[Primary diagnostics of acute diverticulitis of the sigmoid]

AIM

The initial diagnostics of acute diverticulitis of the sigmoid should render the correct diagnosis as well as assisting in the decision on the options of conservative or surgical treatment by ruling out or demonstrating complications. At present, sonography or computed tomography (CT) are the two competing diagnostic options. This study was designed to demonstrate that sonography could be used as the method of choice.

METHOD

63 patients with clinical suspicion of acute diverticulitis of the sigmoid were examined initially by sonography or CT in a prospective study.

RESULTS

Sonography and CT showed a 97 % sensitivity and specificity for reaching the accurate and clinically plausible diagnosis. As to the demonstration of complications of the disease, sensitivity and specificity were comparably high for both diagnostic methods.

CONCLUSIONS

Sonography can compete with the more complex CT examination and therefore represents the recommended primary diagnostic procedure.

Transanal endoscopic microsurgery: indications and results after 100 cases

OBJECTIVE

Transanal endoscopic microsurgery (TEM), a minimally invasive technique has been employed in the excision of benign and well-selected malignant rectal tumours since June 1998. We present a prospective descriptive study and analyse the currently accepted indications.

PATIENTS AND METHODS

Over a 4-year period 100 patients underwent TEM for treatment of rectal tumours located between 4 and 18 cm from the anal verge.

RESULTS

TEM was performed in 71 cases for adenomas, 20 potentially curative excisions for pre-operative staged low-grade carcinoma, 3 palliative procedures for advance carcinoma, 5 carcinoids and 1 solitary ulcer. The local complication rate included wound breakdown in 7 patients, three of them requiring ileostomy. Conversion to laparotomy was performed in two patients. Five adenomas recurred and were successfully treated by TEM. Of the cancers, four patients required immediate salvage therapy by means of total mesorectal excision. Three patients underwent palliative TEM procedures combined with radiotherapy. A single cancer recurrence was treated by means of abdomino-perineal resection after radiotherapy.

CONCLUSIONS

TEM appears to be an effective method of excising benign tumours and selected T1 carcinomas of the rectum. The superior exposure of tumours higher in the rectum combined with the greater precision of excision make this minimally invasive technique an attractive surgical approach.

Monitoring water content of rat lung tissuein vivo using microwave reflectometry

Measurement of lung water is an important diagnostic means of assessing pulmonary oedema. Water content affects the dielectric spectrum at microwave frequencies, but quantification is still a problem. A new lung tissue model is presented that allows the calculation of water content from dielectric permittivity. The dielectric permittivity of lung tissue was measured by microwave reflectometry using a non-invasive surface probe. During perfusion of rat lungs (n = 22) with blood, injury was induced by interruption of the blood supply for a duration between 0 (control) and 2 h. Water content was assessed from dielectric permittivity using a new mixture formula and was also determined by drying and weighing. The mixture formula allows for the dielectric polarisation of water, dry matter and air in the tissue. A linear correlation was found between total water content determined from dielectric permittivity and that from drying and weighing (y= 1.001x, R2 = 0.8). Lung injury showed an increase in total water content from 80.9 +/- 1.2% (control) to 84.1 +/- 0.9% (p < 0.01). The analysis of dielectric permittivity data at microwave frequencies with the new tissue model is sensitive enough to detect water accumulation produced by lung injury and it can be used to monitor total water content without tissue destruction.

Phase III trial of gemcitabine plus tipifarnib compared with gemcitabine plus placebo in advanced pancreatic cancer

PURPOSE

To determine whether addition of the farnesyltransferase inhibitor tipifarnib (Zarnestra, R115777; Johnson and Johnson Pharmaceutical Research and Development, Beerse, Belgium) to standard gemcitabine therapy improves overall survival in advanced pancreatic cancer.

PATIENTS AND METHODS

This randomized, double-blind, placebo-controlled study compared gemcitabine + tipifarnib versus gemcitabine + placebo in patients with advanced pancreatic adenocarcinoma previously untreated with systemic therapy. Tipifarnib was given at 200 mg bid orally continuously; gemcitabine was given at 1,000 mg/m(2) intravenously weekly x 7 for 8 weeks, then weekly x 3 every 4 weeks. The primary end point was overall survival; secondary end points included 6-month and 1-year survival rates, progression-free survival, response rate, safety, and quality of life.

