Risk analysis in esophageal surgery

The postoperative mortality after esophagectomy still remains a major factor influencing the prognosis of esophageal cancer and largely depends on the patient's preoperative physiological status. A composite scoring system was developed to predict the risk of esophagectomy, based on quantitative assessment of preoperatively available physiological parameters. The scoring system was reviewed retrospectively on operated patients and evaluated prospectively in two subsequent patient groups. An initial retrospective multivariate analysis of 432 esophagectomy patients identified a compromised general status (p = 0.001) and poor cardiac (p < 0.001), hepatic (p < 0.05), and respiratory (p < 0.05) functions as independent predictors of a fatal postoperative course. Based on the relative risks associated with individual impaired organ functions--general status 3.6, cardiac function 2.8, hepatic function 2.1, pulmonary function 1.7--a composite risk score was established. A prospective study in 121 patients confirmed that this composite scoring system provides better identification of high-risk patients than does any of the individual parameters alone. Including this composite score into the process of patient selection and choice of procedure resulted in a decrease of postoperative mortality from 9.4% (52/553) to 1.2% (4/323) (p = 0.001). The risk of death after esophagectomy for esophageal cancer can be objectively assessed prior to surgery and quantified by a composite risk score. This score provides a useful tool in refining the criteria of patient selection for resection and choice of procedure, and markedly reduces postoperative mortality when applied prospectively.

Sepsis after major visceral surgery is associated with sustained and interferon-gamma-resistant defects of monocyte cytokine production

BACKGROUND

Recent clinical trials failed to demonstrate beneficial effects of anti-inflammatory sepsis therapy. The present study therefore asked the following questions: Is there evidence for immunosuppression during postoperative sepsis? When, during the septic course, may immunosuppression develop? Can defective cellular functions be restored by in vitro treatment with interferon-gamma (IFN-gamma)?

METHODS

The study included 35 patients with sepsis after major visceral surgery and 85 control patients. Monocyte secretion of interleukin (IL)-1 beta, IL-12 p40 and p70, IL-18, tumor necrosing factor, and IL-10 with or without IFN-gamma treatment and its correlation with the course and outcome of postoperative sepsis were determined.

RESULTS

Postoperative sepsis was associated with an immediate defect of endotoxin-stimulated monocyte production of IL-12 p40, IL-1 beta, and IL-10 in both surviving and nonsurviving patients. During the final phase of postoperative sepsis, a significant recovery of IL-12 p40 and IL-1 beta secretion, but not of IL-10 production, correlated with survival. Despite the exposure of monocytes in vitro to IFN-gamma for 16 hours, the production of the biologically active IL-12 p70 heterodimer was severely suppressed both in survivors and nonsurvivors, although the secretion of the p40 subunit was restored. In contrast, IFN-gamma treatment resulted in a significant suppression of monocyte IL-1 beta production in all patient subgroups. Alterations of monocyte tumor necrosing factor secretion were not observed. The production of IL-18 was below the limits of detection in all samples.

CONCLUSIONS

Postoperative sepsis was associated with immediate monocyte defects that affected both pro- and anti-inflammatory cytokine secretion, which suggests that immunosuppression is a primary rather than a compensatory response to a septic challenge. Sepsis survival correlated with the recovery of the proinflammatory, but not the anti-inflammatory, response. The treatment of monocytes with IFN-gamma did not reconstitute defective proinflammatory cytokine production.

[Immune paralysis of T-lymphocytes and monocytes in postoperative abdominal sepsis. Correlation of immune function with survival]

In vitro functions of stimulated peripheral T cells and monocytes were investigate in patients experiencing sepsis following major visceral surgery. Cell culture supernatants were analyzed by ELISA for IL-2, IFN-gamma, IL-4, IL-10, TNF-alpha, IL-1 beta, and IL-12p40. In addition, monocyte HLA class II expression was determined by flow cytometry. T cell secretion of IL-2, TNF-alpha, and in part IFN-gamma (but not IL-4) was significantly diminished in non-survivors throughout the entire course of sepsis, compared to controls and sepsis survivors. Production of IL-1 beta and IL-12 p40 by monocytes was strongly reduced in both survivors and non-survivors at the onset of sepsis. Persistence of depressed monocyte cytokine secretion correlated with lethality. Thus, overall suppression of cytokine production by T cells and monocytes was already observed at the beginning of postoperative sepsis. HLA class II expression by monocytes exhibited a strong and sustained down-regulation with no significant differences between sepsis survivors and non-survivors. In summary, suppression of both T cell and monocyte functions develops early during postoperative sepsis. Recovery of immune functions and severity of immune defects are associated with outcome.

