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Background: The purpose of this study is to determine prognostic factors and survival in patients who present with combined small-cell lung cancer (SCLC)., Methods: A retrospective review of combined SCLC histology in patients treated between1995-2010 was undertaken. Demographics, diagnostic information, disease characteristics, treatment modality, and survival were captured. Survival estimates were performed using Kaplan Meier analysis. Statistical significance was defined as P < 0.05., Results: Forty-one patients were identified, and 35 records were available for analysis. Median age at diagnosis was 68 (range 50-85). The study included 20 (57%) women and 15 (43%) men; and 94% had a current or former history of smoking. Histology was SCLC/large cell carcinoma not otherwise specified in 28 (80%), and SCLC/adenocarcinoma or SCLC/squamous cell carcinoma in seven (20%). Cardiac or pulmonary comorbidities were present in 80% of patients, and 24 patients had metastatic disease at presentation. Twenty-eight patients received treatment of chemotherapy (n = 24), cranial radiotherapy (n = 5), or thoracic radiotherapy (n = 7). Staging was as follows: stage I-III (n = 11), stage IV (n = 24). Median survival was 15.4 months (range <1-53 months) and 3.4 months (range <1-21.9 months) for American Joint Committee on Cancer (AJCC) stage I-III and stage IV, respectively. Estimated overall six and 12 month survival was 82%, 55%, 37%, and 17% for stage I-III and stage IV, respectively. An improved overall survival rate was found for patients with an Eastern Cooperative Oncology Group performance status of <2, and no weight loss (P < 0.05)., Conclusion: Akin to SCLC, advanced stage combined SCLC portends a poor prognosis. Perhaps novel chemotherapeutic drugs or targeted agents may improve outcomes for future patient populations.

Background: Penetrating arterial injuries to the limbs are common injuries in high volume trauma centers. Their overall surgical results reported in the literature are satisfactory - apart of those of the popliteal artery that still may lead to a significant incidence in amputations. With the present study we assessed our outcome with penetrating arterial injuries to the limb as to see if the direct involvement of vascular surgeons in the management of popliteal artery injuries leads to an improved (lowered) amputation rate. Results were benchmarked with our published results from previous years., Methods: All patients sustaining penetrating arterial injuries to the limbs admitted to the Chris Hani Baragwanath Academic Hospital during an 18- month period ending in September 2011 were included in this study. Axillary, brachial and femoral artery injuries were operated on by the trauma surgeons as in the past. All popliteal artery injuries were operated on by the vascular surgeons (new)., Results: There were a total of 113 patients with 116 injuries, as some patients had multiple vascular injuries: 10 axillary, 47 brachial, 34 femoral and 25 popliteal artery injuries. Outcome of axillary, brachial and femoral artery injury repair were excellent and not significantly different from our previous reported experience. Injury to the popliteal artery showed a diminished re-exploration rate from 34% down to 10% (p = 0,049) and a decrease of amputation rate from 16% to 11% which was statistically not significant (p = 0,8)., Conclusion: Penetrating arterial trauma to the axillary, brachial and femoral artery is followed by excellent results when operated by trauma surgeons. In the case of popliteal artery injury operated by the vascular surgeons, the results of this study do not show any statistically significant difference related to amputation rate from our previous reported studies when operated by trauma surgeons. Taking into consideration the diminished re-exploration rate and a tendency to a lower amputation rate, we feel that there is possible tendency of better outcome if operated by vascular surgeons. Multicenter studies with large number of enrolled patients will be required to prove the validity of this suggestion.

Background: Despite various attempts at modifying usual treatment modalities, anaplastic thyroid cancer (ATC) is still associated with unfavorable prognosis. Results of preclinical investigations are often of limited transferability to clinical tumor biology. Individualized multimodal treatment regimens, including novel growth-inhibiting drugs, might be a future option., Methods: Tumor tissue, freshly prepared from a patient operated for ATC, was xenotransplanted to nude mice. While the patient obtained a hyperfractionated external beam radiation, mice carrying xenotransplanted tumors were randomized (n = 6) and treated by multikinase inhibitors (sorafenib [S]: vascular endothelial growth factor receptor [VEGF-R], platelet derived growth factor receptor, RET; vandetanib [V]: VEGF-R, endothelial growth factor receptor [EGF-R]; and MLN8054 [M]: Aurora kinases [AK]). Antiproliferative, antiangiogenic, and proapoptotic effects were evaluated., Results: Treatment of successfully xenotransplanted fresh ATC tumor tissue by multikinase inhibitors and aurora kinase inhibitor reduced the tumor volume up to 61% depending on the drug and time of application (3 wk of treatment: 46% [M], 34% [V], 30% [S]; 5 wk of treatment: 61% [S]). Tumor cell proliferation (BrdU) was reduced between 34% and 58% [S] and [V]. Reduction of tumor vascularity was between 67% [V] and 33% [S] and was accompanied by decreased EGF-R/VEGF-R2 receptor activity [V/V,S]. Tumor cell apoptosis (caspase 3 activity) increased up to 2.4-fold [S]., Conclusions: Successful in vivo evaluation of novel drugs in xenotransplanted fresh tumor tissue allows in-time (while patient receives standard treatment) prospective analysis for possible additional clinical application. However, technical specifications have to be taken into account to obtain stable in vivo tumor growth. Based on the individual results, a tailored clinical drug application seems possible., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: With pilonidal sinus disease (PSD) incidence increasing, lifestyle issues have been suspected to be responsible to worsen the results of PSD surgery at the same time. The influence of smoking and body mass index (BMI) on long-term recurrence rate in primary PSD surgery has not been investigated yet., Methods: A total of 534 patients (German military cohort) were analyzed, comparing the wound healing rates of non-smoker with smoker, as well as recurrence rates in either groups. Simultaneously, the impact of BMI on wound healing and recurrence was studied. Recurrence rate was determined by Kaplan-Meier calculation following up to 20 years after primary PSD surgery., Results: Using primary open surgery, smokers' and non-smokers' recurrence rates did not differ statistically (p = 0.83; log rank). Comparable rates occurred following the primary midline closure technique (p = 0.14; log rank). A BMI of 25 and higher was not associated with adverse wound healing neither in the primary midline closure (p = 0.14) nor in the primary open treatment group (p = 0.3); nevertheless, a trend may be seen that a BMI of 25 and above could assist a favorable wound healing rate., Conclusions: The lifestyle parameter smoking and body weight statistically do not complicate wound healing or long-term recurrence rates for the first 20 years following primary PSD surgery in this study. As the BMI of 25 and above may have a beneficial influence on wound healing in primary open and primary midline closure, this observation has to be investigated for the today's surgical procedures of elective first choice-asymmetrical and flap procedures.