RESULTS

Six hundred eighty-eight patients were enrolled. Baseline characteristics were well balanced between the two treatment arms. No statistically significant differences in survival parameters were observed. The median overall survival for the experimental arm was 193 v 182 days for the control arm (P =.75); 6-month and 1-year survival rates were 53% and 27% v 49% and 24% for the control arm, respectively; median progression-free survival was 112 v 109 days for the control arm. Ten drug-related deaths were reported for the experimental arm and seven for the control arm. Neutropenia and thrombocytopenia grade > or = 3 were observed in 40% and 15% in the experimental arm versus 30% and 12% in the control arm. Incidences of nonhematologic adverse events were similar in two groups.

CONCLUSION

The combination of gemcitabine and tipifarnib has an acceptable toxicity profile but does not prolong overall survival in advanced pancreatic cancer compared with single-agent gemcitabine.

Postoperative complications of pancreatic cancer surgery

The incidence of ductal adenocarcinoma of the pancreas has been increasing worldwide in recent years. About 5% to 25% of all pancreatic cancers are resectable and only curatively resected patients enjoy a favourable outcome. But even in experienced centers a postoperative morbidity of 30-50% and a mortality around or underneath 5% is reported. As long term-survival is rare and complications are frequent the quality of life for the remaining months or years is of paramount importance. The most severe complications lead to reoperations, prolonged hospital stay, fatigue, and nutritional disorders thereby markedly compromising quality of life. Therefore, prevention and management of complications after pancreatic resections are reviewed. Prevention of disastrous complications is possible using a decent surgical technique and handling the soft pancreatic remnant in cancer patients carefully. The end-to-side, duct-to-mucosa anastomosis is the most preferred technique. The therapy of pancreatic leakage should be individualized and completion pancreatectomy should only be an option for recurrent hemorrhage, and a necrotic pancreatic stump. The continuous postoperative observation of the patient is of paramount importance to diagnose other severe complications, such as hemorrhage and septic complications, in time. Only early diagnosis and management of these complications can improve outcome and save life. Pancreaticoduodenectomy can be a safe procedure in experienced institutions, where the whole medical team is able to diagnose and treat these complications at any time.

Impact of donor dopamine on immediate graft function after kidney transplantation

Optimizing medical donor management may have a considerable impact on transplantation outcome. This study investigated the effect of donor dopamine on initial graft function in renal allograft recipients, involving 254 consecutive recipients of a cadaver kidney, aged 18-74 years, transplanted between 1990 and 2003. Immunosuppression was based on cyclosporine. Patients were grouped according to donor use of dopamine during intensive care. Delayed graft function (DGF), and serial creatinine concentrations were compared between the groups. Dopamine-treated and -untreated donors were very similar regarding hemodynamics and renal function. Delayed graft function occurred in 47/158 treated and 48/96 untreated kidneys (p = 0.001). Donor dopamine was associated with a more rapid decrease of s-creatinine, which became obvious on the first postoperative day. Of patients in the treated and untreated group, respectively, 81.9% and 65.8% reached a s-creatinine level less than 2 mg/dL during the first month (p = 0.005). Donor dopamine remained predictive of a normalized s-creatinine level [HR 1.71; 95% CI 1.22-2.41] after controlling for confounding factors by multivariate Cox regression. Donor dopamine is associated with improvements of initial graft function after kidney transplantation. The beneficial effect of dopamine is achievable without side-effects for the recipients, and correlates with superior long-term graft survival.

Randomized clinical trial of lightweight composite mesh for Lichtenstein inguinal hernia repair

Background

Almost half the patients who undergo hernia repair with mesh report a feeling of stiffness and a foreign body in the groin. This study evaluated whether patients noticed any difference between lightweight and standard polypropylene mesh for the repair of inguinal hernia.

Methods

Patients scheduled for elective repair of unilateral or bilateral, primary or recurrent inguinal hernia by the Lichtenstein technique were randomized to receive either a conventional densely woven polypropylene mesh (100–110 g/m2) or a lightweight composite multifilament mesh (polypropylene 27–30 g/m2). Quality of life was assessed using Short Form 36 before operation and 6 months after surgery. Pain was assessed by means of a visual analogue scale 2 days and 6 months after surgery. The primary outcome measure was the feeling of a foreign body in the groin at 6 months.

