Keratinocyte growth factor prevents intra-alveolar oedema in experimental lung isografts

Primary graft dysfunction, characterised by intra-alveolar oedema, is a major obstacle in pulmonary transplantation. The present study evaluates the potential of keratinocyte growth factor (palmiferin; DeltaN23-KGF) for the prevention of oedema in lung transplants. Intratracheal instillation of 5 mg x kg(-1) DeltaN23-KGF was performed in Lewis rats on days 3 and 2 before explantation. Control animals obtained an equivalent volume of vehicle. Left lungs were isogeneically transplanted and the graft recipients were sacrificed 1 day later for stereological analysis of intra-alveolar oedema and bronchoalveolar lavage. The total protein and phospholipid content, as well as surfactant proteins, were measured. Surfactant activity was analysed with a pulsating bubble surfactometer. In grafts from control treated donors, the fraction of intra-alveolar oedema amounted to 3.4+/-1.1% of the total parenchymal volume. Treatment of donor lungs with DeltaN23-KGF reduced oedema to a fraction of 1.6+/-0.8%. In the lavage fluid of pulmonary grafts from DeltaN23-KGF-treated donors, the total protein content was decreased compared with vehicle-treated lung transplants, whereas phospholipids did not differ. The protein fraction contained increased amounts of surfactant protein-C after DeltaN23-KGF treatment and surfactant function was improved. Treatment of donor lungs with palifermin protects against intra-alveolar oedema formation upon transplantation. This effect appears to be mediated by an improved surfactant homeostasis.

Lung Transplantation in the Fischer 344→Wistar Kyoto Rat Strain Combination is Not Suitable to Study Bronchiolitis Obliterans

BACKGROUND

To elucidate the pathogenesis of bronchiolitis obliterans (BO) a reliable animal model is needed. According to the literature, lung transplantation from Fischer 344 (F344) to Wistar Kyoto (WKY) rats is the only model that reliably results in BO without a further stimulus.

METHODS

We performed orthotopic left lung transplantation in F344 to WKY rats and in both isogeneic rat strain combinations. Suture and cuff techniques for anastomosis were compared. The time course of rejection and the morphology of the bronchial anastomoses were documented by repeated flat-panel volumetric computed tomography (fpVCT) in the living animal. Graft histopathology was analyzed 3 months post-transplant.

RESULTS

According to the graft outcome, as revealed by fpVCT, grafts were sub-divided into two groups: In Group 1, infiltrates due to acute rejection occurred early after transplantation and resolved thereafter. Graft histopathology showed minor changes but no BO. In Group 2, acute rejection caused total atelectasis that never resolved. After 3 months, grafts were shrunken and exhibited tissue remodeling with some similarities to BO. No correlation between graft outcome and anastomotic technique was apparent.

CONCLUSIONS

Modeling lung transplantation using the F344-to-WKY combination is without clinical relevance because BO does not develop in grafts with life-sustaining function. Consecutive fpVCT is useful to monitor pathologic changes in rat pulmonary grafts.

Immunoglobulin Induction Therapy in Renal Transplant Recipients: Effects on Immunoglobulin and Regulatory Antibody Levels

We have previously shown that high pretransplant regulatory autoantibodies are associated with better kidney graft outcome. To analyze the effect of intravenous immunoglobulin (IVIG) induction therapy on these regulatory antibodies, we performed a prospective randomized study in 50 renal transplant recipients who were randomly assigned to receive 7 x 10 g IVIG or 7 x 10 g IV albumin infusions. Basic immunosuppressive therapy consisted of tacrolimus/azathioprine (n = 24) and tacrolimus/mycophenolate mofetil (n = 26), respectively. ELISA was used to assess IgG-/IgA-anti-Fab, -anti-F(ab)2 and -anti-hinge regulatory antibodies. IVIG induction therapy resulted in upregulation of serum IgG and IgA levels within the first 20 days posttransplant (P = .001, IgG; P = .04, IgA), so that a significant IgG deficiency was found only in non-IVIG patients (day 10: IgG <6 g/L: 7/25 (28%) non-IVIG versus 0/25 IVIG patients; P = .005). As the IVIG charges contained all of the regulatory antibodies tested, intravenous administration of these antibodies explain the elevated IgG- and IgA-anti-F(ab)2 antibody levels found in IVIG compared to non-IVIG patients on day 10 (P = .005 and P = .04, respectively). Our data indicated that IVIG induction prevented severe IgG deficiency in the early posttransplant period but had no impact on severe infectious complications. IVIG induction enhanced immunoregulatory antibody levels early posttransplant, which might provide graft protective effects.

