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Oettle H, Neuhaus P, Hochhaus A, Hartmann JT, Gellert K, Ridwelski K, Niedergethmann M, Zülke C, Fahlke J, Arning MB, Sinn M, Hinke A, Riess H. Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial. JAMA 2013; 310:1473-81. [PMID: 24104372 DOI: 10.1001/jama.2013.279201] [Citation(s) in RCA: 1202] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The prognosis for patients with pancreatic cancer is poor, even after resection with curative intent. Gemcitabine-based chemotherapy is standard treatment for advanced pancreatic cancer, but its effect on survival in the adjuvant setting has not been demonstrated. OBJECTIVE To analyze whether previously reported improvement in disease-free survival with adjuvant gemcitabine therapy translates into improved overall survival. DESIGN, SETTING, AND PATIENTS CONKO-001 (Charité Onkologie 001), a multicenter, open-label, phase 3 randomized trial to evaluate the efficacy and toxicity of gemcitabine in patients with pancreatic cancer after complete tumor resection. Patients with macroscopically completely removed pancreatic cancer entered the study between July 1998 and December 2004 in 88 hospitals in Germany and Austria. Follow-up ended in September 2012. INTERVENTIONS After stratification for tumor stage, nodal status, and resection status, patients were randomly assigned to either adjuvant gemcitabine treatment (1g/m2 d 1, 8, 15, q 4 weeks) for 6 months or to observation alone. MAIN OUTCOMES AND MEASURES The primary end point was disease-free survival. Secondary end points included treatment safety and overall survival, with overall survival defined as the time from date of randomization to death. Patients lost to follow-up were censored on the date of their last follow-up. RESULTS A total of 368 patients were randomized, and 354 were eligible for intention-to-treat-analysis. By September 2012, 308 patients (87.0% [95% CI, 83.1%-90.1%]) had relapsed and 316 patients (89.3% [95% CI, 85.6%-92.1%]) had died. The median follow-up time was 136 months. The median disease-free survival was 13.4 (95% CI, 11.6-15.3) months in the treatment group compared with 6.7 (95% CI, 6.0-7.5) months in the observation group (hazard ratio, 0.55 [95% CI, 0.44-0.69]; P < .001). Patients randomized to adjuvant gemcitabine treatment had prolonged overall survival compared with those randomized to observation alone (hazard ratio, 0.76 [95% CI, 0.61-0.95]; P = .01), with 5-year overall survival of 20.7% (95% CI, 14.7%-26.6%) vs 10.4% (95% CI, 5.9%-15.0%), respectively, and 10-year overall survival of 12.2% (95% CI, 7.3%-17.2%) vs 7.7% (95% CI, 3.6%-11.8%). CONCLUSIONS AND RELEVANCE Among patients with macroscopic complete removal of pancreatic cancer, the use of adjuvant gemcitabine for 6 months compared with observation alone resulted in increased overall survival as well as disease-free survival. These findings provide strong support for the use of gemcitabine in this setting. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN34802808.
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Affiliation(s)
- Helmut Oettle
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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Iesalnieks I, Deimel S, Zülke C, Schlitt HJ. Rauchen erhöht das prä- und postoperative Komplikationsrisiko bei Patienten mit Sinus pilonidalis. J Dtsch Dermatol Ges 2013. [DOI: 10.1111/ddg.12140_suppl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Igors Iesalnieks
- Klinik für Allgemein- und Viszeralchirurgie; Marienhospital Gelsenkirchen
| | - Sina Deimel
- Klinik für Allgemein- und Viszeralchirurgie; Marienhospital Gelsenkirchen
| | - Carl Zülke
- Klinik für Allgemein- und Viszeralchirurgie; Marienhospital Gelsenkirchen
| | - Hans J. Schlitt
- Klinik und Poliklinik für Chirurgie; Universitätsklinikum Regensburg
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Iesalnieks I, Deimel S, Zülke C, Schlitt HJ. Smoking increases the risk of pre- and postoperative complications in patients with pilonidal disease. J Dtsch Dermatol Ges 2013; 11:1001-5. [DOI: 10.1111/ddg.12140] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 04/18/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Igors Iesalnieks
- Department of General and Visceral Surgery; Marienhospital Gelsenkirchen; Germany
| | - Sina Deimel
- Department of General and Visceral Surgery; Marienhospital Gelsenkirchen; Germany
| | - Carl Zülke
- Department of General and Visceral Surgery; Marienhospital Gelsenkirchen; Germany
| | - Hans J. Schlitt
- Department of Surgery; University Clinic of Regensburg; Germany
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Deimel S, Kienle K, Zülke C, Iesalnieks I. Anwendung der „Pit Picking„ Operation bei Sinus pilonidalis. Zentralbl Chir 2011. [DOI: 10.1055/s-0031-1289061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Iesalnieks I, Zülke C, Schlitt HJ. Temporäres Stoma bei Patienten mit M. Crohn: Risiken und Prognose der Rückverlagerung. Zentralbl Chir 2011. [DOI: 10.1055/s-0031-1289033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Deimel S, Denecke S, Zülke C, Iesalnieks I. Postoperative Serome nach plastischen Rekonstruktionsverfahren bei Patienten mit Sinus pilonidalis. Zentralbl Chir 2011. [DOI: 10.1055/s-0031-1289050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Denecke S, Deimel S, Zülke C, Iesalnieks I. Karydakis-Operation bei Rezidiv eines Sinus pilonidalis. Zentralbl Chir 2011. [DOI: 10.1055/s-0031-1289065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Wetzka T, Zülke C, Iesalnieks I. Risiken der kolorektalen Chirurgie bei über Achtzigjährigen. Zentralbl Chir 2011. [DOI: 10.1055/s-0031-1288971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Marten A, Schmidt J, Debus J, Harig S, Lindel K, Klein J, Bartsch DK, Capussotti L, Zülke C, Buchler M. CapRI: Final results of the open-label, multicenter, randomized phase III trial of adjuvant chemoradiation plus interferon-α2b (CRI) versus 5-FU alone for patients with resected pancreatic adenocarcinoma (PAC). J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.18_suppl.lba4012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
LBA4012 Background:Adjuvant chemomonotherapy in PAC results in five-year survival of 21% with median overall survival (mOS) of 23 months. Phase II trials evaluating adjuvant CRI showed promising results (mOS 27-44 months). Methods: Patients with an R0/R1 resection for PAC were randomized <12 weeks of surgery to receive either 5-Fluorouracil (200mg/m2/day, CI); Cisplatin (weekly 30mg/m2) and 3 million units IFN-α (three times a week) for 5.5 weeks combined with external beam radiation (50.4Gy in 28 fractions) followed by two more cycles of continuous 5-FU or 5FU/FA (FA, 20 mg/m2, iv bolus injection followed by 5-FU, 425 mg/m2, iv bolus injection given 1-5d every 28 days) for 6 months. Patients treated with CRI were challenged prior to therapy with a single dose of IFN-α. The primary outcome measure was overall survival; the secondary measures were toxicity, progression free survival and quality of life. 110 patients were calculated to detect a difference in hazard on level α= 0.05 and with a power of 80%. Results: 110 patients from five centers in Germany and Italy were randomized from July 2004 and December 2007. Median (range) age was 63 (33-77) years; 60 (57%) were men. 104 (95%) were T3 tumors, 87 (79%) were node positive and 43 (39%) were R1 resections, and 33 (30%) were poorly differentiated tumors. Grade 3 or 4 toxicity (mainly neutropenia) was observed in 68% of CRI and 16% of 5FU/FA (mainly diarrhea). Side effects during the multimodular cycle 1 were manageable and patients recovered completely. There was no difference in quality of life between the treatment groups. Final analysis was carried out on an intention to treat basis with a minimum of 2 years follow-up. Median survival of patients treated with 5FU/FA was 28.5 [95% CI: 19.5, 38.6] months and for patients treated with CRI this was 32.1 [95% CI: 22.8, 42.2] months. Although survival curves are clearly separated the log-rank analysis revealed no statistically significant difference in survival estimates. There was a clear trend towards better response for high risk patients (R1, start of treatment > 8 weeks after surgery; p=0.11). CRI reduced the risk of local recurrence (29.3% vs. 55.6%; p=0.014). Pre-planned testing for predictive markers showed that patients treated with CRI who responded to single IFN-α challenge with a decrease in T helper cells and especially regulatory T cells or with a pronounced increase in NK cell mediated cytotoxicity had a significantly longer survival. Conclusions: This is the highest ever reported mOS for adjuvant PAC in a randomized trial. Unfortunately, this underpowered trial was not able to address the significance of CRI in PAC satisfactorily. There is evidence that especially high risk patients benefit from CRI; local control improved significantly. A strong immune response to a single IFN-α challenge is significantly associated with a good outcome. Confirmatory trials are needed. [Table: see text]
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Affiliation(s)
- A. Marten
