[Development of an immuno-neutral lipid emulsion for optimal postoperative management of intensive care patients]

Lipid emulsions prolong the rejection of allogeneic rat heart grafts in relation to their n-3 to n-6 fatty acid ratio. Because of the predominance of n-6 fatty acids soybean oil, which is clinically applied, shows an immunosuppressive effect. An n-3 to n-6 fatty acid ratio of 1 to 2 proved to be immunoneutral. Intravenous fat emulsions with an impaired n-3 to n-6 fatty acid ratio reduce cytokine release, infiltration and proliferation of immunocompetent cells. Lipids rich in n-3 fatty acids additionally reduce the release of the potent vasoconstrictor thromboxane A3 and increase the synthesis of leukotriene B5, which unlike leukotriene B4 does not activate polymorphonuclear neutrophils. Based on our results, the production of a clinically applicable lipid emulsion with a n-3 to n-6 fatty acid ratio of 1 to 2 can be recommended for the optimal parenteral nutrition of ICU patients with a markedly reduced immune system.

[Tumor dissemination after thoracoscopic resection of malignant pulmonary coin lesions]

We report about two cases of tumor dissemination after thoracoscopic wedge resection of malignant nodules of the lung. In the first case, a metastasis at the extraction site was observed after thoracoscopic resection of a metastasis of the lung. In the second case we diagnosed a pleural carcinosis after thoracoscopic wedge resection (and additional open lobectomy and lymph node dissection) of a pT2 N0 lung cancer. The patient died 12 months after the operation. The indication for thoracoscopic resection of malignant nodules of the lung should be restricted for peripheral tumors smaller than 2 centimetres.

[Is surgical therapy of bronchial carcinoma in advanced age justified?]

It was the aim of this study to evaluate the results of surgical therapy in patients with bronchial carcinoma aged younger and older than 70 years. From 1985 to 1995, 130 patients older than 70 years (group 1) and 572 patients younger than 70 years (group 2) underwent thoracotomy for bronchial carcinoma. The 5-year survival rate was significantly worse in the older group (25%) as compared to group 2 (39%). Postoperative complications such as atelectases, pulmonary insufficiency and cardiac problems were more frequent in group 1. Thirty-day mortality was almost double (9.2%) in the older group.

[Isolated echinococcosis of the lung]

This is a report of a 81 year old women with a cyst of echinococcus granulosus, that was almost completely taking over the lower lobe of the left lung. This case study shows on one hand the diagnosis of echinococcosis is a part of the differential diagnosis even for an elderly patient. On the other hand we were able to demonstrate, that elderly patients can benefit from the surgical treatment especially since medication has a lot of side effects and a fairly high rate of failures.

[Principles of primary and secondary wound management]

Wound management includes treatment of injuries, chronically open wounds of various origin, and incisions. Despite successful primary wound healing has good functional and cosmetic results, primarily closure should not be forced by raising wound tension or in wounds with increased risk of infection, respectively. Standards of trauma wound debridement according to location and type of wound are still in force. Anatomically incorrect type of surgical incisions may disturb wound healing. Sutures of the subcutaneous tissue are associated with increased risk of infection and should therefore be avoided. Alternatively, vacuum drainages may be used. Antibiotics should only be given exceptionally and if so, not as a local application. In case of chronically open wounds, underlying diseases should be treated, respectively. Moist wound healing using occlusive dressings has been established successfully in local management of chronic wounds.

Immunoregulation by parenteral lipids: impact of the n-3 to n-6 fatty acid ratio

BACKGROUND

The immune system is reported to be influenced by polyunsaturated fatty acids. Therefore, immunoregulation caused by intravenous fat emulsions with different n-3 to n-6 fatty acid ratios was studied in an in vivo model.