Adjuvant treatment of clinical stage I seminoma: is a single course of carboplatin sufficient?

OBJECTIVES

Adjuvant radiotherapy produces excellent disease-free rates in clinical Stage I seminoma. However, concern is growing about side effects and late hazards of this treatment. Carboplatin has been suggested to supplant radiotherapy. To date, there is little experience with this drug in the adjuvant treatment of seminoma. In particular, it is unclear whether one or two courses should be administered.

METHODS

In a nonrandomized study, 125 patients with pure clinical Stage I seminoma were given adjuvant carboplatin treatment (400 mg/m2). Ninety-three patients received one course and 32 two courses. The median follow-up time was 48 months. To assess gonadal toxicity, serial measurements of follicle-stimulating hormone (FSH) levels were done. To assess myelotoxicity, platelet counts at 3 and 4 weeks after treatment were monitored.

RESULTS

There were no relapses after two courses of carboplatin. After one course of carboplatin, eight relapses occurred (8.6%; 95% confidence interval [CI] 3.79% to 16.2%). All the relapses were located in the para-aortic region, and all the patients were rescued with cisplatin-based chemotherapy. The median time to recurrence was 16 months. The 5-year actuarial progression-free survival rate after one course was 91.1% (95% CI 85.25% to 97.01%). Younger patients (age groups: less than 30 years and 31 to 38 years) had relapses more frequently (P = 0.038) than those in the older age group (greater than 38 years). After 3 weeks, 32% of the patients had platelet counts below 150/nL. The median FSH level increased immediately after treatment, reaching a peak of 13.6 U/L. After 20 months, the median FSH level had returned to the normal range.

CONCLUSIONS

One adjuvant course of carboplatin was associated with low myelotoxicity and low gonadal toxicity; however, the recurrence rate was almost 9% and thus unsatisfactory. After two courses of carboplatin, no relapse was observed. Thus, the two-course regimen of carboplatin appears to be equivalent to radiotherapy, and because of its favorable toxicity profile, this regimen should be investigated in randomized trials.

The small ribosomal subunit from Thermus thermophilus at 4.5 A resolution: pattern fittings and the identification of a functional site

The electron density map of the small ribosomal subunit from Thermus thermophilus, constructed at 4.5 A resolution, shows the recognizable morphology of this particle, as well as structural features that were interpreted as ribosomal RNA and proteins. Unbiased assignments, carried out by quantitative covalent binding of heavy atom compounds at predetermined sites, led to the localization of the surface of the ribosomal protein S13 at a position compatible with previous assignments, whereas the surface of S11 was localized at a distance of about twice its diameter from the site suggested for its center by neutron scattering. Proteins S5 and S7, whose structures have been determined crystallographically, were visually placed in the map with no alterations in their conformations. Regions suitable to host the fold of protein S15 were detected in several positions, all at a significant distance from the location of this protein in the neutron scattering map. Targeting the 16S RNA region, where mRNA docks to allow the formation of the initiation complex by a mercurated mRNA analog, led to the characterization of its vicinity.

Clinicopathogenetic significance of chromosomal abnormalities in patients with blastic peripheral B-cell lymphoma. Kiel-Wien-Lymphoma Study Group

