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Thyrotoxic crises occurred in six patients (four women aged 51, 63, 72 and 76 years; two men aged 52 and 63 years). In four patients the crisis was triggered by a contrast medium containing iodine, and in one by amiodarone. The cause of the crisis in the 51-year-old woman remained uncertain. After a latent period of up to two months, T3 and T4 concentrations rose in all the patients, and abnormal findings such as tachycardia, increased blood pressure, dehydration, tremor, restlessness, hallucinations and coma ensued. Because of ineffective conservative treatment, five patients underwent subtotal thyroidectomy. In all five the symptoms and signs of hyperthyroidism were promptly relieved, and the postoperative course was uneventful. The 76-year-old woman was considered unfit for surgery because of her cardiac condition, and she died of left ventricular failure resistant to therapy.

Between 1 January 1969 and 30 June 1984 904 patients with acute cholecystitis were treated as inpatients. Including 1976, initial treatment was conservative, and interval operation was recommended after 6-8 weeks. Commencing in 1977 early operation was preferred. Immediate operation within a few hours after admission and preparation for operation was done only in threatening or demonstrable complications of acute cholecystitis. Multimorbidity was highest (39%) in conservatively treated patients (n = 204), it was 26% in immediately operated patients (n = 201) and 23% in patients operated in the interval (n = 199). Early operation (n = 300) was associated with a multimorbidity of only 13%. Postoperative complications occurred most frequently (33%) after immediate operation, and in only 11% after early operation. Exploration of the choledochus was required in 27% of immediately operated cases and in only 19% of early and interval operations. Mortality after exclusively conservative treatment was 3%, after immediate operation 16%, after interval operation 3% and after early operation only 1.3%. Follow-up assessment of 137 primarily non-operated patients (7-15 years) showed a mortality of 48% on subsequently necessary immediate operation (16 out of 33 patients). No symptoms were seen in 14 out of 32 patients, only two of them had no gallstones. The high reliability of establishing the diagnosis (98% correct diagnosis) justifies early operation as preferred concept of treatment. Primary conservative treatment of acute cholecystitis and subsequently planned interval operation should be limited to justifiable exceptions.

D2-LYMPHADENECTOMY IN GASTRIC CANCER: PROGNOSTIC BENEFIT OR INCREASED PERIOPERATIVE RISK? The discussion about prognostic relevance and perioperative morbidity and mortality in gastric cancer surgery caused by systematic lymphadenectomy (D 2 -dissection) is still controversial. The impact of D 2 - and D 1 -dissection on long term survival and perioperative morbidity and mortality was evaluated analysing prospectively documentated data of 281 R 0 -resected gastric cancer patients (time period: 1986-2000; sex ratio: m:f=2:1; mean age: 64 years). Perioperative morbidity (36% vs 38%) and hospital mortality (4% vs 5%) did not differ significantly between D 2 - and D 1 -dissection groups. In contrast, perioperative morbidity increased significantly in multivisceral surgery from 30% to 45% (p=0.008) and perioperative mortality was doubled (3% vs 6%; p=0.293). D 2 -dissection was carried out in 143 patients and 138 patients were treated with D 1 -dis-section. Comparing all 281 R 0 -resected patients we did not find significant differences in 5-year survival (49% vs 43% p=0.283) between both groups. In subgroup analysis patients with pTX pN2/3 tumor stages (n=74) did not significantly benefit from D 2 -dissection (5 year survival: 16% vs 5%; p=0.249). However, the 207 patients with pTXpN0/1 tumor stages demonstrated a signi-ficantly better 5 year survival rate following D 2 -dissection (68% vs 50%; p=0.003). Especially patients younger than 65 years of age (n=96) with pTXpN0/1 tumor stages took advantage from D 2 -dissection. The 5 year survival was 84% in 49 D 2 - and 57% in 47 D 1 -dissections (p

