[Surgical therapy of lung complications of long-term ventilation for severe adult respiratory distress syndrome]

Long-term respiratory therapy with high pressure levels in case of ARDS can lead to several symptoms requiring surgical treatment. Various forms of manifesting barotrauma predominate (bronchopleural fistula, pneumothorax, pneumatocele and soft tissue emphysema), while hematothorax, infected necrosis of parenchyma or esophagotracheal fistula are rare. Most of the operations became necessary because of bronchopleural fistula resp. pneumothorax, and with this indication the number of reoperations was especially high. Of 21 patients 13 (62%) survived.

[Normal value of the number of lymph nodes in the epigastrium. An anatomic study for lymphadenectomy in stomach cancer]

The number of regional lymph nodes relevant for lymphadenectomy in gastric cancer was investigated in an autopsy study. In group N1-16 as described by JRSGC on the average 43 lymph nodes were found (range 25 to 64 lymph nodes). For group N1-11 (R1 and R2 resection, compartments I and II respectively) 27 lymph nodes were found on the average (range 17 to 44 lymph nodes). The results differed considerably in total number as well as within each single group and in the groups N1-16/N1-11. These results can be taken as statistical standard values.

[Reoperations in persistent and recurrent secondary hyperparathyroidism]

Among 181 patients who had been surgically treated in the Department of Surgery, Mainz University, for secondary hyperparathyroidism between 1975 and 1986, 33 had to be reoperated because of persistent or recurrent disease or because of failing autotransplanted tissue after total parathyroidectomy and autotransplantation. In 17 patients 26 reoperations had to be performed in the neck; in 9 patients, 3 of whom are already included in the group mentioned before, autotransplanted tissue had to be reduced eleven times. In another 10 patients autologous, cryopreserved tissue was replanted. 15 of the 17 patients reoperated in the neck became normocalcaemic, postoperatively, as well as 7 out of 9 patients in whom the autotransplanted tissue had been partially taken off. The results with replantation of cryopreserved tissue are being published in a separate article in this volume.

Food-induced histaminosis as an epidemiological problem: plasma histamine elevation and haemodynamic alterations after oral histamine administration and blockade of diamine oxidase (DAO)

In a randomized controlled trial, 30 pigs were orally treated with histamine (60 mg). In addition, half of the animals underwent a specific blockade of the enzyme diamine oxidase (DAO), which is the main histamine catabolising enzyme in the intestinal tract. Only these DAO-blocked animals exhibited severe clinical symptoms (e.g. hypotension, flush, vomiting) and, in parallel, showed tremendous elevations of plasma histamine levels of up to 160 ng/ml. 3 out of 15 animals in this group died within the experimental period. In contrast, the control animals neither exhibited plasma histamine levels above 5 ng/ml nor had any clinical reactions. These results contradict the current opinion that oral histamine intake in food is not clinically relevant, especially since many commonly used drugs are DAO-inhibitors and approximately 20% of our population take these drugs. Apart from drugs, some other factors (alcohol, spoilt food etc.) can also function via a blockade of DAO as an additional risk. DAO-blockade is therefore a real epidemiological problem. Evidence is presented here for the new disease concept: Food-Induced Histaminosis.

Reoperations for persistent and recurrent secondary hyperparathyroidism

Forty-nine reoperations for persistent or recurrent secondary hyperparathyroidism (HPT) in 30 patients are reported. The patients are part of a total of 184 patients operated on for secondary HPT; 28 reoperations in 18 patients were performed in the neck or in the upper mediastinum for remaining glands. Eleven reoperations at the forearm autograft revealed hyperplasia of the grafted tissue as the reason for recurrent disease in seven patients; they were treated by excision of all grossly enlarged particles. Ten patients received autologous cryopreserved tissue because of permanent postoperative hypoparathyroidism. The rate of graft-dependent recurrent HPT was 7%, and inadequate graft function was found in 6% of the patients.

