INTRODUCTION:We present a case of three major lymphomesenteric cysts in a female patient with known basal cell nevus syndrome (BCNS or Gorlin-Goltz syndrome).DISCUSSION:Although those cysts have been reported to appear in this syndrome, the exact prevalence is not known. In this case, the patient suffered from severe and recurrent abdominal pain due to bowel obstruction.CONCLUSION:By causing severe symptoms, cystic lymphangiomas are an important complication of the BCNS despite of their seldom occurrence. Surgeons confronted with intraabdominal masses in a patient with BCNS should always be aware of this manifestation of the disorder and plan interdisciplinary operations.

The purpose was to generate a score targeted at the metastatic risk potentially reflecting oncogenic activation in Gastrointestinal Stromal Tumours (GIST). In 41 patients size and location of the primary, mitotic index, initial symptoms, and histological appearance were rated with 0 to 1 or 2 points. The course of the disease was recorded as incidental, symptomatic, locally recurrent, with peritoneal dissemination, or with hepatic spread. The parameters tumour size (p < 0.001), mitotic index (p < 0.001), localisation of the primary (p < 0.001) and symptoms (p < 0.05) correlated with the course of the disease. This correlation was highly significant (p << 0.0005) when the overall score was applied, the median being 0 in incidental, 3 in symptomatic, 4 in locally recurrent, 4.5 in peritoneal, and 5 points in hepatic spreading GIST. Results were compared with those of an established risk stratification. The sensitivity and specificity of a score> 4 for the occurence of liver metastases were 100 and 73.5% compared with 85.7 and 82.4% for a high risk profile according to Franquemont's classification. The results indicate the ability of routinely recorded data to predict the metastatic outcome of GIST.

Background. In the liver, efficacy of cryosurgical ablation of tumors located near the retrohepatic vena cava is impaired by the heat-sink effect. This could be overcome by total vascular exclusion (TVE) of the liver. In this study, the effect of TVE on cryosurgical ablation of liver tissue close to the retrohepatic vena cava was investigated with regard to the extent of the cryolesion and complications arising from necrosis of the caval wall.Methods. Of a total of 28 pigs, 14 underwent cryotherapy with TVE compared to 14 without TVE, both involving the vena cava. 7 animals in each group were subjected to one freeze cycle and 7 in each group to two freeze cycles. Temperatures in the cryolesion were monitored and cryolesions were documented sonographically. Laboratory parameters were determined pre- and postoperatively. Follow-up was 14 days. Morphology, extent of the cryolesion, damage to the vena cava and complications were assessed after autopsy.Results. With TVE, freezing rates were increased and cryolesions were significantly larger than without TVE. Transmural necroses of the vena cava with complete necrosis of the intima occurred significantly more frequently after TVE. Macro- and microscopically, the damage to the caval wall was considerably more marked after cryotherapy under TVE but in all cases the continuity of the vessel wall remained intact. There were no ruptures, thrombosis, or strictures of the vena cava.Conclusion. The combination of cryotherapy and TVE increases the effectiveness of cryoablation in the liver involving the retrohepatic vena cava without any severe vascular complications occurring in the pig. (C) 2004 Elsevier Science (USA) All rights reserved.

EphB receptors and their ephrinB ligands play a key role in the formation of a regular vascular system. Recent studies have also shown the involvement of Eph/ephrin interactions in malignant tumor progression and angiogenesis. We have generated soluble monomeric EphB4 (sEphB4)-expressing A375 melanoma cells to study the effect of dominant negatively acting sEphB4 on tumor growth and angiogenesis. Soluble EphB4-expressing A375 tumors grown subcutaneously in nude mice show dramatically reduced tumor growth compared to control tumors. The proliferative capacity of sEphB4-expressing cells in monolayer culture is not altered. Yet, sEphB4-expressing A375 cells cannot establish proper cell-cell contacts in three-dimensional spheroids. However, sEphB4 transfectants have reduced proliferation and apoptosis rates when grown in three-dimensional culture in vitro or in subcutaneous tumors in vivo. Analysis of the vascular phenotype of the tumors revealed a reduction of intratumoral microvessel density in sEphB4-expressing tumors. Corresponding to these mouse experiments, a matched pair analysis of EphB4 and ephrinB2 expression in human colon carcinomas revealed significantly upregulated levels of EphB4 expression compared to adjacent normal tissue. Taken together, the data identify dual effects of sEphB4 on the tumor and the vascular compartment that collectively inhibit tumor growth.

Organizer and Guest Editor H.-G. Rau, Dachau, Germany in honor of Prof. Dr. Dr. h.c. F.W. Schildberg, Munich, Germany Basel · Freiburg · Paris · London · New York · Bangalore · Bangkok · Singapore · Tokyo · Sydney Eur Surg Res 2003;35:123–141 DOI:10.159/000070276

Liver tumors located near the retrohepatic vena cava are often considered nonresectable. For these patients cryoablation could be a therapeutic option. In this study the safety and efficacy of hepatic cryosurgery involving the retrohepatic vena cava were investigated. Cryolesions involving the vena cava were created in 26 pigs. Follow-up was 24 h and 14 days. The extent of the cryolesion, damage to the vena cava and complications were assessed after autopsy. The cyronecrosis extended into the wall of the vena cava in 81% of the animals. All animals had an uneventful recovery without any complications such as ruptures of the vessel, thrombosis or pulmonary embolism. Microscopically elastic and collagenous fibers of the cava wall remained intact. The continuity of the vessel wall was conserved. In conclusion, the safety and efficacy of cryosurgical treatment involving the retrohepatic vena cava were shown in a pig model.