METHODS

Experimental rat heart allotransplantation served as a defined immunologic challenge. Twenty percent emulsions of safflower oil (n-3 to n-6 = 1:370), fish oil (n-3 to n-6 = 7.6:1), and soybean oil (n-3 to n-6 = 1:6.5), and a 1:1 mixture of safflower oil and fish oil (n-3 to n-6 = 1:2.1) were continuously infused (9 g of fat per kg of body weight per day) after transplantation until complete rejection. The prolongation of graft survival, an accepted parameter of immunosuppression, was assessed. Beyond that, cytokine release by mitogen-stimulated peripheral-blood mononuclear cells (PBMCs) from animals exsanguinated on day 4 after transplantation was evaluated.

RESULTS

The mean rejection time was 7.8 days in the sham-infused saline control group and 6.7 days in the safflower- and fish-oil-mixture group (oil control group). Continuous infusion of soybean oil prolonged the graft survival time to 10.4 days, fish oil to 12.3 days, and safflower oil to 13.3 days. PBMC alpha-tumor necrosis factor release was significantly reduced in the fish-oil group (51.9 +/- 13.0 pg/10(6) PBMCs vs 70.8 +/- 10.9 pg/10(6) PBMCs [controls], p < .004). Interleukin-6 release was diminished in both the fish-oil group (22.2 +/- 13.6 pg/10(6) PBMCs vs 40.7 +/- 8.3 pg/10(6) PBMCs [controls], p < .002) and the safflower-oil group (28.4 +/- 6.9 pg/10(6) PBMCs, p < .002).

CONCLUSIONS

The n-3 to n-6 fatty acid ratio determined the immunoregulatory potential of intravenous fat emulsions in vivo. Both n-3 and n-6 fatty acids were immunosuppressive when applied as the main polyunsaturated fatty acid sources. PBMC cytokine release was significantly reduced in these groups. The more balanced the n-3 to n-6 ratios, the less immunosuppressive the fat emulsion. There was no immunosuppressive effect at an n-3 to n-6 ratio of 1:2.1.

[Follow-up of heterotopic autotransplantation of splenic tissue after traumatic splenic rupture in childhood]

Children and adolescents, who received an autologous reimplant of the spleen because of traumatic injury between 1979 and 1986 were matched to a cohort of patients, splenectomized because of traumatic injury of the spleen as well and to a control group of healthy age matched individuals. In addition to a physical check-up, markers of humoral and cellular immunity (e.g. lymphocyte subpopulations and phagocytosis of pneumococcy) as well as the coagulatory and fibrinolytic system were examined. All parameters tested, were found to between results from splenectomized and healthy individuals. Our studies stress the fundamental ability of autologous spleen transplants to take over part of the splenic function on the basis of a largerly histomorphologic restitution. Thus autologous reimplantation of the spleen in children and adolescents is an excellent choice as compared to otherwise necessary splenectomy, if preservation of the organ is impossible.

Closure of acute bronchial stump insufficiency with a musculus latissimus dorsi flap

We describe a successful closure of an acute bronchial stump insufficiency after pneumonectomy by intrathoracic transposition of the pedunculated latissimus dorsi muscle: A 56-year-old patient with a necrotizing bronchial carcinoma developed a stump insufficiency after right pneumonectomy. Repeated resection and renewed closure of the completely dehiscent stump was not possible, as the stem bronchus had been separated close to the tracheal bifurcation in the preceding operation. Therefore we transposed the pedunculated musculus latissimus dorsi into the thoracic cavity. The closure of the bronchial stump insufficiency was achieved by fixation of the muscle on to the open stump and surrounding tissue of the mediastinal pleura with fibrin glue. The postoperative course was without complications, no further insufficiency or empyema developed.

[Lung resections for pulmonary infections in intensive care patients]

Pneumonia occurs in about 60% of ventilated patients with a lethality of approximately 40%. Since 1980 we performed a thoracotomy in 16 patients of an intensive care unit suffering from a lung infection (mean age 34 years). In all patients an adequate antibiotic therapy was unsuccessful. By means of the computed tomography we could ascertain a lung infection limited to one part of the lung, mostly combined by an abscess. We performed 14 lobectomies and one atypical wedge resection and segment resection each. Postoperatively 8 patients died: Three of them because of a persisting septic shock and five because of their multiple injuries. Lung resection is a good treatment in case of a lung infection with septic complications.