- University Hospital of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Surgery, University of Heidelberg, Heidelberg, Germany; Department of Radio-Oncology, University of Heidelberg, Heidelberg, Germany; Department of Surgery, University of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Radio-Oncology, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany; Department of Surgery, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany
| | - J. Schmidt
- University Hospital of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Surgery, University of Heidelberg, Heidelberg, Germany; Department of Radio-Oncology, University of Heidelberg, Heidelberg, Germany; Department of Surgery, University of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Radio-Oncology, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany; Department of Surgery, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany
| | - J. Debus
- University Hospital of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Surgery, University of Heidelberg, Heidelberg, Germany; Department of Radio-Oncology, University of Heidelberg, Heidelberg, Germany; Department of Surgery, University of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Radio-Oncology, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany; Department of Surgery, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany
| | - S. Harig
- University Hospital of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Surgery, University of Heidelberg, Heidelberg, Germany; Department of Radio-Oncology, University of Heidelberg, Heidelberg, Germany; Department of Surgery, University of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Radio-Oncology, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany; Department of Surgery, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany
| | - K. Lindel
- University Hospital of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Surgery, University of Heidelberg, Heidelberg, Germany; Department of Radio-Oncology, University of Heidelberg, Heidelberg, Germany; Department of Surgery, University of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Radio-Oncology, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany; Department of Surgery, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany
| | - J. Klein
- University Hospital of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Surgery, University of Heidelberg, Heidelberg, Germany; Department of Radio-Oncology, University of Heidelberg, Heidelberg, Germany; Department of Surgery, University of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Radio-Oncology, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany; Department of Surgery, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany
| | - D. K. Bartsch
- University Hospital of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Surgery, University of Heidelberg, Heidelberg, Germany; Department of Radio-Oncology, University of Heidelberg, Heidelberg, Germany; Department of Surgery, University of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Radio-Oncology, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany; Department of Surgery, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany
| | - L. Capussotti
- University Hospital of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Surgery, University of Heidelberg, Heidelberg, Germany; Department of Radio-Oncology, University of Heidelberg, Heidelberg, Germany; Department of Surgery, University of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Radio-Oncology, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany; Department of Surgery, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany
| | - C. Zülke
- University Hospital of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Surgery, University of Heidelberg, Heidelberg, Germany; Department of Radio-Oncology, University of Heidelberg, Heidelberg, Germany; Department of Surgery, University of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Radio-Oncology, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany; Department of Surgery, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany
| | - M. Buchler
- University Hospital of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Surgery, University of Heidelberg, Heidelberg, Germany; Department of Radio-Oncology, University of Heidelberg, Heidelberg, Germany; Department of Surgery, University of Heidelberg/National Center for Tumor Diseases, Heidelberg, Germany; Department of Radio-Oncology, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany; Department of Surgery, Stádtische Kliniken Bielefeld-Mitte, Bielefeld, Germany
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Kaiser GM, Sotiropoulos GC, Jauch KW, Löhe F, Hirner A, Kalff JC, Königsrainer A, Steurer W, Senninger N, Brockmann JG, Schlitt HJ, Zülke C, Büchler MW, Schemmer P, Settmacher U, Hauss J, Lippert H, Hopt UT, Otto G, Heiss MM, Bechstein WO, Timm S, Klar E, Hölscher AH, Rogiers X, Stangl M, Hohenberger W, Müller V, Molmenti EP, Fouzas I, Erhard J, Malagó M, Paul A, Broelsch CE, Lang H. Liver transplantation for hilar cholangiocarcinoma: a German survey. Transplant Proc 2009; 40:3191-3. [PMID: 19010230 DOI: 10.1016/j.transproceed.2008.08.039] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The present study reports a German survey addressing outcomes in nonselected historical series of liver transplantation (OLT) for hilar cholangiocarcinoma (HL). PATIENTS AND METHODS We sent to all 25 German transplant centers performing OLT a survey that addressed (1) the number of OLTs for HL and the period during which they were performed; (2) the incidence of HL diagnosed prior to OLT/rate of incidental HL (for example, in primary sclerosing cholangitis); (3) tumor stages according to Union Internationale Centre le Cancer; (4) patient survival; and (5) tumor recurrence rate. RESULTS Eighty percent of centers responded, reporting 47 patients who were transplanted for HL. Tumors were classified as pT2 (25%), pT3 (73%), or pT4 (2%). HL was diagnosed incidentally in 10% of cases. A primary diagnosis of PSC was observed in 16% of patients. Overall median survival was 35.5 months. When in-hospital mortality (n = 12) was excluded, the median survival was 45.4 months, corresponding to 3- and 5-year survival rates of 42% and 31%, versus 31% and 22% when in-hospital mortality was included. HL recurred in 34% of cases. Three- and 5-year survivals for the 15 patients transplanted since 1998 was 57% and 48%, respectively. Median survival ranged from 20 to 42 months based on the time period (P = .014). CONCLUSIONS The acceptable overall survival, the improved results after careful patient selection since 1998, and the encouraging outcomes from recent studies all suggest that OLT may be a potential treatment for selected cases of HL. Prospective multicenter randomized studies with strict selection criteria and multimodal treatments seem necessary.
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Affiliation(s)
- G M Kaiser
- Klinik für Allgemein-, Viszeral und Transplantationschirurgie, Universitätsklinikum Essen, Germany
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Kaiser GM, Sotiropoulos GC, Jauch KW, Löhe F, Hirner A, Kalff JC, Königsrainer A, Steurer W, Senninger N, Brockmann JG, Schlitt HJ, Zülke C, Büchler MW, Schemmer P, Settmacher U, Hauss J, Lippert H, Hopt UT, Otto G, Heiss MM, Bechstein WO, Timm S, Klar E, Hölscher AH, Rogiers X, Stangl M, Hohenberger W, Müller V, Molmenti EP, Fouzas I, Erhard J, Malagó M, Paul A, Broelsch CE, Lang H. Liver transplantation for hilar cholangiocarcinoma: a German survey. Transplant Proc 2009; 40:3155-7. [PMID: 19010230 DOI: 10.1016/j.transproceed.2008.08.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The present study reports a German survey addressing outcomes in nonselected historical series of liver transplantation (OLT) for hilar cholangiocarcinoma (HL). PATIENTS AND METHODS We sent to all 25 German transplant centers performing OLT a survey that addressed (1) the number of OLTs for HL and the period during which they were performed; (2) the incidence of HL diagnosed prior to OLT/rate of incidental HL (for example, in primary sclerosing cholangitis); (3) tumor stages according to Union Internationale Centre le Cancer; (4) patient survival; and (5) tumor recurrence rate. RESULTS Eighty percent of centers responded, reporting 47 patients who were transplanted for HL. Tumors were classified as pT2 (25%), pT3 (73%), or pT4 (2%). HL was diagnosed incidentally in 10% of cases. A primary diagnosis of PSC was observed in 16% of patients. Overall median survival was 35.5 months. When in-hospital mortality (n = 12) was excluded, the median survival was 45.4 months, corresponding to 3- and 5-year survival rates of 42% and 31%, versus 31% and 22% when in-hospital mortality was included. HL recurred in 34% of cases. Three- and 5-year survivals for the 15 patients transplanted since 1998 was 57% and 48%, respectively. Median survival ranged from 20 to 42 months based on the time period (P = .014). CONCLUSIONS The acceptable overall survival, the improved results after careful patient selection since 1998, and the encouraging outcomes from recent studies all suggest that OLT may be a potential treatment for selected cases of HL. Prospective multicenter randomized studies with strict selection criteria and multimodal treatments seem necessary.