Background: Post-traumatic acute renal failure requiring renal replacement therapy in an intensive care unit (ICU) is associated with high mortality., Objective: To assess indicators of improved survival., Methods: This was a retrospective cohort study of 64 consecutive trauma patients (penetrating and blunt trauma and burns) who underwent haemodialysis (HD) over a period of 5 years. Information on pre-hospital and in-hospital resuscitation, trauma scores and physiological scores and daily ICU records were collected. The majority of the patients were dialysed with continuous venovenous haemofiltration in the early years of the study and later with sustained low-efficiency dialysis., Results: Of the 64 patients 47 died, giving an overall mortality rate of 73%. Mortality was highest in the burns patients (84%). Survival in all patients, irrespective of injury, was unrelated to the Revised Trauma Score, Injury Severity Score, Acute Physiology and Chronic Health Evaluation Score or Trauma Injury Severity Score. The duration of HD did not differ significantly between the three trauma groups, and age was not a significant predictor of survival. Patients who were polyuric at the time of the initiation of HD had a lower mortality rate than those who were oliguric, anuric or normouric, although this did not reach statistical significance (p=0.09)., Conclusions: Acute renal failure in trauma patients is associated with a low survival rate. Controversial conclusions have been presented in the literature. In this study, none of the parameters previously reported to affect survival proved to be valid, although the number of patients was comparable with those in other studies. Since understanding of the predictors and course of renal failure in trauma patients is still at an early stage, there is a need for multicentre prospective studies.

During the inhalation of anaesthesia use of low fresh gas flow (0.35-1 L/min) has some important advantages. There are three areas of benefit: pulmonary - anaesthesia with low fresh gas flow improves the dynamics of inhaled anaesthesia gas, increases mucociliary clearance, maintains body temperature and reduces water loss. Economic - reduction of anaesthesia gas consumption resulting in significant savings of > 75% and Ecological - reduction in nitrous oxide consumption, which is an important ozone-depleting and heat-trapping greenhouse gas that is emitted. Nevertheless, anaesthesia with high fresh gas flows of 2-6 L/min is still performed, a technique in which rebreathing is practically negligible. This special article describes the clinical use of conventional plenum vaporizers, connected to the fresh gas supply to easily perform low (1 L/min), minimal (0.5 L/min) or metabolic flow anaesthesia (0.35 L/min) with conventional Primus Draeger(®) anaesthesia machines in routine clinical practice.

We present the case of a rare penetrating sledging injury. A 39-year-old male sitting upright had his sledge burst when sliding into a pit. A stick fractured from the sledge's sitting plate and perforated from the infragluteal fold up to the lumbosacral junction. The man arrived in a conscious and cardiovascular stable condition in the ER, where no clinical evidence of vascular, retroperitoneal and pelvic injury was obvious. The anal external sphincter was uninjured and competent although the perforation enabled a look onto its surface. The foreign body was removed without further bleeding. Sledging injuries typically carry blunt characteristics, mainly with neurotrauma or fracture dislocations. As penetrating sledging injuries are exceptionally rare, strategies are discussed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: In clinical practice there are medical and economic reasons against the thoughtless use of packed red blood cells (rbc). Therefore, in searching for alternatives (therapy of anemia) the total costs of allogeneic blood transfusions must be considered. Using a practical example this article depicts the actual costs and possible alternatives from the point of view of a hospital in Germany., Method: To determine the total costs of allogeneic blood transfusions the actual resource consumption associated with blood transfusions was collated and analyzed at the St. Marien-Hospital in Vechta., Results: The authors were able to show that the actual procurement costs (average. 97 EUR) represent only 55  % of the total costs of 176 EUR. The additional expenses are allocated to personnel (78  %) and materials (22  %). Alternatives, such as i.v. iron substitution or stimulation of erythropoesis might be the more economical solution especially if only purchase prices are compared and the total costs of allogeneic blood transfusions are not considered., Discussion: Analyzing a single hospital limits generalization of the results; however, in the international context the results can be recognized as plausible. So far there have been no comprehensive studies on the true costs of blood preparations, therefore, this article represents a first starting point for closing this gap by conducting additional studies.

Aim: The influence of surgical craftsmanship and decision making on long-term recurrence rate has not been investigated yet., Methods: A total of 586 patients with surgery for primary pilonidal sinus disease were subjected to a telephone interview 7-25 years after surgery to determine 10- and 20 year recurrence rate using Kaplan Meier Statistics., Results: Results show that 546 patients had elective surgery showing a recurrence rate of 23.1% (actuarial 10.6-17% after 5-10 years). Forty patients had urgent off-time surgery with crude long-term recurrence rate 30%; actuarial 25.6-28.9% after 5-10 years); P=0.028; logrank. Mind bogglingly, Methylene blue application was dramatically reduced in the urgent group compared to the elective group, although Methylene blue is known to halve recurrence rate., Conclusion: Surgical craftsmanship quality was identical in elective and urgent pilonidal sinus surgery with comparable long-term recurrence rate. Decision making was markedly biased in urgent off-time pilonidal sinus surgery, counteracting the good long-term recurrence rate enabled by proper surgical craftsmanship.

