Biomedical subjects
Publications and source records attributed to R Grüssner.
Immunosuppression to prevent rejection of solid organ transplants is accompanied by an increased risk of infections. The most frequent diseases include cytomegalovirus as well as bacterial infections of the urinary tract and the lung. The rate of enteric salmonella infections is increased in transplant patients. We report on four cases of extraintestinal salmonellosis after kidney allotransplantation.
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We induced, as a precondition for a pancreas transplant, insulin-dependent diabetes mellitus in 67 Yorkshire Landrace pigs by administering streptozotocin. A dosage of 150 mg/kg body weight gave rise to a long-lasting diabetes mellitus that persisted with time (follow-up period: 26 weeks). Consecutive measurements of serum glucose and plasma insulin, before and up to 30 hours after administering streptozotocin, revealed triphasic behavior: initial hyperglycemia (1st to 3rd hour), pronounced hypoglycemia (12th to 18th hour), then hyperglycemia (22nd hour on). IVGTTs done 1 to 7 days after administering streptozotocin revealed a reduction of the K-value (glucose disappearance rate) from 0.3 (day 2) to 0.07 (day 4). Immunohistochemical studies revealed a complete loss of all beta-cells, concomitantly with a relative increase in glucagon- and somatostatin-positive cells. We also observed a complete loss of pp (pancreatic polypeptide)-positive cells. Diabetes induced by streptozotocin at 150 mg/kg body weight is complete and permanent; our mortality rate was 0%. Given the high morbidity rate after pancreatectomy, streptozotocin should be the method of choice for inducing diabetes mellitus in pigs.
After induction of a Streptozotocin-induced diabetes mellitus solitary pancreas transplants were performed in 31 Yorkshire-Landrace pigs. Exocrine pancreatic secretions were bladder drained (duodenocystostomy). Postoperatively all animals were subject to a standardized immunosuppression. The purpose of the study was both to examine the intensity of rejection episodes within a certain time period and to correlate laboratory with histology data. Cystoscopic transduodenal pancreas biopsies in defined intervals were obtained by intraoperative ultrasound control; this technique reduces the complication rate and should be used clinically. The biopsy results showed that severe rejection episodes despite high dose triple-immunosuppression for induction therapy were noted histologically and immunohistochemically as early as postoperative day 6. Morphological changes significantly preceded functional changes. Due to the distinct immunogenicity of pancreas transplants and in order to decrease incidence and severity of rejection episodes, quadruple-immunosuppression (including T-cell-antibodies) is imperative for induction therapy and anti-rejection treatment. Our results demonstrate that solitary pancreas transplantation is clinically indicated only in patients with extremely labile diabetes mellitus due to the high immunosuppression required. This animal model should be utilized for further studies to improve the result of solitary pancreas transplantation.
The high technical complication rate of pancreas transplantation requires large animal models to improve clinical transplant survival rates. The pig is a very suitable animal due to its anatomy, physiology and immunology which are similar to humans. In this study a model of en-bloc simultaneous pancreas and kidney transplantation was established which--in contrast to separate transplantation of both organs--decreases preservation time, operation time, and clamp time. Furthermore, the rates of intra- and postoperative complications were reduced compared with separate transplantation. The donor aorta (encompassing celiac axis, superior mesenteric artery, and left renal artery) is anastomosed en-bloc to the recipients aorta in a an oblique-to-side fashion. The portal vein is anastomosed end-to-side to the left common iliac vein. The exocrine pancreatic secretions are drained via duodenocystostomy to allow for monitoring of urinary amylase for rejection. The en-bloc technique is an alternative for pediatric donor organs since the risk of vascular complications is lower compared with separate implantation of the donor vessels. Based on our results in a large animal model the en-bloc technique could be used in adult uremic diabetic patients who receive a combined pancreas-kidney transplant from a pediatric cadaver donor.
The recurrence rate after 438 curative operations for rectal carcinoma was 44.1% (193 cases). It was independent of age and sex, but correlated closely with tumour stage. Tumours in an early stage recurred rarely and late. The success of a second operation was influenced by the type of local-regional recurrence. Only three of 34 presacral recurrences were again treated surgically with cure as the aim, compared with seven of 17 anastomosis recurrences, five of eight perineal recurrences, four of six recurrences after local dissection, and all colostomy recurrences, vaginal recurrences and metachronic second tumours. The further course demonstrated that about three quarters of patients who had undergone seemingly curative operations died from their tumour. The cure rate was only 8.8% for all patients after operations for recurrence and 22.6% for those who had undergone "curative" second operations.
Esophagotracheal fistula is usually a sequela of irradiation or laser treatment of advanced carcinoma of the esophagus or the tracheobronchial tree. Resection of the tumor in these cases is not possible, and palliative bypass surgery is highly risky. The peroral placement of a prosthesis is less invasive, but conventional prostheses often fail to occlude the fistula. The authors regularly use an endoscopic multiple-diameter bougie for dilation. After dilation, a specially designed prosthesis is pushed through the tumor stenosis to block the fistula. This procedure can be done without general anesthesia. The funnels of conventional prostheses cannot cover the fistula when there is either a wide, proximal esophagus above the fistula or a high fistula. To cope with this particular situation, a special fistula funnel was developed. It perfectly occludes the fistulas in all patients. Of 21 patients, 19 were discharged without further aspiration.
