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Seit der ersten Lebertransplantation durch Starzl 1963 gehoren Tumoren zu deren Indikationsspektrum. Vorteile der Transplantation sind die simultane Behandlung des Tumors, moglicher intrahepatischer Metastasen und der zugrunde liegenden Lebererkrankung. Die ersten Ergebnisse waren durch hohe Rezidiv- und geringe Uberlebensraten ernuchternd. Erst durch Selektionskriterien, multimodale Therapiekonzepte, neue Immunsuppressiva und intensivierte Nachsorge wurde das Outcome verbessert. Recherche und Auswertung der aktuellen Literatur. Haufigste Indikation sind die primaren Lebertumoren mit dem hepatozellulare Karzinom (HCC) an erster Stelle. Durch Etablierung von Selektionskriterien (Mailand-Kriterien) fur das HCC werden Funfjahresuberlebensraten von 75 % bei

The surgical treatment of hepatopancreatobiliary (HPB) diseases requires complex operative procedures. Within the last decades the morbidity (36-50 %) and mortality (

Die operative Therapie primarer und sekundarer Erkrankungen der Leber ist heute ein Standardverfahren. Seit der ersten Leberresektion durch Langenbruch 1888 gab es auf diesem Gebiet zahlreiche Innovationen. Neben der Operationstechnik wurden die Diagnostik und Patientenselektion, die perioperative Betreuung und Narkosefuhrung sowie die Kenntnisse der Leberanatomie und Physiologie weiterentwickelt. Der Anteil komplexer Operationen, auch im Rahmen multimodaler Behandlungskonzepte, hat dabei zugenommen. Trotzdem konnten die Morbiditat (< 45 %) und Mortalitat (< 5 %) nach Leberresektionen in den letzten Jahren deutlich gesenkt werden. Die Inzidenz postoperativer Gallenleckagen betragt in grosen publizierten Serien derzeit zwischen 0 und 30 % und hat sich in den letzten Jahren nur geringfugig reduziert.

Context and objectives The present study was designed to investigate whether 3,4-methylenedioxymethamphetamine (MDMA, 'Ecstasy') increases the sensitivity of the contractile apparatus to calcium in muscle fibres from malignant hyperthermia-susceptible and malignant hyperthermia-negative pigs, whether it causes calcium ion release from the sarcoplasmic reticulum and whether it inhibits calcium reuptake into the sarcoplasmic reticulum. Design Experimental study, using a model of porcine saponin-skinned fibres. Results Administration of MDMA in concentrations of 1, 2 and 4 mmol l(-1)l did not result in relevant force transients in skinned muscle fibres of malignant hyperthermia-susceptible or malignant hyperthermia-negative pigs. Furthermore, MDMA in these concentrations did not alter calcium ion loading of the sarcoplasmic reticulum in either group. With regard to changes in the calcium ion sensitivity of the contractile proteins, however, MDMA dose-dependently increased (pCa50) values (negative decadic logarithm of [Ca2+] at which isometric force is half-maximal) in both groups. Conclusion In the present study, we were able to demonstrate that MDMA dose-dependently increases the sensitivity of the contractile apparatus to calcium in both malignant hyperthermia-susceptible and malignant hyperthermia-negative fibres. Consequently, the malignant hyperthermia status should not affect the calcium sensitivity of the contractile apparatus. However, the increased calcium sensitivity is an important finding that must be appreciated, particularly in relation to the agonistic effect of MDMA at the nicotinic acetylcholine receptor, which increases intracellular calcium ion concentrations.

History and findings A 49-year-old man complained of increasing pain in the lower left abdomen. Three weeks previously joint pain had developed, and in the last 7 days the patient had noted a cutaneous rash at the lower legs. Within three days after admission a paralytic ileus developed, progressed and culminated in a small bowel perforation. In the 60 cm ileum specimen as well as in the skin lesions there was marked intra- und perivascular infiltration with neutrophil granulocytes and focal necrosis, but no granuloma. Diagnosis, treatment and course As the proteinase 3 subtype of antineutrophil cytoplasmic antibodies (ANCA) was positive ANCA-associated vasculitis with gastrointestinal, cutaneous and kidney involvement was diagnosed. After initiation of cytostatic treatment with methylprednisolone boli und cyclophosphamide the patient's condition improved. The post-operative course was uneventful. Conclusion ANCA-associated vasculitis rarely presents with severe gastrointestinal complications. The disease represents an interdisciplinary challenge because of its variable clinical presentation and the possibly lethal outcome if not adequately treated.