[Results of treatment of ulcer hemorrhages]

The results of 270 patients, admitted from 1978 to 1985 because of upper gastrointestinal bleeding from ulcers or erosions were analysed retrospectively. Chronic peptic ulcers were the most common bleeding sites (192 patients, 71%). 49 patients (18%) bled from acute lesions and 29 (11%) from drug-induced ulcers. 53% of all patients exhibited an oozing hemorrhage (type Forrest 1 b) during emergency endoscopy. Within the eight-year-period hospital mortality dropped from 18% to 8%. In parallel the prognosis of oozing bleeding improved. In this period the patients were more often treated with secretin or somatostatin. Hence the frequency of emergency operations for patients with oozing bleeding could be reduced from 44% in 1978 to 10% in 1985 and the death rate from 22% to 5%.

The effect of oxotremorine on in-vitro secretion of parathyroid hormone

The effect of the muscarine-like acting parasympathomimetic drug oxotremorine and its antagonist atropine on PTH release was tested using single cell suspensions obtained from a) primary parathyroid adenomas, and b) secondary hyperplastic parathyroid tissue from patients undergoing chronic hemodialysis. For both cell-types we found a dose-dependent suppression of PTH release with oxotremorine. The suppressive activity could be antagonized with atropine, suggesting that parasympathomimetic nerval impulses play a suppressive role in the regulation of PTH release. Muscarine-receptors appear to be responsible for this mechanism.

The effect of high parathyroid hormone concentration on calcitonin in patients with primary hyperparathyroidism

Serum calcitonin (CT), parathyroid hormone (PTH), and calcium levels were measured in 23 patients with primary hyperparathyroidism. PTH was determined by a midregion (M-RIA) and a carboxyl-terminal (C-RIA) specific PTH-RIA. Only 2 patients had elevated CT levels. In contrast to the findings in 46 healthy controls, the CT levels did not correlate with calcium levels. Patients who had the highest iPTH values showed a negative correlation between CT and iPTH (M-RIA (n = 7): R = -1.0000, p less than 0.001; C-RIA (n = 13): R = -0.5604, p less than 0.05). The results of the C-RIA were subtracted from those of the M-RIA. In 12 patients with the highest levels of intact PTH (M-RIA - C-RIA), serum PTH concentration was inversely correlated with serum CT concentration (R = -0.7343, p less than 0.01). In the same patients a negative correlation between CT and calcium was found (R = -0.6783, p less than 0.02). These findings suggest that high PTH levels may have a direct suppressive effect on CT concentration and this may be, at least in part, responsible for failure of CT concentrations to rise in many patients with primary hyperparathyroidism.

[Reoperations in persistent and recurrent secondary hyperparathyroidism]

Forty-seven reoperations for persistent or recurrent secondary hyperparathyroidism (HPT) in 29 patients are reported. The patients are part of a group of 181 patients operated on for secondary HPT between 1975 to 1986. Most reoperations were performed in the neck (26 operations in 17 patients). The main cause were remaining parathyroid glands in the mediastinum (9 patients), followed by normally localized glands in the neck, which had not been discovered during previous operations. In 7 patients a hyperplasia of the autografted tissue was the reason for recurrent disease. They were treated by resection of the autograft. In 10 other patients autologous cryopreserved parathyroid tissue was reimplanted because of persistent postoperative hypoparathyroidism.

[Replantation of autologous cryopreserved parathyroid tissue in permanent postoperative hypoparathyroidism]

Cryopreserved autologous parathyroid tissue was reimplanted into 16 patients with permanent postoperative hypoparathyroidism. In 13 cases the number of necrotic cells in the thawed cryopreserved tissue was determined histologically and compensated by using a greater amount of tissue particles during re-implantation. These patients had normal transplant functioning after a median period of 6 months. On the other hand, delayed onset of functioning of the autotransplant was seen if the rate of necrotic cells had not been compensated. The results show that re-implantation of autologous cryopreserved parathyroid tissue is a suitable method for treating permanent postoperative hypoparathyroidism. The method should be used as a firmly established part of parathyroid surgery.

