[Timing and concepts of surgical treatment of upper gastrointestinal haemorrhage]

BACKGROUND

Upper gastrointestinal bleeding is a frequently occurring clinical scenario with a potentially serious prognosis. In spite of excellent endoscopic results, the mortality rate after an insufficient endoscopic treatment is exception-ally high (12.5-36 %). It is crucial to recognise factors in which endoscopy reaches its limitations. Until now, no uniform guidelines and concepts concerning diagnosis and treatment as well as timing of surgical interventions, in particular, have been defined. The main goal of this study is to lower the morbidity and mortality rates after upper gastrointestinal bleeding, with potential risk stratification according to the literature and our own data. PATIENTS / MATERIAL AND METHODS: In a retrospectively designed study 220 patients were evaluated with upper gastrointestinal haemorrhage, who were hospitalised as emergencies from 1999 to 2002. Only those patients were accepted in the study who were examined within 48 hours endoscopically by oesophagogastroduodenoscopy. In order to exclude bleeding complications of a preceding endoscopic therapy, those patients were excluded who had been investigated by endoscopy in the past than 8 days.

RESULTS

After endoscopic evaluation of the bleed-ing activity of 33 Forrest I a / I b bleedings 5 patients and of 52 Forrest II a / II b / II c bleedings 6 patients had to undergo surgery. The haemoglobin content of conventionally treated patients was on average 10.3 mg / dL as compared to 8.4 mg / dL for the operated patients. The conventionally treated patients received an average of 3 red cell concentrates whereas the operated patients had 11 blood transfusions. The source of haemorrhage in the operated patients was located in bulbus duodeni (n = 7), cardia and fundus (n = 2) and the corpus (n = 2).

CONCLUSION

The evaluation of our own patient data including the experiences of other authors shows that a risk stratification is possible and meaningful. The indication for surgery thereby -depends on different factors: the comorbidity of the patient, the haemodynamic in- / stability, the number of necessary blood transfusions and the localisation of the bleeding source.

Identification of chromosomal regions that harbor novel genes important for pancreatic cancer pathogenesis by genome-wide screening methods

e15609

Background: Pancreatic adenocarcinoma is a genetically highly complex and heterogenous tumor type with strong genetic instability which makes it resistant to therapy. Known amplifications of oncogenes such as KRAS or MYC and deletions of tumor suppresor genes such as CDKN2A and SMAD4 have demonstrated the importance of genetic alteration in this tumor type. Methods: We report the use of an Affymetrix Genome-Wide Human single nucleotide polymorphism (SNP) Array 6.0 (906,600 SNPs) to screen for gene copy number changes and allelic imbalances in 8 microdissected primary pancreatic tumors and 7 established pancreatic cancer cell lines. Gene Chip Human Genome U133 2.0 Array was used to make an RNA expression profile. Mutation analysis of KRAS and M-FISH analysis of cell lines was performed. Results: SNP arrays confirmed the presence of previously reported cytogenetic abnormalities in the cell lines and primary tumor probes, including MYC amplifikation at 8q24, gain of 17q12 (ERBB2/HER2), 7p12 (EGFR) and 12p12.1 (KRAS). KRAS mutation was seen in 71% of cell lines (5/7). We identified several alterations in signaling pathways such as Wnt/Notch Signaling and KRAS signaling. A sizeable subset ( 7 of 15 cases; 47%) showed an amplikon at 19q13.1–13.2 in which the serine/threonine kinase Mirk/Dyrk1B is localized, a downstream effector of oncogenic k-ras. There was also strong concordance between primary tumors and cell lines with respect to gains on 8q, 12p and 18q. Analysis of gene expression was used to localize potential target genes. M-FISH analysis showed complex karyotypes with chromosomal deletions in 9p and 18q, regions that are known to harbor tumor suppressor genes (CDKN2A, SMAD4 and TP53). Conclusions: Several signaling pathways mediate tumor cell survival. Analysis of gene amplification and RNA expression profile provide molecular biological characteristics and an individual gene signature of the tumor which allow us to choose more efficient drugs to an individualized treatment. Pathways activated by KRAS such as DYRK1B may offer new therapeutic targets. Further functional characterization is needed to provide evidence for the actual role of any putative target gene.