Background and objective Stopping trigger agents and prompt administration of dantrolene are the cornerstones of treatment of malignant hyperthermia. However, significant time is lost in treatment of the condition because of the cumbersome preparation and administration of the commercially available dantrolene sodium for injection. A potential improvement has become available in the form of a novel nanocrystalline dantrolene sodium suspension (DSS), which is 150 times more concentrated (50 mg ml(-1)) than the standard dantrolene sodium solution (0.33 mg ml(-1)). The aims of this study were to measure the effects of DSS on clinical and laboratory variables in malignant hyperthermia normal pigs and to compare the therapeutic management and clinical effectiveness of DSS with standard dantrolene sodium in a fulminant malignant hyperthermia crisis in susceptible pigs. The pig model is a well accepted method of studying the malignant hyperthermia crisis and is an ideal way to evaluate the variables of interest in this study. Methods Seven malignant hyperthermia normal and 10 malignant hyperthermia susceptible pigs were studied. Malignant hyperthermia susceptible pigs (body weight approximately 24 kg) were allocated to a dantrolene sodium group or a DSS group. After induction of anaesthesia, a 22-gauge catheter was placed in an ear vein and trigger-free anaesthesia was performed. After achieving stable conditions, administration of halothane was started with 0.1% and then 0.15%. Halothane was discontinued after the administration of 0.2% (malignant hyperthermia normal pigs) or when a fulminant malignant hyperthermia crisis was achieved (malignant hyperthermia susceptible pigs). After halothane was discontinued, FIO2 was set to 1.0, respiratory minute volume was doubled and sodium bicarbonate 2 mmol kg(-1) was administered. The time required to prepare and administer each formulation was measured. To simulate the administration of the substances under typical clinical conditions for a child weighing approximately 24 kg, dantrolene sodium (5 mg kg(-1)) or DSS (5 mg kg(-1)) was prepared and injected via the intravenous 22-gauge cannula. Bolus administrations of dantrolene sodium or DSS were repeated after 24 min. Results Arterial pH, arterial pCO2, mean arterial pressure and arterial lactate concentration remained stable during the experiment with DSS in malignant hyperthermia normal pigs. A significant decrease in cardiac index and increases in systemic vascular resistance and serum potassium concentration occurred after administration of DSS. In all malignant hyperthermia susceptible animals, the inhaled administration of halothane 0.15% led to a fulminant malignant hyperthermia crisis. The therapeutic regimens with administration of dantrolene sodium or DSS were successful in treating the malignant hyperthermia crisis in all animals. The course of the malignant hyperthermia crisis and the therapeutic effects of dantrolene sodium or DSS were comparable in the two groups. The time needed to prepare DSS for administration was significantly shorter (51 ± 9 s) compared to dantrolene sodium (860 ± 202 s). The time taken to inject DSS (4 ± 2 s) was significantly shorter than for dantrolene sodium (472 ± 51 s). Conclusion The therapeutic action of DSS in a malignant hyperthermia crisis in pigs was effective and comparable to that of standard dantrolene sodium. However, preparation and administration of DSS were significantly faster, which may offer a clinically significant advantage in the treatment of a fulminant malignant hyperthermia crisis and may result in a reduction in stress for the anaesthesia team.