[Asymptomatic hyperparathyroidism. An indication for surgery?]

From 1965 to 1985, 412 patients were operated on for primary hyperparathyroidism (pHPT). Of these, 35 (8.7%) were without specific symptoms and findings. The follow-up investigations after six months to 14 years (median: 31 months) revealed a normalization of the preoperative pathological parameters of alkaline phosphatase, uric acid, creatinine and hypertension in the majority of patients apart from the improvement of their general condition. All patients were normocalcemic. According to these results, the indication for early surgical therapy of the asymptomatic pHPT is to be advocated in order to avoid long-term complications.

The influence of parathyroid hormone and its fragments on results from midregion and C-terminal specific radioimmunoassays

We compared a midregion (44-68) human parathyroid hormone (hPTH) specific radioimmunoassay (M-RIA) with a C-terminal (65-84) hPTH specific radioimmunoassay (C-RIA). The M-RIA discriminated 21 of 23 patients with primary hyperparathyroidism from 95 normals (normal range: 22.4-106.5 pmol/l). With the C-RIA 12 patients including the 2 patients not discriminated by the M-RIA had immunoreactive PTH (iPTH) values within the normal range of this assay (normal range: undetectable to 88.6 pmol/l). To investigate the reasons for these different abilities of separation, hyperparathyroid sera were subjected to gel-filtration and analyzed using the two assays. Intact PTH appeared to have a major influence on the immunoreactivity of circulating PTH in the M-RIA. In contrast, the C-RIA showed the highest immunoreactivity with midregion-C-terminal PTH fragments. Hyperparathyroid sera not discriminated by the C-RIA but with elevated iPTH in the M-RIA showed decreased amounts of midregion-C-terminal PTH fragments, while intact PTH comprised the highest amount of total circulating PTH immunoreactivity in the M-RIA. From the present results we conclude that the superiority of the M-RIA is due to the determination of intact PTH which is preferable for clinical measurements with relation to the diagnosis of primary hyperparathyroidism.

The secretion of parathyroid hormone and its fragments from dispersed cells of adenomatous parathyroid tissue at different calcium concentrations

The effect of varying calcium concentrations on PTH release from dispersed cells of adenomatous parathyroid tissues (n = 15) was studied. During high calcium concentrations PTH secretion was inhibited up to 62.5% as compared to low calcium concentrations. There was no correlation between iPTH secretion rate and suppressibility. Each adenoma had a different iPTH secretion rate. Three adenomas showed a high suppressibility (28.0%, 53.8%, and 62.5%). The supernates of their media were chromatographed and examined by midregion and C-terminal specific PTH-RIAs. Carboxyl-terminal PTH fragments were found to be released by two adenomas. There was no evidence for the release of midregion PTH fragments. Comparison of incubation media revealed that the adenoma with the lowest suppressibility released the highest amount of intact PTH (per 100,000 cells/ml). This adenoma exclusively secreted intact PTH, whereas PTH fragments were only released from two adenomas with higher suppressibility. In these media the ratio of PTH fragments to intact PTH increased with the calcium content of the media. The ratio was also dependent on the suppressibility of the adenomas; i.e. the ratio was greater when the suppressibility was higher. This suggests that in adenomas the intracellular hormone degradation is responsible for the degree of PTH suppression. As the suppressibility of PTH secretion is reduced in hyperfunctioning parathyroid tissue, diminished intracellular hormone degradation seems to be involved in the pathogenesis of primary hyperparathyroidism.

[Simplified procedure for cold preservation of human parathyroid gland tissue for replantation]

A simplified technique for cryopreservation of human parathyroid tissue is described. It allows to achieve the same quality of tissue than using the programmable expensive freezing method which is usually employed up to now. Cryovials are placed in a methanol bath. The temperature is decreased by -1 degree C/min down to -25 degrees C, thereafter by -10 degrees C/min down to -70 degrees C by repeated adding of cryo ice-cubes into the methanol. Thereafter the vials are stored in LN2. The temperature lowering is controlled by a stop watch and a thermometer in a reference vial. This simple and cheap technique may allow a more general application of cryopreservation in surgery of hyperparathyroidism.