Post-transplant sCD30 and neopterin as predictors of chronic allograft nephropathy: impact of different immunosuppressive regimens

Immunological monitoring for chronic allograft nephropathy (CAN) is of great potential interest. We assessed serum soluble CD30 (sCD30) together with in vitro Th2-type responses (IL-4, IL-10, CD4 helper activity) and neopterin in a prospective study of 84 renal transplant recipients with 2-year follow-up. Patients were randomized to CsA/Aza, CsA/MMF and Tacr/Aza, respectively, to analyze the effect of immunosuppression on posttransplant sCD30 and neopterin. ATG induction and acute rejections did not alter sCD30 levels whereas CMV disease was associated with transient upregulation of sCD30 (p = 0.003 at 4 months) and sustained upregulation of neopterin (corrected for graft function (Neo/CR) p = 0.005 at 2 years). Tacr versus CsA treatment proved to be an independent variable associated with downregulation of 1-year sCD30, which was positively related to Neo/CR (p = 0.007 and 0.01, respectively; logistic regression). Importantly, increased 1-year sCD30 and Neo/CR were associated with decreased glomerular filtration rate at 2 years (p = 0.02 and p < 0.0005, respectively) and evidence of CAN (p < 0.0005). High 1-year sCD30 could not be attributed to enhanced Th2-type responses and was not associated with HLA antibody formation. Our data suggest that elevated sCD30 and neopterin predict graft deterioration by CAN. Tacr effectively downregulates these responses and might be of advantage in patients with elevated sCD30 or neopterin.

sCD30 and Neopterin as Risk Factors of Chronic Renal Transplant Rejection: Impact of Cyclosporine A, Tacrolimus, and Mycophenolate Mofetil

High pretransplantation sCD30 levels have been shown to be associated with lower 5-year kidney graft survival in mainly Cyclosporine A (CsA)-treated recipients (Collaborative Transplant Study database). To analyze the effect of different immunosupressive regimens (CsA/Azathioprine [Aza], CsA/Mycophenolate Mofetil [MMF], Tacrolimus [Tacr]/Aza) on sCD30, we assessed serum sCD30 and neopterin together with in vitro cytokine responses in a prospective randomized study of 84 renal transplant recipients before, 4 months, and 1 year after transplantation. Panel-reactive antibody (PRA) formation, HLA matching, ATG induction therapy, and acute rejections had no impact on sCD30 levels, whereas cytomegalovirus (CMV) infections induced an up-regulation of sCD30 4 months posttransplantation (P = .003). Whereas MMF showed no effect on sCD30 compared with Aza therapy, we found a significant impact of Tacr versus CsA treatment (1-year sCD30 > or = 60 U/mL: 14/42 (33%), CsA; 1/38 (3%), Tacr; P < .0005). Chronic rejection 2 years posttransplantation was associated with elevated 1-year sCD30 (P = .001) and neopterin levels (P = .006). Our data indicate that the Th2 activation marker sCD30 provides a risk factor for chronic rejection independent of classical immunological risk factors and may be down-regulated using Tacr treatment.

Prospective pilot study of neoadjuvant chemotherapy with 5-fluorouracil, folinic acid and oxaliplatin in resectable liver metastases of colorectal cancer. Analysis of 42 neoadjuvant chemotherapies

PURPOSE

Since there are currently no data available from a prospective trial, the primary objective of this prospective study was to investigate whether the rate of R0-liver resections without morbidity would be at least 50 % in patients with neoadjuvant chemotherapy for colorectal liver metastases.

PATIENTS AND METHODS

42 patients were treated with a biweekly FOLFOX regimen. Chemotherapy consisted of a 2-hour infusion of folinic acid (FOL) 500 mg/m2, followed by a 24-hour infusion of 5- fluorouracil (F) 2000 mg/m2 daily for two days. Oxaliplatin (OX) 85 mg/m 2 was given simultaneously with FOL. Treatment allocation was randomized with either 3 or 6 cycles for the final 30 patients. A liver resection was performed 2 to 5 weeks after the final infusion.

RESULTS

An objective response was observed in 20 of 42 patients (response rate was 27 % higher after 6 cycles). Liver resection (R0) could be performed in 34 patients. Postoperative complications were reported in 14 patients (13 occurring within 30 days after resection) and severe complications in 5 cases (including two deaths after extended resection). Liver failure and persistent biliary fistula were the most frequently documented complications. There was no relevant difference in safety criteria between 3 and 6 applications.

CONCLUSION

The use of neoadjuvant chemotherapy in resectable liver metastases induced significant remissions without increasing morbidity. The rate of severe complications and cases of no R0-resection in this study was 31 % and was with that significantly lower than 50 % (95 % CI 17.6 %-47.1 %). The risk to the patient is therefore acceptable when undergoing neoadjuvant treatment in a prospective intergroup trial.

[Efficacy of elective lymph node dissection in malignant melanoma of the extremities and trunk. An analysis in view of the sentinel lymph node biopsy]

Elective lymph node dissection (ELND) is increasingly displaced by the Sentinel-lymph node biopsy. In this view we analyzed the efficacy of ELND in the treatment of malignant melanoma of the extremities and the trunc. Between 1979 and 1998 we performed a lymph node dissection in 834 patients (336 male, 498 female; average age 52 years). The analysis of the prospectively collected data was based on those 650 patients in whom an ELND was performed for UICC-stage I (T2) to stage III melanoma. The 5-year survival rate was 75% for all 650 patients. It was 87% for patients suffering from stage I-disease (T2-n = 65), 86% for those with stage II-disease (n = 354) and 47% in case of stage III-disease (n = 231) respectively. In 7 of the 73 patients undergoing ELND for a T2-tumor, in 56 of the 424 patients suffering from T3-tumor and in 38 of the 153 patients with a T4-tumor clinically obvious lymph node metastases had been detected by ELND. Discerning our results, we could demonstrate that a few of our patients profited from ELND, namely the patients in those clinically obvious metastases could be detected and survival could be achieved, i.e. 29 of all 650 electively dissected patients (2 of 7 T2N1-patients, 18 of 56 T3N1-patients and 9 of 38 T4N1-patients). We regard this benefit as an argument not to abandon the histological evaluation of the regional lymph nodes. However, because of the limited efficacy of elective lymphadenectomy, ELND should be displaced by the less invasive Sentinel-lymph node biopsy.