Zusammenfassung Hintergrund Chirurgische Eingriffe in der Nahe des Ruckenmarks bergen das Risiko schwerer neurologischer Komplikationen. Daher ist ein schnelles Aufwachen des Patienten zur Uberprufung neurologischer Funktionen wunschenswert. Fruhere Untersuchungen zeigen, dass sich die Aufwachzeiten von balancierter (BA) und Total-Intravenoser Anasthesie (TIVA) bei Patienten mit Wirbelsaulenoperationen signifikant unterscheiden. Allerdings wurde hierbei die Anasthesietiefe nicht bestimmt, so dass unterschiedliche Anasthesietiefen die Ergebnisse beeinflusst haben konnten. In dieser Studie wurde daher die Anasthesietiefe bei Patienten, die sich einer Bandscheibenoperation unterziehen mussten, in den drei Gruppen BA, TIVA und „target-controlled infusion“ TIVA (TCI) mittels BIS-Monitoring vergleichbar gehalten. Material und Methoden Nach Pramedikation mit Midazolam (0,1 mg/kg KG) und Clonidin (1-2 μg/kg KG) wurden 81 Patienten (Alter: 18-65 Jahre, ASA I-II) wie folgt randomisiert: Gruppe 1: BA (Sevofluran/Sufentanil); Gruppe 2: TIVA (Propofol/Remifentanil); Gruppe 3 TCI, plasmazielkontrolliert nach Modell Schnider (Propofol/Remifentanil). Mittels BIS-Monitoring (Zielwert ≈ 45) wurde eine vergleichbare Anasthesietiefe hergestellt. Nach Beendigung der chirurgischen Masnahmen wurden die Zufuhr der Anasthetika beendet und die Extubationszeit gemessen. Die neurokognitive Erholung wurde mittels des modifizierten Mini-Mental-Status-Tests (MMST) 30 Minuten nach Ankunft im Aufwachraum objektiviert. Die individuelle Schmerzwahrnehmung wurde mittels VAS-Score gemessen und der Schmerzmittelbedarf (Piritramid) uber 24 h postoperativ mittels i.v.-PCA ermittelt. Die Ergebnisse wurden mit One-Way-ANOVA fur die Extubationszeit, Mann-Whitney-U-Test fur den MMST und students-t-test fur Piritramidverbrauch, VAS und BIS wahrend der Anasthesie untersucht; Signifikanzniveau war p Ergebnisse Die Gruppen waren bezuglich demografischer Daten und intraoperativer BIS-Werte vergleichbar. Die postoperativen Daten bezuglich Extubationszeiten (BA: 7,3 ± 3,2, TIVA: 9,8 ± 4,6 und TCI: 8,8 ± 5,8 Minuten), neurokognitiver Erholung (28,1 ± 1,8 vs. 27,2 ± 2,9 vs. 27,7 ± 2,0), VAS (2,6 ± 1,8 vs. 3,0 ± 2,1 vs. 2,8 ± 2,2) und Piritramidverbrauch uber 24 Stunden (34,5 ± 24,2 vs. 31,7 ± 23,9 vs. 37,2 ± 27,5 mg) zeigten keine signifikanten Unterschiede. Schlussfolgerungen Postoperative Aufwachzeiten sowie neurokognitive Erholung scheinen mehr von der Adjustierung stabiler Werte fur die Anasthesietiefe durch das BIS-Monitoring als von einem spezifischen, kurz wirksamen Anasthetikum abhangig zu sein. Aus klinischer und okonomischer Sicht sollte BIS daher als Standardmonitoring fur die Allgemeinanasthesie eingesetzt werden.

PURPOSE: The aim of this prospective study was to examine two port systems for intravenous chemotherapy, authorized for high pressure injection, with respect to implantation, complications, implementation, and patency. MATERIALS AND METHODS: 40 high pressure port systems of the two available models (20 × Power Port [Bard], 20 × T-Port-Contrast [PFM]) and 20 standard port systems (X-Port [BARD]) as the control group were implanted. Both high pressure systems are authorized for injection with a maximum pressure of 300 PSI. The patient population was comprised of patients with different malignomas and liver metastases. At regular intervals following the protocol of the chemotherapy, multiphasic CT for tumor staging was carried out. RESULTS: The intravenous port systems were implanted without complications under sonographic guidance with transjugular access. The mean implantation time was 30 min (range: 22 - 40 min). After a median follow-up time of 6 months, the port patency was 100 %. No port infections and no complications during high pressure injection of contrast agent occurred during this period. The level of contrast measured in the aorta was equivalent to the level of contrast in the vessels when contrast agent is administered over a large peripheral intravenous access. CONCLUSION: The intravenous high pressure port systems are equivalent to standard systems with regard to implantation and implementation. Intravenous chemotherapy can be performed as usual. The advantage is the possibility of multiphasic CT with authorized flow rates of up to 5 ml/sec.