No significant financial relationships to disclose.

Endoscopic mucosal resection of early esophageal squamous cell cancer using the Duette mucosectomy kit

BACKGROUND AND STUDY AIM

Endoscopic mucosal resection (EMR) is a less invasive alternative treatment strategy to surgery for intramucosal esophageal squamous cell carcinoma (SCC). This study described our initial experience with the newly introduced Duette Multiband Mucosectomy Kit (Cook Ireland Ltd, Limerick, Ireland) for the treatment of extensive early esophageal SCC.

PATIENTS AND METHODS

Five patients with extensive early esophageal SCC, covering at least half of the circumference of the esophageal wall and measuring a mean of 2.8 cm longitudinally, underwent EMR after EUS staging.

RESULTS

EMR was successfully completed in one session in five patients. Post-EMR stricture occurred in four patients but was successfully treated with bougienage. One patient did not return for follow-up after bougienage and died from ischemic heart disease 3 months later. For the remaining four patients, there was no recurrence over a mean follow up of 14.7 months.

CONCLUSION

This new device obviates the need for repeated insertion of the endoscope during the process of ligation and resection and thus facilitates EMR of extensive SCC.

Determination of microvessel density by real-time PCR in esophageal cancer: Correlation with histological methods, angiogenic growth factor expression and lymph node metastasis

10053

Background: Neoangiogenesis and lymphangiogenesis represent prognostic factors in human malignancies. Determination of microvessel density (MVD) by immunohistology is labor-intensive and subject to interobserver variability. We evaluated real time PCR to quantify MVD in primary tumor samples from patients with esophageal cancer. Methods: We performed real-time PCR analyzes of endothel-specific (VE-Cadherin, P1H12, VEGFR-2, tie-2), lymphendothel-specific (Prox, LYVE, VEGFR-3) antigens and of angiogenic growth factors (VEGF-A, VEGF-C, VEGF-D, Ang-1, Ang-2) in primary esophageal carcinoma tissue of 54 patients. These results were compared to MVD determined immunohistochemically by CD31 staining. Results: For validation, MNC samples spiked with HUVECs were analyzed by qPCR for VE-CAD and P1H12 yielding a linear correlation (r=0.99 and 0.96 respectively). Expression of endothelial markers was highly correlated in tumor samples, e.g. CD144 with CD146 τb=0.451, CD144 with VEGFR-2 τb =0.744 and CD144 with tie-2 τb=0.684 (p for all comparisons < 0.0001). QPCR results were compared to MVD determination by CD31 staining in a subgroup of 33 patients. The highest association between both methods was found for CD144 (τb=0.258, p=0.0379) and VEGFR-2 (τb=0.222, p=0.0745) indicating that immunohistology and qPCR yield comparable results. MVD was significantly linked to the expression of VEGF-A, -C,-D and Ang1 and Ang2 (p for all comparisons <0.0001). We analyzed expression of lymphendothelial cell antigens Prox, LYVE and VEGFR-3 for quantification of lymphatic vessels. A close association between the expression of different lymphendothelial factors was seen (LYVE with Prox τb=0.334, p=0.0021, LYVE with VEGFR-3 τb=0.450, p=0.0150). MVD and lymphvessel density was not linked. Lymph node metastases detected on surgical specimen were associated with MVD determined immunohistologically (p=0.003)or by qPCR (p=0.048) and to VEGF-C expression (p=0.04). Conclusions: QPCR analysis of CD144 and VEGFR2 represents a novel tool for quantification of MVD in tumor samples. Expression of VEGFR2 and VEGF-C is associated with lymph node metastasis in patients with esophageal carcinoma.

No significant financial relationships to disclose.

[Interdisciplinary surgery of the thorax-from the general surgeon's point of view]

Interdisciplinary professional management is the most important basic principle for successfully mastering thoracic operations including the thoracic wall and adjacent regions such as neck, axilla, mediastinal vessels, upper limb, and spine. Extended oncological resection in advanced malignant diseases, side-effects of radiotherapy and trauma explain the diversity of possible operative procedures. For technical success, the necessity of vascular grafting, reconstruction of the brachial plexus, spine surgery, cardiac surgery, plastic thoracic wall reconstruction, stabilization of the thoracic wall, modern equipment, and know-how are mandatory. We chose some show-cases which-in our opinion-might be appropriate for demonstrating interdisciplinary therapy management. Functional, oncological, and cosmetic/reconstructive aspects should be considered when approaching these cases.