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Affiliation(s)
- G M Kaiser
- Klinik für Allgemein-, Viszeral und Transplantationschirurgie, Universitätsklinikum Essen, Germany
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Henning BF, Kuchlbauer S, Böger CA, Obed A, Farkas S, Zülke C, Scherer MN, Walberer A, Banas M, Krüger B, Schlitt HJ, Banas B, Krämer BK. Percutaneous transluminal angioplasty as first-line treatment of transplant renal artery stenosis. Clin Nephrol 2009; 71:543-549. [PMID: 19473615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Transplant renal artery stenosis (TRAS) is a frequent complication after renal transplantation, however long-term follow-up data after interventional treatment are rare. PATIENTS In our transplant center 11 of 264 consecutive renal transplant recipients (4.17%) were diagnosed with TRAS. In addition, TRAS occurred in 2 renal transplant recipients that had been transplanted at other centers but who had their follow-up examinations in our center. Either a rise of the serum creatinine level and/or worsened systemic hypertension or routine examination with color Doppler sonography were indications for further diagnostic workup. METHODS Direct angiography of the transplant renal artery was performed followed by percutaneous transluminal angioplasty (PTA) after the diagnosis of TRAS was confirmed in all of these patients. RESULTS The immediate success rate for PTA was 92.3% (12/13). Only 1 patient with a severe kinking of the transplant renal artery had to undergo surgery to restore renal function. No complications occurred after the interventions. Thereafter the patients were monitored for a mean observation period of 33.15 months. Serum creatinine levels were significantly lower after the intervention, and estimated glomerular filtration rate (eGFR) increased accordingly. With regard to blood pressure there was only a trend for lower blood pressure levels and less antihypertensive use, whereas the dose of the prescribed drugs decreased significantly with time after interventional treatment of TRAS. In addition, a long-lasting rise of the hemoglobin levels could also be demonstrated. CONCLUSION In summary, the beneficial effect of PTA of TRAS on renal function is long-lasting. Therefore, PTA, usually combined with stent placement, should be first-line treatment in TRAS in all patients. Surgical revascularization is only warranted, if PTA fails.
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Affiliation(s)
- B F Henning
- Department of Medicine I, Marienhospital Herne, Ruhr University, Bochum, Germany.
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Abstract
Benign liver tumors are being detected more frequently due to the widespread use of ultrasound and complementary methods and due to improvements in diagnostic accuracy. In the case of a reliable diagnosis of asymptomatic hemangioma or focal nodular hyperplasia surgery is not indicated. Hepatic adenoma of considerable size should be resected primarily based on the risk of rupture. Improvements in diagnostic imaging as well as the optimization of surgical procedures with extremely low complication rates permit an individualized management strategy founded on evidence-based algorithms. In the case of an equivocal diagnosis, we advocate low-risk tumor resection instead of tumor biopsy due to the inherent complication rates of hemorrhage or tumor-cell dissemination and possible misleading histology.
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Affiliation(s)
- M Loss
- Klinik und Poliklinik für Chirurgie, Klinikum der Universität Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland.
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Abstract
The expanding use of ultrasound in general practice is leading to an ever increasing rate of detection of true hepatic incidentaloma. The correct diagnosis of hepatic incidentaloma may be made in over 90% with non-invasive means. The questionable diagnosis of "symptomatic" incidentaloma should undergo close scrutiny prior to a decision in favour of surgery. With regard to more recent literature, the former "absolute" requirement for surgical resection in all cases of liver cell adenoma may have to be reappraised. Final inability to rule out malignancy represents an unquestionable indication for surgery in the light of low rates of morbidity and lack of mortality in this otherwise healthy patient group. Percutaneous biopsies should not be performed due to oncological hazards, indeterminate results and potential for acute complications.The stage-oriented radical re-resection following diagnosis of an incidentally detected gallbladder cancer may lead to significantly improved long-term survival, especially in the early tumour stages T1b and T2, which represents the most common stage of gallbladder cancer in incidentaloma. Patients at elevated risk for incidental gallbladder cancer should undergo thorough instruction with regard to the potential hazards of laparoscopic cholecystectomy. Multimodal therapeutic strategies directed at advanced stages of incidentally detected gallbladder cancer should be evaluated in prospective multicentre studies.
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Affiliation(s)
- Carl Zülke
- Chirurgische Klinik und Poliklinik, Universitätsklinikum Regensburg.
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Spatz H, Zülke C, Beham A, Agha A, Bolder U, Krenz D, Fürst A, Lattermann R, Gröppner G, Hemmerich B, Piso P, Schlitt H. „Fast-Track” bei laparoskopisch assistierter Rektumresektion - was kann erreicht werden? Erste Ergebnisse einer Machbarkeitsstudie. Zentralbl Chir 2006; 131:383-7. [PMID: 17089286 DOI: 10.1055/s-2006-949659] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AIM "Fast-track" multimodal rehabilitation is increasingly entering the perioperative management strategies in colon surgery aiming at minimized perioperative morbidity and accelerated recovery. So far little is known about the complementary effects of minimally invasive surgery along with "fast-track" rehabilitation in the treatment of rectal cancer. The aim of this pilot study was to investigate the influence of "fast-track" perioperative management on morbidity, recovery and length of hospital stay in laparoscopically-assisted rectum resections and to compare those data to earlier results. METHODS An interdiciplinary "fast-track" multimodal rehabilitation strategy with avoidance of mechanical bowel cleansing, with a restrictive intravenous intra- and postoperative fluid regimen, forced mobilisation, and early enteral nutrition was introduced into clinical practice and applied in 16 laparoscopically-assisted rectum resections. Data were collected in the course af a prospective analysis. The mean patient age was 62 (42-79) years. RESULTS Mean time of surgery was 245 (SD 46) min, and the mean intraoperative infusion rate was 11.2 (SD 2.6) ml/kg/BW. On day 2, 14 of the 16 patients tolerated solid food and 12 patients had had bowel movements. All patients returned to their initial body weight by day 4. The median postoperative hospital stay was 7.5 days (6-20), 12 patients were discharged between day 6 and 8. Two patients were readmitted for intestinal atony, one patient developed an anastomotic leakage. CONCLUSIONS "Fast-track" rehabilitation is feasible in rectum surgery and seems to complement the beneficial effects of minimally invasive surgery without increasing the complication rate.
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Affiliation(s)
- H Spatz
- Klinik und Poliklinik für Chirurgie, Klinikum der Universität Regensburg
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Fischereder M, Graeb C, Krüger B, Kammerl MC, Zülke C, Jauch KW, Krämer BK. Conversion from calcineurin inhibitors to sirolimus in patients with chronic renal allograft dysfunction. Transplant Proc 2006; 38:1295-7. [PMID: 16797286 DOI: 10.1016/j.transproceed.2006.03.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2005] [Indexed: 12/25/2022]
Abstract
BACKGROUND Chronic renal transplant dysfunction in part may be due to the nephrotoxic effects of calcineurin inhibitors, which are still the mainstay of immunosuppressive therapy. Sirolimus, a new immunosuppressive compound devoid of significant nephrotoxicity, might therefore exhibit beneficial effects when used in renal transplant recipients with graft dysfunction. METHODS Twelve renal transplant recipients included in this study had all been receiving calcineurin inhibitors for more than 12 months, and were free of rejection for more than 12 months. However, they demonstrated moderate renal dysfunction with serum creatinine values ranging from 1.8 to 4.0 mg/dL (164 to 351 micromol/L). After reaching a sirolimus level of 10 to 20 ng/mL, calcineurin inhibitor therapy was withheld. RESULTS One month after initiation of sirolimus therapy, all patients were off calcineurin inhibitors. The average daily sirolimus dosage was 5.8+/-3.4 mg. No acute rejection episode and no graft failure was observed. No patient required hemodialysis or admission to the hospital. Calculated creatinine clearance increased from 63.4+/-9.9 to 69.2+/-9.7 mL/min (P=.0368) and serum bicarbonate increased from 20.8+/-3.17 to 22.5+/-3.7 meq/L (P=.001). Serum cholesterol increased from 180+/-26.5 to 239+/-28.8 mg/dL (4.65+/-0.69 to 6.18+/-0.74 mmol/L, P<.001), triglycerides increased from 155+/-53 to 289+/-123 mg/dL (1.75+/-0.6 to 3.26+/-1.39 mmol/L) and low-density lipoprotein cholesterol increased from 99+/-32 to 131+/-25.1 mg/dL (2.56+/-0.83 to 3.39+/-0.65 mmol/L, P=.01). Arterial blood pressure remained well controlled (126+/-15.6/74+/-8.9 vs 134+/-16.8/83+/-9.7). CONCLUSION Conversion from calcineurin inhibitor therapy to sirolimus in patients more than 1 year after transplantation with impaired organ function is feasible, safe, and associated with a trend toward improved renal function.