Die diagnostische Abklarung einer akuten Divertikulitis wird durch den klinischen Schweregrad der Erkrankung bestimmt. Bei der hochakuten Divertikulitis ist es aus chirurgischer Sicht entscheidend, bedrohliche Komplikationen wie bei Vorliegen einer Peritonitis oder eines mechanischen Ileus diagnostisch zu sichern, um die Patienten einer Notfalloperation zufuhren zu konnen. Liegt hingegen eine elektive Situation vor, ist ausschlaggebend, einerseits die Diagnose zu sichern und zudem Differenzialdiagnosen auszuschliesen. Kosten-Nutzen-Analysen zur praoperativen Diagnostik einer Divertikulitis existieren nicht. Die im Notfall durchgefuhrte CT des Abdomens kann als alleiniges diagnostisches Verfahren rasch und sicher die entscheidenden Hinweise zur Operationsindikation geben. Sie erlaubt eine exakte Stadieneinteilung der Erkrankung. Zugleich lasst sich eine gute, fur den Patienten wenig belastende Differenzialdiagnostik zuverlassig durchfuhren. Bei der Elektivoperation sind eine Koloskopie, eine Sonographie und ggf. ein Bariumsulfat-Doppelkontrasteinlauf des Dickdarmes einzufordern.

Die Seltenheit der Syndrome und die Komplexitat der oft durch das ganze Leben fuhrenden Krankheitsverlaufe mit Beteiligung verschiedener Organsysteme macht die Erfassung in klinischen Registern wunschenswert. Im Gegensatz zu rein epidemiologischen Krebsregistern, die regionale Erkrankungshaufigkeiten und zeitliche Trends zuverlassig und zeitnah identifizieren mochten, ist eine Anonymisierung des Patienten im Rahmen des (meist) lebenslangen klinischen Managements nicht intendiert. Wahrend die Registrierung, sofern sie auf personlicher Einwilligung beruht, das Recht auf informationelle Selbstbestimmung wahrt, ist die rechtliche Grundlage fur die namentliche Erfassung der Familienangehorigen in einem hereditaren Kontext nicht geklart.

SummaryIn order to avoid unnecessary diagnostic procedures, the workup of jaundiced patients needs thorough evaluation of the medical history, clinical signs, and physical examination. Co

Bakterielle Infektionen und Infektionskomplikationen stellen fur den Intensivpatienten nach wie vor eine Bedrohung dar. Trotz verbesserter Einsicht in die pathophysiologischen Ablaufe konnte gerade die unkontrollierte und uberschiesende Entzundungsreaktion bisher therapeutisch nicht eingedammt werden. Einen erfolgversprechenden Ansatz verfolgt der Granulozyten Kolonien-stimulierende Faktor (G-CSF), ein hamatopoetischer Wachstumsfaktor, der die Mobilisierung, Teilung und Differenzierung von myeloischen Vorlauferzellen zu neutrophilen Granulozyten positiv reguliert. Seit 1987 wird die rekombinante Form des humanen G-CSF klinisch mit Erfolg fur die Behandlung der Chemotherapie-assoziierten Neutropenie, allen angeborenen Formen der Neutropenie sowie auch zur Mobilisierung von Vorlauferzellen fur die periphere Progenitorzelltransplantation, eingesetzt. Da G-CSF auch Funktionsstorungen des neutrophilen Granulozyten behebt und daruber hinaus endogen bei bakteriellen Infektionen produziert wird, wird diesem Wachstumsfaktor eine wichtige Funktion bei bakteriellen Infektionen zugesprochen. In tierexperimentellen Infektions-Modellen konnte rhG-CSF das Uberleben der Tiere signifikant steigern und reduzierte dabei die Produktion des Tumornekrose-Faktor-α. Bei gesunden Normalspendern zeigt rhG-CSF neben einer Steigerung der Granulozytenaktivitat eine Hemmung proinflammatorischer Zytokine. Erste Studien bei Patienten mit Infektionen (Pneumonie) und bei chirurgischen Intensivpatienten haben gezeigt, das die Therapie mit rhG-CSF keine zusatzlichen Komplikationen auslost und moglicherweise den klinischen Verlauf positiv beeinflussen kann.