Results

Some 122 hernias were randomized; 117 were included in the analysis of perioperative data, and 106 were re-examined after 6 months. There were no differences between the treatment groups with respect to early and late surgical complications. Use of lightweight mesh was associated with significantly less pain on exercise after 6 months (P = 0·042). In addition, fewer patients reported the feeling of a foreign body after repair with lightweight mesh (17·2 versus 43·8 per cent with conventional mesh; P = 0·003). Quality of life was improved significantly at 6 months compared with the preoperative assessment, and there were no differences between the treatment groups.

Conclusion

Lightweight polypropylene mesh may be preferable for Lichtenstein repair of inguinal hernia. Larger cohorts with longer follow-up are needed before it can be recommended for routine use.

[Mimicry of a liver abscess as hepatocellular carcinoma]

HISTORY

We report on a 82 year-old male who presented with chronic pain in the right upper abdomen, nausea and vomitus. An uncomplicated laparoscopic cholecystectomy occurred eight years and a hepatitis 60 years before. Clinical examination showed a normal abdominal status without palpable liver, spleen, enlarged lymph nodes or masses. He had no icteric skin and sclera.

INVESTIGATIONS

The patient was afebrile without leukocytosis. The tumour markers CEA, CA 19 - 9 and AFP were negative. Ultrasound of the abdomen showed a normal homogeneous echotexture of the liver without signs of cholestasis or cirrhosis. In segment 6 a 3 cm large hypoechoic cystic formation with a central echogenic structure with acoustic shadowing was noted. Magnetic resonance revealed a 2.8 x 3.6 cm large lesion in the dorsal region of segment 6 of the liver, infiltrating the perihepatic fat. Pathologic lymph nodes and metastases were not found.

DIAGNOSIS AND TREATMENT

At laparotomy, the tumour appeared to be malignant with invasion to the perirenal fat. Complete resection with negative margins included segment 6 of the liver and the adjacent fat (the kidney itself was not infiltrated). The cut specimen also showed signs of malignancy with central necrosis. However, histology of the resected specimen revealed a sterile liver abscess without malignancy, but with microscopic foreign bodies. The patient had an uneventful recovery without postoperative complications.

CONCLUSIONS

This case report demonstrates the difficulty encountered in the differential diagnosis of inflammatory processes and malignant tumours. Chronic inflammatory changes may mimic solid neoplasms. Despite adequate magnetic resonance imaging and thorough intraoperative examination, the correct diagnosis was finally found by histology. The most likely genesis of the abscess are lost gallstones during cholecystectomy.

[Emergency diagnostic imaging in mesenteric ischemia]

Diagnostic imaging in patients with suspected acute mesenteric ischemia is started with abdominal ultrasound including duplex sonography of the mesenteric vessels. Despite low sensitivity even in experienced hands, ultrasound is used because operative treatment can be initiated without further imaging if a positive diagnosis is made. Plain abdominal X-rays are usually unspecific in acute mesenteric ischemia and are mainly used to rule out differential diagnoses. Spiral CT (ideally using a multislice technique) can accurately demonstrate morphology of the arterial and venous mesenteric vessels, changes in the bowel wall, and additional mesenteric or peritoneal findings. Therefore, CT has the potential for diagnosis of mesenteric ischemia on a pathological basis. Furthermore, CT is successfully used to confirm or exclude most other causes of acute abdominal conditions. Magnetic resonance imaging (MRI) may be as accurate as CT for the diagnosis of acute mesenteric ischemia and its differential diagnoses. However, MRI is not widely available and therefore not used as an emergency imaging modality so far. Catheter angiography remains the diagnostic gold standard for mesenteric vasculature when spiral CT is not available.

