ISSN:0253-4886    

DOI:10.1159/000172516

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Whereas the incidence of squamous cell carcinoma of the esophagus is slightly decreasing, adenocarcinoma shows a strong increase. Currently, the rate of pT1 tumors of both entities in specialized centers is in a range of 10-20% of all resected esophageal carcinomas. 15-25% of the pT1 cancers show multifocal lesions and 20-30% already have lymph node metastasis. Lymphatic involvement nearly exclusively develops in case of submucosal infiltration, whereas mucosal carcinomas mostly have no lymphatic spread. The standard surgical procedure for early esophageal cancer is subtotal esophagectomy and lymphadenectomy, in squamous cell carcinoma by right transthoracic approach as an en bloc esophagectomy, in distal adenocarcinoma via an abdominocervical approach as a transhiatal blunt dissection. Only in unifocal carcinomas limited to the mucosa is endoscopic mucosectomy an appropriate procedure according to preliminary results for squamous cell carcinoma. However, the preoperative endoscopic/endosonographic differentiation between mucosal or submucosal infiltration is difficult. After esophagectomy for early cancer the prognosis of patients with adenocarcinoma is significantly better than of those with squamous cell carcinoma (5-year survival rate: 83 vs. 61%).

ISSN:0253-4886    

DOI:10.1159/000172517

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

The technique of open packing for patients with infected pancreatic necrosis has undergone considerable evolution since 1976 when we first used planned reoperation for this condition. Indications for this operative approach have become more clear and those details necessary for technical success have been refined; extensive initial exposure, thorough blunt debridement, nontraumatic packing, careful re-exploration, and secondary closure. Based upon the operative expression of these principles, in a clinically coherent longitudinal study of open packing in 96 consecutive patients with infected pancreatic necrosis over 20 years, we have been able to achieve an overall surgical mortality rate of 14.5%.

ISSN:0253-4886    

DOI:10.1159/000172518

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Objective: Recent reports have documented the safety and efficacy of laparoscopic hernia repair using polypropylene mesh. However, there is concern regarding the use of polypropylene mesh in young adults with small hernias. Individual laparoscopic hernia repair is proposed according to the Nyhus hernia classification. Methods: From November 1992 to August 1994, 123 patients with 140 hernias received laparoscopic treatment. All of the hernias were classified according to Nyhus. A standardized laparoscopic technique was used. In type-2 hernias, the inner ring was closed with nonabsorbable sutures without inserting mesh. In all type-3 and 4 hernias, large polypropylene mesh was preferred. Results: Of all hernias, 85.3% were primary, 15.7% recurrent and 12.1 % bilateral. 78% of patients were operated on under regional anesthesia, 13% were primarily intubated and 8% were intubated only because regional anesthesia had failed. The mean operating time for all hernias was 85 min (25-180 min). During the mean follow-up time of 23 months no early recurrence, mesh infection or bowel adhesions were detected. Peri-operative complications were seen in 7.3%, early postoperative complications in 19.3% and late postoperative complications in 3.2%. Most complications (like bleeding or nerve damage) occurred within the first 20 patients and can be explained as a steep learning curve. Conclusions: The early outcome after laparoscopic hernia repair seems similar to that of open hernia repair (Shouldice). According to the Nyhus classification inguinal hernias can be individually repaired without using mesh for all hernias.

ISSN:0253-4886    

DOI:10.1159/000172519

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

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 anastomosis. Therefore we conducted a prospective randomized trial on 60 consecutive patients after subtotal esophagectomy and cervical esophagogastrostomy. The patients were assigned to either a drainage (n = 29) or a non-drainage group (n = 31). Suture-line disruption was more common in the non-drainage (n = 6) than in the drainage group (n = 3), and other complications were also more frequent in the non-drainage than in the drainage group. We did not note any adverse effects of drainage itself. Taking this small collective into account, we nevertheless recommend drainage for cervical esophagogastrostomy because it is simple, free of complications and seems to have no major impact on the incidence of anastomotic disruption.