Switch from cyclosporine A to tacrolimus in renal transplant recipients: impact on Th1, Th2, and monokine responses

We showed previously that pretransplant CD4 helper defects and low in-vitro IL-10 responses predict a low risk of acute kidney graft rejection. To compare the effect of tacrolimus (Tacr) and cyclosporine A (CsA) on the humoral immune response we assessed T helper function, B cell/monocyte responses and in-vitro cytokine responses (TNF-alpha, GM-CSF, IL-1 beta, IL-2, IL-4, IL-6, IL-10) in 20 renal transplant recipients before and 3 months after they were switched from CsA to Tacr because of hyperlipoproteinemia, hirsutism, or gum hyperplasia. T helper function was assessed using a PWM-driven allogeneic coculture system of patient T cells together with control B cells. B cell/monocyte responses were determined using a PWM-stimulated allogeneic coculture system, SAC I-stimulated B-cell cultures and LPS-stimulated monocyte cultures. Immunoglobulin-secreting cell (ISC) responses were assessed in a reverse hemolytic plaque assay, and ELISA were used to determine cytokine secretion. Treatment with Tacr resulted in a decreased expression of costimulatory ligands and adhesion molecules (T cells: CD40L, p < 0.05; CD28 and CD54, p < or = 0.01; B cells: CD25, p = 0.05; CD40, p < 0.001; monocytes: CD40, p < 0.05), which coincided with decreased PHA-stimulated T cell IL-2 responses (398 +/- 153 versus 43 +/- 15 pg/ml, p < 0.05), impaired CD4 helper activity (117% +/- 22% versus 73% +/- 19%, p < 0.05) and increased CD4 suppressor activity (-120% +/- 28% versus -18% +/- 27%, p = 0.02). We observed enhanced CD4 IL-10 responses (p < 0.01) and LPS-stimulated monocyte responses (TNF-alpha, IL-1 beta, and IL-6, p < 0.005; IL-10, p < 0.05), indicating an increased humoral immune responsiveness under treatment with tacrolimus. Our data show that switching of immunosuppressive therapy from CsA to tacrolimus results in suppression of costimulatory ligands, adhesion molecules, Th1 responses and CD4 helper activity. However, enhanced humoral immune responses, Th2 and monokine responses, might have a negative impact on long-term graft function.

Effects of dopexamine and volume loading on hemodynamics and oxygenation parameters in patients undergoing pulmonary resection

BACKGROUND

Pulmonary resection may result in a reduction in arterial oxygen pressure as well as in cardiac output. Since cardiac index, oxygen delivery, and oxygen consumption are considered as important determinants of patients' outcome, we evaluated the effects of dopexamine and volume loading on cardiopulmonary variables in patients undergoing pulmonary resection.

METHODS

Forty adult patients undergoing pulmonary resection for lung or bronchial tumors were included in an open placebo-controlled study. The patients were selected according to a randomized sequence to group A (n=20) or group B (n=20). Dopexamine (2 microg x kg(-1) x min(-1)) was started when steady state conditions were achieved after induction of anesthesia in group A. Saline 0.9% was given as control (group B). Hemodynamic monitoring was performed using a pulmonary artery catheter.

RESULTS

Dopexamine increased heart rate, cardiac output and oxygen delivery compared with control without increasing oxygen consumption during anesthesia and surgery. Furthermore, dopexamine was found not to alter the course of PaO2/FiO2 values.

CONCLUSION

In patients undergoing pulmonary resection, dopexamine can be used perioperatively to increase cardiac index without decreasing the PaO2/FiO2 ratio.

Synthesis of arachidonic acid-derived lipoxygenase and cytochrome P450 products in the intact human lung vasculature

Lipoxygenase (LO) and cytochrome P450 monooxygenase products of arachidonic acid (AA) have been implicated in a large number of vasoregulatory processes. In intact, blood-free, perfused and ventilated human lungs (n = 8), isolated during surgery for bronchial carcinoma, we analyzed leukotrienes (LTs), hydroxyeicosatetraenoic acids (HETEs), and epoxyeicosatrienoic acids (EETs) by sequential sampling of the recirculating buffer fluid. For the analysis we used multistep, solid-phase extraction, isocratic reversed-phase high-performance liquid chromatography, with elution of all metabolites within one run and photodiode array detection to obtain full UV spectra of eluting compounds. We detected no LT release in a 15-min baseline period, but the admixture of the calcium ionophore A23187 with the buffer fluid provoked the rapid appearance of all LTs. Some baseline release of 15-HETE was observed, and in response to A23187, maximum buffer concentrations were noted for 5-HETE, with 8-HETE, 9-HETE, 11-HETE, and 12-HETE being detected at lower levels. Marked baseline liberation of 11,12-EET and 8,9-EET was observed. In response to A23187, high oxirane buffer concentrations were registered, which far surpassed those of LTs and HETEs. The eicosanoid release was paralleled by a limited pulmonary artery pressor response and progressive vascular leakage. We conclude that ex-vivo-perfused human lungs release EETs > LTs > HETEs into the vascular compartment in response to inflammatory challenge. The marked oxirane synthesis in the lung vasculature may have major impact on lung vasoregulation when considering the possible function of these AA epoxides as endothelium-derived hyperpolarizing factors.