So far, reproducible histomorphologic and immunological criteria to distinguish clinicopathologic subtypes of blastic peripheral B-cell non-Hodgkin's lymphoma (BBCL), especially centroblastic (cb) and immunoblastic (ib) lymphomas, for daily diagnostic use are still lacking. Therefore, we correlated the cytogenetic findings in 126 patients with BBCL with histopathologic diagnoses. Subclassification of cb and ib lymphomas relied on the criteria defined in the updated Kiel classification; these subtypes are also listed in the Revised European-American Lymphoma (REAL) classification and in a preliminary report on the newly established World Health Organization classification, to investigate their clinical significance. Moreover, we performed a multivariate analysis to compare the prognostic significance of cytogenetic findings with the International Index. There were significant differences in the frequency of chromosome aberrations between different BBCL subtypes: t(8;14) was predominantly present in Burkitt's lymphomas, t(14;18) in centroblastic lymphomas, deletions in 8q and 14q, changes of 4q and losses of chromosome 10 in immunoblastic lymphomas; t(11;14) was restricted to blastoid mantle cell lymphomas and associated with a poor prognosis. In cb lymphomas, deletions in 1q42-qter, duplications in 1q23-32, trisomy 5, and changes of 15q were identified as independent prognostic factors. In ib lymphomas, changes of 7q and 8q had stronger impact on survival than the International Index. These findings underline that Burkitt's, cb, ib, and blastoid mantle-cell lymphoma are biologically distinct and clinically relevant entities and that cytogenetic findings can be helpful to subtype BBCL.

Metal compounds as tools for the construction and the interpretation of medium-resolution maps of ribosomal particles

Procedures were developed exploiting organometallic clusters and coordination compounds in combination with heavy metal salts for derivatization of ribosomal crystals. These enabled the construction of multiple isomorphous replacement (MIR) and multiple isomorphous replacement combined with anomalous scattering medium-resolution electron density maps for the ribosomal particles that yield the crystals diffracting to the highest resolution, 3 A, of the large subunit from Haloarcula marismortui and the small subunit from Thermus thermophilus. The first steps in the interpretation of the 7. 3-A MIR map of the small subunit were made with the aid of a tetrairidium cluster that was covalently attached to exposed sulfhydryls on the particle's surface prior to crystallization. The positions of these sulfhydryls were localized in difference Fourier maps that were constructed with the MIR phases.

[Early extubation vs. late extubation after esophagus resection: a randomized, prospective study]

In the present study, so far 131 patients with transmediastinal esophagectomy and 104 patients with transthoracic esophagectomy were investigated concerning clinical results (complication rate/mortality) following early extubation (within 6 h postoperatively) or prolonged ventilation (> 24 h). Age tumor stage and risk profile did not differ between the two patient groups.

RESULTS

Following transmediastinal esophagectomy, early extubation is superior concerning "stay in the ICU" (7.1 days vs 12.3 days) and complication rate (13.4% vs 32.8%). In contrast, following transthoracic esophagectomy, hospital lethality increases after early extubation (9.8% vs 1.9%).

[Achalasia and carcinoma of the esophagus: incidence, prevalence and prognosis]

Although the prevalence of patients with achalasia developing an esophageal carcinoma is low the risk is nearly 140-fold; there is no difference in prognosis between patients with achalasia-carcinoma and those with esophageal cancer without achalasia. We propose a follow-up with biennial endoscopies after 15-20 years of known achalasia. This is accordance with a recent consensus conference, which accepted the recommendation of the American Society of Gastrointestinal Endoscopy [3]. In doubtful findings we recommend brush cytologies and/or biopsies, especially if there should be a recurrence of "old symptoms" or the appearance of "new difficulties" which suggest the possibility of a malignant growth.

Intensified conditioning regimen in bone marrow transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia

We investigated an intensified conditioning regimen including fractionated total body irradiation (12 Gy), etoposide (30-45 mg/kg) and cyclophosphamide (120 mg/kg), followed by autologous (n = 5), allo-related (n = 13) or allo-unrelated (n = 6) bone marrow (n = 22) or peripheral stem cell (n = 2) transplantation in patients with Philadelphia chromosome-positive acute lymphoblastic leukemia. One patient received busulfan (16 mg/kg) instead of TBI. Nineteen patients were transplanted in 1CR, two in 2CR, one in 1PR and two in relapse. Major toxicity was mucositis grade II according to the Bearman scale in all patients. The treatment-related mortality was 25%, mainly due to infection or GVHD after allogeneic transplantation. After a median follow-up of 45 months (range 2-93), nine patients (37.5%) remain alive in CR. Nine patients (37.5%) relapsed and eight (33.3%) of these subsequently died. After autologous transplantation, four of five patients (80%) relapsed and died. Late relapse was seen after allogeneic, as well as autologous transplantation, at 33 and 59 months, respectively. The Kaplan-Meier estimate of leukemia-free survival for all patients is 38% at 3 years (95% CI: 18-58%) and 35% at 5 years (95% CI: 15-55%). For allogeneic transplants in first CR (n = 15) the estimate of disease-free survival was 46% at 3 years (95% CI: 19-73%) and 34% at 5 years (95% CI: 17-51%). Patients aged below 30 years had a better estimated overall survival at 3 years (61% vs 11%, P < 0.001). The bcr-abl fusion transcript (p210 vs p190 vs p210/190) did not affect disease-free or overall survival. In our experience, an intensified conditioning regimen seems to improve the results of bone marrow transplantation in patients with Ph+ acute lymphoblastic leukemia. However, the high relapse rate warrants novel approaches to enhance anti-leukemic efficacy.