Sessile adenomas are predominantly localized in the rectum and lower sigma. Surgical removal is indicated but often implies an invasive surgical procedure. Using conventional transanal surgical techniques, only the lower rectum can be reached and there are high rates of recurrence. The new technique combines an endoscopic view of the rectum under gas insufflation via a stereoscopic telescope with conventional surgical preparation and suturing. Adenomas can be excised using the mucosectomy technique or full-thickness-excision, whereas carcinomas should be excised using full-thickness excision with a sufficient border of healthy mucosa. In carcinomas of the sacral cavity, we remove the retrorectal fat up to the fascia of Waldeyer, including the regional lymph nodes. Transanal endoscopic microsurgery is the most economical and tissue-saving surgical technique for the removal of rectal adenomas and early rectal carcinomas.
The histopathological grading exerted a significant influence on prognosis in patients with colonic carcinoma. More than half of the well differentiated tumors were found in early stage pT1-3 N0 M0 compared to 25% of the G2- and 10% of the G3-tumors. The percentage of incurable cases in G2-tumors was twice as high and in G3-tumors three times as high as in patients with well differentiated carcinomas. The recurrence rate increased significantly with decreasing tumor differentiation from 21% to 51%. Despite the correlation with tumor stage the histopathological grading could be established as an independent prognostic variable and had an influence on the recurrence rate especially within tumor stage pT1-3 N0 M0.
Fifty-one patients below the age of forty were treated for stomach carcinoma at the Surgical Hospital of Mainz University, between 1970 and 1986. They accounted for 5.2 per cent of all patients with stomach carcinoma. Diagnosis had been delayed under the following characteristic circumstances: The interval between onset of symptoms and diagnosis had been more than a year in 34 per cent of all cases. Fifty per cent of the patients had been originally hospitalised, following false suspicious diagnosis. Primary examination for gastro-intestinal passage produced falsely negative results in 43 per cent. The same falsely negative outcome was recorded from 24 per cent, following gastroscopy, and from twelve per cent, following gastroscopy combined with tissue sampling. The percentage of early stomach carcinomas was twice as high as that recorded from patients over forty. Undifferentiated carcinomas, on the other hand, were predominant in patients below forty, whereas adenocarcinomas were primarily recorded from patients over forty. Curative resection was successful in 55 per cent of the over-forties and 44 per cent of the under-forties. No-recurrence intervals were longer among the over-forties. However, five-year survival rates in Stages I, II, and III were better among the under-forties. Hence, the conclusion has been drawn from these findings that stomach carcinoma prognosis of patients below forty is better than that in higher age groups. This, however, is contradictory to other investigations reported in the literature.
From 1979 to 1986, seven patients with multiple endocrine neoplasia (MEN) type IIa and three with type IIb were treated. Nine had a C-cell carcinoma, one had C-cell hyperplasia. None had hyperparathyroidism. Three patients had multiple mucous neuromas. Six patients had proven pheochromocytoma: adrenalectomy was performed in these six (unilateral or bilateral depending on whether the tumor was uni- or bilateral). All ten patients had a total thyroidectomy--three later required neck dissection for regional lymphnode metastases. One patient died from the consequences of diffuse liver metastases of a C-cell carcinoma. Extensive family screening is necessary with patients who have MEN type II, in order to discover early any occult disease carriers. In addition, MEN type II should be excluded in all patients who have C-cell carcinoma, pheochromocytoma or hyperparathyroidism.
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Following rectal irrigation, it is possible to demonstrate the ileo-caecal valve sonographically, using a right para-inguinal approach. The shape, position and motility of the valve can be evaluated. The normal valve is two to three mm. thick, similar to the colonic wall, but its lips are thickened. Two distinct mechanisms are responsible for opening the valve, the ileocolic pressure gradient and relaxation of the circular muscle round the valve. The resulting intraluminal flow can be quantified by duplex sonography. The information may be of diagnostic and therapeutic significance, particularly during childhood.
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From 1.1.1976 to 31.12.1983 1,793 laparotomies were performed on children up to the age of 15 years at the Hospital of Pediatric Surgery, Mainz University. The incidence of acute unplanned relaparotomies was 4.6%. The most frequent indication of acute relaparotomy was postoperative obstruction due to adhesions (in 53% of all cases); burst abdomen, peritonitis, intestinal perforation, anastomotic insufficiency and secondary hemorrhage were less frequent causes of repeated abdominal procedures. 15% of all relaparotomised children underwent more than one repeat laparotomy. More than 40% of acute relaparotomies were performed on children within their first year of life. 56% of all relaparotomies had to be performed within the first four postoperative weeks, 87% within the first year. The lethality rate of acute relaparotomy was 15%. Lethality was especially high in children suffering from anastomotic insufficiency or burst abdomen; it increased with the number of relaparotomies. The significance of preoperative sonography for the diagnosis leading to acute unplanned relaparotomies is discussed and commented with examples.
Report on intraoperative sonography in 257 patients (89 with pancreatic and 67 with liver disease, 24 with vascular surgery and 24 with bile duct disease). Intraoperative sonography was helpful for the detection of tumors not evident by inspection and palpation. In vascular surgery it proved to be an excellent means for quality control. The main problems encountered concerned the evaluation of the bile ducts and of haemodynamically insignificant vessel wall lesions.
The authors report on the first case of haematobilia diagnosed in childhood by means of sonography. Massive haematemesis occurred in a six-year-old boy on the 57th postoperative day after an oversewn rupture of the liver. Sonography revealed an atonic gallbladder with stratification phenomena and free floating highly reflecting coagulates, as well as pulsations and flow phenomena in an area of the size of a bean at the floor of a necrotic cavity of the liver (aneurysm). Relaparotomy was done by locating the aneurysm via sonography and performing a purse-string ligature. The high mortality rate of 10 to 20% can be reduced if the gradually evolving condition is identified at an early stage, which means that regular sonographic examinations should be conducted in the postoperative control of liver rupture. Intraoperative sonography with sterilisable sound heads enables accurate location of the source of bleeding.
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