With increasing number of patients with silicone implants for breast augmentation or reconstruction we are confronted with more and more cases of capsular contracture. Not every case is resolved by resection of the capsule and exchange of implants. Many patients rather bear the consequences of severe fibrosis than to have their implants removed. The one stage procedure of implant removal and lipofilling proved to be highly efficient with good to excellent results and high patient satisfaction. Between January 2008 and October 2012 a total of 64 patients (124 breasts) with capsular fibrosis Baker III to IV were treated with autologous fat grafts collected with the body-jet(®) by water-assisted liposuction ("BEAULI Method"). Magnetic resonance imaging (MRI) of the breasts was performed in 5 patients preoperatively and 6 month postoperatively, a clinical examination and photo documentation of all patients was done on day 1 and after 4 weeks, 12 weeks and 6 months postoperatively. The procedure included implant removal and lipofilling of the subcutaneous and intramuscular space in a single procedure by means of the BEAULI Method. The average gross amount of grafted fat was 260 ml. The average drainage time was one day. The shape of the breast changed to a more natural and ptotic form. Negative side effects like oily cysts or infections were not observed. The time of the overall procedure including liposuction was 70±15 min. Reoccurring capsular contracture is one of the hazards in plastic surgery. Until now the treatment of choice after more than two failed implant changes combined with resection of the capsule is usually the final removal of implants with or without possible additional autologous tissue transfer (microvascular flaps). We could add a relatively simple and efficient procedure to resolve and improve those cases by autologous fat transfer using water-assisted liposuction and the BEAULI Method.

Despite several decades of intensive effort to improve the imaging techniques for lung cancer diagnosis and treatment, primary lung cancer is still the number one cause of cancer death in the United States and worldwide. The major causes of this high mortality rate are distant metastasis evident at diagnosis and ineffective treatment for locally advanced disease. Indeed, approximately forty percent of newly diagnosed lung cancer patients have distant metastasis. Currently, the only potential curative therapy is surgical resection of early stage lung cancer. Therefore, early detection of lung cancer could potentially increase the chance of cure by surgery and underlines the importance of screening and detection of lung cancer. In the past fifty years, screening of lung cancer by chest X-Ray (CXR), sputum cytology, computed tomography (CT), fluorescence endoscopy and low-dose spiral CT (LDCT) has not improved survival except for the recent report in 2010 by the National Lung Screening Trial (NLST), which showed a 20 percent mortality reduction in high risk participants screened with LDCT compared to those screened with CXRs. Furthermore, serum biomarkers for detection of lung cancer using free circulating DNA and RNA, exosomal microRNA, circulating tumor cells and various lung cancer specific antigens have been studied extensively and novel screening methods are being developed with encouraging results. The history of lung cancer screening trials using CXR, sputum cytology and LDCT, as well as results of trials involving various serum biomarkers, are reviewed herein.

Background: It has long been suspected that acute infection leads to less satisfactory results in soft tissue surgery. Its influence on long-term recurrence rate in primary pilonidal sinus surgery has not been investigated yet., Patients and Methods: 583 patients (military cohort) were analyzed, comparing an incision and drainage (I&D) group preceding surgery (n = 286 pts) with a spontaneous abscess and empyema rupture group (n = 297 pts). Long-term recurrence rate up to 25 years following surgery was determined., Results: The I&D group achieved a 20 year recurrence rate of 24 %, whereas the non-I&D-group had 35 % recurrences (p = 0.0034). Analyzing the subgroup with primary open wound treatment (n = 349 pts), the I&D group did significantly better after 20 years (16 % actuarial recurrence rate versus 34 %; p = 0.009; log-rank-test)., Conclusions: Early I&D treatment preceding definite surgery for some weeks seem to give significant superior results compared to primary surgery without I&D. The combination of early I&D and asymmetric excision and out of the midline closure is expected to give even further improved results compared to this cohort. The optimum interval between I&D and definite surgery has still to be determined., (© The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin.)

This is a case report of a previously undescribed 20q chromosomal deletion (del(20q)) in marginal zone lymphoma (MZL). A 54-year-old Caucasian male presented with an enlarging neck mass and multiple violaceous skin nodules over his chest. Biopsy of the neck mass and cervical lymph nodes revealed MZL. Cytogenetic evaluation of both lymph node and bone marrow tissue revealed del(20q). This was an unexpected finding, as del(20q) is associated with myelodysplastic syndromes and myeloproliferative neoplasms and rarely seen in diffuse large B-cell lymphoma, follicular lymphoma, and T-cell lymphoma, but has not previously been described in MZL. We describe the case presentation and histologic findings and discuss the significance of this novel finding.

Background: We found a high incidence of patients with gynecomastia in the German Ministry of Defense Guard Battalion in Berlin. For this reason, we conducted the present study to investigate etiological and pathological aspects of this condition., Methods: Within six years, a total of 211 patients underwent surgery for gynecomastia. We compared this group of patients with a control group of healthy males without signs or symptoms of gynecomastia. The two groups were matched for median age., Results: The groups showed significant differences (p<0.05) in serum testosterone, free triiodothyronine (fT3), LH (luteinizing hormone) and prolactin levels and in body mass index (BMI). In addition, there was a highly significant correlation between left-sided gynecomastia and membership in the Guard Battalion., Conclusions: We found differences in hormone blood levels between gynecomastia patients and a control group. Moreover, gynecomastia was predominantly seen on the left side in guard soldiers. A possible explanation is the mechanical impact of the carbine against the left side of the body during rifle drills.