Crystallographic studies on the ribosome, a large macromolecular assembly exhibiting severe nonisomorphism, extreme beam sensitivity and no internal symmetry

Crystals, diffracting best to around 3 A, have been grown from intact large and small ribosomal subunits. The bright synchrotron radiation necessary for the collection of the higher-resolution X-ray diffraction data introduces significant decay even at cryo temperatures. Nevertheless, owing to the reasonable isomorphism of the recently improved crystals of the small ribosomal subunits, reliable phases have been extracted at medium resolution (5-6 A) and an interpretable five-derivative MIR map has been constructed. For the crystals of the large subunits, however, the situation is more complicated because at higher resolution (2.7-7 A) they suffer from substantial radiation sensitivity, a low level of isomorphism, instability of the longest unit-cell axis and nonisotropic mosaicity. The 8 A MIR map, constructed to gain insight into this unusual system, may provide feasible reasoning for the odd combination of the properties of these crystals as well as hints for future improvement. Parallel efforts, in which electron-microscopy-reconstructed images are being exploited for molecular-replacement studies, are also discussed.

Increased susceptibility to postoperative sepsis in patients with impaired monocyte IL-12 production

IL-12 is a potent immunoregulatory cytokine that is essential for the development of protective immunity, as demonstrated by numerous animal models of infection. Here, we provide evidence for a critical role of IL-12 in human sepsis. The results of a prospective study of 184 patients undergoing major elective surgery of the upper and lower gastrointestinal tract revealed that, in contrast to patients showing uneventful recovery, monocyte IL-12 production was severely and selectively impaired in patients developing postoperative sepsis. Moreover, the extent of monocyte IL-12 suppression correlated with the severity of postoperative sepsis. Monocyte IL-12 secretion was suppressed before surgery and remained low until the onset of sepsis. Therefore, the suppression of IL-12 secretion preceded the onset of postoperative sepsis but did not occur as a consequence of major surgery. In contrast, IL-1beta production was only reduced during the late postoperative course in patients developing postoperative sepsis, and TNF-alpha release was even increased at different time intervals before the onset of sepsis. Thus, reduced IL-12 release does not reflect a general defect in monocyte cytokine production. Consequently, these results establish a critical role for IL-12 in early resistance to postoperative infection and may allow for the development of novel therapeutic strategies designed to stimulate host defense mechanisms and to reduce the incidence and severity of septic complications.

Preoperative risk analysis and postoperative mortality of oesophagectomy for resectable oesophageal cancer

BACKGROUND

Postoperative mortality after oesophagectomy for oesophageal cancer depends largely on the preoperative physiological status of the patient.

METHODS

A composite scoring system to predict the risk of oesophagectomy based on objective preoperative parameters was developed based on a retrospective review of patients operated on and evaluated prospectively in two subsequent patient groups.

RESULTS

An initial retrospective multivariate analysis of 432 patients who had oesophagectomy identified a compromised general status (P < 0.001) and poor cardiac (P < 0.001), hepatic (P < 0.05) and respiratory (P < 0.05) function as independent predictors of a fatal postoperative course. Based on the relative risk associated with the individual impaired organ functions, a composite risk score was established. A prospective study in 121 patients confirmed that this composite scoring system provides a better identification of high-risk patients than any of the individual parameters. Inclusion of the composite score into the process of patient selection and choice of the procedure resulted in a decrease of postoperative mortality rate from 9.4 per cent (52 of 553) to 1.6 per cent (four of 252) (P < 0.001).