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Iesalnieks I, Rümmele P, Dietmaier W, Jantsch T, Zülke C, Schlitt HJ, Hofstädter F, Anthuber M. Factors associated with disease progression in patients with gastrointestinal stromal tumors in the pre-imatinib era. Am J Clin Pathol 2005; 124:740-8. [PMID: 16203282 DOI: 10.1309/akk3-vff6-10cw-m566] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
The aim of this study was to determine the predictors of survival in 38 patients with curatively resected gastrointestinal stromal tumors (GISTs). The tumor was located in the stomach in 23 cases, the small bowel in 13, and the colon in 2. In 23 patients (61%), a mutation in exon 11 of the kit gene was detected. In 7 cases, all small gastric tumors, a mutation in the platelet-derived growth factor receptor a (PDGFRA) gene was detected. The overall 5-year survival rate was 70%. In 9 patients, GISTs relapsed, leading to an actuarial 5-year disease-free survival of 78%. By multivariate analysis, the presence of distant metastases, the proliferative (MIB-1) index, and deletional mutation in codons 557 and/or 558 of kit exon 11 correlated significantly with poor outcome. None of the PDGFRA mutant GISTs relapsed. These findings suggest a strong relationship between various tyrosine kinase receptor mutations and survival outcome in patients with GISTs.
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Affiliation(s)
- Igors Iesalnieks
- Department of Surgery, University of Regensburg, Regensburg, Germany
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18
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Iesalnieks I, Rümmele P, Dietmaier W, Jantsch T, Zülke C, Schlitt HJ, Hofstädter F, Anthuber M. Factors Associated With Disease Progression in Patients With Gastrointestinal Stromal Tumors in the Pre-Imatinib Era. Am J Clin Pathol 2005. [DOI: 10.1309/akk3vff610cwm566] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Zülke C, Matejovic M, Träger K, Radermacher P. Validation of portal vein flow measurement by color flow Doppler sonography in a porcine model of septic shock. Intensive Care Med 2005; 31:1288-91. [PMID: 16086179 DOI: 10.1007/s00134-005-2722-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2003] [Accepted: 06/21/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare portal vein flow values gained by color flow Doppler sonography with simultaneously derived data from an ultrasound transit time flow probe. DESIGN Repeated, simultaneous flow measurements were performed in a prospective study investigating the effect of various drugs on hepatosplanchnic perfusion and energy balance in a long-term model of stable, hyperdynamic endotoxin shock. SETTING Investigational animal laboratory. SUBJECTS Domestic pigs. INTERVENTIONS Alterations in respirator setting were studied with regard to their effect on the quality of color flow Doppler data in comparison to flow probe data. Additional experiments included variation in PEEP level in conjunction with volume resuscitation. MEASUREMENTS AND RESULTS Respiratory rates of 14-18/min led to color Doppler flow values consistently 20-40% above simultaneously measured flow probe data. Temporary apnea led to enhanced agreement of data. Reduction in respiratory rate to 8/min with increase in tidal volume consistently led to color Doppler data within 10% of the corresponding flow probe values. CONCLUSIONS A short-term period of respirator-dependent, constant portal vein inflow enables color Doppler sonography to detect correct values in a clinically relevant setting of hyperdynamic endotoxin shock.
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Affiliation(s)
- Carl Zülke
- Klinik und Poliklinik für Chirurgie, Universität Regensburg, Regensburg, Germany.
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20
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Neuhaus P, Oettle H, Post S, Gellert K, Ridwelski K, Schramm H, Zülke C, Fahlke G, Langrehr J, Riess H. A randomised, prospective, multicenter, phase III trial of adjuvant chemotherapy with gemcitabine vs. observation in patients with resected pancreatic cancer. J Clin Oncol 2005. [DOI: 10.1200/jco.2005.23.16_suppl.lba4013] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- P. Neuhaus
- Charité Campus Virchow-Klinikum, Berlin, Germany; Ruprecht-Karls-Universität, Mannheim, Germany; Oskar-Ziethen-Krankenhaus, Berlin, Germany; Städtisches Klin Magdeburg, Magdeburg, Germany; Waldklinikum, Gera, Germany; Universitätsklinikum Regensburg, Regensburg, Germany; Otto-von-Guericke-Universität, Magdeburg, Germany
| | - H. Oettle
- Charité Campus Virchow-Klinikum, Berlin, Germany; Ruprecht-Karls-Universität, Mannheim, Germany; Oskar-Ziethen-Krankenhaus, Berlin, Germany; Städtisches Klin Magdeburg, Magdeburg, Germany; Waldklinikum, Gera, Germany; Universitätsklinikum Regensburg, Regensburg, Germany; Otto-von-Guericke-Universität, Magdeburg, Germany
| | - S. Post
- Charité Campus Virchow-Klinikum, Berlin, Germany; Ruprecht-Karls-Universität, Mannheim, Germany; Oskar-Ziethen-Krankenhaus, Berlin, Germany; Städtisches Klin Magdeburg, Magdeburg, Germany; Waldklinikum, Gera, Germany; Universitätsklinikum Regensburg, Regensburg, Germany; Otto-von-Guericke-Universität, Magdeburg, Germany
| | - K. Gellert
- Charité Campus Virchow-Klinikum, Berlin, Germany; Ruprecht-Karls-Universität, Mannheim, Germany; Oskar-Ziethen-Krankenhaus, Berlin, Germany; Städtisches Klin Magdeburg, Magdeburg, Germany; Waldklinikum, Gera, Germany; Universitätsklinikum Regensburg, Regensburg, Germany; Otto-von-Guericke-Universität, Magdeburg, Germany
| | - K. Ridwelski
- Charité Campus Virchow-Klinikum, Berlin, Germany; Ruprecht-Karls-Universität, Mannheim, Germany; Oskar-Ziethen-Krankenhaus, Berlin, Germany; Städtisches Klin Magdeburg, Magdeburg, Germany; Waldklinikum, Gera, Germany; Universitätsklinikum Regensburg, Regensburg, Germany; Otto-von-Guericke-Universität, Magdeburg, Germany
| | - H. Schramm
- Charité Campus Virchow-Klinikum, Berlin, Germany; Ruprecht-Karls-Universität, Mannheim, Germany; Oskar-Ziethen-Krankenhaus, Berlin, Germany; Städtisches Klin Magdeburg, Magdeburg, Germany; Waldklinikum, Gera, Germany; Universitätsklinikum Regensburg, Regensburg, Germany; Otto-von-Guericke-Universität, Magdeburg, Germany
| | - C. Zülke
- Charité Campus Virchow-Klinikum, Berlin, Germany; Ruprecht-Karls-Universität, Mannheim, Germany; Oskar-Ziethen-Krankenhaus, Berlin, Germany; Städtisches Klin Magdeburg, Magdeburg, Germany; Waldklinikum, Gera, Germany; Universitätsklinikum Regensburg, Regensburg, Germany; Otto-von-Guericke-Universität, Magdeburg, Germany
| | - G. Fahlke
- Charité Campus Virchow-Klinikum, Berlin, Germany; Ruprecht-Karls-Universität, Mannheim, Germany; Oskar-Ziethen-Krankenhaus, Berlin, Germany; Städtisches Klin Magdeburg, Magdeburg, Germany; Waldklinikum, Gera, Germany; Universitätsklinikum Regensburg, Regensburg, Germany; Otto-von-Guericke-Universität, Magdeburg, Germany
| | - J. Langrehr
- Charité Campus Virchow-Klinikum, Berlin, Germany; Ruprecht-Karls-Universität, Mannheim, Germany; Oskar-Ziethen-Krankenhaus, Berlin, Germany; Städtisches Klin Magdeburg, Magdeburg, Germany; Waldklinikum, Gera, Germany; Universitätsklinikum Regensburg, Regensburg, Germany; Otto-von-Guericke-Universität, Magdeburg, Germany
| | - H. Riess
- Charité Campus Virchow-Klinikum, Berlin, Germany; Ruprecht-Karls-Universität, Mannheim, Germany; Oskar-Ziethen-Krankenhaus, Berlin, Germany; Städtisches Klin Magdeburg, Magdeburg, Germany; Waldklinikum, Gera, Germany; Universitätsklinikum Regensburg, Regensburg, Germany; Otto-von-Guericke-Universität, Magdeburg, Germany
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Golling M, Becker T, Broelsch C, Candinas D, Faust D, Fischer L, Geissler E, Graeb C, Iberer F, Klupp J, Kraus T, Müller AR, Neuhaus P, Strassburg CP, Wolff M, Zülke C, Bechstein WO. Konsensusempfehlung zum Einsatz von Sirolimus in der Lebertransplantation. Z Gastroenterol 2004; 42:1333-40. [PMID: 15558447 DOI: 10.1055/s-2004-813703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Sirolimus is an m-TOR inhibitor without renal side effects and potentially protects against the development of malignancy. Due to a higher incidence of complications in two trials and an official warning in the drug information, the use of Sirolimus in liver transplantation is limited. The participants of this consensus meeting had to analyse and evaluate the literature with respect to the potential role of Sirolimus in liver transplantation. This consensus statement follows the scheme normally employed for the presentation of guidelines including the grading of evidence (1a-5) and the extent of recommendation (A-C). Moreover, the consensus included the experience of the authors with respect to the handling of Sirolimus after liver transplantation.