Primary adenoid carcinoma are rare skin tumors. We present a 75-year-old female with this primary cutaneous tumor of the scalp with additional bone involvement. Wide scalp excision with bone enclosure, latissimus-dorsi-free-flap defect overage, and subsequent radiation slowed down the disease but could not prevent further skull infiltration.

Case report of a 27-year-old patient who presented with a stab wound in the posterior aspect of the right chest. The patient was physiologically unstable and not responding to fluid resuscitation. A right intercostal drainage was inserted which immediately drained 1100 ml of blood. Thoracotomy was performed where a large clot was removed from the pleural cavity and followed by massive bleeding from the hilum of the lung as well as an intercostal artery posteriorly. Control of the hilar hemorrhaging necessitated right middle lobe resection. Attempts to control the bleeding from the intercostal artery were futile becoming technically more difficult due to a comminuted fracture of the ribs at the site of entry of the knife. During these attempts the patient became moribund. As a last resort the pleural cavity was packed with abdominal towels and the patient was transferred to the intensive care unit (ICU). The patient was returned to surgery after 48 h at which time the packing was removed with no further bleeding. On day 11 postoperatively drainage of the pleural collection was carried out and decortication of the right lower lobe. The patient was discharged 23 days after admission in a good general condition. This case report demonstrates that in exceptional circumstances packing of the pleural cavity to control bleeding can be considered as a method of damage control in penetrating chest trauma.

Objectives: To investigate the trends in incidence and long-term recurrence rate of pilonidal sinus disease (PSD) within the German Armed Forces, and analyse the influence of variable factors, such as different surgical methods, body constitution and smoking amount, to incidence and long-term recurrence rate of PSD., Methods: Information of all the patients being admitted with primary PSD to the surgical departments of three hospitals of the German Armed Forces between 1980 and 1996 was collected and analyzed, 500 patients of which were interviewed., Results: Two of the 500 patients were dead, and every one of the rest 498 patients agreed to take part in the interview. The incidence of PSD rose from 0.3/1000 in 1985 to 2.4/1000 in 2007. The recurrence rates were decreasing within 16 years of treatment from 33% in 1981 via 23% in 1986 to 12% in 1996 (P = 0.01). Recurrence rates of primary open wound healing (16.8%) compared to primary suture (31.0%) differ significantly (P < 0.01). While the mean body weight within the army rose 1 kg per decade, population shows an increase of 1.9 kg per decade though not being an influencing factor on the recurrence rate (P = 0.72). Smoking of more than 20 cigarettes per day proved to be a significant factor on the recurrence rate of PSD (P = 0.015)., Conclusion: While the recurrence rates-especially of primary open wound treatment-decreased, the incidence of PSD rose nearly tenfold.

Due to an unfavorable prognosis using the usual therapy, patients with anaplastic thyroid cancer (ATC) are in desperate need of new therapeutic strategies. The objective of this study was to evaluate the effects of MLN8054, an inhibitor of the Aurora serine/threonine kinases, on ATC cells in vitro and on ATC xenografts as a new therapeutic strategy for ATC. Three anaplastic (Hth74, C643, Kat4) and one follicular (FTC133) thyroid cancer cell lines were evaluated in vitro and Kat4 xenografts in vivo. The antiproliferative effect of MLN8054 (0.1-10 μM) on thyroid cancer cells was quantified by sulphorhodamine B-assay. The proapoptotic effect and the effects on the cell cycle were evaluated by flow cytometry after Annexin-V-FITC staining. Further Histone H3 phosphorylation was analysed. In vivo, antiproliferative and antiangiogenic effects were assessed by tumor volume and morphometric analysis following immunohistochemical staining (Ki-67, pHisH3, CD31). Treatment of the different TC cells with MLN8054 inhibited proliferation in a time- and dose-dependent manner, with IC(50) values between 0.1 and 10 μM. Administration of MLN8054 resulted in an increase of apoptotic cells, decreased Histone H3 phosphorylation and induced cell cycle arrest. In vivo, treatment of ATC by MLN8054 resulted in an up to 86% reduced tumor volume and 89% reduced tumor vascularity. In conclusion, our data demonstrated that Aurora kinase inhibition is effective in reducing cell growth and inducing apoptosis of ATC in vitro and tumor growth and vascularity in vivo. Controlled clinical studies on MLN8054 or comparable compounds would be worthwhile to evaluate its potential therapeutic value for treatment of ATC., (© 2011 Japanese Cancer Association.)

The term "Damage-control" is borrowed from naval terminology. It means the initial control of a damaged ship. Because of the lethal triad in multiple injured patients the classical concept of definitive surgically therapy in the acute phase of the injury has a high rate of complications such as exsanguination, sepsis, heart failure and multiple organ failure. The core idea of the damage control concept was to minimize the additional trauma by surgical operations in these critical patients in the first phase. This means temporary control of a hemorrhage and measures for stopping abdominal contamination. After 24 - 48 hours in the intensive care unit and correction of physiological disturbances further interventions are performed for definitively treatment of the injuries. Summarized, the damage control strategy comprises an abbreviated operation, intensive care unit resuscitation, and a return to the operating room for the definitive operation after hemodynamic stabilisation of the patient., (© Georg Thieme Verlag Stuttgart · New York.)