[Abdominal drainages]

The use of drainages in abdominal surgery is characterized by tradition and personal experience of the surgeon. There are only a few high-quality, randomized studies on the use of prophylactic drainages. The risk of postoperative mediastinitis leads surgeons to maintain the use of drainages in esophageal anastomosis. The use of drainages in gastric and small bowel surgery appears to be negligible. There are evidence grade A recommendations for hepatobiliary surgery (without biliodigestive anastomosis) to abstain from the use of drainages. One prospective, randomized study showed an advantage of surgery without drainage in pancreatic resections (and bilioenteric anastomosis). The situation is clear for colorectal surgery. Several prospective, randomized studies have shown the advantages of avoiding drainages. The use of drainages in perforated appendicitis appears to be associated with an increased rate of postoperative complications. There are no general recommendations for the use of drainages in cases of peritonitis. The few high-quality studies published show that the use of drainages in visceral surgery has to be questioned continuously. High-quality clinical studies are necessary to obtain evidence-based recommendations for the use of drainages in visceral surgery.

[Results of emergency ERCP in the treatment of acute biliary pancreatitis]

Indication for emergency ERCP (< 48 hours after onset of symptoms) with stone extraction from the common bile duct (CBD) in patients with biliary pancreatitis remains controversial. In our hospital emergency ERCP with stone extraction from CBD is part of the therapeutical concept in patients with biliary pancreatitis. The aim of the study was to elucidate retrospectively results and impact of this concept on morbidity and lethality in surgical intensive care patients. We included all patients with a documented indication for emergency ERCP. Among 4 466 patients (1. 1. 1999-31. 12. 2000) treated in the SICU, 37 (0.9 %) required an emergency ERCP due to a biliary pancreatitis. (26 females/11 males, 62.0 +/- 15.4 years). After ERCP stones were present in 32 of the 37 patients with subsequent successful endoscopic extraction in all cases but one. The mean duration from admission to ERCP was 11.6 +/- 10.1 hours. Bilirubin as well as amylase and lipase decreased after ERCP (p < 0.05). Only in one case an elevation of pancreatic enzymes over the pre-ERCP values was observed, an aggravation of pancreatitis was not seen in our series. In 5 of the 37 cases bile duct stones were not found after ERCP despite strong clinical suggestion (elevation of bilirubin and pancreatic enzymes, ultrasound). During the observational period 2 patients died, in one case possibly due to the ERCP. Emergency ERCP removed in our series the pancreatitis causing agent. Still considering the limitations of a retrospective study these positive results are stimulating us to continue with our therapeutical concept.

[Vascular injuries after extremity trauma]

The aim of the present examination was to analyse extremity trauma with additional vascular injuries. Between 1973-2000 78 patients with traumatic peripheral vascular injuries have been treated at the Surgical Department of the University Hospital of Mannheim. In addition to clinical examination Doppler-Duplex ultrasonography (cw-Doppler) was routinely performed. In selected cases either conventional or magnetic resonance angiography completed the diagnostic procedure. Vascular injuries to the upper extremities were found in 46.2 % (n = 36) whereas 53.8 % (n = 42) of the patients suffered from trauma of the lower extremities. The popliteal artery was affected in 28.2 % followed by the brachial artery with 23.1 %. 52.6 % of the patients had interposition of autologous vein for reconstruction. Only 7.7 % of the cases needed interposition of alloplastic material. In general the injured extremity was immobilised by external fixation, followed by secondary vascular reconstruction. An efficient trauma management reduced amputation rate as low as 2.6 %.

Evidence for non-neurotensin receptor-mediated effects of xenin (1-25)--focus on intestinal microcirculation

Xenin (1-25) has been detected in various locations in mammalians. It has structural similarities with neurotensin and its intestinal effects are claimed to be mediated by neurotensin receptors. It has been shown to influence gastrointestinal motility. The effects of xenin (1-25) on intestinal microvascular perfusion after ischemia/reperfusion have not been investigated yet. Therefore, the superior mesenteric artery was clamped for 40 min in Wistar rats (n=8). Ten minutes prior to reperfusion, intravenous infusion of xenin (1-25) (5 nmol/kg/h) was started. By means of intravital microscopy, microvascular perfusion in the mucosal layer was assessed. Animals (n=8) with and without clamping of the superior mesenteric artery and infusion of the carrier solution served as controls. After ischemia/reperfusion, xenin (1-25) increased the density of perfused microvessels and the capillary red blood cell velocity compared to ischemic controls. Capillary red blood cell velocity was elevated (p<0.05). Xenin (1-25) improved the heterogeneous distribution of mucosal blood flow during reperfusion demonstrated by an increase of both the perfusion index and the percentage of perfused microvessels. We conclude that the effects of xenin (1-25) on intestinal microcirculation are significantly different from those previously described for neurotensin. A more complex effector mechanism must be postulated that may involve other regulatory peptides and receptors.

