increased quality of life. Overall survival for patients with pancreatic cancer is determined predominantly by the pathology within the resected specimen.
Adenocarcinoma↗