Background and Aim: Chemotactic cytokines play a role in angiogenesis and attraction of immune cells. However, their contribution to tumor formation remains incompletely understood. In a previous transcriptome study, we identified a family of structurally related chemokines of the CXC-family to be specifically up-regulated in colorectal cancer. The aim of the present study was to investigate the regulation of their expression in colon cancer cells and to test the hypothesis that altered CXC-chemokine expression is related to critical clinical parameters, such as survival or metastasis formation., Materials and Methods: Expression levels of interleukin-8 (CXCL-8) and growth-related oncogenes 2 and 3 (GRO-2/CXCL-2 and GRO-3/CXCL-3) were quantified using qRT-PCR in 97 patients with completely resected colon carcinoma and correlated with clinical parameters. Moreover, 16 samples of normal mucosa, nine samples of benign adenoma, and 11 samples of liver metastasis were analyzed. Next, the regulation of chemokine expression in response to various stimuli was tested in colon cancer cell lines (HT29, HCT116, CaCO2)., Results: Expression of GRO-2, GRO-3, and IL-8 was significantly increased in colon cancer as compared to normal colon tissue. Expression of GRO-2 and GRO-3 was already enhanced in premalignant adenomas, and GRO-3 was significantly down-regulated in liver metastasis as compared to the primary tumor. Importantly, expression of GRO-3 was significantly higher in patients with local versus systemic disease. Moreover, IL-8 expression was significantly associated to overall post-operative survival. Finally, all chemokines were strongly induced by IL-1alpha in the colon cancer cell lines tested, indicating a potential link to inflammatory processes., Conclusion: In accordance with earlier findings, we report here a significantly increased expression of GRO-2, GRO-3, and IL-8 in colon carcinoma as compared to normal tissue. Furthermore, GRO-3 was related to metastasis formation, and IL-8 was associated with survival, suggesting a potential predictive power of these markers.

Purpose: The selective inhibition of tyrosine kinases is a promising strategy in the treatment of several human malignancies. This study aimed to clarify expression patterns of therapeutically addressable receptor tyrosine kinases in colorectal cancer., Materials and Methods: In this study, we used tissue arrays to analyze 263 specimen of colorectal carcinoma for the expression of the tyrosine kinases c-kit (CD117), epidermal growth factor receptor (EGF-R), and platelet-derived growth factor receptor (PDGF-R). Staining patterns were then correlated with tumor stage and survival., Results: Five tumors (1.9%) showed a strong expression of c-kit (CD117), while in 40 samples (15.2%), a weak/intermediate expression was observed. Positive staining did not correlate with histopathological parameters although a trend toward a better survival of c-kit-positive patients was observed. No positivity for PDGF-R was observed in 263 samples of colorectal carcinomas. Positive EGF-R expression was identified in 39 cases (15.2%), whereas 218 samples (84.8%) stained negative., Conclusions: Our study confirms that expression of the tyrosine kinases c-kit and PDGF-R are rare in colorectal carcinomas and do not correlate with tumor stage.

Background: To provide a score to predict the risk of early mortality after single craniocerebral gunshot wound (GSW) based on three clinical parameters., Methods: All patients admitted to Baragwanath Hospital, Johannesburg, South Africa, between October 2000 and May 2005 for an isolated single craniocerebral GSW were retrospectively evaluated for the documentation of (i) blood pressure (BP) on admission; (ii) inspection of the bullet entry and exit site; and (iii) initial consciousness (n= 214)., Results: Conscious GSW victims had an early mortality risk of 8.3%, unconscious patients a more than fourfold higher risk (39.2%). Patients with a systolic BP between 100 and 199 mm Hg had an 18.2% risk of mortality. Hypotension (<100 mm Hg) doubled this risk (37.7%) and severe hypertension (> or =200 mm Hg) was associated with an even higher mortality rate of 57.1%. Patients without brain spilling out of the wound ('non-oozer') exhibited a mortality of 19.7%, whereas it was twice as high (43.3%) in patients with brain spill ('oozer'). By logistic regression, a prognostic index for each variant of the evaluated parameters could be established: non-oozer:0, oozer:1, conscious:0, unconscious:2, 100 < or =RR(sys) < 200 mm Hg:0, RR(sys) < 100 mm Hg:1, RR(sys)>/= 200 mm Hg:2. This resulted in a score (0-5) by which the individual risk of early mortality after GSW can be anticipated., Conclusions: Three immediately obtainable clinical parameters were evaluated and a score for predicting the risk of early mortality after a single craniocerebral GSW was established.

Purpose: It has long been suspected that a family history of pilonidal sinus disease may predispose to higher disease incidence. The influence of family history on recurrence rate has not been investigated. The purpose of this study was to evaluate the recurrence rate in patients with both a personal and a family history of pilonidal sinus disease., Methods: A standardized telephone interview was used to retrospectively study 578 patients who underwent primary surgery between 1980 and 1996. Differences concerning the long-term recurrence rate between patients with a positive or negative family history were analyzed using Kaplan-Meier statistics., Results: Sixty-eight of 578 patients (12%) had a positive family history with first-degree relatives, in which 28 brothers and 25 fathers were similarly involved. The long-term recurrence rate was significantly elevated when family history was positive (35% vs. 22% after 15 years and 52% vs. 28% after 25 years; P = 0.02). The long-term recurrence rate was elevated if surgery was needed at a younger age (P = 0.03). The body mass index measured at time of admission for surgery did not seem to have any negative influence on recurrence rates (P = 0.31). Although a positive family history predisposes a person to earlier onset of disease, recurrences occur within 5.1 +/- 6.2 years (mean +/- standard deviation) in patients with a positive family history and within 5.3 +/- 5.2 years in patients with a negative family history (P = 0.95)., Conclusion: Patients with a positive family history need closer surgical monitoring because primary disease will manifest earlier. A remarkable long-term recurrence rate exceeding 50% after 25 years places a much higher disease burden on patients with a positive family history. All available interventions known to reduce recurrence rate should be applied to this group of patients.