[Actinomycosis of the colon as a rare differential diagnosis of colonic carcinoma]

INTRODUCTION

Abdominal actinomycosis is an uncommon disease. Nevertheless it should be considered in case of unclear tumor-like abdominal masses.

METHODS

We report a case of a 49-year-old patient with an intrauterine device. The patient was submitted with a solid and painful tumor in the upper abdomen. After sonography, computerized tomography, gastroduodenoscopy and colonoscopy the preoperative presumptive diagnosis was a carcinoma of the transvers colon invading the abdominal wall. Pathological examination after a right hemicolectomy surprisingly revealed an actinomycosis.

RESULTS

Based on this case diagnostic tools and therapeutic options of actinomycosis of the colon are discussed.

CONCLUSIONS

This case illustrates the importance to consider the possibility of actinomycosis when finding an unclear abdominal mass. After a surgical excision an abdominal actinomycosis requires antibiotic therapy.

[Value of locoregional chemotherapy in liver metastases of breast carcinoma]

Between 1985 and 1997, we performed a locoregional chemotherapy in 59 patients suffering from non-resectable liver metastases of breast cancer. 36 of them only had liver metastases, in 23 patients liver metastases were combined with extrahepatic tumor spread. Furthermore, in 7 patients locoregional chemotherapy was used as a adjuvant regimen after metastasectomy. The average age of our patients was 52 (32-81) years. In most of our patients, a cytostatic scheme of mitoxantron, 5-fluorouracil and doxorubicin or a scheme of vincristin, mitomycin and mitoxantron was administered. The median survival of all patients was 11 months, in the patients with no additional extrahepatic tumor spread it was 16, in the patients with extrahepatic metastases 3 months, respectively.

Retracted: Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

BACKGROUND

Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties.

METHODS

The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 micrograms.kg-1.min-1 of dopexamine (n = 15) or placebo (n = 15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day.

RESULTS

Cardiac index (CI) increased significantly in the dopexamine group (from 2.61 +/- 0.41 to 4.57 +/- 0.78 l.min-1.m-2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO2I) and oxygen consumption index (VO2I) were also significantly increased in the dopexamine group (DO2I: from 416 +/- 91 to 717 +/- 110 ml/m2.m2; VO2I: from 98 +/- 25 to 157 +/- 22 ml/m2.m2), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37 +/- 1.1 to 35.9 +/- 12.1 pg/ml; ET-1: from 2.88 +/- 0.91 to 6.91 +/- 1.20 pg/ml).

CONCLUSION

Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.

Simultaneous analysis of 4- and 5-series lipoxygenase and cytochrome P450 products from different biological sources by reversed-phase high-performance liquid chromatographic technique

Quantification of lipoxygenase and cytochrome P450 products of both arachidonic acid (AA) and eicosapentaenoic acid (EPA) is of broad interest due to the multiple biological activities of these compounds. We developed a method combining (i) solid-phase extraction, (ii) isocratic reversed-phase high-performance liquid chromatographic separation, and (iii) online photodiode array detection with spectrum analysis for identification and measurement of all main 4- and 5-series eicosanoids (leukotrienes, hydroxyeicosatetraenoic acids/hydroxyeicosapentaenoic acids, epoxyeicosatrienoic acids) within one run. With these procedures, standard mixtures of AA- and EPA-derived lipid mediators were recovered from different biological liquids, like lung perfusate, human bronchoalveolar lavage fluid, and cell supernatant with linear characteristics for each compound. Recoveries of the different lipid mediators exceeded 80% showing excellent reproducibility. Application of the method to isolated, perfused, and ventilated human lungs challenged with the calcium ionophore A23187 and to human neutrophils stimulated in the presence of arachidonic acid and eicosapentaenoic acid with N-formyl-methionyl-leucyl-phenylalanine demonstrated the generation of a large array of lipoxygenase and cytochrome P450 products. Thus, convenient quantification of 4- and 5-series eicosanoids in fluids of biological interest is achieved by a technique comprising solid-phase extraction, isocratic reversed-phase high-performance liquid chromatography, and photodiode array-based online spectrum analysis of eluting compounds.

[Use of preoperative infusion cholangiography before laparoscopic cholecystectomy]

In the present study, we intend to evaluate whether intravenous cholangiography, performed on a routine basis in the preoperative period, in addition ultrasonography, history or elevations of serum bilirubin and alkaline phosphatase, provides any supplementary information in detecting patients with asymptomatic calculi in the common bile duct before laparoscopic cholecystectomy is carried out. Therefore, 513 patients were included in a retrospective analysis. From our data, we conclude that preoperative intravenous cholangiography cannot be recommended, when costs and risks and a potential benefit for the patient are considered.