High-dose 5-fluorouracil / folinic acid in combination with three-weekly mitomycin C in the treatment of advanced gastric cancer. A phase II study

BACKGROUND

The 24-hour continuous infusion of 5-fluorouracil (5-FU) and folinic acid (FA) as part of several new multidrug chemotherapy regimens in advanced gastric cancer (AGC) has shown to be effective, with low toxicity. In a previous phase II study with 3-weekly bolus 5-FU, FA and mitomycin C (MMC) we found a low toxicity rate and response rates comparable to those of regimens such as ELF, FAM or FAMTX, and a promising median overall survival. In order to improve this MMC-dependent schedule we initiated a phase II study with high-dose 5-FU/FA and 3-weekly bolus MMC.

PATIENTS AND METHODS

From February, 1998 to September, 2000 we recruited 33 patients with AGC to receive weekly 24-hour 5-FU 2,600 mg/m(2) preceded by 2-hour FA 500 mg/m(2) for 6 weeks, followed by a 2-week rest period. Bolus MMC 10 mg/m(2) was added in 3-weekly intervals. Treatment given on an outpatient basis, using portable pump systems, was repeated on day 57. Patients' characteristics were: male/female ratio 20/13; median age 57 (27-75) years; median WHO status 1 (0-2). 18 patients had a primary AGC, and 15 showed a relapsed AGC. Median follow-up was 11.8 months (range of those surviving: 2.7-11.8 months).

RESULTS

32 patients were evaluable for response - complete remission 9.1% (n = 3), partial remission 45.5% (n = 15), no change 27.3% (n = 9), progressive disease 15.1% (n = 5). Median overall survival time was 10.2 months [95% confidence interval (CI): 8.7-11.6], and median progression-free survival time was 7.6 months (95% CI: 4.4-10.9). The worst toxicities (%) observed were (CTC-NCI 1/2/3): leukopenia 45.5/18.2/6.1, thrombocytopenia 33.3/9.1/6.1, vomitus 24.2/9.1/0, diarrhea 36.4/6.1/3.0, stomatitis 18.2/9.1/0, hand-foot syndrome 12.1/0/0. Two patients developed hemolytic-uremic syndrome (HUS).

CONCLUSIONS

High-dose 5-FU/FA/MMC is an effective and well-tolerated outpatient regimen for AGC (objective response rate 54.6%). It may serve as an alternative to cisplatin-containing regimens; however, it has to be considered that possibly HUS may occur.

Malignant intestinal non-Hodgkin's lymphoma from the surgical point of view

BACKGROUND

Primary intestinal non-Hodgkin's lymphoma (I-NHL) is much less frequent than gastric lymphoma and has hardly been studied in prospective trails. To the surgeon, patients frequently present with abdominal emergencies.

PATIENTS AND METHODS

A consecutive series of patients subjected to surgery because of I-NHL between 1998 and 1999 was evaluated retrospectively for characteristic clinical, radiographic and intraoperative findings. Patients with gastric lymphoma were not considered.

RESULTS

10 patients, 8 males and 2 females, with I-NHL were subjected to first-line surgery because of painful abdominal tumor, intestinal hemorrhage, obstruction or perforation. I-NHL was located most often in the small bowel (n = 7). It was rare in the colon (n = 2) and the duodenum (n = 1). Median postoperative follow-up was 28 months. Perioperative mortality was 10% (n = 1). Probability of survival 3 years after surgery was 60%.

CONCLUSIONS

Patients with I-NHL frequently present with complications of tumor growth, requiring urgent surgical treatment. Irrespective of surgical complications we advocate surgery in cases of resectable disease as first-line treatment. Adjuvant treatment is indicated with respect to resection status and histopathological staging.

[Concepts of the German Society of Tropical Surgery]

The DTC promotes access to surgical care facilities of acceptable medical quality for all people in third world countries. To achieve this goal following concepts and activities are persued: Establishment of a 2-year training programme district surgery Postgraduate surgical training in Germany Workshops and annual scientific meetings Development of adapted surgical technologies Cooperation with national and international organisations Promotion of north-south partnerships between colleagues and hospitals.