Objective: Orthotopic liver transplantation (OLT) in rats is frequently used as an experimental model. Numerous surgical techniques have been developed that enable the investigator to conduct clinically relevant studies. The objective of this study was to develop a rat model of acute and chronic rejection, to explicitly study technical modifications of vascular anastomoses with precision, and to examine histopathologic and functional changes in the graft., Materials and Methods: With DA-(RT1av1) rats as donors and Lewis-(RT1) rats as recipients, arterialized OLT was performed using a combined suture, cuff, and splint method. Recipients were divided into 5 groups: syngeneic control rats (group 1), allogeneic control rats (group 2), allogeneic OLT rats with low-dose tacrolimus (FK506) immunosuppression (group 3), allogeneic OLT rats with high-dose tacrolimus immunosuppression (group 4), and allogeneic OLT rats with high-dose tacrolimus immunosuppression and retrograde reperfusion via the infrahepatic caval vein (group 5). After OLT, serum parameters were determined and hepatic biopsy specimens were sampled. We examined the effects of acute rejection with or without immunosuppression therapy at histopathologic evaluation., Results: Liver grafts in syngeneic and allogeneic rats (groups 1, 2, 4, and 5) demonstrated normal serum parameters and histopathologic findings at 10 days after OLT, and 93% survival at 3 months. The simplified technique using 1 suture and 2 cuff anastomoses provided the best short- and long-term survival after OLT in all groups. Retrograde perfusion via the infrahepatic caval vein resulted in lower postoperative liver enzyme values., Conclusion: The present model is feasible, enabling comprehensive preclinical experimental research on liver transplantation. Furthermore, we provide helpful instructions for learning this surgical technique.

Saving more human lives through more effective reanimation measures is the goal of the new international guidelines on cardiopulmonary resuscitation as the decisive aspect for survival after cardiovascular arrest is that basic resuscitation should start immediately. According to the updated guidelines, the greatest efficacy in cardiac massage is only achieved when the right compression point, an adequate compression depth, vertical pressure, the correct frequency, and equally long phases of compression and decompression are achieved. The very highest priority is placed on restoring continuous circulation. Against this background, standardized continuous chest compression with active decompression has contributed to a favorable outcome in this case. The hydraulically operated and variably adjustable automatic Lund University Cardiac Arrest System (LUCAS) device (Jolife, Lund, Sweden) undoubtedly meets these requirements. This case report describes a 44-year-old patient who - approximately 15 min after the onset of clinical death due to apparent ventricular fibrillation - received cardiopulmonary resuscitation, initially by laypersons and then by the emergency medical team (manual chest compressions followed by situation-adjusted LUCAS compressions). Sinus rhythm was restored after more than 90 min of continuous resuscitation, with seven defibrillations. Interventional diagnostic workup did not reveal a causal morphological correlate for the condition on coronary angiography. After a 16-day period of hospital convalescence, with preventive implantation of an implantable cardioverter defibrillator and several weeks of rehabilitation, the patient was able to return home with no evidence of health impairment.

It is well known that so-called bullet-proof vests offer protection against a wide range of penetrating trauma, but their protection against blunt trauma is less well understood. Fast projectiles may result in hematomas and contusions behind the armour. We report a traffic accident involving a young soldier wearing a ballistic protection vest resulting in a right thoracoabdominal blunt trauma leading to a confined liver compression rupture. As nearly no skin marks were detectable, we point out that every emergency department surgeon should be very suspicious if a patient wore a ballistic vest at the time of the accident--there may be no skin marks despite severe intra-abdominal trauma. Our patient recovered following hypotensive ICU treatment, thrombocyte mobilization, and factor VIIa substitution.

Gunshot wounds to the head are associated with poor outcome. We reviewed data to identify prognostic factors. We performed a retrospective study of all patients admitted to a Level 1 trauma center with isolated gunshot injury to the head during 6 1/2 years. Data collected included demographics, mechanism of injury, prehospital and resuscitation room data, and initial CT scan characteristics. The primary outcome measure was the Glasgow Outcome Scale. Seventy-two patients with isolated gunshot wounds to the head were admitted. Overall mortality was 58 per cent. The mortality for patients with an initial Glasgow Coma Scale score of < or = 8 was 81 per cent versus 14 per cent for those with initial Glasgow Coma Scale score > 8 (P < or = 0.0001). Fifty per cent had pupillary abnormalities on arrival at the Emergency Department. Mortality in this group was 78 per cent versus 53 per cent in those with normal pupillary reflexes (P = 0.06). Elevated plasma lactate was associated with nonsurvival. Thirteen per cent of survivors were assessed as able to live independently after their injury. Civilian gunshot injury to the head is related to high mortality. Indicators of outcome are the admission Glasgow Coma Scale score, pupillary abnormality, metabolic acidosis, and CT pattern of severe injury. The majority of deaths occur at an early stage. Among survivors the functional outcome can be acceptable.

Ischemia/reperfusion (I/R) injury is a main cause of primary dysfunction or non-function after liver transplantation (LTx). Recent evidence indicates that an increase in nitric oxide (NO) production after LTx is associated with I/R injury. The aim of this study was to demonstrate that low-dose FK506 in combination with aminoguanidine (AGH), which leads to a reduction of NO levels, has a protective effect by reducing I/R associated injury after LTx. Fortyone DA-(RT1av1) rats served as donors and recipients for syngenic orthotopic arterialised LTx. They were divided into 4 groups: controls without pre-/treatment (I), pre-/treatment with high-dose FK506 (II), pre-/treatment with AGH only (III), and pre-/treatment with low-dose FK506 in combination with AGH (IV). After LTx the laboratory parameters and liver biopsy were performed. The levels of transaminase (ALT) in groups I, II and III were significantly higher on day 3 after LTx compared to group IV (p = 0.001, p = 0.001, p = 0.000). In group IV the I/R-associated liver necrosis rate was reduced significantly. Our results demonstrated that a combined dual pharmacological pretreatment (group IV) reduced I/R injury of the graft after LTx in a rat model.