[The effects of dopexamine. Transpulmonary shunt volume in thoracic surgical procedures with one-lung respiration]

OBJECTIVE

To study the influence of dopexamine on pulmonary shunt and hypoxic pulmonary vasoconstriction during major thoracic surgery with one-lung ventilation (OLV).

DESIGN

Prospective, randomised, placebo-controlled study.

SETTING

University hospital.

PATIENTS

Twenty adult patients undergoing elective pulmonary resection. ANAESTHESIA: General anaesthesia was performed using propofol, fentanyl, N2O and vecuronium. Volume-controlled ventilation was performed to maintain normocapnia over the whole investigation period. During OLV, the tidal volume was reduced and the respiratory rate was increased to avoid a peak airway pressure exceeding 40 cm H2O. Furthermore the FiO2 was increased to 1.0 and the external PEEP was removed during OLV.

INTERVENTIONS

The patients received either dopexamine at 2 micrograms/kg/min (group A, n = 10) or 0.9% saline as control (group B, n = 10) after assessing the baseline values.

MEASUREMENT AND RESULTS

The following cardiorespiratory variables were recorded: Heart rate, mean arterial pressure and mean pulmonary arterial pressure. Cardiac output was measured by thermodilution using a continuous cardiac output thermodilution catheter. Arterial and mixed venous blood gas analysis were measured from simultaneously drawn samples. Cardiac index (CI), systemic vascular resistance index, pulmonary vascular resistance index, oxygen delivery index (DO2I), oxygen consumption index and the venous admixture were calculated using standard formula. Furthermore, pressure-flow-curves were constructed to analyse flow independent changes in the pulmonary vascular resistance. Data were recorded at the following times: After induction of anaesthesia in stable haemodynamics during two-lung ventilation (baseline values, T0), intraoperatively during one-lung ventilation (T1) and postoperatively after re-establishing two-lung ventilation (T2). Patients characteristics, data from the preoperative lung function testing and surgical procedures did not differ significantly between the groups. CI increased in the dopexamine group from 2.5 +/- 1.2 1.min-1.m-2 (T0) to 3.6 +/- 0.9 l.min-1.m-2 (T1) and 4.0 +/- 1.3 l.min-1.m-2 (T2). The course of the intrapulmonary right-to-left shunting did not differ between the groups. In the dopexamine-treated group the DO2I increased from 430 +/- 143 ml.min.m-2 (T0) to 652 +/- 255 ml.min.m-2 (T1) and 653 +/- 207 ml.min.m-2 (T2). Regarding the pressure-flow-curves there was no difference during OLV between the two groups indicating no major blocking effect of dopexamine on hypoxic pulmonary vasoconstriction.

CONCLUSION

It is concluded that dopexamine can be used to improve haemodynamics and oxygen delivery during thoracic surgery without increasing venous admixture during one-lung ventilation.

[Primitive neuroectodermal tumor]

The primitive neuroectodermal tumor is a rare soft tissue neoplasm occurring in children and young adults. It derives from a carcinogeneic alteration of pluripotent neural crest cells, caused by a balanced reciprocal translocation t(11;22) (q24;q12). Treatment of this undifferentiated, extremely malignant small cell tumor is carried out in compliance with the soft tissue trail (CWS) from the German Society of Pediatric Oncology. Biopsy-proven diagnosis is followed by primary chemotherapy, which in 95% of cases leads to remission, allowing excision of the remainder of the tumor without mutilation and avoidance of intraoperative tumor cell dissemination. After excision, irradiation of the tumor site and two further sequences of chemotherapy are performed. If PNETs of the paravertebral region cause symptoms of paralysis and immediate surgery is required, postoperative chemotherapy, a second-look operation and irradiation are mandatory. Between 1986 and 1994, in cooperation with our pediatric and radiotherapy colleagues, we treated ten patients. In four patients (median age, 14 years) the PNET originated from the chest wall, in six patients from the paravertebral and retroperitoneal region. Five patients died after 20 months on average, while the remaining five patients are in full remission after 31, 46, 50, 51 and 91 months, respectively.

Cardiorespiratory changes in patients undergoing pulmonary resection using different anesthetic management techniques

OBJECTIVE

Pulmonary resection may be associated with considerable alterations of the cardiorespiratory system. The ideal anesthetic regimen for these patients is not yet definitely determined.

DESIGN

Prospective, randomized study.

SETTING

Single-institutional, clinical investigation in a thoracic anesthesia department of a university hospital.

PARTICIPANTS

Fifty consecutive patients scheduled for elective thoracic surgery for lung cancer.

INTERVENTIONS

In 20 patients undergoing lobectomy, fentanyl/propofol/nitrous oxide/vecuronium anesthesia was used, and extubation was planned immediately after surgery (group 1A, early extubation). Another 20 patients with lobectomy were anesthetized during fentanyl/midazolam/vecuronium, and they were extubated in the intensive care unit (ICU) (group 1B, late extubation). Ten patients underwent pneumonectomy (extubation planned in the ICU) (group 2, pneumonectomy). Patients of groups 1A and 1B were selected according to a randomized sequence.

