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The objective of this study was to analyze factors leading to explantation of totally implanted access ports (TIAPs) and to assess its occurrence and clinical relevance. Of 438 patient consecutive patients with a port explantation, 385 were eligible for this retrospective cohort study. Reasons for explantation as well as demographic, clinical, and surgical characteristics were analyzed by univariate and multivariate models. The diagnoses leading to TIAP implantation were hematological malignancies in 142 patients (36.8%), breast cancer in 103 patients (26.8%), gastrointestinal cancer in 76 patients (19.8%), nonmalignant diseases in 46 patients (11.9%), and other malignant diseases in 18 patients (4.7%). The reasons for TIAP explantation were infection in 178 patients (46.2%), end of treatment in 129 patients (33.5%), thrombosis in 44 patients (11.4%), TIAP dysfunction in 22 patients (5.7%), and other reasons in 12 patients (3.2%). At the time of TIAP explantation, 115 patients (29.9%) were receiving chemotherapy, and 49 patients (12.7%) were considered immunocompromised. In case of TIAP explantation due to infection, the median length of TIAP in situ time was 303.3 days, whereas the cumulative 10-day and 30-day explantation rates were 2.8% and 10.6%, respectively. By multivariate models, TIAP explantation due to infection is statistically significantly decreased in patients with breast cancer (P

Objectives: To assess the use of Holter monitoring for evaluating the incidence of post-anaesthetic cardiac arrhythmias and associated anaesthetic risk for two different anaesthetic protocols. Methods: Patients undergoing orthopaedic surgery were randomly divided into two groups with different anaesthetic regimens (group A, isoflurane n=30; group B, propofol n=30). Two 24-hour Holter recordings were performed for each patient: the first directly following anaesthesia and the second, as a comparison, on the fifth postoperative day. Results: Although all dogs were healthy on pre-anaesthetic cardiac evaluation, 56 dogs showed arrhythmias in the two 24-hour (Holter) electrocardiograms performed. However, the number of arrhythmias recorded was low in most cases (less than 10 supraventricular extrasystoles and less than 100 ventricular extrasystoles). One patient in group A showed 94 supraventricular extrasystoles during the second monitoring period. Three patients in each group developed more than 100 ventricular extrasystoles during both Holter recordings. There were no statistically significant differences between the two anaesthetic regimens or between the two recordings in both groups. Clinical Significance: The two anaesthetic protocols investigated in this study did not induce an increased incidence of severe arrhythmias in healthy dogs in the post-anaesthetic phase.

Background: It has long been suspected that mechanical influences may enhance the release of viable colorectal cancer cells into the circulation. The objective of this study was to determine the extent of hematogenous tumor cell spread in colorectal cancer patients during colonoscopy. Methods: Peripheral venous blood samples were taken before and after colonoscopy from 44 patients with colorectal cancer. Blood samples were examined using a reverse-transcriptase polymerase chain reaction assay to amplify cytokeratin 20 transcripts. Results: Eleven patients with colorectal cancer displayed circulating tumor cells before and after colonoscopy (25%), whereas tumor cells were detected in six of 44 patients (14%) only after the procedure (p = 0.03, McNemar’s test: tumor cell detection before after colonoscopy). All control samples consistently tested negative. Conclusions: Mechanical forces may result in enhanced release of viable colorectal cancer cells into the circulation; however, the clinical significance of these results needs to be clarified.

Background Peritoneal seeding or liver metastases found at laparotomy usually preclude curative treatment in patients with gastric adenocarcinoma. Such exploratory laparotomies may be avoided by diagnostic laparoscopy. However, routine diagnostic laparoscopy does not benefit those patients who proceed to laparotomy after negative laparoscopy. The aim of this study was to evaluate prospectively the selective use of laparoscopy in uncertain situations. Methods One hundred and twenty consecutive patients with primary gastric adenocarcinoma were studied prospectively. Diagnostic laparoscopy was performed in patients with clinical T4 tumours or suspected metastases, unless laparotomy was required for symptomatic disease. Results Ninety-six of 120 patients were selected for immediate laparotomy with curative intent (n = 81) or for palliation (n = 15). In two of the 81 patients gastrectomy was abandoned because of unexpected peritoneal carcinomatosis. Fifteen patients underwent diagnostic laparoscopy, which identified intra-abdominal metastases in six; the other nine patients proceeded to laparotomy, which revealed peritoneal metastases not detected at laparoscopy in four patients. The remaining nine patients had overt metastases and were referred for systemic chemotherapy without abdominal exploration. Conclusion Diagnostic laparoscopy in selected patients effectively limits the number of unnecessary invasive staging procedures. Routine use of diagnostic laparoscopy in all patients with gastric adenocarcinoma is not warranted.