Background: In colorectal surgery UICC/AJCC criteria require a yield of 12 or more locoregional lymph nodes for adequate staging. Neoadjuvant radiochemotherapy for rectal carcinoma reduces the number of lymph nodes in the resection specimen; the prognostic impact of this reduced lymph node yield has not been determined., Methods: One hundred two patients with uT3 rectal carcinoma who were receiving neoadjuvant radiochemotherapy were compared with 114 patients with uT3 rectal carcinoma who were receiving primary surgery followed by adjuvant radiochemotherapy. Total lymph node yield and number of tumor-positive lymph nodes were determined and correlated with survival., Results: After neoadjuvant radiochemotherapy both total lymph node yield (12.9 vs. 21.4, p < 0.0001) and number of tumor-positive lymph nodes (1.0 vs. 2.3, p = 0.014) were significantly lower than after primary surgery plus adjuvant radiochemotherapy. Reduced total lymph node yield in neoadjuvantly treated patients had no prognostic impact, with overall survival of patients with 12 or more lymph nodes the same as that of patients with less than 12 lymph nodes. Overall survival of neoadjuvantly treated patients was significantly influenced by the number of tumor-positive lymph nodes with 5-year-survival rates of 88, 63, and 39% for 0, 1-3, and more than 3 positive lymph nodes (p < 0.0001)., Conclusion: The UICC/AJCC criterion of a total lymph node yield of 12 or more should be revised for rectal carcinoma patients.

Background: For experimental basic research, standardized transplantation models reflecting technical and immunologic aspects are necessary. This article describes an experimental model of combined pancreas/kidney transplantation (PKTx) in detail., Materials and Methods: Donor rats underwent en bloc pancreatectomy and nephrectomy. Revascularization was performed using the aorta with the superior mesenteric artery and the inferior vena cava with the portal vein. Exocrine drainage of the pancreas took place over a segment of the duodenum which was transplanted side-to-side to the jejunum. The kidney vessels were transplanted end-to-side. The ureter was anastomosed by patch technique. Postoperatively, serum parameters were monitored daily. Biopsies for histopathology were taken on days 5, 8 and 12., Results: All 12 recipients survived the combined PKTx without serious surgical complications. One thrombosis of the portal vein led to organ failure. Blood glucose levels were normal by the 3rd postoperative day. The transplanted duodenal segment showed slight villous atrophy, and the kidneys were well perfused without vascular complications. The anastomosis between ureter and bladder was leakproof., Conclusions: Excellent graft function and survival rates can be achieved due to simplified operation technique and short operation time. It may thus have high clinical relevance to immunologic issues within the scope of basic research., (Copyright 2009 S. Karger AG, Basel.)

Purpose: To study potential benefits of postoperative epilation after pilonidal sinus surgery, the long-term effect of hair removal on pilonidal recurrence was investigated., Methods: A total of 1,960 patients with pilonidal sinus treated surgically from 1980 to 1996 in three hospitals of the Deutsche Bundeswehr were eligible for the study. Regular hair removal with a razor was recommended for all patients after surgery. A randomly selected sample of 504 patients was contacted for a follow-up telephone interview., Results: The mean follow-up time was 11.3 (standard deviation, 6.4) years. Overall, pilonidal sinus disease recurred in 111 (22 percent) of the 504 patients. A total of 113 patients followed the recommendation to perform epilation (mean duration, 7.5 months), and 391 patients did not. Recurrence was observed in 30.1 percent (34/113) of patients who performed postoperative epilation and in 19.7 percent (77/391) of patients who did not perform postoperative epilation (P = 0.01)., Conclusions: Razor hair removal increases the rate of long-term recurrence after surgery for pilonidal sinus disease and therefore should not be recommended. However, the rationale for hair removal in pilonidal sinus disease is compelling. Other epilation techniques such as laser hair removal should be investigated in appropriate studies.

Introduction: Asymptomatic pilonidal sinus disease (PSD) discovered incidentally is regarded as a precursor of symptomatic disease, which is characterized by intradermal hair eliciting an inflammatory reaction. We aimed to investigate whether asymptomatic PSD already shows inflammation, though clinically inapparent, or represents a 'virgin' sinus., Materials and Methods: One thousand seven hundred and thirty-one medical records of patients presenting with primary PSD, which underwent surgery, were analysed to identify patients with surgically resected incidental PSD., Results: Acute purulent pilonidal disease was seen in 514 of 1,731, whereas chronic fistulating pilonidal disease was the most common diagnosis group with 1,019 of 1,731 (58.9%). One hundred and forty-three of 1,731 (8.3%) patients had a previous chronic remitting pilonidal sinus. A total of 55 (3.2%) patients with clinically asymptomatic PSD were identified. Histological workup documented hair in 64.6% (1,119/1,731), with comparable rates between 68% and 71% in chronic fistulating disease, chronic remitting disease and incidental PSD (p = 0.80). Inflammation was found in 53 of 55 (96.4%) incidental PSD specimens, with two thirds (37 of 55) showing chronic inflammatory changes and one third (16 of 55) combining acute and chronic inflammation., Conclusion: Our findings support the idea that incidental PSD is a sub-clinically inflamed pilonidal sinus, with hair and chronic infection present. However, the data suggest that a prophylactic surgery for asymptomatic PSD provides no benefit for the patient compared to surgery in chronic PSD; thus, observational treatment is most likely sufficient for asymptomatic PSD.

Penetrating injury to the subclavian arteries is one of the most taxing arterial injuries a trauma surgeon can encounter. Operative access for repair is difficult, crossing two separate anatomical areas-superior mediastinum and base of the neck. The artery runs well protected behind sternum and clavicle and tears easily if clamped. Physiologically unstable patients must be rushed to theatre in an attempt to control exanguinating haemorrhage and to repair the injury. In the rare circumastance of being confronted with it, it is imperative for the occasional trauma surgeon to have a practical operative concept for dealing with this type of injury. This tutorial describes a practical approach for penetrating subclavian injuries, and it discusses alternative surgical strategies when supraclavicular expanding hematomas deny straightforward access.