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Affiliation(s)
- M Golling
- Klinik für Allgemein- und Gefässchirurgie am Klinikum der Johann-Wolfgang-Goethe-Universität, Frankfurt am Main
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22
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Krämer BK, Zülke C, Kammerl MC, Schmidt C, Hengstenberg C, Fischereder M, Marienhagen J. Cardiovascular risk factors and estimated risk for CAD in a randomized trial comparing calcineurin inhibitors in renal transplantation. Am J Transplant 2003; 3:982-7. [PMID: 12859533 DOI: 10.1034/j.1600-6143.2003.00156.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Cardiovascular morbidity and mortality is high in patients following renal transplantation. The present analysis assessed major cardiovascular risk factors and estimated the risk of coronary artery disease in the largest present-day comparative trial of tacrolimus vs. microemulsified cyclosporine A. In this 6-month study, 557 patients were randomly allocated to therapy with tacrolimus (n = 286) or cyclosporine A (n = 271) concomitantly with azathioprine and corticosteroids. The primary endpoint was the incidence of and time to acute rejection. Blood pressure, serum cholesterol, HDL cholesterol, triglycerides, and blood glucose were measured at baseline, and at months 1, 3, and 6. Ten-year risk of coronary heart disease was estimated according to the Framingham risk algorithm. Tacrolimus resulted in significantly lower summary measures (time-weighted average) of serum cholesterol (p = 0.0004) and mean arterial blood pressure (p = 0.0156), but in a higher summary measure of blood glucose (p = 0.0028) than cyclosporine. The summary measure of serum triglycerides was not different between treatment groups (p = 0.368). The mean 10-year coronary artery disease risk estimate was significantly lowered in men (p = 0.0032) treated with tacrolimus, but was unchanged in women. Tacrolimus and cyclosporine A microemulsion exert a compound-specific impact on cardiovascular risk factors and appear to affect the predicted rate of cardiovascular morbidity in different manners.
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Affiliation(s)
- Bernhard K Krämer
- Klinik und Poliklinik für Innere Medizin II, Chirurgie, and Nuklearmedizin, Klinikum der Universität, University of Regensburg, Regensburg, Germany.
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23
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Stehr A, Ploner F, Tugtekin I, Matejovic M, Theisen M, Zülke C, Georgieff M, Radermacher P, Jauch KW. Effect of combining nicotinamide as a PARS-inhibitor with selective iNOS blockade during porcine endotoxemia. Intensive Care Med 2003; 29:995-1002. [PMID: 12739012 DOI: 10.1007/s00134-003-1739-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2002] [Accepted: 03/03/2003] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate the effects of combined selective inducible nitric oxide synthase (iNOS) inhibition using 1400 W with nicotinamide (NAD) as a PARS-inhibitor on hepato-splanchnic hemodynamics, O(2) kinetics, and energy metabolism during hyperdynamic porcine endotoxemia. DESIGN Prospective, randomized, controlled, interventional experiment. SETTING Animal research laboratory. SUBJECTS Seventeen domestic pigs. INTERVENTIONS After 12 h of continuous i.v. endotoxin (LPS) infusion 17 pigs received either no drug (CON, n=9) or 1400 W, titrated to maintain mean arterial pressure (MAP) at pre-endotoxin level, plus 10 mg.kg.h NAD ( n=8;). Measurements were obtained before, 12 h, 18 h, and 24 h after starting LPS infusion. MEASUREMENTS AND RESULTS In addition to systemic and pulmonary hemodynamics and gas exchange, we measured hepatic arterial and portal venous blood flow, liver and portal venous drained viscera O(2) exchange, ileal mucosal-arterial PCO(2) gap, and portal as well as hepatic venous lactate/pyruvate ratios. Expired NO and plasma nitrate levels were assessed as a parameter of NO production. Without affecting cardiac output, therapy maintained MAP and blunted the LPS-induced rise in expired NO levels, attenuated the progressive fall in liver lactate clearance, and blunted the impairment of hepato-splanchnic redox state. The rise of ileal mucosal-arterial PCO(2) gap was not influenced. CONCLUSIONS Combining selective iNOS inhibition with NAD as a PARS blocker may prevent circulatory failure and attenuate the detrimental consequences of LPS in intestinal and hepatocellular energy metabolism. Given the potential hepatotoxicity of high-dose NAD treatment, more potent PARS blockers with higher selectivity might further enhance the benefit of this therapeutic approach.
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Affiliation(s)
- A Stehr
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum, 93053, Regensburg, Germany.
| | - F Ploner
- Abteilung für Anästhesie, Landeskrankenhaus, 39049, Sterzing/Südtirol, Italy
| | - I Tugtekin
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinik für Anästhesiologie, 89073, Ulm, Germany
| | - M Matejovic
- Interni Kliniky, Karlova Univerzita, 30460, Plzen, Czech Republic
| | - M Theisen
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinik für Anästhesiologie, 89073, Ulm, Germany
| | - C Zülke
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum, 93053, Regensburg, Germany
| | - M Georgieff
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinik für Anästhesiologie, 89073, Ulm, Germany
| | - P Radermacher
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinik für Anästhesiologie, 89073, Ulm, Germany
| | - K-W Jauch
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum, 93053, Regensburg, Germany
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Gölder S, Strotzer M, Grüne S, Zülke C, Schölmerich J, Messmann H. Combination of colonoscopy and clip application with angiography to mark vascular malformation in the small intestine. Endoscopy 2003; 35:551. [PMID: 12783364 DOI: 10.1055/s-2003-39656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- S Gölder
- Department of Internal Medicine I, University Hospital of Regensburg, 93042 Regensburg, Germany.
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26
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Gölder S, Strotzer M, Grüne S, Zülke C, Schölmerich J, Messmann H. Combination of colonoscopy and clip application with angiography to mark vascular malformation in the small intestine. Endoscopy 2003; 35:378. [PMID: 12664406 DOI: 10.1055/s-2003-38141] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- S Gölder
- Department of Internal Medicine I, University Hospital of Regensburg, Regensburg, Germany.
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27
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Krüger B, Zülke C, Fischereder M, Leingärtner T, Kammerl M, Fürst A, Graeb C, Anthuber M, Jauch KW, Krämer BK. Early experience with the ET Senior Program "Old For Old"; better to be number one? Transpl Int 2002; 15:541-5. [PMID: 12461657 DOI: 10.1007/s00147-002-0439-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2001] [Revised: 01/21/2002] [Accepted: 05/29/2002] [Indexed: 10/27/2022]
Abstract
Eurotransplant offers a Senior Program to extend the donor pool for renal transplantation. The study comprised 14 patients of the ET Senior ("Old For Old") Program. Kidneys from five cadaveric donors were transplanted in pairs to ten recipients with a difference in cold ischemia time (CIT) of >4 h, and grouped according to CIT (group 1: patients that underwent transplantation first; group 2: patients that underwent transplantation second). CIT was shorter (5.5+/-2.0 h vs. 11.7+/-3.1 h, P<0.01), and the first day diuresis was higher (287.4 ml/h vs. 134.8 ml/h, P<0.05) in group 1 than in group 2. No patient in group 1 required dialysis, 3/5 patients in group 2. Rejection episodes occured more often in group 2 (5/5 vs. 3/5), and the hospital stay tended to be shorter in group 1 (33.0 days (27-43) vs. 54.2 days (27-112)). Our study confirms the positive effect of ultra-short CIT on early graft function in marginal donors, despite overall short CIT. The increase in delayed graft function (DGF) may lead to an extended hospital stay and dialysis requirements. Efforts to realize simultaneous transplantation in two recipients seem necessary to optimize results.