Leakage from a cervical esophagogastric anastomosis still accounts for major morbidity and mortality after subtotal esophageal resection. Its prevalence might adversely be affected by drainage of the

Background: The incidence of ulcer bleeding has not decreased despite effective medical treatment of peptic ulcer disease. Numerous studies have been performed on risk factors for ulcer bleeding, but only a few studies have related the risk of developingulcer bleeding to the risk of developing uncomplicated ulcer disease. Methods: This study was performed as a multicenter interdisciplinary case-control study and was based on diagnosis by endoscopy, prospective data collection, and multivariate analysis. To every study patient with ulcer bleeding (case) one patient with uncomplicated peptic ulcer proven at endoscopy (control) was assigned with regard to sex, ulcer localization, and age (± 5 years). The controls were randomly taken from three sources: inpatients, outpatients, and patients treated by a private physician. Results: Owing to strict inclusion and exclusion criteria, 209 matched pairs were available for evaluation out of 401 patients with peptic ulcer bleeding. In univariate analysis the duration...

Besonderheiten der topographischen Anatomie der Nebennieren und ihrer pathohistologischen Morphologie, die Vielfalt erkrankungsspezifischer endokrin-funktioneller Storungen sowie epidemiologische Char

We propose a simple and reliable method to increase the sensitivity of mutation specific oligonucleotide hybridization (MSOH) at least 2.5 times, when it is used to detect mutations in samples of DNA from tumor tissues. The method is based on using single stranded (ss) DNA, amplified by asymmetric PCR, as a target for MSOH analysis. During the first step, genomic DNA, isolated from tissue samples, has to be amplified by "standard", symmetric PCR, with sense and antisense primers in equimolar concentration. This amplification can be performed in a diminished volume of reaction mixture. In the second step obtained double stranded (ds) PCR DNA-product can be used as a template for asymmetric PCR, using only a single primer. The ss DNA must be complementary to the set of mutation specific oligonucleotides. By this innovation we have been able to clarify questionable results of MSOH using ds DNA as a target. Comparing MSOH from ss DNA to that from ds DNA, the observed rate of Gs-alpha mutations in thyroid tumor tissue samples increased to 16.7% (14/66) from 6% (4/66).

Reoperation was performed in 110 of 185 patients with a differentiated thyroid carcinoma. In 25 patients (23 per cent) the indication for reintervention was a large thyroid remnant and in the other 85 (77 per cent) persistent or recurrent cancer was suspected. In 32 (29 per cent) of the 110 patients undergoing reoperation no evidence of cancer tissue was found. Tumour tissue in 33 patients (30 per cent) was resectable. Of 45 patients (41 per cent) with residual tumour after operation 24 showed only occult thyroid carcinoma with a raised serum thyroglobulin level. Eight of 21 patients with macroscopically persistent tumour died from the disease during a mean follow-up of 2·3 years. In 13 of 38 patients the investigated recurrent tumours were histologically less differentiated than the primary lesions, stressing the importance of total tumour clearance. The treatment of choice for persistent and recurrent differentiated thyroid carcinoma is surgical reintervention, if feasible, before radioiodine and radiation therapy are considered.