[The role of angiography in the diagnosis and therapy of gastrointestinal hemorrhage]

PURPOSE

Evaluation of angiography in the diagnosis and treatment of acute and chronic gastrointestinal bleeding.

MATERIALS AND METHODS

Thirty-seven consecutive patients with clinically suspected gastrointestinal bleeding underwent selective angiography of the visceral arteries. If technically possible, patients with radiologically proven hemorrhage underwent selective embolization with microcoils. Not all angiographically detected bleeding vessels were embolized. Clinical outcome was determined from a review of the medical records.

RESULTS

37 patients underwent 43 angiographies, which demonstrated 25 bleedings considered acute and 18 considered chronic. Seventeen patients had previous intestinal surgery. In 9 of the 37 patients, 12 of the 43 (sensitivity: 28 %) hemorrhages were detected. A postoperative bleeding was found in 6 patients. With one exception, all angiographically positive cases were clinically considered to be acute. Transcatheter embolization of the bleeding vessels with microcoils was performed in 6 patients, with 3 patients having the bleeding stopped permanently and 3 patients requiring further surgical treatment. In 3 patients, embolization was not possible for technical reasons. No complications attributable to angiography were seen.

CONCLUSION

Angiography should be performed in patients with spontaneous and postoperative gastrointestinal bleeding. Transcatheter embolization is an effective and safe therapeutical option in both clinical settings.

Chronic pancreatitis: etiology, pathogenesis, diagnosis, and treatment

BACKGROUND AND AIMS

This review discusses current concepts regarding the etiology, pathogenesis, diagnosis, and treatment of chronic pancreatitis.

RESULTS

Treatment of patients suffering from complications of chronic pancreatitis remains a major challenge. Continuous alcohol consumption, a disease with enormous personal and social impact, is still the leading factor in the development of chronic pancreatitis. The most distressing symptom for the patient is pain, which in many instances has already led to a considerable analgesic abuse before a specialist is even consulted. The development of an enlargement of the pancreatic head, the "pacemaker of the disease," parallels pain and potential organ complications such as common bile duct stenosis or portal hypertension. What triggers pancreatic head enlargement is still not known; in particular it is unclear what triggers growth factors to step into action. Pain is most likely due to a combination of hypertension in the organ and parenchymal alterations. Current therapeutic concepts therefore aim at alleviating pain and at management of organ complications while preserving functional tissue to best prevent exocrine and endocrine dysfunction. The ideal procedure thus seems today to be the "customized" pancreatic head resection with additional optional drainage of the pancreatic body and tail.

Boerhaave-mimicking esophageal perforation with subsequent esophagobronchial fistula formation as the primary manifestation of Crohn's disease

BACKGROUND

Spontaneous ruptures of the esophagus are rare, but may lead to deleterious courses, even if diagnosed early.

CASE REPORT

We report a case of Boerhaave's syndrome-mimicking esophageal perforation due to a stricture of the distal esophagus as the primary manifestation of Crohn's disease. Diagnosis was delayed resulting in a complicated clinical course. The presented patient is the first case in the literature with esophageal perforation related to a previously undiagnosed Crohn's disease that lead to stenosis of the distal esophagus before becoming clinically apparent.

CONCLUSION

Difficulties in differential diagnosis, problems related to initial misdiagnosis and consecutive mismanagment of spontaneous esophageal perforation, and treatment options including nonsurgical approaches are discussed.

[Squamous epithelial carcinoma in a Zenker diverticulum]

Zenker's diverticulum is a common anomaly in the elderly patient. Carcinoma in such a diverticulum is a rare but recognized complication of a posterior pharyngeal pulsion diverticulum. We present a case of a 67-year-old patient with a long-standing symptomatic Zenker's diverticulum. The diagnosis of the neoplasm was only achieved intraoperatively. The patient underwent a proximal esophageal resection with lymphadenectomy. Reconstruction was done with a microvascular free jejunal transplant. The postoperative course was uneventful. Wide oncologic surgical resection is the therapy of choice in cases of carcinoma in a Zenker's diverticulum.