CONCLUSION

The risk of death after oesophagectomy for oesophageal cancer can be assessed objectively before surgery and quantified by a composite risk score. This score provides a useful tool for refining the criteria of patient selection for resection or the choice of procedure.

[Interventional therapy of intra-abdominal abscess: outcome and limits]

The postoperative course following digestive surgical procedures was prospectively analysed in 2985 patients between 6/92 and 12/96. A CT-guided percutaneous drainage of intraabdominal abscesses was performed in 144 patients (4.8%). In 123 patients (85.4%) percutaneous abscess drainage (PAD) was successful, additional surgery was not required. Twenty-one patients (14.6%) underwent additional surgery. Reasons for drainage failure were abscesses caused by internal fistulas (8 patients), pancreas involvement of the abscesses (5 patients), infected clots impossible to drain (3 patients), multiple abscesses (3 patients) and persistent abscess formation despite drainage (2 patients). Puncture-related complications were seen in 8 patients (5.5%). Puncture-related mortality was 0.7%.

[Acute renal failure]

Acute renal failure is defined as a multifactorial syndrome that occurs--depending of definition and selection of patients--in 2%-25% of all ICU patients. Most frequent in surgery (approximately 70%), ARF is caused by septic complications. Renal replacement therapy is managed today by dialysis, hemofiltration or the combination of both. Lethality of ARF ranges from 50% to 80%. High lethality rates are not related to ARF itself, but to uncontrolled septic MOF. The consequences for surgical ICU patients are: First of all, protective measures are mandatory. If ARF occurs, septic complications have to be considered. Renal replacement therapy has to be integrated into the management of septic MOF.

Simple, rapid and sensitive determination of protionamide in human serum by high-performance liquid chromatography

A simple high-performance liquid chromatography method has been developed that allows the sensitive determination of protionamide (2-n-propyl-pyridine-4-carboxylic acid thioamide, PTH) in human serum. After pretreatment of the serum with trichloroacetic acid (TCA) and centrifugation the supernatants were neutralized using NaHCO3. PTH was separated on a Kromasil 100 C4 column (acetonitrile-sodium tetraborate buffer pH 8-dibutylamine) and determined photometrically at 291 nm. The lower limit of quantification for 300 microl serum precipitated with 60 microl TCA and injection of 50 microl was 27 microg/l and linearity was observed up to 15 mg/l.

Correlation of cytogenetic, molecular cytogenetic, and clinical findings in 59 patients with ANLL or MDS and abnormalities of the short arm of chromosome 12

Abnormalities of the short arm of chromosome 12 (12p) are found in about 5% of acute nonlymphocytic leukaemias (ANLL) and myelodysplastic syndromes (MDS). They are described to be characteristic of secondary leukaemias, especially after prior mutagenic exposure, and to be associated with a poor prognosis. In our series of 59 patients with 12p abnormalities and ANLL or MDS, exposure to genotoxic agents was proven only in five patients, but in 13/44 patients ANLL evolved from an MDS. Patients with a small deletion del(12)(p11.2p13) having a mild clinical course were distinguished from those with a large del(12)(p11.2), additional chromosomal anomalies, and a poor clinical course. Among the 31 patients with translocations or dicentric chromosomes involving 12p, a group of eight with t/dic(12;13) was the most frequent and was associated with a poor prognosis. The clinical outcome was adverse in the majority of patients with complex karyotype abnormalities, but in some patients a milder clinical course seems likely. A new, hitherto undescribed, abnormality in an MDS case with a duplication dup(12)(p11.2p13) was the amplification of the signal of the yeast artificial chromosome (YAC) clone 964c10 (D12S736). In 38 cases with deletions or unbalanced translocations/dicentrics one YAC signal was lost. Five patients with balanced translocations demonstrated breakpoints within the YAC, containing the ETV6 (TEL) gene. The breakpoints were telomeric to the YAC 964c10 in seven cases and centromeric in one patient.