Introduction Perforation represents a severe complication of gastric cancer. Because it is rare, only few data are available regarding treatment and prognosis. Methods Patients with perforated gastric cancer were identified from two prospective registers of gastric cancer and of gastroduodenal ulcer. Results Between February 1982 and June 1999 23 patients with perforated gastric cancer were treated surgically. This corresponds to only 1.8% of 1273 patients presenting with gastric cancer, but to 14% of 161 patients presenting with gastric perforation during this time period. Overall, post-operative mortality was 13% (3/23). Initially, 21 patients had palliative operations. Two patients had a potentially curative procedure at the emergency operation and one of the two died post-operatively. Another six patients had potentially curative gastrectomy at a second stage and no patient died post-operatively. The 5-year overall survival was estimated at 50% for all eight curatively-treated patients. Median survival of palliatively treated patients was 6 months. Conclusions Perforation of the stomach should raise suspicion of malignancy, particularly in elderly patients. At the time of perforation radical gastrectomy with lymphadenectomy is mostly not advised, either because a diagnosis of gastric cancer is not confirmed or because the patient's condition does not allow extended surgery. In this situation it is suggested to consider a two-stage procedure and direct the primary operation at the treatment of perforation and peritonitis. Tumour staging can be completed when the patient has recovered and a radical operation with curative intent can be planned without compromising long-term prognosis. Our observations and a review of the literature confirm that perforation of gastric cancer does not preclude long-term survival per se in a substantial number of patients.

Background and Study Aims: Based on the positive results of endorectal ultrasound we evaluated flexible colonic endosonography for colonic tumors. At present there are no generally accepted indications for this procedure. Moreover, it is unclear whether the results are valid enough to warrant specific therapeutic interventions. Patients and Methods: Over a one-year period we performed flexible colonic endosonography (12 MHz rotating scanner) on 31 patients with colonic tumors. The examination was only performed when therapeutic implications were expected (e.g. endoscopic procedure when there was no sign of malignancy; oncological resection when there were signs of malignancy in ulcerative colitis or familial polyposis). Results: Of 40 tumors examined, 36 were correctly staged by endosonography, compared to postoperative histology as the gold standard (16 of 17 adenomas, 5 of 5 pT1 carcinomas, 8 of 8 pT3 carcinomas). In two cases pT4 carcinomas were wrongly classified endosonographically as uT3 carcinomas, because the infiltration of the visceral peritoneum was technically not recognizable. Overall the accuracy rate of staging was 85 %. Lymph node staging was correct in 36 of 40 patients, amounting to an accuracy rate of 90 %. Conclusion: Because of its high accuracy rate flexible colonic endosonography has a place in the preoperative staging of colonic tumors in selected patients, especially those with ulcerative colitis, familial adenomatous polyposis or macroscopically suspicious adenomas. It helps to clarify the extent (oncological resection, lymphadenectomy) of resection required in conventional surgery and helps to avoid laparoscopic procedures in advanced colonic cancer.

Male Wistar rats were treated concurrently with a combination of the carcinogen N-methyl-N'-nitro-N-nitrosoguanidine (MNNG; CAS 70-25-7) and the polyamine-synthesis inhibitor alpha-difluoromethylornithine (DFMO) at two different doses of 0.5% and 1.0% (w/v). Experimental groups were treated with (I) MNNG alone (n = 25), (II) MNNG plus 0.5% (w/v) DFMO (n = 25), (III) MNNG plus 1.0% (w/v) DFMO (n = 25), (IV) 1.0% (w/v) DFMO alone (n = 25). Group V represented untreated controls (n = 20). Both the carcinogen and DFMO were administered in drinking water. The treatment time with the carcinogen and DFMO was 35 weeks. After treatment was completed animals were followed for an additional 50 weeks to cover a total observation time of 85 weeks. Significantly fewer animals developed gastric adenocarcinoma in the two groups of animals that received a combined treatment of MNNG plus DFMO compared to animals treated with the carcinogen alone (P0.05 and 0.005). No benign or malignant neoplastic lesions were observed in the stomach or duodenum of animals treated with DFMO alone or in untreated controls. It is concluded that concurrent treatment with DFMO prevents the development of malignant gastric epithelial tumors induced by MNNG in rats.