MEASUREMENTS AND MAIN RESULTS

Extensive hemodynamic monitoring was performed using a pulmonary artery catheter by which right ventricular hemodynamics (right ventricular ejection fraction [RVEF], right ventricular end-systolic, and end-diastolic volumes) were additionally measured. Measurements were performed after induction of anesthesia (supine position, baseline values), before surgery (lateral position), 30 minutes after one-lung ventilation (OLV) was induced, at the end of surgery (supine position), 2 hours after surgery (in ICU), and on the morning of the first postoperative day. Pneumonectomy resulted in an increase in the pulmonary wedge pressure (from 12.2 +/- 2.9 to 18.3 +/- 3.8 mmHg) and a deterioration in right ventricular hemodynamics with a decrease in RVEF from 40.6 +/- 3.4% to 28.8 +/- 4.3% at the end of surgery. These changes were also seen on the morning of the first postoperative day. PaO2/FI02, Qs/Qt, VO2I, and DO2I were also significantly different between pneumonectomy and lobectomy patients. Intraoperatively, patients of group 1A and 1B showed almost similar cardiorespiratory data. During OLV, PaO2/FIO2 was significantly less reduced in group 1A (to 292 +/- 98 mmHg) than in group 1B (to 200 +/- 120 mmHg). Postoperatively, patients of group 1A were orientated, and physiotherapy could be started early. No relevant differences with regard to cardiorespiratory parameters were observed between group 1A and group 1B in the postoperative period until the first postoperative day.

CONCLUSIONS

In comparison with lobectomy patients, pneumonectomy resulted in more pronounced and sustained deterioration in right ventricular hemodynamics. The kind of anesthesia regimen did not influence most of the cardiorespiratory parameters intraoperatively, except for Qs/Qt, which was least compromised in the propofol patients during OLV. Early extubation could safely be performed in the lobectomy patients anesthetized with propofol without showing any negative cardiorespiratory effects.

The influence of volume therapy and pentoxifylline infusion on circulating adhesion molecules in trauma patients

Adhesion molecules appear to play a pivotal role in tissue damage secondary to the inflammatory process. Besides neutrophil- and endothelial-bound adhesion molecules, soluble forms have been detected in the circulating blood. They seem to be good markers of endothelial damage, but they may also have other biological functions. Plasma concentrations of soluble adhesion molecules (endothelial leucocyte adhesion molecules (sELAM-1), intercellular adhesion molecule-1 (sICAM-1), vascular cell adhesion molecule-1 (sVCAM-1), and granule membrane protein 140 (sGMP-140) were serially measured over 5 days by enzyme-linked immunosorbent assays (ELISA) in 45 consecutive trauma patients. These received, by random allocation, only either hydroxyethylstarch solution 10% (mean molecular weight 200,000 daltons) (n = 15) or human albumin 20% (n = 15) for volume therapy. Another 15 patients without defined volume therapy received pentoxifylline continuously (1.2 mg.kg-1.h-1). Measurements were carried out on the day of admission to the intensive care unit (baseline) and during the next 5 days. At baseline, plasma concentrations of all adhesion molecules were similar in all groups. In the hydroxyethyl starch group, sELAM-1 and sICAM-1 concentrations decreased significantly (p < 0.05) reaching normal values during the study period whereas the mean (SD) values increased in the pentoxifylline group (sELAM-1: 71.1 (16.7) to 91.6 (17.8) ng.ml-1) and the albumin group (sICAM-1: 400 (81) to 749 (101) ng.ml-1) (p < 0.05). sVCAM-1 increased outside the normal range only in the human albumin group (to 760 +/- 69 ng.ml-1) (p < 0.05). sGMP-140 plasma concentration increased only in those receiving albumin (432 (85) to 550 (93) ng.ml-1) and this was significantly different to the other groups (p < 0.05). None of the other haemodynamic or laboratory factors could be correlated with plasma concentrations of the adhesion molecules. We conclude that volume therapy with hydroxyethyl starch resulted in a decrease in circulating adhesion molecules in our trauma patients. In contrast, volume therapy with albumin did not exert this effect. Continuous infusion of pentoxifylline did not have a beneficial modulating action on circulating adhesion molecules.

[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.

[Primary neuroectodermal tumor (PNET): a rare highly malignant soft tissue tumor in children and young adults]

The PNET is an extremely malignant soft tissue neoplasm resulting from a balanced reciprocal translocation t (11; 22) (q24; q12). Treatment of the undifferentiated small cell tumor is carried out in compliance with the protocol of the soft tissue trail (CWS) from the German Society of Pediatric Oncology. Biopsy-proven diagnosis is followed by primary chemotherapy which leads in 95% of cases to remission. After excision of the remainder of the malignancy, an irradiation of the tumor site and two further sequences of chemotherapy are performed. Between 1986 and 1994, in cooperation with our pediatric and radiotherapeutical colleagues, we treated ten patients. In four patients (median age, 14 years) the PNET originated from the chest wall, in six patients from the paravertebral and retroperitoneal region. Five patients died after 20 months on average, while the remaining five patients are in full remission after 22, 37, 41, 42 and 82 months, respectively.

Does the type of volume therapy influence endothelial-related coagulation in the critically ill?