Background: Maintenance of telomeres has been identified as an essential regulator of proliferative capacity and genomic integrity in malignant tumors. The authors evaluated telomere length and telomerase subunits, hTR and hTERT, as prognostic markers in patients with Barrett carcinoma., Methods: Telomere length was measured by Southern blot analysis and hTR expression and hTERT expression by real-time polymerase chain reaction in both cancer tissue and adjacent noncancerous Barrett mucosa in resection specimens from 46 patients with Barrett carcinoma (International Union Against Cancer [UICC] stages I-III). The median follow-up time of the surviving patients was 79 months., Results: Cancer tissue expressed more hTERT-mRNA than noncancerous mucosa (P < .05). Telomere lengths in cancer tissue and in noncancerous mucosa increased with higher pT category (P = .08 and P = .05, respectively). Twenty-one patients who died of tumor recurrence showed significantly longer telomeres in cancer tissue compared with 25 patients without tumor-related deaths (P < .05). Telomere length in both cancer tissue and in noncancerous mucosa and the telomere-length ratio cancer:noncancerous tissue were correlated with overall survival. In multivariate analysis, the telomere-length ratio proved to be an independent prognostic parameter (P < .02; relative risk of death 3.4; confidence interval, 1.3-8.9). Ten patients with telomere-length ratios >1.17 had a significantly poorer overall survival compared with 36 patients with telomere-length ratios

Background: and aims To elicit mechanisms and timing of sinus development, the role of age at onset of symptoms, symptomatic disease duration, and consecutive number of sinuses were investigated., Materials and Methods: Analysis of 1,962 medical records of patients admitted for primary surgical pilonidal sinus treatment., Results: Sinus number ranged from 1 to 16 (median 2), with chronic pilonidal disease showing more sinuses than acute disease (mean 2.6 vs 2.1 sinuses; p < 0.0001; Kolmogorov-Smirnov). Disease duration in chronic pilonidal disease was not linked to sinus formation (p = 0.98; Spearman). In acute pilonidal disease, duration was linked to the development of six sinuses per 1,000 symptomatic disease years (p = 0.0001; Spearman). A larger sinus number correlated with earlier onset of symptoms (p = 0.009; Spearman)., Conclusion: Long-standing chronic disease does not produce sinus per se. As sinus does not substantially arise during the course of symptomatic disease, there must be a time before the start of symptomatic disease when the sinus originates. These findings suggest that sinus can only be acquired up to a certain age, even if occupational exposure continues.

Herpes simplex infection is characterized by acute or subacute infection, often followed by a chronic carrier state. Consecutive recurrences may flare up if immunocompromise occurs. Herpes simplex associated esophagitis or duodenal ulcer have been reported in immunocompromised patients due to neoplasm, HIV/AIDS or therapeutically induced immune deficiency. Here we report the case of an HSV-DNA seronegative patient who developed grade III dysphagia 13 days after allogeneic liver transplantation. Endoscopy revealed an esophageal-gastric ulcer, and biopsy histopathology showed a distinct fibroplastic and capillary ulcer pattern highly suspicious for viral infection. Immunohistochemistry staining revealed a distinct nuclear positive anti-HSV reaction. Antiviral therapy with acyclovir and high-dose PPI led to a complete revision of clinical symptoms within 48 h. Repeat control endoscopy after 7 days showed complete healing of the former ulcer site at the gastroesophageal junction. Although the incidence of post-transplantation Herpes simplex induced gastroesophageal disease is low, the viral HSV ulcer may be included into a differential diagnosis if dysphagia occurs after transplantation even if HSV-DNA PCR is negative.

Objective: To study the potential benefits of intraoperative methylene blue (MB) use in pilonidal sinus surgery, the correlation between long-term recurrence rate and intraoperative MB use in pilonidal sinus surgery was investigated., Background: Explicit investigations of MB effects in sinus surgery are scarce and inconclusive; an effect on long-term recurrence rate has never been systematically investigated., Materials and Methods: A random selection of 247 patients out of 1,960 patients with primary sinus surgery was drawn, and the patients were subjected to a telephone interview according to a specific questionnaire. The interview covered a recurrence follow-up time of 14.9 years after surgery (mean, standard deviation=3.8 years, range 8.6-25.4 years)., Results: Recurrence was less likely to occur when MB was used intraoperatively (32 of 197, [16% actuarial 20-year recurrence rate, Kaplan-Meier estimate] recurrences with MB vs 15 of 50, 30% [actuarial 20-year recurrence rate, Kaplan-Meier estimate] recurrences without MB; p=0.018; log-rank test). This effect was especially pronounced in acute abscess-forming disease (8 of 46, 17% [actuarial 20-year recurrence rate, Kaplan-Meier estimate] recurrences with MB; 11 of 33, 33% [actuarial 20-year recurrence rate, Kaplan-Meier estimate] recurrences without MB; p=0.078; log-rank test) compared to chronic disease (24 of 151, 16% [actuarial 20-year recurrence rate, Kaplan-Meier estimate]) recurrences with MB; 4 of 17, 24% [actuarial 20-year recurrence rate, Kaplan-Meier estimate] recurrences without MB; p=0.35; log-rank test)., Conclusions: MB application halves the long-term risk of recurrence for pilonidal sinus patients. This significant reduction in recurrence rate can be achieved by a single careful injection of non toxic inexpensive dye into the sinus at the start of the operation. MB application should therefore be considered as an integral part of pilonidal sinus surgery.