Post-anesthetic holter monitoring was performed in 2 patient groups in order to compare the incidence of cardiac arrhythmias as a result of different anesthetic protocols. The 2 groups differed in their anesthetic protocol. Both groups received levomethadone as pre-anesthetic. The dogs in group A (n = 30) additionally received diazepam, the dogs in group B (n = 30) received propofol instead. Anesthesia was maintained by isoflurane in group A and a propofol constant rate infusion in group B. In each patient 2 holter monitorings were performed. The first recording began directly after anesthesia. As a comparison a second recording was performed on the 5th post-operative day. The recorded number of arrhythmias was low and no statistical difference was demonstrated between the 2 patient groups.

The appearence of distant metastases or local recurrence is assumed to render gastric cancer incurable. However, experience with colorectal cancer has shown that patients with recurrent disease may have a chance for cure, if recurrent or metastatic disease can be completely resected. Since improved imaging allows detection of ever smaller tumour deposits, we have reviewed the pertinent literature to determine the current surgical options for recurrent or metastatic gastric cancer. Metastatic disease or local recurrence is rarely resectable. Tumour recurrence in the remnant stomach after partial gastrectomy can be treated by secondary total gastrectomy and may occasionally result in long-term survival. Other types of local recurrence are generally not amenable to complete resection. The same is true for distant metastases. If, however, distant metasases are technically resectable, 5 year survival of approximately 20% has been documented. Solitary and late appearing metachronous tumours are associated with an improved prognosis. As a consequence resection of distant metastases should be considered, because the risk of metastasectomy is generally low and there is no alternative treatment with a chance for cure.

The introduction of the Gamma nail (GN) as an intramedullar implant for pertrochanteric femoral fractures that allowed full weight bearing decreased the death rate from 17% (methods without full weight bearing) to 6%. The long Gamma nail (LGN) is a logical supplement of the standard version, designed to treat unstable per-, subtrochanteric and segmental fractures. This study evaluated 44 consecutive operations. Seventy percent of the patients had to be classified ASA III and IV, due to their high morbidity. The median age was 73.5 years. Multiple injuries occurred in 30.2%. All fractures were considered unstable. Surgery was usually performed within 24 h. The median duration of the surgical treatment was 120 min. In five cases technical problems were observed. Radiological controls showed a good positioning of the head screw. Early complications consisted of four local wound infections, three of them deep infections with a osteomyelitis. Deep venous thrombosis was observed in four cases, two of which included a pulmonary embolism (conservative treatment). The 30-day death toll was 2.3% (one patient). The median survival time (using Kaplan-Meier) in the study was 46 months, compared to 80 months in a matched population. This difference has to be linked to high premorbidity. The median duration of admission was 15 days. Mobilisation with full weight bearing was theoretically possible in all cases, but additional injuries or preoperatively impaired walking ability prevented full mobilisation in 15 cases. Functional assessment uncovered a decrease in Merle d,Aubigne score of 26.7% due to an impaired walking ability. Seventy-three percent of the patients regained their preoperative social status. In conclusion the long Gamma nail is a universal, less invasive implant with high early weight bearing. It thus allows early remobilization and reduces lethality in the treatment of complex, unstable coxal fractures.

In animal studies, glutamine (Gln) reduces chemotherapy-associated mucositis and mucosal atrophy. Therefore, this study examined the protective effects of a parenteral Gln supplementation in patients with metastatic colorectal carcinoma receiving 5-fluorouracil (5-FU)/calcium-folinate (CF) chemotherapy. In a prospective study, a total of 24 patients underwent three courses of 5-FU/CF chemotherapy and were randomised with (n = 12) or without (n = 12) glycyl-L-glutamine. Effects on gastrointestinal mucosa were assessed by endoscopic examinations and histomorphometric measurements. Clinical side-effects were documented according to the World Health Organisation grading. In the Gln group, a significant reduction in mucositis and ulcerations of the gastric (P < 0.01) and duodenal mucosa (P < 0.05) was documented after the third course of chemotherapy. In the same group, the villus height/crypt depth ratio was significantly higher after therapy than in the unsupplemented group (1st course P < 0.01; 3rd course P < 0.05). However, there were no significant differences in the incidence and severity of clinical side-effects. The results suggest that parenteral Gln supplementation protects the gastrointestinal mucosa against 5-FU/CF chemotherapy-induced damage.

Transabdominal ultrasound in the hydrotechnique (hydrosonography) was compared with endosonography for the locoregional staging of gastric cancer. For this purpose 52 consecutive patients were examined by endosonography (7.5 and 12 MHz) and hydrosonography (3.75 MHz). Forty-nine of the 52 tumors could be examined by endosonography and 41 by hydrosonography. The T-staging accuracy rate of endosonography was 74% and 46% for hydrosonography. Carcinoma of the cardia are often classified as uT3 and hT3 preoperatively and pT2 postoperatively due to infiltration of the subserosal fat. The N-staging accuracy rate of endosonography was 86% and 61% for hydrosonography. Based on these results, transabdominal ultrasound in the hydrotechnique (hydrosonography) cannot replace endosonography in gastric cancer staging. However, when performed in conjunction with conventional ultrasound, hydrosonography provides useful information about the local tumor stage, especially in cases of advanced and stenotic tumors.