The endothelium plays an important role in the regulation of haemostasis by producing substances such as thrombomodulin (TM). The influence of long-term volume replacement with different types of fluid on the TM-protein C-protein S system was investigated in a prospective, randomized study. Thirty trauma patients and 30 patients suffering from sepsis after major surgery received either 10% low-molecular weight (LMW) hydroxyethylstarch solution (HES-trauma, n = 15; HES-sepsis, n = 15) or 20% human albumin (HA-trauma, n = 15; HA-sepsis, n = 15) for 5 days to maintain central venous pressure (CVP) between 12 and 16 mm Hg. Plasma concentrations of TM, protein C, (free) protein S and thrombin-antithrombin (TAT) were measured in arterial blood samples obtained on the day of admission to the intensive care unit or on the day of diagnosis of sepsis and over the next 5 days. There were no differences between HA- and HES-treated trauma patients. Protein C and protein S also did not differ between HA- and HES-treatments. At baseline, TM plasma concentrations were increased to > 40 micrograms litre-1 in both sepsis groups only. In the HA-sepsis group, TM increased significantly (from 48.1 (SD 13.9) to 68.4 (13.0) micrograms litre-1), whereas it remained almost unchanged in the HES-sepsis group. In HES-sepsis patients, protein C (from 51.0 (10.1) to 71.9 (8.9)%) and protein S (from 19.0 (6.0) to 40.8 (11.4)%) increased significantly during the study, whereas both remained reduced in HA-patients. TAT (indicating intravascular coagulation) did not differ between the two fluid groups. We conclude that in trauma patients, the type of volume therapy had no influence on the TM-protein C-protein S system. In sepsis patients, volume therapy with HES was beneficial, whereas infusion of HA had no substantial positive effect on endothelial-associated coagulation.

[Congenital tracheoesophageal fistula in the adult]

Congenital esophago-tracheal and esophago-bronchial fistulae are rare. Symptoms are recurrent pneumonia, cough, dysphagia and pain. The diagnosis is made by bronchoscopy or esophagoscopy. Every time the diagnosis is certain, the fistula has to be exstirpated by means of a thoracotomy and plastic reconstructive flap surgery.

[Surgical treatment of tracheal injuries]

Traumatic and iatrogenic injuries of the trachea are rare. In case of suspected rupture of the trachea a bronchoscopy remains the 'gold standard' of diagnostic procedures. The injuries should be repaired as soon as possible through a right thoracotomy or a collar incision using resorbable sutures. In case of small lesions a conservative treatment may be discussed. Overall the prognosis of tracheal injuries is good.

[Palliative therapy of primary liver tumors]

In Europe and North America, primary liver tumors are rare. Resection is the only means of cure, but is possible in only 20-30% of the patients affected, so that in all other patients, i.e. the vast majority, only palliative treatment is possible. In a retrospective analysis we investigated the 68 patients we had treated for hepatocellular or cholangiocellular carcinoma of the liver. In 14 patients resection was possible, while 28 patients were treated by chemoembolization and 26 by intraarterial regional chemotherapy to the liver. There was no difference in tumor stage between the two groups receiving different palliative treatments. The patients in whom resection was performed, in contrast, mostly had less advanced tumors. For chemoembolization we used a mixture of Ethibloc, mitomycin, Adriamycin and cisplatin. Up to 1986, the intraarterial chemotherapy was performed with mitomycin and 5-FU. Since 1986 we have used Adriamycin and cisplatin. The overall median survival time was 8 months: after resection 17 months, after chemoembolization 6.5 months, and after intraarterial chemotherapy 6.5 months. There was a significant difference in survival between patients with tumor stage II and those with tumor stages III and IV. On comparing the survival time achieved with our treatments and that ensuing in the natural course of patients with liver tumor we found no improvement.

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.

[Stomach and duodenal cancers in familial adenomatosis coli]

In the last years the number of patients with familial adenomatosis coli and metachrone carcinoma of the upper gastrointestinal tract is increasing. We describe two patients who, 9 and 15 years after colectomy for adenomatosis coli, developed a duodenal carcinoma. Each patient was treated with a partial duodeno-pancreatectomy. Another patient was resected prophylactically because of a diffuse adenomatosis of the duodenum three years after colectomy. We suggest that each patient with a history of colectomy for adenomatosis coli should have regular follow-ups including endoscopy of the upper gastrointestinal tract.

[Acute stress-induced cholecystitis]

Acute posttraumatic and postoperative cholecystitis is a serious and life-threatening complication with mortality rates ranging from 10 to 50%. The pathogenesis is multifactorial: possible reasons are blood transfusions, dehydration, narcotics, shock and positive end-expiratory pressure (PEEP). Between 1980 and 1990 12 patients underwent surgery for acute cholecystitis. Six of them suffered from a so-called acute acalculous cholecystitis. Two patients died postoperatively. The symptoms are that of a "common" cholecystitis with leukocytosis, fever, abdominal distension and upper right abdominal pain. Sonography is a good method to establish the diagnosis and helps in the decision for cholecystectomy. Clinicians must remember the possibility of an acute cholecystitis in any surgical patient developing abdominal pain or unexplained fever.

[Inflammatory fibroid polyp of the stomach as an unusual differential diagnosis of epigastric tumor]

We describe the case of a 5 months old infant with an inflammatory fibroid polyp of the stomach. The girl presented with inflammatory symptoms and a tumor in the upper abdomen which was confirmed by sonography and computer-tomography. This very rare benign tumor has not yet been described in an infant.