The surgical treatment of hepatopancreatobiliary (HPB) diseases requires complex operative procedures. Within the last decades the morbidity (36-50 %) and mortality (5 %) of these procedures could be reduced; nonetheless, postoperative complications still occur in 41.2 % of cases. Compared with hepatobiliary procedures, pancreatic surgery shows an increased rate of complications. Postoperative bleeding has a major effect on the outcome and the incidence is 6.7 % after pancreatic surgery and 3.2 % after hepatobiliary surgery. The major causes of early postoperative hemorrhage are related to technical difficulties in surgery whereas late onset postoperative hemorrhage is linked to anastomosis insufficiency, formation of fistulae or abscesses due to vascular arrosion or formation of pseudoaneurysms. In many cases, delayed hemorrhage is preceded by a self-limiting sentinel bleeding. The treatment is dependent on the point in time, location and severity of the hemorrhage. The majority of early postoperative hemorrhages require surgical treatment. Late onset hemorrhage in hemodynamically stable patients is preferably treated by radiological interventions. After interventional hemostatic therapy 8.2 % of patients require secondary procedures. In the case of hemodynamic instability or development of sepsis, a relaparotomy is necessary. The treatment concept includes surgical or interventional remediation of the underlying cause of the hemorrhage. Other causes of postoperative morbidity and mortality are arterial and portal venous stenosis and thrombosis. Following liver resection, thrombosis of the portal vein occurs in 8.5-9.1 % and in 11.6 % following pancreatic resection with vascular involvement. Interventional surgical procedures or conservative treatment are suitable therapeutic options depending on the time of diagnosis and clinical symptoms. The risk of morbidity and mortality after HPB surgery can be reduced only in close interdisciplinary cooperation, which is particularly true for vascular complications.

The surgical treatment of primary and secondary liver pathologies is nowadays standard practice. Since the first major resections performed by Langenbruch in 1888 there have been significant developments in the surgical technique. In addition to the surgical technique, the diagnostics and patient selection, perioperative care and anesthetic management as well as knowledge of liver anatomy and physiology have also shown significant developments. The proportion of complex operations, even within the framework of multimodal concepts has also increased. Despite this increasing complexity, the morbidity ( 45 %) and mortality ( 5 %) of liver surgery could be clearly reduced; however, the incidence of postoperative biliary leaks in large published series currently lies between 0 % and 30 % and has only shown a minimal reduction in recent years. The management of bile leakage requires an interdisciplinary management involving endoscopic and radiological, interventional or operative therapy. Most leakages (69-94 %) persist under conservative treatment (drainage and if necessary antibiotic therapy). For high volume fistulas and persistent biliary leakage endoscopic retrograde cholangiography (ERC) with stent placement represents the therapy of choice. Infections with biliary peritonitis and failure of interventional strategies often require revision surgery, possibly consisting of suturing if a leakage is identifiable, replacement of drainages or application of a bile duct drainage (e.g. T-drain or transhepatic external biliary drainage).

Liver function and tumor staging are essential parameters for selection of treatment modalities in patients with hepatocellular carcinoma (HCC). Transarterial chemoembolization (TACE) is associated with a risk of deterioration of liver function. In clinical routine hepatic function in patients with liver cirrhosis is assessed by the Child-Pugh-classification. Dynamic breath tests allow the assessment of the hepatic functional mass and have the potential to give more accurate information on hepatic function periinterventionally.A prospective clinical study was performed in 13 patients receiving a total of 18 TACE sessions. (13)C-aminopyrine breath test was performed the day before TACE, 2 days and 30 days after TACE and correlated with standard laboratory work-up of the patients.Fourteen TACE sessions were performed in Child A liver cirrhosis, 4 in Child B cirrhosis. All patients presented with impaired aminopyrine metabolism at baseline. No significant changes in the (13)C aminopyrine breath test following TACE were observed. Two patients treated in Child A cirrhosis decompensated to Child B, one of them recovered. No further decompensation was observed in patients treated in Child B cirrhosis.Liver function assessment with (13)C-aminopyrine breath test and Child-Pugh-classification following TACE was discordant in a large proportion of patients. Whether a quantification of mitochondrial liver function in patients planned to undergo locoregional treatment of HCC in liver cirrhosis is helpful in the prediction of postprocedural liver decompensation needs to be addressed in larger prospective clinical trials.

Rhabdomyolysis describes a clinical syndrome based on different etiologies. It is defined by the breakdown of skeletal muscle fibers with leakage of toxic metabolites into circulation. Clinical presentation varies from mild levels to potentially life threatening complications. The pathophysiology of rhabdomyolysis can be subdivided into traumatic and non-traumatic forms. From the anaesthesiological point of view trauma, patient positioning, drugs, perioperative medication as well as malignant hyperthermia and propofol infusion syndrome play a major role concerning the development of rhabdomyolysis.