In a recent patient cohort surgically treated for pancreatic cancer, the 1987 UICC classification was applied. One-year survival served as the sole parameter for evaluating its prognostic relevance as

The key-enzyme for the metabolism of diamines in man is diamine oxidase (DAO). Its highest activities are in the intestinal mucosa, localized in the cytoplasm of the mature enterocytes of the small and large bowel. If the gut is affected by inflammation in Crohn's disease macroscopical changes are observed. This prospective study investigated if these mucosal alterations are also reflected in changes of mucosal diamine oxidase activity and/or mucosal histamine content respectively. Twenty patients (12 female, 8 male; age: means = 31, range 18-49 years) undergoing gut resection because of complications in Crohn's disease (Jan.-Dec. 1988) formed the basis of the study. Tissue samples of the resected material from areas inflamed and histologically not involved in the disease were investigated for diamine oxidase activities and histamine content. Diamine oxidase activities in the mucosa obtained from the macroscopically normal proximal (155.6; (76-393) mU/g (means, range)) and distal (132; (58.5-295) mU/g) resection margins were similar to our previous findings. In all patients, however, samples from the diseased mucosa had significantly (ca. 50%) lower diamine oxidase activities (74.5; (5-262) mU/g) compared to the healthy tissue. Similar differences were found in material obtained either from whole intestinal wall or from the mucosa. The determination of diamine oxidase activity constitutes possibly a more unambiguous and earlier parameter for assessing the extent of the inflamed area than histological disease presentations. Using biopsies the necessary extent of resection could be estimated before operation: this may influence operative strategies and help in the definition of the minimum amount of inflamed gut to be removed.

Porcine liver was perfused by heated blood for 45 min. Vascular isolation was not needed as blood was collected from the aorta, heated and infused in the portal vein by a roller pump. Blood temperature was 43 degrees C, 43.2 degrees C, 43.6 degrees C and 44 degrees C. During perfusion, the liver was thermally insulated by a double layer polyethylene sheet. One pig died during perfusion because of a cardiac arrest, another pig after perfusion of 44 degrees C because of an acute liver failure. Serological examinations after perfusion showed a transient increase of liver enzymes. Morphological changes were obvious but seemed to be reversible. These examinations proved that by this method porcine liver can be heated precisely and homogeneously at temperatures required for extreme hyperthermia.

Mild injuries to the head are a common everyday occurrence. Only one out of 30,000 patients suffering mild traumatization of the brain subsequently goes on to develop a complication that requires treatment. Such patients can be identified on the basis of the Glasgow Coma Scale and the determination of risk factors, and these data also serve as an aid for deciding whether surveillance at home or hospitalization is indicated.

To heat the livers in ten pigs (20–30 kg) a system of two pumps, both connected to the cannulated A.femoralis and to two radio-wave heating devices, was used. With pump I the arterial vascular system of the liver was perfused for 45 min via the A.gastroduodenalis with a constant volume of 150–200 ml blood/min, heated to 44–45 °C. With pump II 50–700 ml/min heated blood was pumped into the portal vein to raise the temperature and oxygen content of the portal flow. During the heating period the A.hepatica was clamped. A temperature of 45 °C is a highly toxic for the differentiated liver tissue, but the more simply structured wall of the arteries tolerates this temperature. This difference in heat resistance allows the perfusion of the arterial vascular system of the liver with blood heated to a temperature that is fatal to liver tissues. On the way from the A.gastroduodenalis to the liver periphery the heated blood becomes cooled by the surrounding cooler liver tissues. Finally the supply to the lobules is a mixture of arterial and venous blood, i.e. the highly toxic agent, heat, becomes “detoxified” by cooling before reaching the heat-sensetive liver lobules. Changing flow and temperature in the portal vein allows the temperature of the liver lobules to be kept within a safe range, i.e. below 43 °C. The raised oxygen content in the portal flow allows the arterial perfusion to be stopped for 10 min (to subject a heated metastasis to a period of hypoxia). Liver enzymes reached their maximal level 2 days after heating and returned to normal within 1 week. It is supposed that this method allows the temperature in a liver metastasis to be raised to a tumoricidial level.