[Diagnosis of pancreas tumors: MRI or multidetector spiral CT?]

Recent technical advances in the field of abdominal MRI and multi-detector spiral-CT (MSCT) have resulted in improved diagnostic capabilities of pancreatic tumors. Preliminary data demonstrate slight advantages of MRI in the detection of liver metastases and papillary tumors as well as in the differential diagnosis of pancreatic masses while MSCT might be advantageous in the assessment of vascular infiltration, particular in uncooperative patients.

Phosphorylation of serines 635 and 645 of human Rad17 is cell cycle regulated and is required for G(1)/S checkpoint activation in response to DNA damage

ATR [ataxia-telangiectasia-mutated (ATM)- and Rad3-related] is a protein kinase required for both DNA damage-induced cell cycle checkpoint responses and the DNA replication checkpoint that prevents mitosis before the completion of DNA synthesis. Although ATM and ATR kinases share many substrates, the different phenotypes of ATM- and ATR-deficient mice indicate that these kinases are not functionally redundant. Here we demonstrate that ATR but not ATM phosphorylates the human Rad17 (hRad17) checkpoint protein on Ser(635) and Ser(645) in vitro. In undamaged synchronized human cells, these two sites were phosphorylated in late G(1), S, and G(2)/M, but not in early-mid G(1). Treatment of cells with genotoxic stress induced phosphorylation of hRad17 in cells in early-mid G(1). Expression of kinase-inactive ATR resulted in reduced phosphorylation of these residues, but these same serine residues were phosphorylated in ionizing radiation (IR)-treated ATM-deficient human cell lines. IR-induced phosphorylation of hRad17 was also observed in ATM-deficient tissues, but induction of Ser(645) was not optimal. Expression of a hRad17 mutant, with both serine residues changed to alanine, abolished IR-induced activation of the G(1)/S checkpoint in MCF-7 cells. These results suggest ATR and hRad17 are essential components of a DNA damage response pathway in mammalian cells.

Impact of inhibition of complement by sCR1 on hepatic microcirculation after warm ischemia

Recent observations provide evidence that complement is implicated as an important factor in the pathophysiology of ischemia/reperfusion injury (IRI). Here, we assessed the effects of complement inhibition on hepatic microcirculation by in vivo microscopy (IVM) using a rat model of warm hepatic ischemia clamping the left pedicle for 70 min. Ten animals received the physiological complement regulator soluble complement receptor type 1 (sCR1) intravenously 1 min prior to reperfusion. Controls were given an equal amount of Ringer's solution (n = 10). Microvascular perfusion and leukocyte adhesion were studied 30 to 100 min after reperfusion by IVM. Microvascular perfusion in hepatic sinusoids was significantly improved in the sCR1 group (80.6 +/- 0.6% of all observed sinusoids were perfused [sCR1] vs 67.3 +/- 1.2% [controls]). The number of adherent leukocytes was reduced in sinusoids (49.9 +/- 3.4 [sCR1] vs 312.3 +/- 14.2 in controls [adherent leukocytes per square millimeter of liver surface]; P < 0.001) as well as in postsinusoidal venules after sCR1 treatment (230.9 +/- 21.7 [sCR1] vs 1906.5 +/- 93.5 [controls] [adherent leukocytes per square millimeter of endothelial surface]; P < 0.001). Reflecting reduced hepatocyte injury, liver transaminases were decreased significantly upon sCR1 treatment compared to controls. Our results provide further evidence that complement plays a decisive role in warm hepatic IRI. Therefore, we conclude that complement inhibition by sCR1 is effective as a therapeutical approach to reduce microcirculatory disorders after reperfusion following warm organ ischemia.

[Detection of micrometastases after curative resection for ductal adenocarcinoma of the pancreas]

OBJECTIVES

Despite apparently curative resection adenocarcinomas of the pancreas early recur. Thus, the pathological examination should be enriched by sensitive methods to detect minimal residual disease (MRD). Mutant K-ras is the most promising genetic alteration in ductal adenocarcinoma and may serve to detect malignant cells by polymerase chain reaction (PCR) based techniques. Therefore, we set out to detect K-ras mutations by PCR for evaluation of MRD in patients after curative resection of pancreatic adenocarcinoma.