OBJECTIVE: To evaluate the efficacy and safety of alpha-lipoic acid given intravenously, followed by oral treatment in type 2 diabetic patients with symptomatic polyneuropathy. RESEARCH DESIGN AND METHODS: In a multicenter randomized double-blind placebo-controlled trial (Alpha-Lipoic Acid in Diabetic Neuropathy [ALADIN] III Study), 509 outpatients were randomly assigned to sequential treatment with 600 mg alpha-lipoic acid once daily intravenously for 3 weeks, followed by 600 mg alpha-lipoic acid three times a day orally for 6 months (A-A; n = 167); 600 mg alpha-lipoic acid once daily intravenously for 3 weeks, followed by placebo three times a day orally for 6 months (A-P; n = 174); and placebo once daily intravenously for 3 weeks, followed by placebo three times a day orally for 6 months (P-P; n = 168). Outcome measures included the Total Symptom Score (TSS) for neuropathic symptoms (pain, burning, paresthesias, and numbness) in the feet, and the Neuropathy Impairment Score (NIS). Data analysis was based on the intention to treat. RESULTS: No significant differences between the groups were noted for the demographic variables and the nerve function parameters at baseline. The TSS in the feet decreased from baseline to day 19 (median [range]) by -3.7 (-12.6 to 5.0) points in the group given alpha-lipoic acid intravenously and by -3.0 (-12.3 to 8.0) points in the placebo group (P = 0.447), but the area under curve on a daily basis was significantly smaller in the active as compared with the placebo group (85.6 [0-219] vs. 95.9 [5.5-220]); P = 0.033). After 7 months, the changes in the TSS from baseline were not significantly different between the three groups studied, which could be due to increasing intercenter variability in the TSS during the trial. The NIS decreased after 19 days by -4.34+/-0.35 points (mean +/- SEM) in A-A and A-P and -3.49+/-0.58 points in P-P (P = 0.02 for alpha-lipoic acid versus placebo) and after 7 months by -5.82+/-0.73 points in A-A, -5.76+/-0.69 points in A-P, and -4.37+/-0.83 points in P-P (P = 0.09 for A-A vs. P-P). The rates of adverse events were not different between the groups throughout the study. CONCLUSIONS: These findings indicate that a 3-week intravenous treatment with alpha-lipoic acid, followed by a 6-month oral treatment, had no effect on neuropathic symptoms distinguishable from placebo to a clinically meaningful degree, possibly due to increasing intercenter variability in symptom scoring during the study. However, this treatment was associated with a favorable effect on neuropathic deficits without causing significant adverse reactions. Long-term trials that focus on neuropathic deficits rather than symptoms as the primary criterion of efficacy are needed to see whether oral treatment with alpha-lipoic acid over several years may slow or reverse the progression of diabetic neuropathy.

Tobacco smoke, with its complexity of constituents, damages the pancreatic organ in multiple ways. Smoke not only affects pancreatic secretion patterns via its nicotine content but induces inflammatory reactions and exerts carcinogenic effects by several other constituents. Smoke enhances ethanol-induced pancreatic injury and accelerates the development and progression of chronic pancreatitis independent of etiology. Through the process of inflammation, smoking contributes to pancreatic carcinogenesis. The experiment of Wittel and colleagues published in this issue of the American Journal of Gastroenterology sheds further light on this topic by reporting in great detail two different kinds of pancreatic damage in rats exposed to high doses of smoke.

The use of acid suppression in patients with exocrine pancreatic insufficiency (EPI) additionally to enteric-coated pancreatic enzyme preparations (PEPs) is controversial. In current recommendations, the prescription of proton pump inhibitors (PPIs) is not generally recommended, but mentioned as an auxiliary agent if PEPs alone are not effective and a dose augmentation does not lead to a satisfying improvement of symptoms. Adverse effects of PPI treatment are rare while several beneficial aspects of their use in patients with EPI have become evident. The addition of PPIs to PEPs in patients with EPI results in a higher duodenal pH and thus a reduced inactivation of the residual enzyme secretion of patients, an earlier dissolution of PEPs from enteric coating, and a prevention of bile salt precipitation. These factors contribute to a more effective and physiological digestive pattern in patients with EPI. This article gives a detailed overview of why we believe the recommendation for the use of acid-suppressing drugs in patients with EPI is justified.