[Pancreatic pseudocysts after blunt abdominal trauma]

Pancreatic pseudocyst caused by trauma is rare. Only in 5 of 98 patients on whom we operated between 1977 and 1991 for pancreatic pseudocyst were we able to detect previous blunt abdominal trauma. In a 4-year-old girl just a slight abdominal trauma had given rise to a cyst, while in 2 other patients (aged 9 and 26 years) pancreatitis occurred after trauma that was treated medically. Two patients had to undergo laparotomy immediately after suffering serious abdominal blunt injury. Diagnosis was established sonographically, except in one case, in which a large cyst was determined to originate from the pancreas, but only intraoperatively. The time-span between trauma and treatment of the pseudocyst ranged from 3 months to 1 year. Thus, continuous percutaneous suction, which is basically considered a promising therapy for cysts in their early stages of development, was obviously not feasible in our patients. We therefore carried out cysto-jejunostomy with formation of a Roux-en-Y jejunum loop. At follow up 1-10 years after operation, all patients were asymptomatic and no cyst formation could be detected sonographically.

[Surgical treatment and regional chemotherapy in melanoma of the extremities]

Since 1979, our treatment protocol for extremity melanoma includes wide local excision, regional lymph node dissection and hyperthermic limb perfusion. We report on the results of a follow-up of the patients treated in the first decade (n = 451). According to the UICC Classification of 1987, 4% of our patients were in stage I, 36% in stage II, 50% in stage III and 9% in stage IV. The respective 5-year survival rates were 93%, 91%, 49%, and 20%. We conclude that regional chemotherapy appears to be beneficial even for stage II patients, as 5-year survival rates of more than 90% can be achieved.

Fluorescence studies on lung tumors

Illumination of unstained 9 microns cryosections of lung tissue with 365 nm results in visible fluorescence light with a maximum intensity at about 460 nm. These fluorescence tomographical studies can be used for detecting carcinoma of the lung. The fluorescence pattern obtained can be matched nicely with histological findings. Since it takes less than 5 min for getting the fluorescence images, the fluorescence tomographical technique might be used in addition to established methods for determining the histology of a biopsy sample.

[Therapy concepts in colorectal liver metastases. What is proven, what is open to discussion?]

Isolated liver metastases of colorectal carcinomas principally can be treated by surgical intervention or cytostatic chemotherapy. Unquestionable indications for resection therapy are either solitary metastases or metastases limited to one liver lobe, since resection provides the best long-time results. In multilocular metastases or non-resectable liver metastases systemic monochemotherapy with 5-Fluorouracil (5-FU) presents respondance rates of about 20 percent with remissions lasting 3 to 6 months. Thereby a prolongation of life could not be proven statistically. Initial studies with a combination therapy of 5-FU/Folinic acid promise higher remission rates due to an increased cytotoxicity caused by a synergistic effect. Because of the mainly arterial supply of liver metastases the different procedures of regional chemotherapy-intraarterial infusion, isolated liver perfusion, chemoembolisation-provide the tumor with high drug concentrations without provoking systemic side effects. This advantage of a regional application of cytostatic drugs is reduced by the high percentage (2 to 87 percent) of extrahepatic tumor manifestations occurring after an average of 6 to 8 months.

Concentration and time dependence of the toxicity of fluorinated pyrimidines to HT 29 colorectal carcinoma cells