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing worldwide, and classification systems and resection procedures are being controversially discussed.We report on 225 AEG patients undergoing primary resection in our unit (1986-2000) with a special focus on perioperative morbidity, mortality, and long-term prognosis under consideration of the AEG type (Siewert classification) and operative procedure performed (subtotal esophagectomy with proximal gastric resection in AEG I, total gastrectomy with distal esophageal resection in AEG II and AEG III).Types I, II, and III carcinomas were found in 32%, 42%, and 26% of the patients, respectively, with R(0) resections in 65%, 69%, and 51% ( P=0.039). The overall 5-year survival rates were 29%, 31%, and 14% ( P=0.068), respectively; in R(0)-resected patients, they were 40%, 41%, and 27% ( P=0.771). In univariate analysis, the TNM classification ( P0.001), R classification ( P0.001), and tumor stage ( P0.001) were relevant prognostic factors. In multivariate analysis, only the R classification ( P=0.003), LN ratio ( P=0.012), and N stage ( P=0.027) were independent prognostic factors. In 35 of 177 patients resected with curative intent, R(0) resections could not be achieved, mainly because of residual tumor in the circumferential plane (22/35=63%). Only in 37% of cases (13/35) was the R(1) situation due to exclusive positive oral or aboral resection margins. Therefore, in only 7% of all patients resected with curative intent (13/177) did the question arise of whether the R(1) resection could have been avoided by a different surgical approach. Surgical, pulmonary, and cardiac complications were found in 33%, 26%, and 10%, respectively. The mortality within 30 days was 4%.Failure of R(0) resection in patients treated with curative intent is mostly caused by residual tumor in the circumferential plane. Therefore, different surgical approaches with varying oral and aboral resection margins are of minor importance for reducing the frequency of R(1) resections. Downstaging of tumors by neoadjuvant treatment may increase the R(0) resection rate.

Biallelic polymorphism in the promotor region of the TNF-alpha gene have been associated with variation in TNF-alpha production. We determined the TNFA polymorphism (position--308) and related these data to plasma cytokine levels of TNF alpha, IL6, IL6R and IL8 in patients with SIRS and sepsis. Although there seems to be a different cytokine secretion pattern for both allelic groups (TNFA1 and TNFA2), a clear risk group could not be determined. It still remains unclear whether there is a genetic factor that influences the development of sepsis and multi organ failure.

Endoscopic ultrasound (EUS) is an important diagnostic tool for determining the best therapeutic strategy (primary resection, neoadjuvant therapy or palliation only) to offer esophageal or gastric cancer patients.In the present study (1992-2001),we evaluated the accuracy of EUS in adenocarcinomas of the distal esophagus and stomach and compared our results with pathologists findings as the gold standard.Of the 222 patients studied, the precise examination of 11% EUS was not completely possible due to severe tumor stenosis. The accuracy of EUS with respect to T, N+/- and TN+/- amounted to 51%, 65% and 34% in 131 patients with adenocarcinomas of the esophageal gastric junction and to 50%, 66% and 37% in 91 patients with adenocarcinomas located in the fundus, corpus or antrum of the stomach respectively. With respect to T-stage, the overstaging of tumors was more common than understaging, especially in pT2b-carcinomas. The subgroup analysis of the 131 EGJ adenocarcinoma patients showed that the results obtained by EUS were slightly better in type I (distal esophageal cancer) than in type II and III cardia carcinomas (proximal gastric cancer).When comparing two observation periods (1992-1996 and 1997-2001), the accuracy of endoscopic ultrasound staging was very similar in both periods for T-category (51% vs 49%) and N-category (63% vs 64%) as well as for combined TN-staging (36% vs 35%) respectively.In clinical routine examinations of adenocarcinomas of the stomach and the distal esophagus, the accuracy of EUS is not as good as the excellent results in the past--mostly obtained under study conditions--may suggest.

Die elektive chirurgische Therapie der Ulkuserkrankung wird immer seltener. Ob dies auch fur das komplizierte Ulkus gilt, haben wir am Beispiel der Perforation in unserem Krankengut untersucht.