Categorization of the mitochondria-rich cells in the gill epithelium of the freshwater phases in the life cycle of lampreys

The distribution and ultrastructure of the mitochondria-rich (MR) cells in the gills of larval (ammocoetes) and adult lampreys (Petromyzon marinus and Geotria australis) have been studied. One type of MR cell, which is found only in ammocoetes, occurs in groups on and between gill lamellae. Freeze-fracture replicas show that the apical membrane of this ammocoete MR cell contains globular particles. The second type of MR cell, which is present in both ammocoetes and adults in freshwater, is located between lamellae and at the base of the filament. This cell usually occurs singly and is typically intercalated between ammocoete MR cells in larval lampreys and between pavement cells and pavement and chloride cells in adult lampreys. It contains rod-shaped particles in either the apical membrane (subtype A) or, far less frequently, the lateral membrane (subtype B) and in membranes of cytoplasmic vesicles and tubules. These features characterize this intercalated MR cell as a member of a group of MR cells that are also found in urinary epithelia of tetrapods and the amphibian epidermis, where they are involved in H+ and HCO3- secretion. Because this type of MR cell disappears when the young adult lamprey enters the sea and reappears immediately after the fully grown adult re-enters freshwater on its spawning run, it is presumably essential for osmoregulation in freshwater. On the basis of electrophysiological studies on frog skin, it is proposed that the subtype A of the branchial intercalated MR cell of lampreys provides the driving force for the Na+ uptake by active H+ secretion. By analogy with urinary epithelia, the subtype B cells may exchange Cl- for HCO3-.

Studies of persistent infection by Chlamydia trachomatis serovar K in TPA-differentiated U937 cells and the role of IFN-gamma

Inoculation of phorbol ester-differentiated U937 cells as a model for human macrophages with Chlamydia trachomatis of the urogenital serovar K resulted in a persistent infection, with maximal growth at day 7, until day 10 post-infection. At these times inclusion bodies were present in 0.5-2% of the cells. Typical inclusion bodies containing elementary bodies and reticulate bodies were observed by electron microscopy. Furthermore, single chlamydial particles resembling atypical elementary or intermediate bodies were identified in the cytoplasm in > 80% of the host cells. IFN-gamma exerts antichlamydial activity in epithelial and fibroblastoid cells, but the infection of U937 cells by C. trachomatis was not affected by IFN-gamma. The activity of the tryptophan-degrading enzyme indoleamine 2,3-dioxygenase (IDO) was not detected in untreated or in IFN-gamma-treated or chlamydiae-infected or mock-infected U937 cells. The presence of atypical persisting chlamydiae and the lack of IDO expression in U937 cells indicates that the development of these atypical bacteria is independent from IFN-gamma-mediated tryptophan deprivation and other IFN-gamma-mediated effects. Evaluation of persistently infected cells revealed that the expression of the chlamydial major outer-membrane protein, heat-shock protein (hsp60) and lipopolysaccharide (LPS) antigens was not significantly altered in the course of the culture. An intense staining of the LPS on the surface of the host cells was demonstrated by immunofluorescence. The data show that phorbol ester-differentiated U937 cells restrict chlamydial growth strongly but not completely through a mechanism distinct from IDO-mediated tryptophan deprivation. The mechanisms of persistence of chlamydiae in monocytes, which differ considerably from those described for other cells, require further investigation.

[Special therapeutic approaches for interrupting the cascade--from systemic inflammatory response syndrome to multiple organ failure]

SIRS, sepsis and MOF are clinical sequelae related to persistent, uncontrolled inflammation. Therefore, different strategies for treatment were designed to block the cascade from SIRS to MOF (anti-inflammatory therapies). However, clinical trials using these agents have failed to demonstrate any benefit. In sepsis the body also mounts an anti-inflammatory response, which has been largely ignored. If the anti-inflammatory reaction is sufficiently severe, we might increase the susceptibility to infection or even exacerbate immunosuppression by using anti-inflammatory agents. In contrast, agents to stimulate the immune system--like IFN-gamma or G-SCF--may prove beneficial.