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Affiliation(s)
- Bernd Krüger
- Klinik u. Poliklinik f. Innere Medizin II, Universität Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.
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28
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Seeliger H, Fürst A, Zülke C, Jauch KW. Surgical management of bile duct injuries following laparoscopic cholecystectomy: analysis and follow-up of 28 cases. Langenbecks Arch Surg 2002; 387:286-93. [PMID: 12447554 DOI: 10.1007/s00423-002-0330-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2002] [Accepted: 09/26/2002] [Indexed: 11/28/2022]
Abstract
BACKGROUND Biliary tract lesions pose a dreaded complication of laparoscopic cholecystectomy. In a retrospective study we analyzed the clinical presentation, diagnostic and therapeutic management and outcome of 28 patients presenting with iatrogenic bile duct injuries. PATIENTS AND METHODS Between 1994 and 2001 we treated 28 patients with bile duct lesions following laparoscopic cholecystectomy at our center. Operation notes and charts of all patients were reviewed systematically. A follow-up examination of each patient was performed after a median of 12 months (range 1-90). RESULTS Twenty-two patients presented with major circumferential bile duct defect lesions. Less severe injuries (n=6) were two minor bile leaks, one bile duct stricture and three tangential lesions. Twenty-six patients were referred to our institution within 16 days (range 0-226 days). Six patients were treated by nonsurgical procedures: endoscopic stenting in four and percutaneous intervention in two. In one of the remaining patients a cystic duct leak was closed via laparotomy, and in 21 a hepaticojejunostomy was performed. Reconstruction of a hepaticojenunostomy was performed in two of these patients. Patients were dismissed from the hospital after a median of 13 days (range 4-156). Four patients presenting with generalized biliary peritonitis required prolonged intensive care. One or more episodes of cholangitis were seen in five patients during follow-up examinations. CONCLUSIONS Major iatrogenic bile duct injuries are associated with high morbidity and prolonged hospitalization. Interdisciplinary cooperation and early referral to an experienced center is crucial in the management of patients suffering from this affliction. Cholangitis is a marked problem in the follow-up.
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Affiliation(s)
- Hendrik Seeliger
- Klinik und Poliklinik für Chirurgie, Klinikum der Universität Regensburg, Germany.
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29
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Krüger B, Schröppel B, Ashkan R, Marder B, Zülke C, Murphy B, Krämer BK, Fischereder M. A Monocyte chemoattractant protein-1 (MCP-1) polymorphism and outcome after renal transplantation. J Am Soc Nephrol 2002; 13:2585-9. [PMID: 12239249 DOI: 10.1097/01.asn.0000031701.53792.54] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Among the factors modulating transplant rejection and cardiovascular disease, chemokines and their respective receptors deserve special attention. In this respect, increased expression of MCP-1 and the corresponding receptor CCR2 have been demonstrated in renal transplant rejection and coronary artery disease. The impact of the MCP-1-2518G and CCR2-64I genotypes on renal allograft function was investigated in 232 patients who underwent transplantation over an 11-yr period. Genomic DNA was genotyped using PCR with sequence-specific primers followed by restriction fragment length polymorphism analysis. Eighteen (7.8%) patients were homozygous for the MCP-1-2518G mutation. The G/G allele of MCP-1 -2518 behaved as a determinant for long-term allograft survival and resulted in reduction of the mean graft survival, as compared with the heterozygous (A/G) or wild-type (A/A) allele (67 +/- 14 versus 95 +/- 4 mo; Log rank P = 0.0052). The 64I mutation of CCR2 had no effect on kidney graft failure (93 +/- 6 and 91 +/- 5 mo, respectively; P = 0.81). None of the investigated polymorphisms showed a significant shift in gene frequency in acute rejection and rejection-free groups. In conjunction with these findings, peripheral blood mononuclear cells from kidney transplant recipients carrying the G-allele were characterized by a 2.5-fold higher MCP-1 secretion (P < 0.05). In conclusion, recipients of renal transplants homozygous for the -2518 G mutation of the MCP-1 gene are at risk for premature kidney graft failure. This variant of MCP-1 may be a future predictor for long-term kidney graft failure.
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Affiliation(s)
- Bernd Krüger
- Klinik für Innere Medizin II, University of Regensburg, Germany
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30
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Affiliation(s)
- M Fischereder
- Klinik und Poliklinik für Innere Medizin II, Klinikum der Universität Regensburg, Regensburg, Germany.
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Zülke C, Ulbrich S, Graeb C, Hahn J, Strotzer M, Holler E, Jauch KW. Acute pneumatosis cystoides intestinalis following allogeneic transplantation -- the surgeon's dilemma. Bone Marrow Transplant 2002; 29:795-8. [PMID: 12040479 DOI: 10.1038/sj.bmt.1703527] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2001] [Accepted: 01/03/2002] [Indexed: 01/02/2023]
Abstract
Pneumatosis cystoides intestinalis (PCI) is still a poorly understood phenomenon, currently considered to result from primary mucosal insult from varying causes. We report a case of severe PCI in a patient with chronic GVHD after bone marrow transplantation (BMT) performed to treat secondary AML. Post BMT, the patient suffered acute intestinal and cutaneous GVHD, eventually developing intestinal and biopsy-proven cutaneous chronic GVHD, which necessitated continuous steroid therapy. Chronic pancreatitis associated with GVHD was diagnosed by explorative surgery in February 2000 on the basis of increasing epigastric discomfort, tumour marker (CA 125) increase and the CT finding of a suspicious mass in the pancreas. Readmission occurred in April 2000 for rapid onset of inferior abdominal pain with distinct peritoneal signs. Relaparotomy, deemed necessary on the grounds of both clinical and radiological findings, revealed marked PCI of the ascending and transverse colon and attached mesentery in an otherwise intact gastrointestinal tract. Post-operative reconvalescence was uneventful, with no clinical or radiological recurrence of PCI in the following 10 months. In the context of a review of the relevant literature, this case report illustrates the complex underlying pathophysiology, and difficulty in making a differential diagnosis and treating PCI.
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Affiliation(s)
- C Zülke
- Department of Surgery, University Hospital Regensburg, Bavaria, Germany
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Bolley R, Zülke C, Kammerl M, Fischereder M, Krämer BK. Tacrolimus-induced nephrotoxicity unmasked by induction of the CYP3A4 system with St John's wort. Transplantation 2002; 73:1009. [PMID: 11923712 DOI: 10.1097/00007890-200203270-00035] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Träger K, Matejovic M, Vogt J, Zülke C, Vlatten A, Wachter U, Altherr J, Brinkmann A, Brückner UB, Jauch KW, Georgieff M, Radermacher P. Hepatic oxygen exchange and energy metabolism in hyperdynamic porcine endotoxemia: effects of the combined thromboxane receptor antagonist and synthase inhibitor DTTX30. Intensive Care Med 2001; 27:416-25. [PMID: 11396287 DOI: 10.1007/s001340000839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We compared the effects of thromboxane receptor antagonist and synthase inhibitor DTTX30 on systemic and liver blood flow, oxygen (O2) exchange and energy metabolism during 24 h of hyperdynamic endotoxemia with untreated endotoxemia. DESIGN Prospective, randomized, experimental study with repeated measures. SETTING Investigational animal laboratory. SUBJECTS Twenty-seven domestic pigs: 16 during endotoxemia with volume resuscitation alone; 11 with endotoxemia, volume resuscitation and treatment with DTTX30. INTERVENTIONS Continuous infusion of Escherichia coli lipopolysaccharide (LPS) for 24 h together with volume resuscitation. After 12 h of endotoxemia, DTTX30 was administered as a bolus of 0.12 mg kg-1 followed by 12 h continuous infusion of 0.29 mg kg-1 per h. MEASUREMENTS AND RESULTS DTTX30 effectively counteracted the endotoxin-associated increase in TXB2 levels and increased 6-keto-PGF1 alpha with a significant shift of the thromboxane/prostacyclin ratio towards predominance of prostacyclin. DTTX30 prevented the significant progressive endotoxin-induced decrease of mean arterial pressure (MAP) below baseline while maintaining cardiac output (CO), and increased the fractional contribution of liver blood flow to CO without an effect on either hepatic O2 delivery or O2 uptake. The mean capillary hemoglobin O2 saturation (HbO2) on the liver surface and HbO2 frequency distributions remained unchanged as well. CONCLUSIONS DTTX30 significantly attenuated the endotoxin-induced derangements of cellular energy metabolism as reflected by the diminished progressive decrease in hepatic lactate uptake rate and a blunted increase in hepatic venous lactate/pyruvate ratios. While endotoxin significantly increased the endogenous glucose production (EGP) rate, EGP returned towards baseline levels in the DTTX30-treated group. Thus, in our model DTTX30 resulted in hemodynamic stabilization concomitant with improved hepatic metabolic performance.