Anti-oxidant treatment has been shown to prevent nerve dysfunction in experimental diabetes mellitus, thus providing a rationale of potential therapeutic value for diabetic patients. The effects of the anti-oxidant alpha-lipoic acid (thioctic acid) were studied in a 3-week multicentre, randomized, double-blind placebo-controlled trial (Alpha-Lipoic Acid in Diabetic Neuropathy; ALADIN) in 328 non-insulin-dependent diabetic patients with symptomatic peripheral neuropathy who were randomly assigned to treatment with intravenous infusion of alpha-lipoic acid using three doses (1200, 600, or 100 mg ALA) or placebo (PLAC). Neuropathic symptoms (pain, burning, paraesthesiae, and numbness) were scored at baseline and at each visit (days 2-5, 8-12, and 15-19) prior to infusion. In addition, the Hamburg Pain Adjective List, a multidimensional specific pain questionnaire, and the Neuropathy Symptom and Disability Scores were assessed at baseline and day 19. According to the protocol 260 (65/63/66/66) patients completed the study. The total symptom score in the feet decreased from baseline to day 19 by -4.5 +/- 3.7 (-58.6%) points (mean +/- SD) in ALA 1200, -5.0 +/- 4.1 (-63.5%) points in ALA 600, -3.3 +/- 2.8 (-43.2%) points in ALA 100, and -2.6 +/- 3.2 (-38.4%) points in PLAC (ALA 1200 vs PLAC: p = 0.003; ALA 600 vs PLAC: p < 0.001). The response rates after 19 days, defined as an improvement in the total symptom score of at least 30%, were 70.8% in ALA 1200, 82.5% in ALA 600, 65.2% in ALA 100, and 57.6% in PLAC (ALA 600 vs PLAC; p = 0.002). The total scale of the Pain Adjective List was significantly reduced in ALA 1200 and ALA 600 as compared with PLAC after 19 days (both p < 0.01). The rates of adverse events were 32.6% in ALA 1200, 18.2% in ALA 600, 13.6% in ALA 100, and 20.7% in PLAC. These findings substantiate that intravenous treatment with alpha-lipoic acid using a dose of 600 mg/day over 3 weeks is superior to placebo in reducing symptoms of diabetic peripheral neuropathy, without causing significant adverse reactions.

A 49-year-old man complained of increasing pain in the lower left abdomen. Three weeks previously joint pain had developed, and in the last 7 days the patient had noted a cutaneous rash at the lower legs. Within three days after admission a paralytic ileus developed, progressed and culminated in a small bowel perforation. In the 60 cm ileum specimen as well as in the skin lesions there was marked intra- und perivascular infiltration with neutrophil granulocytes and focal necrosis, but no granuloma.As the proteinase 3 subtype of antineutrophil cytoplasmic antibodies (ANCA) was positive ANCA-associated vasculitis with gastrointestinal, cutaneous and kidney involvement was diagnosed. After initiation of cytostatic treatment with methylprednisolone boli und cyclophosphamide the patient's condition improved. The post-operative course was uneventful.ANCA-associated vasculitis rarely presents with severe gastrointestinal complications. The disease represents an interdisciplinary challenge because of its variable clinical presentation and the possibly lethal outcome if not adequately treated.

In the management of gastrointestinal tumour lesions, palliative treatment has attained an increasing role. As also in curative treatment, an interdisciplinary cooperation between gastroenterologists and surgeons has to be aimed for.The aim of this study is to illustrate the diagnostic and therapeutic management of frequently occurring diseases in palliative medicine from a gastroenterological point of view.Complementary short overviews on clinical experience and selectively searched references from the current scientific literature were evaluated.The symptomatic complex is very heterogeneous and requires an adequate approach taking into account the differential diagnosis. The palliative gastroenterological approach is characterised by the competent care on ascites, management of "malignant intestinal obstruction and obstipation" (MIO) as well as appropriate nutrition and analgetic therapy. The surgical approach is indicated after sequential exhaustion of medical, interventional endoscopic and (eventually) image-guided radiological measures; it comprises creation of a peritoneovenous shunt (ascites), bypass procedures (gastroenteral, biliodigestive, enteroenteral) as well as, in extraordinary cases, resection in addition to the implantation of an i. v. port-a-cath or surgical revision of a PEG / stent complication; in particular, in case of recurrent and massive haemorrhage and perforation (absolute indication), surgery becomes necessary.A lack of appropriate studies, absence of adequate study results including the difficult initiation of medical studies with palliative intention aggravate a competent evidence-based approach. Therefore, the management is considerably affected by clinical experience.Efficacious care in palliative visceral medicine requires relevant clinical expertise and interdisciplinary action because of the occurrence of clinical cases in gastroenterology at the border to surgery.