[Carbohydrate-deficient transferrin (CDT) as preoperative alcohol marker in surgical risk patients]

In a prospective study the preoperative risk of alcohol addiction was evaluated in 46 patients with squamous cell carcinoma of the esophagus. In all patients the alcohol marker carbohydrate-deficient transferrin (CDT) was measured prior to esophagectomy and correlated with the incidence of postoperative withdrawal symptoms (yes/no) and the postoperative course (good/moderate/poor/fatal). Withdrawal symptoms were more frequently observed in cases of elevated CDT values (median of CDT with withdrawal 17.0 U/l vs without withdrawal 10.7 U/l; P = 0.0006). CDT values were significantly increased in case of a complicated postoperative course (median of CDT for moderate/poor/fatal postoperative course 14.0 U/l vs good course 10.8 U/l; P = 0.02). The CDT value correlated (P = 0.04) with the patient's history of preoperative alcohol consumption (normal/increased/high). In a multivariate logistic regression analysis CDT and preoperative alcohol consumption were independent parameters to predict significantly the postoperative course and withdrawal. The sensitivity was 71.4% and the specificity 84.4% selecting the parameter "postoperative withdrawal" and a CDT cut-off point of < 15.3 U/l. CDT can effectively identify patients with high alcohol consumption prior to esophagectomy.

[Respiratory burst and phagocytosis activity in patients with infection after surgical abdominal interventions]

Phagocyte functions such as respiratory burst or phagocytic activity allow the determination of septic courses. Already in case of surgical stress a reduced constitutive generation of reactive oxygen metabolites could be shown, which is assumed to influence the outcome of following septic courses. The results of septic patients suggest that in spite of a functioning uptake of particles and germs (phagocytosis) a defect of intracellular killing (respiratory burst) exists.

Radical transhiatal esophagectomy with two-field lymphadenectomy and endodissection for distal esophageal adenocarcinoma

Distal adenocarcinoma of the esophagus is defined as a tumor originating from an endobrachyesophagus or a tumor with its main tumor mass (more than two-thirds) located in the distal tubular esophagus. Controversy exists about the optimal mode of surgical resection. Some favor transthoracic esophagectomy, whereas others prefer transhiatal (blunt) esophagectomy. A radical transhiatal esophagectomy (RTE) combined with two-field lymphadenectomy and mediastinoscopic dissection of the upper thoracic esophagus (endodissection) is described herein. We assessed the short- and long-term results of this technique and compared them to a historical group of patients undergoing conventional transhiatal esophagectomy (THE) for adenocarcinoma of the distal esophagus. Altogether 124 patients underwent transmediastinal esophagectomy because of adenocarcinoma of the distal esophagus in our department between January 1986 and May 1995. Thirteen of these patients were excluded from this analysis because of preoperative chemotherapy. The remaining 109 patients were divided into two groups: 62 patients who underwent THE between January 1986 and March 1991 (51 men, 11 women; mean age 65.3 years, range 31-83 years) and 47 patients who had RTE between April 1991 and May 1995 (44 men, 3 women; mean age 63.4 years, range 41-84 years). To compare the long-term results of RTE and THE, we used a matched-pairs analysis considering tumor stage and age. The hospital (30-day) mortality was marginally lower in the RTE group (4.3% versus 6.4%), resulting in an overall mortality of 5.5%. The rate of pulmonary complications was insignificantly lower in the RTE group [19.1% RTE versus 25.8% THE; not significant (NS), and the rate of postoperative cardiac abnormalities significantly decreased after RTE (2.6% RTE versus 19.3% THE; p < 0.05). The overall rate of R0 resections was 87.2% (82.2% RTE, 87.1% THE). Overall survival was similar within the two study groups. Complete tumor removal, T and N stages, and the lymph node ratio were identified as prognostic factors for long-term survival. Overall survival was better after RTE than after conventional THE in patients with involved lymph nodes. The mean number of resected lymph nodes per patient in the RTE group was 26.7. Positive lymph nodes were most common in the paracardial region and at the lesser curvature (72%/10.8% of all invaded abdominal nodes). In the mediastinum positive nodes were most common in the paraesophageal and paraaortal region (48%/27% of all mediastinal nodes). Patients with positive abdominal and mediastinal lymph nodes had a poor long-term prognosis. Distal adenocarcinoma of the esophagus can be safely resected by RTE with two-field lymphadenectomy and endodissection. This technique allows radical "enbloc" resection of the tumor-bearing distal third of the esophagus, which includes the primary area of lymph node metastasis of adenocarcinoma of the distal esophagus: the lower mediastinum and paracardial region. The analysis showed that RTE incurred fewer cardiac complications and a better overall survival in N1-positive patients when compared retrospectively to THE. Intraoperative mediastinoscopy allows controlled dissection of the upper mediastinum and biopsy of several mediastinal lymph nodes, with the advantage of providing additional staging information.