Because this disease is so rare the optimum treatment of pigmented villonodular synovitis (PVNS), in particular the diffuse form differs in the literature. The most important surgical procedures are arthroscopic and open synovectomy. The prevention of disease progression, as well as joint destruction and dysfunction, depends upon the early diagnosis of PVNS. During 1994 and 1995, we treated four cases of PVNS surgically and followed the patients for a time period of more than 12 months. Two patients were treated with complete synovectomy, one patient underwent partial synovial resection, and in the final case an arthrodesis was performed. Our results indicate that an MRI is essential for diagnosis and treatment planning. For the localized form of PVNS, it appears that a partial synovectomy is appropriate. However, in the event of diagnostic uncertainty or obvious diffuse involvement of the synovium, a total synovectomy is indicated because of the high recurrence rate. In our study, all four patients had disease involving secondary bony lesions and, in one case, joint destruction. Based on our findings, it is clear that early surgical therapy is the only recommended curative intervention. The decision regarding the surgical approach, arthroscopic versus open, depends on the form of PVNS, the extent of the disease and secondary changes of the joint.

In a one year period 15 ankle fractures (13 B-type, two fractures of the medial malleolus) and six flake fractures were operated using biodegradable pins and documented prospectively. These are made of polyglycol acid fibrils compressed by use of a melting technique. They are available in different lengths and strengths. The shear strength is decreasing about half of the initial value within four weeks. The ankle fractures were stabilized with two systems of PGS-pins and PDS or Maxon figure-of-0 tension bands. Postoperative functional treatment was applied. The ankle fractures had healed after six weeks in twelve patients, after seven weeks in two, and in one patient only after nine weeks. Osseous healing of the flake fractures took more time. After six weeks was only one, after seven weeks were two and after nine weeks three fractures healed. Full load bearing was achieved after 8.9 weeks in the malleolar fracture group and after 10.8 weeks in the flake fracture group. Total duration of treatment was 10.2 weeks, respectively 12.4 weeks. It could be shown with this study that osteosynthesis of the ankle with biodegradable pins and functional postoperative treatment is basically possible. Furthermore these pins are apted ideally for fixation of flake fractures due to their high stiffness and simple application technique.

Neodymium: YAG laser has become an alternative to conventional palliative therapy for rectal cancer. Between January 1986 and December 1989, 31 patients were treated with endoscopic laser evaporation for rectal cancers with obstruction (n = 17), bleeding (n = 3) and non-obstructive luminal narrowing (n = 11). Contraindications against surgery were multiple metastases (n = 16), poor general health (n = 7), refusal by patient (n = 5) and extensive local invasion (n = 3). Laser treatment was tolerated well with an initially good response in 29 patients. Palliation could be maintained in 20 patients with laser only; two patients had an unsatisfactory control of symptoms and in eight cases a diverting colostomy was eventually required, largely due to extramural tumor growth. Complications were limited to one stenotic scar. There were no laser-related deaths. Patients survived on average 10.8 (0.1-49) months, 2-year survival was 26%. We conclude that endoscopic neodymium: YAG laser therapy is an efficient and safe palliative method to control intraluminal, obstructing or bleeding rectal cancers.

Thirty-three patients with liver metastases of colorectal cancer were treated by intra-arterial 5-FU chemotherapy. The median survival time of all patients was 14 months. A partial remission could be observed in nine patients, and a further 15 patients had stable disease. Patients were treated on an outpatient basis and the toxicity of treatment was mild. We observed no case of sclerosing cholangitis or chemical hepatitis. Intra-arterial 5-FU chemotherapy provided treatment results similar to those reported for FUdR but with less hepatobiliary toxicity.