ISSN:0253-4886    

DOI:10.1159/000172520

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

We evaluated the effects of TxA2 analog (STA2), TxA2 inhibitor (OKY-046) and PGI2 analog (OP-2507) on the dog hepatocytes isolated after 84% hepatectomy. Cells isolated after 6 h following hepatectomy were cultured with normal medium (control) and in the presence of STA2. OKY-046 and OP-2507, respectively. In the presence of 0.1 nM STA2, cytosolic free CA2+ as well as LDH and bleb formation was significantly higher, and intracellular cAMP was significantly lower than those in the control, respectively. In the presence of 1 nM OP-2507, these changes were significantly inhibited. OKY-046 had no direct effect on hepatocytes. Present data shows the cytotoxic effect of TXA2 analog and the cytoprotective effect of PGI2 analog on hepatocytes.

ISSN:0253-4886    

DOI:10.1159/000172521

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

In 74 patients consecutively operated on with subtotal pancreatectomy (pancreatic duct ligation and no pancreatico-digestive anastomosis) for cancer, we analyzed to what extent size and grade of fibrosis of the gland remnant and the type of cancer (diagnosis), respectively, influenced the risk of early complications after subtotal pancreatectomy. Of the 74 patients 34 (46%) had 52 complications, corresponding to 1.5 complications per patient. Seven patients (9%) needed a reoperation. The 30 days’ mortality was 4% and hospital mortality 5%. The risk of postoperative complications was significantly reduced in the presence of fibrosis of the pancreatic remnant (p < 0.001). There were no intraabdominal complications in the 27 patients who had severe fibrosis. Also, the smaller the pancreatic remnant the less the risk of complications, especially intraabdominal abscesses (p < 0.001). The degree of pancreatic fibrosis was significantly more pronounced in patients with pancreatic cancer than in those with periampullary tumors of other origin (p < 0.005). Intraabdominal complications were more common in patients with other diagnoses than pancreatic cancer (p < 0.05). Pancreatic fistula formation was significantly influenced by the grade of fibrosis of the pancreatic body, but the size of the pancreatic remnant and the tumor origin (diagnosis) was of no importance. Multivariate analysis of factors prognostic for the development of postoperative intraabdominal complications (abscess, bleeding and fistulas) showed that the grade of fibrosis and the size of the pancreatic remnant were independent such factors. The results show that intraabdominal complications after subtotal pancreatectomy are less common in patients with pancreatic cancer than in those with other types of periampullary malignancies. This may partly be explained by the increased degree of fibrosis in the pancreatic remnant in pancreatic cancer which facilitates safe suturing. It was also found that small size of the remnant was accompanied by less morbidity indicating a role of the remaining secretory volume in the development of complication

ISSN:0253-4886    

DOI:10.1159/000172522

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Vascular complications in chronic pancreatitis are not common, but once they occur they may be life-threatening and difficult to treat. There is a lack of classification that would help us to identify these patients at risk who may benefit from timely intervention and adequate treatment. The aim of the study is to analyze this question and to present a classification system of vascular complications in chronic pancreatitis. 154 patients with chronic pancreatitis treated during the 15-year period 1977-1992 were analyzed in this study. 73 patients treated before 1986 have been analyzed retrospectively. The remaining 81 patients were studied prospectively according to a defined protocol. 72 vascular lesions occurred in 46 of the 154 patients (30%). 21 patients had ‘nonbleeding’ (group I) vascular complications mainly due to venous thrombosis or compression. 25 patients suffered from bleeding complications (group II) and were further divided into ‘nonpancreatic’ versus ‘pancreatic’ bleeding subgroups. Comparing morbidity and mortality in group I and group II, we found a low morbidity and a zero mortality in group I as compared with a 32% morbidity and a 24% mortality in group II. Further comparing the ‘nonpancreatic’ and the ‘pancreatic’ bleeding subgroups, ‘nonpancreatic’ bleeders showed low morbidity and mortality as compared with a 50% morbidity and a 50% mortality in the ‘pancreatic’ bleeder subgroup. Indeed, 83% of all deaths with vascular complications occurred in this ‘pancreatic’ bleeder subgroup. Pancreatic bleedings also showed a high coincidence with pancreatic pseudocyst formation and fistula formation. This proposed classification concept of vascular lesions in chronic pancreatitis enables the detection of truly high-risk patients for severe complications and, therefore, those who may benefit from timely intervention before a potential life-