Selective immunosuppression with anti-interleukin 2 receptor-targeted therapy: helper and suppressor cell activity in rat recipients of cardiac allografts

(LEW X BN)F1 cardiac allografts are rejected within 8 days in unmodified LEW rats. ART18, a mouse anti-rat IgG1 monoclonal antibody which binds specifically in vitro to the interleukin 2 receptor (IL 2R) molecule expressed primarily on activated T cells, prolongs allograft survival in a dose-dependent fashion to ca. 3 weeks (p less than 0.001) after being administered for 10 days after transplantation. This effect was related to the specificity of the antibody for IL 2R, as therapy with ART62 (a monoclonal antibody recognizing MHC class I antigen but not binding the rat IL 2R) was ineffectual. Suppressor activity was detected in spleen cells of ART18-treated grafted hosts: in vivo, splenic T suppressor/cytotoxic fraction adoptively transferred into normal LEW improved donor-specific but not third-party test graft survival (17 days, vs. 8 days, respectively, p less than 0.001); in vitro, mixed lymphocyte reaction was profoundly but nonspecifically inhibited (less than 5% of test mixed lymphocyte reaction, p less than 0.001 as compared to acutely rejecting controls). In contrast, splenic T helper (Th) cells from ART18-treated hosts were functionally depressed, as noted by their passive transfer into immunologically anergic B recipients of cardiac allografts (rejection in ca. 40 days, vs. ca. 13 days after transfer of Th from specifically sensitized rats). ART18 treatment also resulted in diminished elaboration of IL 2 as compared to normal (p less than 0.005) or acutely rejecting hosts (p less than 0.001); however, a remarkable increase in the production of IL 3 occurred (p less than 0.001). These results demonstrate that IL 2R-targeted therapy of immunocompetent graft recipients produces a selective immune defect in which donor-specific T suppressor cells are spared, but Th cells attenuated or destroyed. Decreased elaboration of IL2 concomitantly augments the release of IL 3, a lymphokine which might play a role in suppressor effect in vivo. In addition, IL 2R-targeted therapy of the immunodeficient graft recipients abrogates the capacity of alloactivated T cells to re-establish acute immune responsiveness.

Development of suppressor lymphocytes during acute rejection of rat cardiac allografts and preservation of suppression by anti-IL-2-receptor monoclonal antibody

Suppressor activity was investigated in rats undergoing acute rejection of heterotopic cardiac allografts. Spleen cells were harvested at 7 days from LEW rats rejecting (LEW x BN)F1 heart grafts and fractionated into their T, T suppressor/cytotoxic, and T helper subpopulations. Transfer of alloimmune unseparated spleen cells to syngeneic recipients of (Lew x BN)F1 test grafts accelerated rejection from 8 to 6.5 days (P less than 0.01). Graft survival was prolonged to about 15 days (P less than 0.005) after transfer of the splenic T suppressor/cytotoxic fraction. Treatment of test graft recipients with ART-18, a mouse antirat monoclonal antibody directed against the rat interleukin 2 receptor on the surface of activated lymphocytes, increased graft survival to about 3 weeks (P less than 0.005), and to about 23 days (P less than 0.005) when test graft recipients were treated with ART 18 following transfer of alloimmune unseparated spleen cells. In contrast, ART-18 treatment of test graft recipients already injected with T suppressor/cytotoxic cells had no additive effect. Increased production of endogenous interleukin 2 occurred concomitantly with the onset of rejection in these animals; interleukin 2 release declined during the late stages of rejection when suppressor activity had increased. Similarly, in T-cell-depleted (B) rats, allograft rejection could be produced by immune reconstitution with sensitized lymphocytes, but could be significantly delayed by prior transfer of suppressor cells. These data document the presence of potent suppressor activity in the acutely rejecting host and suggest that the suppressor mechanisms are inhibited less than effector mechanisms by interleukin-2-receptor-targeted therapy.

Cyclosporine and experimental skin allografts. II. Indefinite survival and development of specific immunologic unresponsiveness

Immunological unresponsiveness toward skin allografts was studied in cyclosporine (CsA)-treated rats. BN skin grafts survive about 22 days and about 34 days in LEW hosts following 7 or 14 days of daily CsA treatment (15 mg/kg/day), respectively; in unmodified hosts grafts are rejected by 9 days. Indefinite (greater than 100 days) survival can, however, be produced by administering maintenance 15 mg/kg CsA every fourth day, following an initial course of the agent for 14 days. Early signs of graft rejection (hair loss, localized epidermal breakdown, and ulcerations) occurring in some animals were reversed by a CsA "pulse" (15 mg/kg/day) for 7 days, reduced gradually to the maintenance dose. CsA was equally effective when started as late as 4 days after grafting, but ineffectual when started after day 4. Once BN grafts were rejected, the agent could not prevent second-set rejection of donor-specific grafts, but significantly prolonged the survival of third-party (WF) skins. Survival of original BN grafts was unchanged by the placement of second BN grafts during both the inductive and maintenance phases; these second grafts survived as long as the original grafts. In contrast, secondary third-party (WF) grafts were promptly rejected; their destruction did not influence survival of the original grafts. Thus, indefinite survival of rat skin allografts is feasible with low maintenance doses of CsA. Graft rejection at later stages can be reversed by resuming daily therapy. Host unresponsiveness is stable and specific both during the early inductive and later maintenance phases.