Surgical treatment of liver metastases from colorectal carcinoma can achieve 5-year survival rates of up to 40%, and 10 year survival rates of up to 20%, making resection the only potentially curative treatment option. This applies, however, only when metastatic disease is confined to the liver and when complete removal of the metastases is possible. Patients with liver metastases from non-colorectal primaries--with the exception of the rare neuroendocrine tumors--are not usually candidates for surgery.

Klinisches Merkmal gastrointestinaler Stromatumoren (GIST) ist das variable biologische Verhalten, welches von benignen Zufallsbefunden bis zu metastasierenden Tumoren reicht. In dieser Arbeit wurden klinischer Verlauf und pathohistologische Parameter von 26 Patienten retrospektiv untersucht mit dem Ziel, Prognosefaktoren zu definieren. Das Risiko eines Tumorrezidives war bei Tumoren > 4 cm signifikant (p = 0,024) erhöht. Ein erhöhter Proliferationsindex gemessen mit dem Anti-Ki-67-Antikörper MIB-1 war bei MIB-1 > 3 auch mit einer signifikant (p = 0,0031) gesteigerten Rezidivrate assoziiert. Der MIB-1 Index erscheint daher zur Abschätzung der Prognose geeignet.

In dieser tierexperimentellen Studie an insgesamt 38 Schweinen wurde untersucht, ob und wie eine wirksame Gewebedestruktion in unmittelbarer Nähe der V. cava erzielt werden kann und ob sich dabei Komplikationen wie Blutung, Gefäßruptur, Thrombose oder Embolie entwickeln, welche insbesondere unter totaler vaskulärer Exklusion (TVE) zu erwarten wären. Die Kryotherapie wurde nach Laparotomie intrahepatisch, cavanah durchgeführt. Folgende Gruppen wurden gebildet: A (n = 11): ohne TVE, 1 Frierzyklus (10 min), B (n = 15): ohne TVE, 2 Zyklen; C (n = 6): TVE, 1 Zyklus, D (n = 6): TVE, 2 Zyklen. Die Tiere wurden nach 24 h bzw. 14 Tagen autopsiert und die Leber pathologisch untersucht. Es zeigten sich transmurale Gefäßwandnekrosen der V. cava. Unter TVE entstanden signifikant größere Nekrosen und Kryoläsionsvolumina als bei erhaltener Durchblutung. In keinem Fall kam es zu Embolien oder Blutungen, Ruptur oder Thrombose der V. cava. Die Studie zeigt, daß auch in unmittelbarer Nähe der intrahepatischen V. cava eine effektive und sichere Gewebedestruktion möglich ist.

INTRODUCTION Postoperative nerve lesions beyond the operative area, the so called positioning traumas are considered uncommon in general surgery. But they can have serious consequences for the patient and the surgeon, including forensic sequelae. The objective of this work was to describe the incidence, pattern, risk factors and course of postoperative neuropathies in general surgery and to identify indicators to prevent these complications. METHODS Based on neurologic records we reviewed all postoperative peripheral neuropathies that occurred in the Department of General Surgery of the University Hospital Freiburg in the time period from January 1979 to December 1990. Lesions that occurred as a direct operative effect were excluded. RESULTS In 35 patients 50 nerve lesions were observed, representing an incidence of 0.12% of all operations during this time period. Most frequently lesions of the n. peroneus occurred, followed by the n. ulnaris, n. cutaneous femoris lateralis and n. medianus. Nerve lesions were observed in every body position and as early as after 15 min. Postoperative nerve lesions have a favorable prognosis. DISCUSSION Nerve lesions caused by positioning can occur during any operation with any duration in general surgery. They should be avoided by thorough and careful positioning. Also the patient must be informed about the possibility of nerve lesions caused by the positioning.

BACKGROUND Mitogen activated protein kinases (MAPKs) play a central role in the regulation of both cell growth and differentiation. They are involved in signal transduction of oncogenes and growth factors. The role of MAPK in colonic carcinoma is unknown. AIMS To establish whether the expression and activity of p42/44 MAPKs are altered in colorectal tumours as compared with normal mucosa. METHODS The expression and activity of p42/p44 MAPK were investigated in 22 colorectal carcinomas, four adenomas, and the corresponding normal colorectal mucosa by the use of western blotting, immunoprecipitation, and in vitro kinase assays. RESULTS After immunoprecipitation with an antibody specific for p42 MAPK, we found significant inactivation of p42 MAPK in colonic carcinomas as well as in adenomas, whereas most sample pairs showed only minor differences in p42 MAPK expression. Investigation of MAPK with an antibody capable of detecting both p42 and p44 MAPK showed a slight but significant decrease in p44 MAPK content in malignant tissues. With this antibody, only minor alterations in MAPK activity and no correlation with p42 MAPK activity were found. CONCLUSIONS Inactivation of p42 MAPK could be associated with colonic carcinogenesis.