Bradykinin B2-receptor antagonism attenuates fatal cardiocirculatory breakdown induced by severe experimental pancreatitis

OBJECTIVES

To investigate the impact of the long-acting bradykinin B2 receptor antagonist HOE 140 (Icatibant) on survival time in a model of severe porcine pancreatitis.

DESIGN

Randomized, controlled intervention trial.

SUBJECTS

Thirty domestic pigs of either gender anesthetized by intravenous application of piritramide, midazolam, and pancuronium and mechanically ventilated.

INTERVENTIONS

Pancreatitis was induced by an injection of sodium taurocholate (5%, 1 mL/kg body weight [BW]) and enterokinase (10 U/kg BW). Control animals (group 1, n = 10) underwent the spontaneous course of the disease. In two treatment groups, Icatibant was administered either in a low (100 nmol/kg BW; group 2, n = 10) or in a high dosage (5000 nmol/kg BW; group 3, n = 10).

MEASUREMENTS AND MAIN RESULTS

Mean survival time was significantly prolonged by Icatibant (controls, 6.6 hrs; group 2, 9.8 hrs; p = .022; group 3, 10.9 hrs; p = .007). Six hours postinduction, the decline of total peripheral resistance (52% of baseline) and cardiac index (92% of baseline) in controls was significantly improved by Icatibant, both in the low (16% and 44%; p < .05) and high (6% and 45%; p < .05) dosage. The concentrations of free, nonreceptor-bound kinin in plasma 6 hrs postinduction were significantly lower in controls than in groups 2 and 3 animals (111+/-50 vs. 208+/-40 and 237+/-52 fmol/mL, respectively). Six hours postinduction, the pretreatment with Icatibant was associated with significantly higher plasma concentrations of phospholipase A2 (controls, +1194%; group 2, +2000%; group 3, +2285% of baseline values) and interleukin-1 receptor antagonist (controls, 1900+/-800; group 2, 3100+/-800; group 3, 3600+/-800 pg/mL). In contrast, the increase of urinary trypsinogen activation peptides indicating local pancreatic damage (589+/-114 nmol/L in controls) was substantially attenuated by pretreatment with Icatibant (group 2, 467+/-102, NS; 352+/-91 nmol/L in group 3; p = .022 vs. controls). Systemic inflammatory reactions, however, as quantified by C-reactive protein and the extracellularly discharged neutrophil cytosolic inhibitor leukocyte neutral proteinase inhibitor were not influenced by the bradykinin B2-receptor antagonist.

CONCLUSIONS

Pretreatment with the bradykinin B2 receptor antagonist Icatibant resulted in prolonged survival time and in delayed impairment of major macrocirculatory and pulmonary variables. Icatibant resulted in elevated concentrations of free, circulating kinin. This was associated with increased concentrations of phospholipase A2 and interleukin-1 receptor antagonist, suggesting that circulating kinins strengthen the activation of some mediator cascades, the association of which with the kinin metabolism requires further experimental clarification. Other variables indicating a systemic inflammatory response (C-reactive protein, leukocyte neutral proteinase inhibitor) remained unaffected by Icatibant. Bradykinin antagonism distinctly ameliorated the local pancreatic damage, indicated by increased urinary concentrations of trypsinogen activation peptides. It is concluded that the kinin metabolism plays an important role in the pathophysiology of systemic complications after severe experimental pancreatitis.

[Diffuse pseudo-diverticulosis of the esophagus with severe cranial stricture, axial hiatal hernia and Barrett syndrome]

We report about a patient with esophageal intramural pseudodiverticulosis (EIP) who was referred to our department for further investigation of dysphagia. EIP is a rare, pathologically well defined disease, most frequently characterized by stricture-associated symptoms. The diagnosis of EIP is made by barium swallow and can be confirmed by endoscopy which shows typical diverticula-like changes of the esophageal wall.

