The standard treatment in forearm fractures of children is usually conservative. Unstable fractures of the proximal parts of the forearm often show poor results after nonoperative management, requiring surgical intervention. We report on 30 children from 4 to 14 years of age who were treated by elastic intramedullary nailing. Sixteen patients were treated by intramedullary pinning immediately after the accident; 14 required intramedullary nailing after failure of the conservative treatment and fracture redislocations. At the time of follow-up 6 months later, functional results were "excellent" in 24 children, "good" in 5 and "fair" in one child. There were no serious complications apart from the occurrence of one delayed union. According to these results intramedullary nailing can be recommended for the treatment of unstable fractures of the proximal and middle parts of the forearm in children.
Since therapy options in the treatment of advanced pancreatic cancer are rare, the present study has investigated whether patients with advanced pancreatic cancer may profit from isolated hypoxic perfusion (IHP) of the abdomen with mitomycin C. None of the 17 treated patients responded to IHP with mitomycin C, and the survival time corresponded to that of untreated patients. On the basis of these results, this procedure should no longer be used as treatment for patients with advanced pancreatic cancer.
Gadolinium-DTPA enhanced dynamic MR imaging is a new method for the quantification of portal bloodflow and liver perfusion. In this study we evaluated the validity of this method comparing it with thermodiffusion and dopplerflowmetry in pigs. We found a significant correlation of tissue perfusion between dMRI and thermodiffusion and of portal bloodflow between dMRI and dopplerflowmetry. Partial occlusion of the portal vene was accurately detected by dMRI. Dynamic MRI could become a valuable diagnostic method for the quantification of liver perfusion.
Deficits in the treatment of patients with chronic pain lead the German Parliament of Physicians (Deutscher Arztetag) in 1996 to adapt a special curriculum called "Special Pain Treatment". Objectives and contents are defined in detail in guidelines accepted from 10 out of 17 federal commissions in Germany at this time. Because transitional regulations have been administered until now, surgeons have not yet been required to obtain the qualification. The prescribed curriculum and particularly the contract between the association of general practitioners and the insurance companies make the acquisition of the qualification and the permission to use it in private practice covered by insurance very difficult for surgeons.
Among radiological diagnostical procedures, the conventional chest X-ray has retained its significance as a screening investigation up to the present. Digital imaging does not reveal any advantages. Due to its higher resolution the CT scan, particularly the spiral CT scan, has markedly increased radiological possibilities, thus influencing surgical oncology significantly. Tumor invasion of the mediastinum, heart, and thoracic wall has become detectable, as well as enlarged lymph nodes and metastases. CT angiography permits a better assessment of large vessels by aortic rupture or dissection and pulmonary embolism, to name a few. MRI is inferior to CT scan in this respect, displaying a slight advantage in terms of detecting tumor infiltration of the nerval plexus, i.e. pancoast syndrome.
Deficits in the treatment of patients with chronic pain lead the German Parliament of Physicians (Deutscher Arztetag) in 1996 to adapt a special curriculum called "Special Pain Treatment". Objectives and contents are defined in detail in guidelines accepted from 10 out of 17 federal commissions in Germany at this time. Because transitional regulations have been administered until now, surgeons have not yet been required to obtain the qualification. The prescribed curriculum and particularly the contract between the association of general practitioners and the insurance companies make the acquisition of the qualification and the permission to use it in private practice covered by insurance very difficult for surgeons.
The complexity of daily clinical work requires a sophisticated collaboration of surgery and anesthesiology. This can be accomplished by a rational approach to the following topics: clear definition of areas of competence respecting the principle of mutual trust, integration of anesthesiologists into the basic physical examination, proposal of case-oriented preoperative diagnostics, agreement on necessary preoperative therapy, common consultational meetings for outpatient surgery, recovery room available 24 h a day, instruction of the surgical personnel in specific pain therapy, availability of coworkers who are competent and willing to cooperate, no unilateral renunciation of clinical knowledge, ability and execution, no renunciation of organizational and structural self-determination, no monopoly on perioperative medicine.
Poorly and highly liver metastatic colon carcinoma cell lines have different integrin-mediated adhesion to extracellular matrix. Specific integrin-mediated interactions between tumor cells and extracellular matrix (ECM) in the host organs are important for organ-specific metastasis. In colon carcinoma integrin expression differs depending on the metastatic potential of the tumor. Integrin-mediated adhesion of poorly (HT-29P) and highly liver-metastatic (HT-29LMM) colon carcinoma to extracellular matrix (ECM; Collagen I-C I, Collagen IV-C IV, Laminin LN, Fibronectin FN, Vitronectin VN) was investigated. HT-29LMM showed significant better adhesion to LN (45% vs. 26%; p < 0.001) and FN 20% vs. 1%; p < 0.001). No adhesion was found to VN. RGD-oligopeptides completely inhibited adhesion to FN. Using inhibition with anti-integrin-mAB it was shown, that adhesion to C I and C IV is mediated by alpha 2 beta 1-integrin, adhesion to LN by alpha 6 beta 1 and adhesion to FN by alpha v beta 1. These results have shown that adhesion of HT-29 cells is mediated by different integrins depending on ECM components. Poorly and highly metastatic cells possessed different patterns of adhesion to various substrates.
