Biomedical subjects

Theodor Junginger

Publications and source records attributed to Theodor Junginger.

29 records · Page 2Linked to original sources

PubMed2005

Pseudoachalasia: a case series and analysis of the literature.

OBJECTIVE: Pseudoachalasia frequently cannot be distinguished from idiopathic achalasia by manometry, radiologic examination or endoscopy. Mechanisms proposed to explain the clinical features of pseudoachalasia include a circumferential mechanical obstruction of the distal esophagus or a malignant infiltration of inhibitory neurons within the myenteric plexus. MATERIAL AND METHODS: Between January 1980 and December 2002, the clinical features of 5 patients with pseudoachalasia and 174 patients with primary achalasia, diagnosed in a single center, were compared. A literature analysis of the etiology of pseudoachalasia for the time period 1968 to December 2002 was performed. The search concentrated on the databases and online catalogues PubMed, Web of Science, Cochrane Library and Current Contents Connect. RESULTS: In our case series, patients with pseudoachalasia reported a shorter duration of symptoms and tended to be older than patients with primary achalasia. Conventional manometry, endoscopy and radiologic examination of the esophagus proved to be of little value in distinguishing between the diseases. In the majority of cases only surgical exploration revealed the underlying cause. A coincidence of primary achalasia and disorders of the gastroesophageal junction was excluded by showing return of peristalsis following treatment. The analysis of the literature showed a total of 264 cases of pseudoachalasia in 122 publications. Most cases of were due to malignant disease (53.9% primary and 14.9% secondary malignancy), followed by benign lesions (12.6%) and sequelae of surgical procedures at the distal esophagus or proximal stomach (11.9%). In rare instances, the disease was an expression of a paraneoplastic process due to distant neuronal involvement rather than to local invasion with destruction of the myenteric plexus (2.6%). CONCLUSIONS: The diagnosis of pseudoachalasia is difficult to establish by conventional diagnostic measures. The main distinguishing feature of secondary versus primary achalasia is the complete reversal of pathologic motor phenomena following successful therapy of the underlying disorder.

Adult↗

PubMed2005

Surgery for obesity.

PURPOSE OF REVIEW: Bariatric surgery today is the only effective therapy for morbid obesity. Commonly performed procedures include adjustable gastric banding and vertical banded gastroplasty, variations of the Roux-en-Y gastric bypass, biliopancreatic diversion or duodenal switch, and mixed procedures. This review discusses key issues in the surgical management of morbid obesity. RECENT FINDINGS: The two most common bariatric procedures performed worldwide are laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass. Controversy exists regarding the best surgical procedure. Weight loss decreases according to the procedures performed in following decreasing order: biliopancreatic diversion, Roux-en-Y gastric bypass, vertical banded gastroplasty, adjustable gastric banding. Concerning the complications and quality of life, there is no single operation for morbid obesity without drawbacks. Cost-effectiveness analyses have demonstrated that bariatric surgery is cost effective at less than 50,000 US dollars/quality-adjusted life years. SUMMARY: According to current opinion, gastric restrictive procedures (adjustable gastric banding, vertical banded gastroplasty) are generally considered safe and quick to perform, but the long-term outcome and quality of life have been questioned. By contrast, the long-term efficacy of adjustable gastric banding can be improved by the development of new band devices. More complex bariatric procedures, such as the Roux-en-Y gastric bypass or biliopancreatic diversion, have a greater potential for serious perioperative complications but are associated with good long-term outcome in terms of weight loss combined with less dietary restriction.

Bariatric Surgery↗

PubMed2005

Effects of pneumatic dilation and myotomy on esophageal function and morphology in patients with achalasia.

Only two treatment modalities-pneumatic dilation and Heller myotomy-promise long-term relief from dysphagia and regurgitation in patients with achalasia. The objective of this study was to determine whether both options differ in their effects on esophageal function, morphology, and improvement in symptoms. Eighty-nine patients diagnosed with achalasia between January 1980 and December 2002 at a single center were enrolled in this study. Sixty-four patients underwent pneumatic dilation and 25 Heller myotomy in combination with an anterior semifundoplication (Dor procedure). Clinical evaluation (Eckardt-Score), esophageal manometry, and barium swallow were performed before and within 6 months after treatment. Our data shows that Heller myotomy reduces the LES resting pressure more markedly (7.9 [3.7-16.9] mm Hg) than pneumatic dilation (14.5 [2.7-36.0] mm Hg) (P < 0.0001) with similar pressures at diagnosis in both groups. Morphologic changes, assessed by the diameter of the esophageal corpus, were also more pronounced after surgical therapy (P > 0.05). Both options will lead to an immediate and significant improvement in symptoms, although the two treatment modalities did not differ in their subjective results. As only objective findings, such as those obtained by manometry and the timed barium swallow, have proven relevance for the assessment of long-term results, surgical therapy is the superior and more effective treatment option in patients with achalasia.