PATIENTS AND METHODS

Tumor tissue and corresponding paraaortic lymph nodes were obtained from 51 patients, who underwent surgery for pancreatic head tumors. The paraaortic lymph nodes were staged as tumor-free by routine histopathology in all cases diagnosed for ductal adenocarcinoma (study group, n = 40) or other tumors (control group, n = 11). Therefore, DNA of both primary tumors and lymph nodes was extracted and analysed by a PCR-based assay with respect to mutated K-ras. As a positive control the human pancreatic cancer cell line PaTu-8902 was used.

RESULTS

K-ras mutations were detected in 73 % (29/40) of primary tumors of ductal adenocarcinomas and in 17 % (5/29) in the corresponding paraaortic lymph nodes, which were diagnosed as tumor-free by routine pathology. The identical type of point mutation was found in primary tumors and corresponding lymph nodes by use of sequence specific primers. In the control group no K-ras mutation was detected.

CONCLUSION

Tumor cell DNA can be detected sensitively in tumor- and lymph node specimen with the described method. Routinely assessed, this method is able to detect MRD and could enrich the pathological examination, in order to determine prognostic relevant subgroups of patients.

Dacron vs. polytetrafluoroethylene grafts for femoropopliteal bypass: a prospective randomised multicentre trial

OBJECTIVES

To compare the patency of PTFE (Polytetrafluoroethylene) and unsealed knitted Dacron femoro-popliteal bypasses.

DESIGN

Multi-centre prospective randomised trial.

MATERIALS AND METHODS

Of 203 patients randomised, 194 were included in the final analysis (103 Dacron grafts and 91 PTFE grafts). The median follow-up was 36 months (range: 6-72 months); the distal anastomosis was above-knee in 141 and below-knee in 53 cases. Univariate comparisons of patency were made by the Kaplan-Meier method, multivariate calculations on the effects of covariables by a Cox regression analysis.

RESULTS

There was no difference regarding primary and secondary patency or limb salvage between Dacron and PTFE. The primary 3-year patency for Dacron grafts was 64% (95% confidence interval [C.I.] 55-74%) and for PTFE grafts 61% (C.I. 49-72%). The corresponding 3-year secondary patency was 81% (C.I. 73-89%) and 75% (C.I. 65-86%) respectively, the limb salvage rate 90% (C.I. 84-96%) and 91% (C.I. 84-97%). Upon multivariate analysis below-knee anastomosis was the principal independent predictor of primary graft failure (risk ratio 1.7 [C.I. 1.05-2.8]), impaired secondary patency was associated with infragenicular bypass (risk ratio 3.3 [C.I. 1.8-6.3]) and distal gangrene (risk ratio [C.I. 1.01-3.8]p=0.048), major amputation was independently predicted by below-knee bypass, tissue necrosis, and poor run-off index.

CONCLUSIONS

PTFE and Dacron are equally suitable for femoro-popliteal bypass.

[Locally ablative therapies of hepatocellular carcinoma]

Locally Ablative Therapies of Hepatocellular Carcinoma Delayed diagnosis of hepatocellular carcinomas (HCC) leads to a poor prognosis with a median survival time of less than 10 months. Surgical resection of small HCCs is the treatment of choice in patients with good residual liver function. The recurrence-free 5-year survival rate after curative resection is 33%. Resectability of HCC is often limited by the low hepatic functional reserve. Only 20% of all HCC are resectable in spite of novel diagnostic tools, an intensified screening, and advances in surgical technique. Local methods for tumor ablation are promising extensions of tumor therapy, especially in patients with limited liver function, nonresectable tumors, or multifocal tumors. Vis-à-vis a change of therapeutic options, local methods of tumor ablation in combination with tumor resection promise a yet unknown improvement of the prognosis for patients with HCC. Controlled randomized studies comparing and validating these methods of local tumor ablation are eagerly awaited. In the following article different methods of tumor ablation are described. Percutaneous interventions can be distinguished into vascular regional (TAE = transarterial embolization and TACE = transarterial catheter embolization) and local ablative approaches like PEI (percutaneous ethanol instillation), LITT (laser-induced thermotherapy), Cryo (cryotherapy), and RFA (radio frequency ablation).