Raf-1, p42 MAPK (erk2) and p44 MAPK (erk1) are important signaling components leading to cell proliferation and differentiation as well. In this study activity of p42/p44 MAP kinase and expression of Raf-1 were investigated in 22 gastric adenocarcinomas and corresponding normal mucosa by using in-vitro kinase assays and western blotting, respectively. In gastric carcinomas the activity of p42 MAPK and expression of Raf-1 was significantly decreased. These results suggest that inactivation of the Raf-1/p42 MAP kinase kinase pathway could be associated with gastric carcinogenesis.

In 14 gastric cancer specimens expression of the adhesion molecule E-cadherin was determined and correlated with their histological type according to Lauren's classification as well as with their ability to metastasize to distant organs. E-cadherin mRNA was determined for further characterization of the epigenetic processing. Expression of beta-catenin was determined in 4 specimens to gain information about the cadherin / catenin-complex. Expression of E-cadherin was higher in specimens of intestinal type compared to diffuse type histology. E -cadherin and its mRNA were highly expressed in one patient with liver metastasis. beta-catenin was consistently expressed. Allthough not yet significant, the data support the hypothesis that E-cadherin may positively contribute to formation of liver matestasis.

The expression of different MAP kinases was examined in 22 paired samples of adenocarcinomas and mucosae derived from patiens operated on gastric carcinoma. Five different MAPK forms, p42 (ERK2), p34 (ERK1), p54, p57 and p85 were detected in each sample by western blotting using an anti-pan ERE: antibody. The expression of the p44 MAPK was significantly decreased in gastric carcinoma compared to corresponding mucosa samples. Using an antibody detecting tyrosine/threonine phosphorylated MAPK, we found a significantly decreased portion of activated p54/p57 MAPK in gastric cancer.

In this study the results of simple closure of perforated peptic ulcers were investigated. A total of 50% of the 84 patients operated from 1.1.1988 to 31.12.1993 were over 60 years old. Severe comorbidity was reported in 80% of the patients. Most of them suffered from cardiovascular diseases or malignancies. A total of 76/84 were treated by simple closure followed by medical therapy of the ulcer. Complications occurred in 58%, while the lethality rate was 26%. A total of 19/56 discharged patients died within 5 years due to their comorbidity. Only 15% of 47 patients who were followed-up for 2-7 years suffered from recurrent ulcers. We conclude that perforated peptic ulcers should be treated routinely by simple closure. Definitive ulcer surgery is only indicated for patients who meet the criteria for elective ulcer surgery (when medical treatment is ineffective or impossible).

Epidermal growth factor receptors (EGFR) and ras mutations are known to play a significant role in controlling cell growth and tumor promotion. Both of them transmit mitogenic signals to the nucleus by activation of Raf-1 kinase. In this study, the expression of EGFR and mutant Ras proteins, and, for the first time, the expression, phosphorylation and kinase activity of Raf-1 kinase have been determined in paired samples of colorectal cancer and mucosa. The tumor and mucosa samples did not differ significantly with regard to Raf-1 kinase content and activity. A major difference between tumors and mucosa was found, however, in the phosphorylation of Raf-1. Most of the mucosa samples (13/20), but only 1/20 of the cancer samples, contained hyperphosphorylated Raf-1. EGFR were significantly (p = 0.0025) decreased in the tumors. The decreased phosphorylation of Raf-1 in colonic carcinomas could be the result of activation of Raf-1 phosphatases or inactivation of kinases phosphorylating Raf-1. New forms of treatment based on EGFR overexpression do not seem to be suitable for the majority of colonic cancers.

Diese Studie untersucht die Ergebnisse nach einfacher Übernähung peptischer Ulzera. Die Hälfte der 84 vom 1.1.1988 bis 31.12.1993 operierten Patienten war über 60 Jahre alt, bei 80% lag eine schwere Komorbidität vor, meist kardiovaskuläre Erkrankungen oder Malignome. 76mal wurde das Ulkus übernäht und anschließend medikamentös behandelt. Die Komplikationsrate lag bei 58%, die Letalität bei 26%. 19/56 aus der Klinik Entlassenen verstarben innerhalb von 5 Jahren an ihren Begleiterkrankungen. Ulkusrezidive waren mit 15% (bei 47 Nachuntersuchten) selten. Wir schließen daraus, daß die Ulkusperforation in der Regel mit der einfachen Übernähung und medikamentöser Therapie behandelt werden sollte. Eine definitive Ulkusoperation sollte nur dann durchgeführt werden, wenn die Indikation zur elektiven Ulkusoperation (Versagen/Unmöglichkeit der medikamentösen Therapie) gegeben ist.