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Affiliation(s)
- K Träger
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinik für Anästhesiologie, Universität Ulm, Parkstrasse 11, 89073 Ulm, Germany.
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Kammerl MC, Fischereder M, Zülke C, Obermann EC, Anthuber M, Riegger GA, Krämer BK. Renal transplantation in a patient with end stage renal disease due to cholesterol embolism. Transplantation 2001; 71:149-51. [PMID: 11211182 DOI: 10.1097/00007890-200101150-00024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Renal failure due to cholesterol emboli is mostly irreversible. Therefore chronic renal replacement therapy is necessary. However, to the best of our knowledge no published experience exists with renal transplantation in patients with end-stage renal disease (ESRD) due to cholesterol embolization (CE). METHODS Renal transplantation was performed in a 64-year-old man who suffered from ESRD due to CE after coronary angiography. Because our patient presented with a typical profile of cardiovascular risk factors effective long-term control of these risk factors before and after transplantation was a mandatory prerequisite before considering transplantation. RESULTS After one rejection episode serum creatinine values have been stable and no major complications have occurred during a follow-up of 18 months. No signs of recurrent cholesterol emboli into the donated kidney were seen in renal biopsies performed due to graft rejection. CONCLUSION Cholesterol embolization is an uncommon reason for ESRD and mainly occurs after invasive vascular procedures in patients with hyperlipidemia, arterial hypertension, and smoking. Because ESRD due to CE often is irreversible, chronic renal replacement therapy may be necessary. As demonstrated in our report, renal transplantation should be considered. However, in this setting effective long-term control of the underlying risk factors before and after renal transplantation has to be ensured.
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Affiliation(s)
- M C Kammerl
- Klinik und Poliklinik für Innere Medizin II, Klinik und Poliklinik für Chirurgie, and Institut für Pathologie, University of Regensburg, Germany
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Lock G, Zülke C, Lerch K, Andreesen R, Eilles C, Jauch KW, Feuerbach S, Schölmerich J. [The ultrasound centre as a medically and economically relevant alternative--a report of the Regensburg experience]. Z Gastroenterol 2000; 38:941-4. [PMID: 11194883 DOI: 10.1055/s-2000-10022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
In most medical centres, ultrasonography is performed independently by several departments. In october 1997, the University hospital of Regensburg founded an ultrasound centre, integrating surgical and medical departments as well as the institutes for radiology and nuclear medicine. The aims of this centre were the concentration of organization, machines, financial resources, manpower and know-how, standardized training and quality, and strengthening of interdisciplinary cooperation in clinic, medical education and research. Booking, standardized reports and a joint archiving of reports are assisted by a collective computer system. Most examinations in the centre are performed by three all-day present gastroenterology, surgery and radiology residents who are supported by licensed sonographers of the other departments. Training is standardized, and the certification for ultrasound examinations is acquired after a test with theoretical and practical parts. The integration of various departments in the ultra-sound on-call service has led to significant savings. The pool of ultrasound machines is used jointly, department-specific resources for new machines have been put together. We are convinced that this way of a close interdisciplinary cooperation will result in improvements in quality, utilization of financial resources and clinical research.
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Affiliation(s)
- G Lock
- Klinik und Poliklinik für Innere Medizin I, Universität Regensburg.
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Träger K, Matejovic M, Zülke C, Vlatten A, Vogt J, Wachter U, Altherr J, Brinkmann A, Jauch KW, Georgieff M, Radermacher P. Hepatic O2 exchange and liver energy metabolism in hyperdynamic porcine endotoxemia: effects of iloprost. Intensive Care Med 2000; 26:1531-9. [PMID: 11126268 DOI: 10.1007/s001340000645] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the effects of a 12 h continuous infusion of iloprost, a stable prostacyclin analogue, on hepatic blood flow (Qliv), O2 exchange, and energy metabolism during a 24 h hyperdynamic, porcine endotoxemia with volume resuscitation alone. DESIGN Prospective, randomized, experimental study with repeated measures. SETTING Investigational animal laboratory. SUBJECTS Twenty-eight domestic pigs: 16 animals during endotoxemia with volume resuscitation alone (ETX), 12 with endotoxemia, volume resuscitation, and treatment with iloprost (ILO). INTERVENTIONS Endotoxemia was initiated by continuous infusion of E. coli lipopolysaccharide. Animals were resuscitated with hetastarch, aimed at maintaining a MAP of > 60 mmHg. After 12 h of endotoxemia, iloprost was administered for 12 h in the treatment group, titrated to avoid pharmacologically induced hypotension (MAP < 60 mmHg). MEASUREMENTS AND RESULTS Iloprost significantly increased Qliv, with no effect on hepatic O2 delivery. Mean capillary hemoglobin O2 saturation (HbScO2) on the liver surface, as well as HbScO2 frequency distributions--a measure of microcirculatory O2 availability--remained unchanged. Treatment with iloprost, however, significantly attenuated the endotoxin-induced derangements of cellular energy metabolism as reflected by the diminished progressive decrease in hepatic lactate uptake rate and a blunted increase in hepatic venous lactate/pyruvate ratios. While endotoxin significantly increased endogenous glucose production (EGP) rate, iloprost restored EGP to normal at the end of the experiment. CONCLUSIONS Thus, in a clinically relevant model of human sepsis, iloprost did not produce potential adverse effects but rather ameliorated hepatic metabolic disturbances and, thereby, hepatic energy balance.
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Affiliation(s)
- K Träger
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinik für Anästhesiologie, Universiät Ulm, Germany.
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Matejovic M, Radermacher P, Zülke C, Vlatten A, Altherr J, Brinkmann A, Brückner UB, Jauch KW, Georgieff M, Träger K. Effects of the combined thromboxane receptor antagonist and synthase inhibitor DTTX-30 on intestinal O2-exchange and energy metabolism during hyperdynamic porcine endotoxemia. Shock 2000; 13:307-13. [PMID: 10774620 DOI: 10.1097/00024382-200004000-00009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Sepsis may lead to deranged thromboxane-prostacyclin ratio with consecutive organ dysfunction. Because of the suggested role of the gut in the pathogenesis of septic shock and multiple organ failure, we investigated the effects of the novel dual thromboxane synthase inhibitor and receptor antagonist DTTX-30 (TRASI) on intestinal tissue perfusion, O2 kinetics, and energy metabolism over 24 h of hyperdynamic, normotensive porcine endotoxemia. Before, 12, 18, and 24 h after starting continuous i.v. endotoxin (LPS), we measured portal venous (PV) blood flow, intestinal oxygen extraction (iO2ER), intracapillary hemoglobin O2 saturation (HbO2%) of the ileal wall, intramucosal ileal PCO2, PV lactate-pyruvate (L-P) ratio, and plasma levels of thromboxane and prostacyclin. Treatment with TRASI (0.12 mg/kg i.v. bolus injection followed by an infusion of 0.29 mg/kg/h) initiated after 12 h of LPS infusion markedly reduced the plasma thromboxane levels and attenuated the LPS-induced fall in systemic vascular resistance, resulting in hemodynamic stabilization. TRASI did not influence the LPS-induced increase in PV blood flow nor intracapillary HbO2%, thus reflecting unchanged microcirculatory O2 availability and decreased iO2ER, possibly because of reduced O2 requirements. Nevertheless, TRASI prevented the LPS-induced increase in the PV L-P ratio, attenuated the progression of the ileal mucosal-arterial PCO2 gap, and tended to attenuate the gradual fall of PV pH. Hence, compounds like TRASI may beneficially influence LPS-related derangements of gut energy metabolism.