Adolescent↗

PubMed2004

Prospective evaluation of positron emission tomography in the preoperative staging of esophageal carcinoma.

HYPOTHESIS: Positron emission tomography (PET) is a useful tool in the selection of patients with esophageal cancer who may not benefit from esophageal resection. DESIGN: Case series. SETTING: Tertiary care hospital. PATIENTS: Eighty-one patients with newly diagnosed esophageal cancer who underwent PET and computer tomography (CT) of the chest and abdomen (and of the neck in 45 patients) within 45 days were included. MAIN OUTCOME MEASURES: We calculated the sensitivity and specificity in detecting metastatic sites on the basis of 31 histologically verified lesions. In addition to results obtained on CT, the information provided by PET was evaluated with a view to the choice of management strategies. RESULTS: The PET findings had a higher specificity (89% vs 11%) but a lower sensitivity (38% vs 63%) than CT findings in the detection of metastatic sites. The CT results showed greater agreement with histopathological findings than did PET results. In 8 patients (10%), PET detected distant metastases that were not identified with CT. In 4 patients (5%), PET detected bone metastases only, but in all of these patients metastases in other locations were detected by CT. Although PET led to upstaging (M1) in 2 patients (2%), it did not enable the exclusion of esophageal resection. CONCLUSIONS: Preoperative PET was not characterized by greater accuracy in the detection of metastatic sites previously identified by CT. Therefore, PET did not lead to a change in the indication for esophagectomy. An increase in the sensitivity and the combined use of CT and PET may lead to new indications for this staging procedure.

Adenocarcinoma↗

PubMed2004

Intraoperative identification and neurophysiologic parameters to verify pelvic autonomic nerve function during total mesorectal excision for rectal cancer.

BACKGROUND: Preservation of parasympathetic and sympathetic nerves is required to avoid urogenital function disturbances after total mesorectal excision (TME) for rectal carcinoma. This study sought to determine whether intraoperative stimulation of parasympathetic nerves with monitoring of bladder contraction is useful in meeting this demand. STUDY DESIGN: In a prospective pilot study, 17 patients, 11 men and 6 women, underwent TME with pelvic autonomic nerve preservation performed by an experienced surgeon. The parasympathetic nerves were stimulated by an electrostimulation device (Screener 3625, Medronic), and the resulting bladder contraction was measured manometrically in all patients. Variations in pulse rate and voltage were measured to determine optimal stimulation parameters. A standardized questionnaire was used to record urogenital function disturbances. Residual urine volume was measured by ultrasound pre- and postoperatively. Shortterm outcomes data were evaluated to establish a possible association between intraoperative test results and postoperative bladder function. RESULTS: In 15 of 17 patients undergoing TME with pelvic autonomic nerve preservation for rectal carcinoma, the parasympathetic nerves were identified based on nerve stimulation-induced bladder contraction. Two patients with negative results on intraoperative nerve stimulation had persisting bladder dysfunction requiring an indwelling catheter after discharge from hospital. In spite of a short median followup of 2 months (range 1 to 4 months), in 7 of 10 men with intact erectile function prior to surgery, postoperative erectile dysfunction could be excluded. The study showed a pulse rate of 35 Hz and an electric potential of 12 V to be optimal stimulation parameters, associated with a mean intravesical pressure rise of 12.7 cm H(2)O (range 2.8 to 18.0 cm H(2)O). CONCLUSIONS: Intraoperative nerve stimulation with monitoring of intravesical pressure represents a technically simple procedure for the identification and verification of function of pelvic parasympathetic nerves during TME for rectal carcinoma.

Electric Stimulation↗

PubMed2004

(Neo)adjuvant strategies of advanced gastric carcinoma: time for a change?