ISSN:0253-4886    

DOI:10.1159/000172523

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Objective: The very limited efficacy of current chemotherapeutic strategies in advanced pancreatic cancer (APC) and the pattern of metastastic spread, largely confined to the upper abdominal organs within the arterial supply of celiac axis, induced us to design this phase-II study of locoregional intra-arterial chemotherapy. The aim of the present study was to evaluate the feasibility, the toxicity, the response rate and survival of a new combination of drugs administered intra-arterially in the treatment of APC. Methods: From January 1994 to August 1995, thirty-six consecutive patients with APC were given intra-arterial cycles of chemotherapy every 3 weeks through a catheter in the celiac axis introduced via the femoral artery. Seventeen patients were classified as UICC stage III and 19 as stage IV. Nineteen had liver metastases and 1 patient also had lung metastases. The schedule was: 5-fluorouracil 1,000 mg/m2; folinic acid 100mg/m2; epirubicin 60 mg/m2 and carboplatin 300 mg/m2. Each drug was infused over a period of 10 min and only 1 day of hospitalization was necessary for each cycle. After 3 cycles, when a response or stable disease had been obtained, another 2 cycles were planned, health conditions permitting. Results: A total of 114 courses of chemotherapy were administered with a mean of 3 for each patient (range 1-5). 33 patients were evaluable for response by CT scan: 7 of 33 (21%) had a partial response; 16 of 33 (49%) had stable disease; 10 of 33 (30%) had a progressive disease, and 23 of 36 (64%) had a decrease in Ca 19-9. A reduction in pain was reached in 16 of 26 patients (62%) and particularly 9 of 26 patients (35%) showed complete regression for 8 weeks or more. Weight increase was obtained in 13 of 28 patients (46%). Grade-3-4 hematological toxicity was observed in 9 of 36 (25%), and ematemesis in 2 of 36 patients (6%). Grade-3 gastrointestinal toxicity was observed in 4 of 36 (11%); alopecia in 3 of 36 (8%). One sudden death was observed in a patient on day 23 after the third cycle. No complication related to the angiographic procedure was noted. At a median follow-up of 7 months (range 1-17), the median survival was 6.2 months and, according to stage, 4.9 and 13.4 months for stages IV and III, respectively. The median time to progression was 4 months (range 2-11). Conclusions: This study shows that this drug combination, given through a celiac axis infusion, is well tolerated and active, requires only 1 day of hospitalization and might become an interesting form of integrated strategy in a palliative setting. Stage-111 patients are probably the group that might profit most with prolonged survival.

ISSN:0253-4886    

DOI:10.1159/000172524

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Two cases of strangulated foramen of Winslow hernia are presented, seen at a single Institution during a 40-year period (1955-1995). In the first case, strangulation of the gallbladder was found, with gangrene of the latter and pus and gallstones spillage into the lesser sac. In the second patient, a strangulated segment of the terminal ileum with gangrenous destruction and pus in the bursa omentalis was found. The authors stress the necessity of opening the lesser sac through the gastrocolic ligament in cases of obvious gangrene or irreducibility of the hernia, in order to ensure the least traumatic reduction of the hernia, and to clean and drain the sac. An update of the literature is presented, and the diagnosis and treatment options of this rare entity are briefly discussed.

ISSN:0253-4886    

DOI:10.1159/000172525

出版商:S. Karger AG    

年代:1997

数据来源: Karger