Despite its rare occurrence, inflammatory myofibroblastic pseudotumour (IMT) is relevant in the differential diagnosis of intestinal lesions. By the mean of an extraordinary case report, tumour site and specific characteristics, finding of the correct diagnosis, therapeutic management, and outcome of extrapulmonary IMT is decribed based also on relevant references from the literature.A 39-year old man experienced a multifocal thoracic recurrence and abdominal metastasis of IMT 12 years after successful primary resection of pulmonary IMT. The intra-abdominal lesion localised in the jejunal mesenteric tissue was removed surgically (resection status, R 0) by segmental resection of the mid-jejunum (length: 80 cm) followed by jejunojejunostomy. Histology evaluation confirmed IMT. Thoracic surgeons advised against a surgical approach to the pulmonary and thoracic lesions because of their number and proximity to the superior vena cava as well as mediastinal infiltration. Despite receiving repeated advice from his physicians, the patient has not agreed to combined immunosuppressive treatment with cyclophosphamide and steroids, because of his desire for children. He underwent 5 months of systemic steroid treatment, starting in the third postoperative month, which he then chose to stop because of Cushing symptomatology. He agreed to a computed tomography (CT) scan follow-up 12 months after surgery, which revealed slight local progression of the remaining pulmonary lesion. Administration of a second steroid medication was initiated at a lower dose. No further CT scans were obtained. At present, he is consulting with an alternative medicine practitioner.This report documents a rarely described case of IMT at a jejunal mesenteric tumour site, interpreted as an uncommon late and extraordinary, metastatic, multifocal recurrence found 12 years (!) after surgical resection of the primary pulmonary tumour.

The aim of this prospective study was to examine two port systems for intravenous chemotherapy, authorized for high pressure injection, with respect to implantation, complications, implementation, and patency.40 high pressure port systems of the two available models (20 x Power Port [Bard], 20 x T-Port-Contrast [PFM]) and 20 standard port systems (X-Port [BARD]) as the control group were implanted. Both high pressure systems are authorized for injection with a maximum pressure of 300 PSI. The patient population was comprised of patients with different malignomas and liver metastases. At regular intervals following the protocol of the chemotherapy, multiphasic CT for tumor staging was carried out.The intravenous port systems were implanted without complications under sonographic guidance with transjugular access. The mean implantation time was 30 min (range: 22 - 40 min). After a median follow-up time of 6 months, the port patency was 100%. No port infections and no complications during high pressure injection of contrast agent occurred during this period. The level of contrast measured in the aorta was equivalent to the level of contrast in the vessels when contrast agent is administered over a large peripheral intravenous access.The intravenous high pressure port systems are equivalent to standard systems with regard to implantation and implementation. Intravenous chemotherapy can be performed as usual. The advantage is the possibility of multiphasic CT with authorized flow rates of up to 5 ml/sec.

Summary Aims To evaluate the efficacy and safety of short-term oral treatment with the antioxidant thioctic acid (TA) on neuropathic symptoms and deficits in patients with Type 2 diabetes mellitus with symptomatic polyneuropathy. Methods Patients were randomly assigned to oral treatment with 600 mg of TA t.i.d. (n= 12) or placebo (n= 12) for 3 weeks. Neuropathic symptoms (pain, burning, paraesthesiae, and numbness) in the feet were scored at weekly intervals and summarized as a Total Symptom Score (TSS). The Hamburg Pain Adjective List (HPAL) and the Neuropathy Disability Score (NDS) were assessed at baseline and day 19. Results At baseline the TSS, HPAL, and NDS were not significantly different between the groups. The TSS in the foot decreased from baseline to day 19 by − 3.75 ± 1.88 points ( − 47%) in the TA group and by − 1.94 ± 1.50 points ( − 24%) in the placebo group (P= 0.021 for TA vs. placebo). The total HPAL score decreased from baseline to day 19 by − 2.20 ± 1.65 points ( − 60%) in the TA group and by − 0.96 ± 1.32 points ( − 29%) in the placebo group (P= 0.072 for TA vs. placebo). The NDS decreased by − 0.27 ± 0.47 points in the TA group, whereas it slightly increased by + 0.18 ± 0.4 points in the placebo group (P= 0.025 for TA vs. placebo). No differences between the groups were noted regarding the rates of adverse events. Conclusions These preliminary findings indicate that oral treatment with 600 mg of TA t.i.d. for 3 weeks may improve symptoms and deficits resulting from polyneuropathy in Type 2 diabetic patients, without causing significant adverse reactions.