Heparin-protamine reactions in pigs: role of oxygen-derived free radicals

We tested the hypothesis that pulmonary hypertension and thromboxane A2 release after heparin neutralization by protamine are mediated by oxygen free radicals. Forty-five pigs in five groups were studied during general anesthesia. Group I animals received 250 IU heparin followed by 100 mg protamine after 15 min. Group II and group III animals received dimethyl sulfoxide (DMSO) and dimethylthiourea (DMTU) 30 min before heparin infusion. Group IV animals were given superoxide dismutase (SOD) 5 min before protamine. Group V served for testing the pulmonary vascular reactivity in DMTU-treated animals to a thromboxane A2 analogue (U-46619). Generation of oxygen free radicals by polymorphonuclear granulocytes (PMNs) was measured in vitro by chemiluminescence. Severe pulmonary hypertension and thromboxane A2 release after protamine were not prevented by either DMSO or SOD. DMTU reduced pulmonary vasoconstriction to U-46619 and protamine but not to TxA2 release, indicating that DMTU had unspecific vascular effects in group III. Heparin-protamine released no oxygen free radicals from isolated PMNs. The results indicate that oxygen free radicals do not have a key role in mediating pulmonary vasoconstriction after protamine neutralization of heparin.

Effect of leukopenia on pulmonary hypertension after heparin-protamine in pigs

Heparin neutralization by protamine after cardiac surgery and cardiopulmonary bypass may be associated with complement activation, transient leukopenia, thromboxane A2 release, and severe pulmonary hypertension. The role of leukocytes in the heparin-protamine reaction was studied in leukopenic pigs (n = 9) and a control group (n = 8). Leukopenia was induced by pretreatment with cyclophosphamide (30 mg.kg-1.day-1) for 6-7 days. During general anesthesia and after catheterization, baseline recordings of hemodynamics were performed and blood samples were withdrawn. Heparin (250 IU/kg) was injected and measurements were repeated after 10 min. Protamine sulfate (100 mg) was then infused over 2 min and measurements were performed after 2, 5, and 15 min. Prostanoid concentrations were measured by radioimmunoassays. In additional in vitro experiments, the release of thromboxane B2 from washed platelets and leukocytes after heparin-protamine stimulation was measured. Pretreatment with cyclophosphamide reduced leukocyte counts by 95.5% and the number of neutrophils by greater than 99.9%. Protamine infusion increased mean pulmonary arterial pressure by 74 and 46% and pulmonary vascular resistance by 185 and 384% in control and leukopenic animals, respectively. Thromboxane B2 concentrations increased in both groups. Stimulation by heparin, protamine, or heparin and protamine in sequence did not induce any thromboxane A2 release from washed blood cells. It is concluded that leukocytes do not contribute to pulmonary hypertension after heparin-protamine.

Pulmonary hypertension after heparin-protamine: roles of left-sided infusion, histamine, and platelet-activating factor

Severe pulmonary hypertension after protamine neutralization of heparin is an infrequent but life-threatening event following cardiopulmonary bypass. The effect of left ventricular infusion of protamine on pulmonary hypertension as well as a possible role of platelet-activating factor (PAF) or histamine in the heparin-protamine reaction was investigated in 30 pigs in four different groups during general anesthesia. Group 1 animals received 250 IU/kg heparin, followed by 100 mg protamine intravenously after 15 min. In group 2 protamine was infused into the left ventricle. Group 3 animals received the histamine H1- and H2-antagonists clemastine and ranitidine 5 min before protamine infusion. In group 4 the PAF receptor blocker WEB 2086 was given 5 min before protamine. Platelet-activating factor was measured by a bioassay in serum samples of group 1 and group 4 animals. In all four groups protamine caused severe pulmonary hypertension, thromboxane A2 release, and a transient decrease in leukocyte counts. No PAF release was detected after protamine infusion. Neither left ventricular infusion of protamine nor histamine or PAF antagonists prevented or attenuated the reactions after protamine infusion. The authors conclude that left ventricular infusion of protamine provides no protection from pulmonary hypertension, and that histamine and PAF are not involved in the acute pulmonary vasoconstriction after protamine neutralization of heparin.