Despite surgical R0 resections, patients with gastric cancer stage UICC II-III have a high risk of recurrence and metachronic metastases. Preliminary evidence exists that adjuvant chemotherapy or neoadjuvant chemo(radio)therapy protocols may improve the prognosis of these patients undergoing surgery of gastric cancer with curative intention. As for palliative regimens, 5-fluorouracil and cisplatin are integral components of such (neo)adjuvant strategies. Upcoming cytostatic agents, i.e. irinotecan, docetaxel, oxaliplatin, and oral fluoropyridines are currently under investigation in new multimodality treatment regimens and may further increase R0 resection rates and may prolong disease-free and overall survival in the treatment of advanced localized gastric cancer.

Carcinoma↗

PubMed2004

Subtotal esophageal resection in motility disorders of the esophagus.

BACKGROUND: Esophagectomy for motility disorders is performed infrequently. It is indicated after failed medical therapy, pneumatic dilation, non-resecting surgical and redo procedures. Patient selection in this group is challenging and the operative risk has to be weighted carefully against the poor quality of life with persistent or recurrent dysphagia. PATIENTS AND METHODS: Between September 1985 and April 2004, subtotal esophageal resections for advanced esophageal motility disorders of the esophagus not responding to previous therapy were carried out in 8 patients (6 females, 2 males). The median age of these patients was 59.5 (43-78) years. Six patients had a megaesophagus secondary to achalasia; 1 patient had a non-specific esophageal motility disorder with a stenosis of the distal esophagus, and a further patient displayed a recurrent huge epiphrenic diverticulum, which occurred in the context of a collagen disease. A transhiatal esophageal resection was performed in 6, a transthoracic procedure in 2 patients. RESULTS: Outcome assessment was done after a follow-up of 43.5 (3-92) months in median. The resection and reconstruction of the esophagus in advanced and decompensated esophageal motility disorders led to a marked functional improvement with disappearance of dysphagia. Despite previous therapeutic failures, alimentation could be restored in all patients. CONCLUSION: Favourable long-term results with significant improvement of symptoms can be achieved by esophageal resection even if endoscopic therapy or non-resecting surgical measures are unsuccessful. Transhiatal esophagectomy with gastric pull-up should be the preferred procedure and can be performed with low morbidity.

Adult↗

PubMed2004

Laparoscopic gastric banding as a universal method for the treatment of patients with morbid obesity.

INTRODUCTION: This study analyzed the influence of potentially negative predictors such as sweet-eating behavior, super-obesity, social and psychological status, family and education situation, intake of sedative drugs, and the distance between hospital and home on the outcome of laparoscopic adjustable gastric banding (LAGB). METHODS: 77 women and 29 men with mean age 40.6 years (28-47) underwent LAGB. Preoperative mean body weight was 146 kg (99-179), and mean BMI was 48.1 kg/m2 (36.4-73.5). The influence of the above-mentioned potentially negative predictors on weight loss was the primary end point. RESULTS: Mean follow-up was 44.6 +/- 19.7 months. Follow-up was possible in all but 6 patients. Median excess weight loss (EWL) was 52.1% (range 28.6-72.2%). Univariate analysis revealed no influence of the investigated negative predictors on the weight reduction. Median EWL in 24 sweet-eater patients was 55.6% compared to 55.4% in 82 non-sweet-eaters (P=0.65). A significant difference in the weight reduction was found between super-obese and non-superobese groups (P <0.001). CONCLUSIONS: LAGB should be recommended without limitation as the operation of choice for morbidly obese patients. Gastric bypass operations should be recommended only in cases of unsuccessful LAGB.

Adult↗

PubMed2003

Positron emission tomography for staging esophageal cancer: does it lead to a different therapeutic approach?