AIM: To analyze the importance in predicting patients risk of mortality due to upper gastrointestinal (UGI) bleeding under today's therapeutic regimen. METHODS: From 1998 to 2001, 121 patients with the diagnosis of UGI bleeding were treated in our hospital. Based on the patients’ data, a retrospective multivariate data analysis with initially more than 270 single factors was performed. Subsequently, the following potential risk factors underwent a logistic regression analysis: age, gender, initial hemoglobin, coumarines, liver cirrhosis, prothrombin time (PT), gastric ulcer (small curvature), duodenal ulcer (bulbus back wall), Forrest classification, vascular stump, variceal bleeding, Mallory-Weiss syndrome, RBC substitution, recurrent bleeding, conservative and surgical therapy. RESULTS: Seventy male (58%) and 51 female (42%) patients with a median age of 70 (range: 21-96) years were treated. Their in-hospital mortality was 14%. While 12% (11/91) of the patients died after conservative therapy, 20% (6/30) died after undergoing surgical therapy. UGI bleeding occurred due to duodenal ulcer (n = 36; 30%), gastric ulcer (n = 35; 29%), esophageal varicosis (n = 12; 10%), Mallory-Weiss syndrome (n = 8; 7%), erosive lesions of the mucosa (n = 20; 17%), cancer (n = 5; 4%), coagulopathy (n = 4; 3%), lymphoma (n = 2; 2%), benign tumor (n = 2; 2%) and unknown reason (n = 1; 1%). A logistic regression analysis of all aforementioned factors revealed that liver cirrhosis and duodenal ulcer (bulbus back wall) were associated risk factors for a fatal course after UGI bleeding. Prior to endoscopy, only liver cirrhosis was an assessable risk factor. Thereafter, liver cirrhosis, the location of a bleeding ulcer (bulbus back wall) and patients’ gender (male) were of prognostic importance for the clinical outcome (mortality) of patients with a bleeding ulcer. CONCLUSION: Most prognostic parameters used in clinical routine today are not reliable enough in predicting a patient’s vital threat posed by an UGI bleeding. Liver cirrhosis, on the other hand, is significantly more frequently associated with an increased risk to die after bleeding of an ulcer located at the posterior duodenal wall.

Despite the progress made in tumor and reconstructive surgery of the maxillofacial region, postoperative problems, such as malnutrition and dysfunction of the oral-oesophageal tract are still encountered. Nutrition via a nasogastric tube often complicates the rehabilitation process of these patients. Percutaneous endoscopic gastronomy (PEG), as opposed to nasogastral feeding, is presented. The technique, possible long-term complications, and the easy usage of the mechanical pump system, are presented. In our study of 40 patients, PEG, objectively, proved useful for functional, esthetic, practical, economical, and psychological reasons.

We have attempted to determine how far it would be feasible to administer intraarterial chemotherapy in patients with colorectal liver metastases on a domiciliary basis. Care of the patients was in the hands of a permanent team consisting of a doctor, a nurse and a psychologist. So far 43 patients have been treated this way. An increased complication rate has not been found during the 225 chemotherapy cycles carried out to date. The median survival of the patients was 14 months, with enhanced quality of life through chemotherapy performed at home.

Histometric microscopic quantifications of stromal and glandular portions of BPH revealed a significant correlation of the amount of the stromal portion to the individual estrogens in the serum and to the estrogen secretion in the urine. The serum androgen level, the so-called androgen/estrogen ratio, and age had no influence.

Fifteen patients with intracranial aneurysms have been treated by coating the aneurysms with Biobond. Three patients died in the postoperative period. Only one patient had recurrent haemorrhage one year after operation. In this case the sac had not been wrapped completely at operation. Histological examination of this aneurysm revealed macrophage reaction and signs of slow disappearance of the plastic. Ten patients, who were followed up for a period of 3 to 8 years after operation, had no recurrent haemorrhage and were in good clinical condition, 8 of them doing full-time work. No complications caused by the material have been encountered. In 5 patients carotid angiography was performed after operation. In 2 cases the size of the aneurysm was diminished and in 3 cases was unchanged. There were no signs of thrombosis or narrowing of the adjacent arteries. We believe that Biobond is suitable for coating intracranial aneurysms that cannot be treated by clipping or ligature. As Biobond in vivo seems partially to disappear after long periods, it should be applied in thick layers.

The authors have carried out an analysis of the mortality among Danish patients with tuberculosis whose condition was diagnosed between 1925 and 1954 in order to obtain a picture of the trend of tuberculosis mortality over a period during which a dramatic improvement in the prognosis of the disease has taken place. The data originate from clinical records and follow-up during 10 years of all notified cases fulfilling certain conditions in Arhus, the largest provincial town in Denmark.The mortality of the patients was highest immediately after diagnosis and decreased during the 10 years they were followed. The relative changes during the follow-up period, however, appeared to be the same in all patient groups and this fact has greatly simplified the comparison of the mortality among patients diagnosed in the different calendar years.Analysis of the data according to year of diagnosis showed a consistent and substantial decrease in the mortality of young patients before the antituberculosis drugs came into use. This was true even within groups of patients with similar radiological findings. For patients over 45 years of age, however, there was no significant decrease in mortality before 1950.