The authors retrospectively analyzed 523 patients with large bowel obstruction (LBO): 126 (24.09%) right-sided (RSLBO) and 397 (75.91%) left-sided (LSLBO), treated at the Emergency Medicine Institute "N. I. Pirogov" in Sofia. For the period 1988-1997, a trend toward more radical and aggressive surgery is shown: compared to a previous period (1964-1983) the one-time operations (partial, subtotal and total colectomy with primary anastomoses) are becoming standard operations in RSLBO as well as in LSLBO. A classification based on objective clinical, X-ray and intraoperative findings is considered in the diagnostic and therapeutic algorithm of the LSLBO.
Despite R0-resection up to 30% of patients with colorectal cancer stage UICC I and II die of recurrent disease. This tumor progression could be caused by isolated disseminated tumor cells in lymph nodes which are not detected by current staging methods. The purpose of this study was to develop a system for detecting lymphogenic tumor cell dissemination in colorectal cancer. With the established CK 20-RT-PCR we detected tumor cells in 32 of 107 histopathologically negative lymph nodes from patients with colorectal cancer. We conclude that the CK 20-RT-PCR is more sensitive than immunohistochemical methods in detecting isolated disseminated tumor cells of colorectal cancer in lymph nodes. To evaluate the prognostic significance of lymphogenic disseminated tumor cells the examination and follow-up of more patients is necessary.
We made PET scans using 18 FDG for 46 patients admitted for pancreatic surgery. The method yielded a sensitivity of 86% and a specificity of 67%. PET does not allow precise exclusion of malignant tumors and therefore invasive diagnostic procedures may not be reduced.
Both, burn trauma and sepsis induce the generation of reactive oxygen intermediates which often coincides with increased nitric oxide (NO) levels. NO takes part in both circulatory disorders and cell protection. Therefore, in a prospective (pre-)clinical study we focused on the detection of NO in polytrauma patients (pts) starting as early as at the scene of accident. Upon approval of the local ethics committee, pts with an injury severity score (ISS) ranging from 9 to 75 (mean 22) were enrolled. Subsets were performed according to the different injury pattern (long bone fractures, head injury, polytrauma with and without damage to the thorax, isolated chest trauma). The first blood sample was obtained at the scene of accident. Then, blood was collected in hourly to daily intervals. NO production was assessed by the nitrate + nitrite plasma levels. To eliminate dilution effects following volume substitution, all values were recalculated on the plasma protein content. Immediately after trauma, NO plasma levels were elevated. This was most pronounced in pts that have experienced thoracic injuries irrespective of with or without additional polytrauma. There is evidence that NO production always starts immediately after major trauma but depends on the individual trauma pattern. In addition, the results reveal that lethal outcome is associated with an increased NO generation in the early post-injury period. We conclude that NO overproduction does not necessarily prime an overall protection in patients that have suffered from mechanical trauma. The role of NO after severe trauma and especially in thoracic injury should further be elucidated in a specific study on that topic.
Despite clear margins at the time of resection, 7 to 20% of the patients experience local recurrence of the primary stomach tumor. Intraluminal recurrence is rare but curable in 50% of the cases without distant metastases. Extraluminal recurrent gastric cancer comprises the typical pattern of recurrence and cannot be removed in most of the patients. Predisposing factors that favor the development of recurrent tumors are: higher tumor stages, extended lymph node involvement, tumor grades 3 and 4, diffuse type according to Lauren's classification, and intraoperative perforation of the primary gastric carcinoma.
In patients with peritoneal carcinomatosis, multimodal therapy consisting of extensive resections including peritonectomy and open hyperthermic intraperitoneal chemotherapy appears to be a promising approach. These time-consuming procedures can be performed with an acceptable morbidity and mortality and may improve the poor prognosis of these patients. Further studies are necessary to answer such questions as patient selection and optimal mode of cytostatic application.
Anal cancers have to be looked at either as cancers of the anal canal or those of the anal margin. During the past years, evidence has been obtained that human papilloma virus (HPV) contributes to the formation of cancers, particularly in homo-sexual males. Surgical treatment alone, may only be considered in tumors with less than 2 cm in size. Combined radio-chemotherapy (RCT) using 45 Gy of RT + 5-FU/Mitomycin C is the treatment of choice with superiority to RT alone proven in randomized trials. Abdominoperineal excision is indicated only in case of a tumor recurrence or with stable disease or progression after RCT. Multimodal treatment after discussion in an experienced tumor board may result in recurrence-free and colostomy-free survival at 5 years in up to 80% of our patients.
A prospective, randomized study of patients with gastric cancer was performed to examine whether or not the jejunal pouch interposition between esophagus and duodenum after gastrectomy is of importance. At fixed postoperative times, standardized scintigraphic measurements were performed; the quality of life was evaluated by the EORTC quality of life questionnaire. Our findings suggest that interposition of a jejunal pouch reservoir between esophagus and duodenum may be due to a prolonged transit time and a better quality of life.
A multimodal interdisciplinary concept including an aggressive neoadjuvant radiochemotherapy and a multivisceral resection with esophagolaryngectomy and bilateral modified neck dissection was introduced for the treatment of tumors of the cervical esophagus and hypopharynx. In 75% of the patients a R0-resection was achieved resulting in a 5-year survival rate of 38.5% and good functional results. Free jejunal interposition was the most favorable reconstruction because gastric transposition was followed by an increased rate of anastomotic insufficiencies and stenoses requiring bouginage.