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Affiliation(s)
- M Matejovic
- Sektion Anasthesiologische Pathophysiologie und Vefahrensentwicklung, Universitätsklinik für Anasthesiologie, Ulm, Germany
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Zülke C, Graeb C, Rüschhoff J, Wagner H, Jauch KW. [Differential diagnosis and therapy of acute abdomen in sickle cell crisis. A rare case in visceral surgery]. Zentralbl Chir 2000; 125:166-73. [PMID: 10743038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Surgical therapy of the acute abdomen often allows only limited time for differential diagnosis to confirm the indication for surgery. Under consideration of clinical aspects and case history both common and rare causes of an acute abdomen should be investigated without undue loss of time. Differential diagnostic considerations and eventual therapy are presented in the following case of a 25-year-old Afro-american who developed multiorgan failure after an initial course of lower-back pain. In addition to the clinical setting of an acute abdomen the patient presented with acute respiratory failure and laboratory signs of severe hemolysis in combination with newly detected splenomegaly. The indication for splenectomy was made following CT-proven complete splenic infarction due to repeated acute squestration. Histologic examination of the spleen together with hemoglobin electrophoresis confirmed the clinical assumption of unusually late primary manifestation of a sickle cell crisis. In the underlying case, the hemoglobinopathy was in fact the less common form of combined sickle-cell-beta-thalassemia. A ten-day course of intensive care therapy was necessary to treat ongoing multiorgan failure due to persistent sickle cell crisis. Current diagnostic and therapeutic procedures in connection with sickle cell crisis as a rare cause of an acute abdomen with the necessity for surgical intervention are presented.
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Affiliation(s)
- C Zülke
- Klinik und Poliklinik für Chirurgie, Universität Regensburg.
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Glück T, Krämer BK, Zülke C, Rüschoff J, Rogler G, Schweda F, Anthuber M, Lang B, Schölmerich J. Late onset primary oxalosis type I: an uncommon presentation of a rare disease. Eur J Gastroenterol Hepatol 1998; 10:809-12. [PMID: 9831280 DOI: 10.1097/00042737-199809000-00016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
A 46-year-old woman developed rapidly worsening renal insufficiency. Extensive calcification of the kidneys was found. The patient also suffered from ischaemic neuropathy, myopathy and arthritis. In a muscle biopsy multiple calcium oxalate crystals could be demonstrated surrounded by inflammatory infiltrates. Levels of oxalate in serum were markedly elevated. Diagnosis of primary hyperoxaluria type I was made by measuring alanine/glyoxylate aminotransferase activity in a liver biopsy. The patient underwent kidney transplantation twice, but each of the transplants failed after a very short time owing to hyperacute rejection and rupture of the organ, respectively. Eventually, combined liver/kidney transplantation was successfully performed. Two years after the transplantation, both organs work with good function. This case of primary hyperoxaluria type I is remarkable for the late onset of symptoms and the extensive involvement of other organ systems in addition to the kidneys. This case presentation confirms previous reports discouraging isolated kidney transplantation for patients with primary hyperoxaluria. Only combined liver/kidney transplantation can correct the metabolic defect and may give these patients superior long-term benefit.
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Affiliation(s)
- T Glück
- Department of Internal Medicine I, University Medical Center, University of Regensburg, Germany
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Zülke C, Anthuber M, Krämling HJ, Berger H, Jauch KW, Schildberg FW. Primary shunt perfusion detected by colour flow Doppler imaging and its impact on liver allograft survival. Clin Transplant 1997; 11:163-8. [PMID: 9193836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Primary dysfunction (PDF) and eventual primary nonfunction (PNF) of liver allografts have been characterized by various clinical and laboratory parameters reflecting graft function, cellular integrity and extrahepatic influence following orthotopic liver transplantation (OLT). During the past 6 yr we have been able to demonstrate that this potentially devastating condition is routinely accompanied by a pathological initial perfusion pattern detected by colour flow doppler imaging (CFDI) within hours following OLT. In the majority of PDF cases (n = 30) CFDI revealed increased vascular resistance in regard to arterial blood flow to the malfunctioning graft, with a resulting 1-yr graft survival rate of 80% following the institution of early prostaglandin therapy in this group of patients. A completely different perfusion pattern was noticed by CFDI in a total of 13 cases with grossly decreased arterial resistance, resulting in an apparently supranormal arterial blood supply together with a reduced portal inflow in comparison to primarily functioning grafts. The presence of this pathologic graft perfusion was explained by the formation of arterio-portal shunts within the graft during conservation and reperfusion, leading to a 1-yr graft survival of merely 46.1%.
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Affiliation(s)
- C Zülke
- Department of Surgery, University Hospital, Regensburg, Germany
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Berger H, Stäbler A, Kunzfeld A, Zülke C, Anthuber M, Krämling HJ. [Interventional radiologic procedures in postoperative complications after liver transplantation]. Radiologe 1997; 37:205-10. [PMID: 9182309 DOI: 10.1007/s001170050200] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Postoperative complications contribute significantly to the morbidity and mortality of liver transplant patients. The management of these complications requires a multidisciplinary approach in which interventional radiology plays an integral role. Indications, techniques, and results of radiological interventions in the management of the liver transplant patient are presented. MATERIAL AND METHODS During a 10-year period, 52 out of 420 liver transplant recipients underwent radiological interventions, including angioplasty (n = 20), embolization (n = 2), percutaneous drainage (n = 11), and biliary interventions (n = 19). RESULTS Nine out of ten arterial stenoses located at the anastomoses (n = 8), within the liver (n = 1) and in the coeliac trunk (n = 1) were successfully treated by balloon dilatation. Angioplasty of supra- or infrahepatic anastomotic stenoses of the i.c.v. (n = 5) provided long-term success only in combination with stent implantation. Portal vein stenoses and chronic thrombosis were treated by balloon dilatation and stent insertion via transhepatic catheterization of the portal vein. Late strictures of bile-duct anastomoses can be managed by ante- or retrograde interventions. If biliary complications are related to inflammatory or septic problems, the prognosis of graft survival is poor. CONCLUSION Interventional radiological procedures are very useful in the management of vascular and biliary complications after liver transplantation. These techniques provide a cure in many situations, and thus, surgical interventions may be avoided in selected cases.
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Affiliation(s)
- H Berger
- Institut für Radiologische Diagnostik
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Zülke C, Berger H, Anthuber M, Jauch KW. Detection of suprahepatic caval stenosis following liver transplantation and treatment via balloon-expandable intravascular stent. Transpl Int 1995. [DOI: 10.1111/j.1432-2277.1995.tb01531.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Zülke C, Berger H, Anthuber M, Jauch KW. Detection of suprahepatic caval stenosis following liver transplantation and treatment via balloon-expandable intravascular stent. Transpl Int 1995; 8:330-2. [PMID: 7546159 DOI: 10.1007/bf00346890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Sauter G, Zülke C, Pape GR. [Right-sided epigastric pain and ascites in a 24-year-old female patient]. Internist (Berl) 1993; 34:274-7. [PMID: 8473102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- G Sauter
- Medizinische Klinik II, Ludwig-Maximilians-Universität München
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45
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Briegel J, Haller M, Zülke C, Kilger E, Pratschke E, Jauch KW, Berger H, Forst H. Primary graft nonfunction following orthotopic liver transplantation: treatment with prostacyclin. Transplant Proc 1992; 24:2693-5. [PMID: 1465903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- J Briegel
- Department of Anesthesiology, Ludwig-Maximilians-University of Munich, Germany
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Abstract
Determinants for homologous blood transfusion and its influence on postoperative and long-term results were evaluated in 439 curatively resected colorectal cancer patients. The rate of transfusion was significantly higher in rectal cancer, large tumors, advanced pT stage and extended resection but not in tumor stenosis, lower graded tumors, advanced Dukes stage or less experienced surgeons. Transfused patients showed significantly more postoperative complications, higher recurrence rates as well as less favorable long-term survival. Homologous blood transfusions are negatively correlated to survival rates.
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Affiliation(s)
- F Liewald
- Department of Surgery, Ludwig-Maximilians University Munich, F.R.G
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47
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Billing A, Zülke C, Huf R, Denecke H. [Blunt injuries of the gastrointestinal tract]. Unfallchirurg 1990; 93:62-5. [PMID: 2315715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This study represents our experience with severe blunt gastrointestinal injury in 29 polytrauma and 3 solitary trauma patients. The primary diagnosis was missed in intestinal perforation (4x) and mesenteric disrupture (1x). In 2 other patients contusion of the gastrointestinal wall led to postprimary perforation. The average mortality was 21.8%; only 2 patients died from abdominal sepsis. Blunt gastrointestinal trauma differs from penetrating injury as far as the diagnostic and therapeutic aspects are concerned. In some cases, explorative laparotomy alone leads to early diagnosis. For sufficient management, the blunt contusion/compression aspects must be taken into account.
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Affiliation(s)
- A Billing
- Chirurgische Klinik und Poliklinik, Ludwig-Maximilians-Universität, München
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