The effect of cryopreservation on hormone secretion in vitro and morphology of human parathyroid tissue

The hormone secretion from human parathyroid tissue autografted after cryopreservation can fail frequently. In this study we examined the effects of the cryopreservation procedure on parathyroid hormone secretion in vitro and the viability of parathyroid cells to identify possible reasons for graft failure. Cryopreservation did not affect quantitative parathyroid hormone release from single-cell suspensions or its calcium-and magnesium-dependent regulatory mechanisms. However, morphometric analysis of thawed 1 mm3 graft particles showed various degrees of necrosis when compared with fresh grafts. Thus partial necrosis of cryopreserved tissue appears to contribute to poor transplantation results compared with immediate replantation of fresh parathyroid tissue. This limitation can be overcome by increasing the number of frozen graft particles used for autotransplantation. The percentage of viable cells should be accounted for by morphometric analysis and this factor used when calculating the number of graft particles employed.

[Artificial respiration in a surgical intensive care unit]

An indication for respiratory treatment is given in manifest and for prophylactic mechanical ventilation in expected pulmonal insufficiency. The mortality rate can be reduced by an early respiratory treatment, therefore prophylactic mechanical ventilation should be performed liberally. Mainly patients after abdomino-thoracal operations and major vascular or upper abdominal surgery are at risk for lethal postoperative pulmonary complications.

[Embolization of a pseudoaneurysm of the hepatic artery with hemobilia by direct percutaneous puncture]

Haemobilia is a rare cause of gastrointestinal bleeding that carries a high mortality. It occurs as a complication of percutaneous trans-hepatic biliary drainage in up to 6% cases. The cause is usually a pseudo-aneurysm of the hepatic artery, which can be treated by trans-catheter embolisation. If this fails, direct puncture and embolisation of the aneurysm is a possible alternative to surgical ligation of the hepatic artery.

[Autotransplantation of cold preserved human parathyroid gland tissue. Indications--technic--results]

Autotransplantation of cryopreserved tissue is of increasing clinical value after parathyroid surgery became more common. The results in the literature show a high rate of non functioning grafts after autotransplantation of cryopreserved tissue in comparison to fresh autografted tissue. The reason for that is a partial necrosis of the tissue caused by the freezing and thawing process. To obtain better results after autotransplantation of cryopreserved tissue the rate of necrosis should be estimated. The loss of functioning cells should be compensated by autografting a greater amount of tissue fragments.

Xanthogranulomatous cholecystitis mimicking carcinoma of the gallbladder: CT findings

The CT findings in a case of xanthogranulomatous cholecystitis are reported. Irregular thickening of the gallbladder wall and poorly defined borders of the underlying liver and the adjacent duodenum suggested a tumorous lesion.

[Cryopreservation of human parathyroid tissue. Effect of in vitro secretory behavior and morphology]

The effects of cryopreservation on in vitro secretion and on the survival rate of parathyroid cells were investigated, in order to find possible causes for the frequent failure of autologous, human parathyroid tissue. A reduction in the hormone secretion or an influence on the secretion could be excluded. The freezing procedure, however, leads to a partial necrosis of the tissue. Similarly good results, as in the replantation of fresh tissue, can be achieved by compensating the necrotic cells using more particles.

[Perioperative antibiotic prophylaxis (single or multiple dose) in elective colorectal surgery. A randomized study]

In a randomized trial in 60 patients undergoing elective colorectal surgery the efficiency of intravenous antibiotic short time prophylaxis was determined. We compared single dose application with multiple dose prophylaxis for 24 h. The substance used was cefotaxime. The rate of wound infections was comparable in both groups (16.6 vs. 13.3%) as well as postoperative infections of the urinary tract (33.3 vs. 23.3%). The results of the study suggest that single dose prophylaxis is as efficient as multiple dose application to reduce postoperative infections in elective colorectal surgery.