Accurate preoperative staging is essential for the indication and selection of the appropriate surgical procedure in patients with esophageal cancer. The present prospective study was designed to determine if the preoperative use of (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) increases the accuracy of staging esophageal cancer compared with computed tomography (CT) and if it thereby leads to a different therapeutic approach. A total of 58 patients, 46 men and 12 women (mean age 61 years), with histologic proof of esophageal carcinoma underwent FDG-PET of the neck, chest, and abdomen, as well as CT of the chest and abdomen, to determine tumor stage. FDG-PET and CT data were compared with each other and with pathohistologic findings. Sensitivity, specificity, and overall accuracy for detecting histologically verified lymph node and distant metastases were calculated for FDG-PET and CT. FDG-PET showed a higher specificity, whereas CT had higher accuracy for detecting both abdominal (73% vs. 59%) and thoracic (73% vs. 63%) lymph node metastases. The accuracy of detecting blood-borne and lymphatic distant metastases was identical for CT and FDG-PET imaging (50%). FDG-PET had a higher specificity than CT (87% vs. 13%) but lower sensitivity (35% vs. 67%). FDG-PET did not provide new information on the indication for surgery, nor was it helpful for choosing the appropriate surgical procedure in patients with esophageal carcinoma. In view of the relatively high cost of FDG-PET examinations, the use of this modality is indicated primarily in patients with inconclusive CT findings or for scientific research projects. Higher sensitivity as a result of tumor-affinity radiopharmaceuticals and optimized apparatus resolution, in addition to the advantages offered by whole-body PET scanning, may lead to new indications for this staging procedure in the future.

Aged↗

PubMed2003

A pig model of hepatic cryotherapy. In vivo temperature distribution during freezing and histopathological changes.

We aimed to assess the temperature distribution in the cryolesion during hepatic cryotherapy and the association with postoperative histological changes to optimise the technique and allow better preoperative planning. Hepatic cryolesions were produced in 22 pigs following laparotomy using a CMS-cryosystem and 8mm-AccuProbe-Cryoprobes. The temperature was measured in 1 min intervals at different distances from the probe during freezing. The animals were treated in 5 groups: (i) single freezing of 20 min; (ii) double freezing of 20 min each; (iii) single freezing of 40 min; (iv) single freezing of 20 min (n=4), histology at 1 week p.o., and (v) single freezing of 20 min and Pringle manoeuvre; [(i)-(iii) and (v): histology at 24 h p.o.]. The mean diameter of the -38 degrees C isotherm, i.e., the zone of effective treatment for colorectal metastases was 37 mm for group (i) with a mean iceball diameter of 59 mm and about 46 mm for groups (ii, iii, and v) with mean iceball diameters of 78, 75, and 75 mm, respectively. At 7 days postoperatively secondary necrosis was seen in the largest central part of the lesion, wherever temperatures of -15 degrees C or lower were achieved during cryosurgery. Under the hypothesis that -38 degrees C is the effective temperature for the destruction of colorectal liver metastases, a lesion of 37-mm diameter may be effectively treated with a single 8mm-AccuProbe-Cryoprobe and a 20 min single freeze cycle and a lesion of 46 mm may be effectively treated when a double freeze-thaw cycle of 20 min each, a single freeze cycle of 40 min, or a 20 min single freeze cycle with additional Pringle manoeuvre is used, when it is perfectly placed in the lesion.

Animals↗

PubMed2002

Large volume hepatic freezing: association with significant release of the cytokines interleukin-6 and tumor necrosis factor a in a rat model.

Although cryotherapy of liver tumors is generally considered a safe procedure, a syndrome of coagulopathy and fatal multiorgan failure has been observed in some patients and is called the cryoshock phenomenon. Our aim was to establish an animal model of this phenomenon and examine the effects of the basic parameters of freezing or cryotherapy on it. A group of 75 female Sprague-Dawley rats were allocated randomly to five groups: (1) sham laparotomy (n = 15); (2) small (25% liver volume) single freeze (n = 15); (3) small (25% liver volume) double freeze (n = 15); (4) large (50% liver volume) single freeze (n = 15); (5) large (50% liver volume) double freeze (n = 15). Blood samples were collected at different postoperative times, and organs were harvested for histopathology. There was a significant release of tumor necrosis factor-a (TNFa) and interleukin 6 (IL-6) following hepatic freezing, which was greatest in group 5. Postoperative serum cytokine levels were significantly associated with hepatocellular injury, as measured by postoperative serum aspartate transaminase (AST) concentrations. Severe hemoglobinuria and renal injury, as demonstrated by the serum creatinine level and the glomerular neutrophil count, were observed and were greatest in group 5. Hepatic cryosurgery is associated with release of IL-6 and TNFa and renal injury in a rat model. It is likely that the cryoshock phenomenon is another form of the systemic inflammatory response syndrome. Based on the results of this study, it is possibly mediated by cytokines released from the frozen liver tissue. We therefore caution against cryotherapy of large tumor volumes.

Animals↗