The starch-binding domains of glucoamylase I (SBD of GA-I) from Aspergillus awamori and of cyclodextrin glucanotransferase (domain E of CGTase) from Bacillus macerans were fused to the C-terminus of beta-galactosidase (beta-gal) The majority of the fusion proteins produced in Escherichia coli were found as inclusion bodies. Active fusion proteins were purified by partial solubilization of the inclusion bodies with 2 M urea followed by affinity chromatography. Adsorption isotherms of purified fusion proteins on corn starch and cross-linked amylose were generated. The beta-gal fusion proteins had similar affinities for cross-linked amylose and corn starch but significantly different saturation capacities on corn starch. The adsorption and elution data from the potato starch column as well as the adsorption isotherms of p-gal-domain E fusion protein (BDE109) on corn starch and cross-linked amylose demonstrated that domain E of CGTase is an independent domain, which retained its starch-binding activity when separated from the other four (A-D) domains in CGTase. (c) 1995 John WileySons Inc.

The oral calcium (Ca) load test has been applied to estimate the enteral absorbability of Ca salts in humans; provided that the deep bone compartments are filled up, excess Ca should be excreted in the urine. Using this "overflow model" three Ca salts were tested in rats at increasing oral doses of 0 to 14 mmol/kg body weight: CaCO3 and two other compounds containing chloride at a Ca:Cl ratio of 1:2 (CaCl2) and 1:1 (Ca-aspartate-hydrochloride). The carbonate was poorly absorbed and hence did not significantly affect acid-base metabolism nor urine pH. Both chloride-containing salts increased Ca excretion to a significantly higher degree in a dose-dependent manner; in contrast to the organic compound, the CaCl2 induced metabolic acidosis at 14 mmol/kg body weight. At decreasing base excess and urinary pH, renal excretion of Ca and of magnesium (Mg) increased, indicating that acid-base alterations must be considered when evaluating the oral load test. All Ca salts induced moderate hypomagnesemia pointing to decreased enteral absorbability of food-borne Mg in rats. Studies on volunteers reported in the literature suggest, however, that this effect is not relevant for humans.

OBJECTIVE--To evaluate the first year's experience of an informal patient complaints system that encourages extensive patient participation. DESIGN--Audit of an informal complaints procedure. SETTING--The Marylebone Health Centre, London. SUBJECTS--39 complaints received over the audit period. MAIN OUTCOME MEASURES--Types of complaints (administrative, about doctors or medical care or both, staff about patients, mixed, other) and resolution of complaints (how complaints were dealt with and their resolution). RESULTS--37 of the 39 complaints were resolved within two weeks. Two complaints sent direct to the family health services authority were resolved (with patients' agreement) by the informal complaints procedure. CONCLUSIONS--The informal complaints procedure was more cost effective than the family health services authority system and was comparatively straightforward to implement within the practice without major organisational restructuring. The two way process of the procedure ensured patients received a quick response to complaints and helped morale of health centre staff.

The properties of bubbles in a bench-scale fluidized bed reactor, 30 cm in diameter, during coal combustion were determined by means of a newly developed cooled bubble probe and a data processing system at temperatures up to 850°C and fluidization indexes up to 10 in axial and radial positions in the bed. The fluidization index above 4 and the temperature have only slight effect on the bubble properties. Their variation along the height above the gas distributor is dominant. Oxygen and Co2-concentration profiles were measured in the bed and in the freeboard, and the o2-profiles were calculated by means of measured bubble data and bubble models. A comparison of measured and calculated o2-profiles indicates that the mass transfer rates between the emulsion and bubble phases are larger than the ones calculated by the models.