To determine the optimal concentration time factors for the fluoropyrimidines 5-fluorouracil (FU), 5-fluorouridine (FUR), and 5-fluoro-2'-deoxyuridine (FUdR) in regional chemotherapy, we tested these drugs against the colorectal carcinoma cell line HT 29 at various dosages and exposure times. The measure of cytotoxicity used was the degree of inhibition of colony formation in soft agar after drug treatment compared with untreated control cells. Colonies were visible after 6 days of growth in soft agar, so the initial evaluation of toxicity was done at this time. Additional colonies were found 10 and 16 days after the first evaluation, so the dishes containing the treated cells were also evaluated for this delayed growth phenomenon ("regrowth"), which we considered to be due to a cell growth inhibition effect of the drugs rather than a cytocidal effect. Exposure times of the cells to the drugs ranged from 5 min to 24 h and the doses, between 0.01 and 1000 micrograms/ml. The toxicity of FUdR was concentration-dependent, but its time dependence ceased after a relatively short exposure time. There was a cell population that was not susceptible to FUdR regardless of dose and exposure time; consequently, FUdR treatment was always accompanied by substantial regrowth of colonies. With FU and FUR, conditions could be achieved that resulted in complete cell death (no regrowth), but high concentrations and long exposure times were required with FU. With FUR, on the other hand, both cytostasis and cytotoxicity could be achieved with substantially lower doses and shorter exposure times than with FU. These results indicate that FUR has the potential to be an effective drug in chemotherapy protocols not involving systemic administration.

[Experimental and clinical results with the ileum pouch as a continence-preserving replacement bladder]

Clinical use of the ileum-pouch for bladder reconstruction without stoma and direct anastomosis to the urethra is mandatorily based upon the three following conditions: sufficient capacity, low pressure values and protection of reflux in the neobladder. In an experimental study, we constructed a U-pouch with anastomosis to the urethra and implantation of both ureters into a cranial ileum horn. Already six weeks postoperatively an optimal capacity and real low pressure conditions of the neobladder have been achieved. Without any ileoileal invagination as antirefluxive procedure simple ureter-nippling provides a highly efficient protection against renal reflux in the so constructed neobladder. Our first clinical results do confirm our experimental data, demonstrating no reflux and almost total continence.

[Cold struma nodule--enucleation or resection]

During 1969-1984 2,408 patients underwent thyroid surgery at the Dept. of General Surgery, Giessen University. In 72.5% cold nodules have been diagnosed. However, a cold nodule has been in less than 50% of all cases with cold nodules the causal indication for operation. Inspecting closely the whole thyroid gland, the operating surgeon removes the nodule with a segmental resection if there are no further regressions or suspicion of malignancy. This technique facilitates the histological detection of a possible highly differentiated carcinoma because of its invasion into the capsule.

Prospective correlative chemosensitivity testing in high-dose intraarterial chemotherapy for liver metastases

Clinical response of liver metastases treated by high-dose intraarterial chemotherapy (HDIAC) delivered via the hepatic artery was predicted by a modification of the human tumor colony-forming assay (HTCFA) originally described by Hamburger and Salmon [Science (Wash. DC), 197:461-463, 1977. In a first set of experiments, the immediate clinical response to HDIAC was determined in 12 patients with colorectal liver metastases. Biopsies were taken immediately before and after HDIAC, and cells were plated in the HTCFA. Three patients received intraoperative 4-epidoxorubicin and another 9 received mitomycin C by 15-min intraarterial infusions. Sensitivity in the HTCFA was defined as 50% inhibition of colony formation in tumors exposed to the chemotherapeutic agent, compared to the untreated controls. Clinical response was accurately predicted by the HTCFA in 11 of 12 cases. Eight patients had a regression of disease following HDIAC treatment with mitomycin C, as evidenced by either greater than 50% reduction in carcinoembryonic antigen serum level (7 patients) or regression of tumor by computed tomography scan (1 patient). Three patients had no evidence of clinical response to epidoxorubicin, and their tumors were resistant to epidoxorubicin in the HTCFA. One tumor was sensitive to mitomycin C in the HTCFA, but serum carcinoembryonic antigen in the patient continued to increase following HDIAC. The HTCFA was also performed on untreated biopsies following incubation in vitro with the drug used for HDIAC. Results correlated with clinical response in all 12 cases. In a second set of experiments, the HTCFA was used to predict the long-term clinical response to HDIAC of 30 patients with liver metastases. One patient had breast cancer metastases, one patient had carcinoid liver metastases, 4 had liver metastases of malignant melanoma, and 24 patients had colorectal liver metastases. All 21 of the patients whose tumors were sensitive in vitro had clinical response, while 6 of 9 patients predicted by the HTCFA to be resistant had no clinical response. Our results demonstrate a high correlation between the HTCFA and clinical response.