"Heidelberg standard examination" and "Heidelberg standard procedures" - Development of faculty-wide standards for physical examination techniques and clinical procedures in undergraduate medical education

The competent physical examination of patients and the safe and professional implementation of clinical procedures constitute essential components of medical practice in nearly all areas of medicine. The central objective of the projects "Heidelberg standard examination" and "Heidelberg standard procedures", which were initiated by students, was to establish uniform interdisciplinary standards for physical examination and clinical procedures, and to distribute them in coordination with all clinical disciplines at the Heidelberg University Hospital. The presented project report illuminates the background of the initiative and its methodological implementation. Moreover, it describes the multimedia documentation in the form of pocketbooks and a multimedia internet-based platform, as well as the integration into the curriculum. The project presentation aims to provide orientation and action guidelines to facilitate similar processes in other faculties.

[The competent surgeon. Bridging the gap between undergraduate final year and postgraduate surgery training]

Competency-based frameworks rely on relevant professional competency rather than formal regulations. The transitional phase between final year undergraduate and common trunk postgraduate medical training is characterized by an increase of professional responsibility whereby previously acquired knowledge, skills and abilities have to be merged and applied to patients. Undergraduate and postgraduate training programs should ensure a successive transfer of responsibility for medical practice to final year students and young residents depending on individual competence. The concept of entrustable professional activities (EPA) represents a curricular concept based on concrete medical tasks which may be assigned to the responsibility of the trainee.

Early postoperative complications after stapled vs handsewn restorative proctocolectomy with ileal pouch-anal anastomosis in 148 patients with familial adenomatous polyposis coli: a matched-pair analysis

AIM

Restorative proctocolectomy with ileal pouch-anal anastomosis for patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) has been modified from a transanal hand-suture after mucosectomy to a stapled ileal pouch-anal anastomosis (IPAA) without mucosectomy. Better functional results favour stapled anastomosis; however, stapled anastomosis results in higher rates of adenomas in persisting anorectal mucosa. The purpose of this study was to compare the two techniques of pouch-anal anastomosis with respect to early postoperative complications in a collective of FAP patients.

METHOD

The study was performed as a matched-pair analysis. Data were obtained from a prospectively collected database.

RESULTS

The overall rate of postoperative complications was higher after stapled IPAA (31% stapled vs 23% handsewn), with anastomotic stricture occurring in 24.3% (stapled) and 16.2% (handsewn) (P = 0.22). Any leakage or pelvic abscess formation after stapled anastomosis occurred within 30 days in almost all patients, whereas these were mainly diagnosed between 30 days and 6 months after handsewn IPAA. A laparoscopic approach was used in 56.7% of patients in the stapled group but in only two patients in the handsewn group. Intra-operative blood loss was significantly higher in the handsewn group (mean ± SD: 699 ± 511 ml vs 369 ± 343 ml; P < 0.0001), as was the volume of blood transfused (mean ± SD: 205 ± 365 ml vs 8 ± 49 ml; P < 0.0001). Function did not differ between the groups.

CONCLUSION

There was a nonstatistically significant tendency towards a higher rate of early postoperative complications after stapled IPAA. The timing of anastomotic leakage and abscess formation differed between the groups.

Desmoid tumour biology in patients with familial adenomatous polyposis coli

BACKGROUND

Familial adenomatous polyposis (FAP) is caused by mutations in the adenomatous polyposis coli (APC) gene. Desmoid tumours affect up to 26 per cent of patients and contribute significantly to death. This study aimed to assess the influence of sex and mutation site on desmoid tumour development and sex-specific genetic differences in patients with FAP with and without desmoid tumours.

METHODS

Patients with FAP-associated desmoid tumours recorded in the Heidelberg Polyposis Register between 1991 and 2010 were identified. These patients were analysed with respect to clinical parameters and possible risk factors.

RESULTS

Some 105 patients with FAP-associated desmoid tumours of a total of 585 patients with FAP were analysed. Male patients had a significantly greater number of desmoid tumours and a larger tumour mass, although tumours were more common in female patients. Desmoid tumours in male patients were located more often in the abdominal wall. Seventy-nine (75.2 per cent) of the 105 patients demonstrated a clear temporal association between a previous operation and subsequent desmoid tumour development; most of these patients were female. Mutation sites in male patients were limited to exons 5, 14 and 15, whereas female patients carried mutations along the entire coding region of the APC gene. Twenty-one per cent of patients with desmoid tumours carried mutations within the 'desmoid region', compared with only 4.1 per cent of the control group without desmoids.

CONCLUSION

There are significant sex differences concerning desmoid tumour manifestation. Female patients appear to have a higher risk of desmoid tumour occurrence independent of the mutation site, whereas in male patients the mutation site seems to exert more influence.

[Modular postgraduate training in surgery - a national concept with future]

BACKGROUND

The quality of postgraduate training is an important motivating factor for the career decisions of young doctors and has an impact on the satisfaction of postgraduate trainees. In Germany, we still lack a postgraduate training programme in surgery that defines the competency profile at the time of certification. This article describes the development of a national modular competency-based core curriculum for postgraduate surgery training as well as first experience and evaluation data from the initial period of implementation.

METHODS

The curriculum was developed in a group of highly motivated surgeons according to the "Kern-cycle", a conceptual framework for curriculum development in medicine, and includs considerations from the "CanMEDS"-competency framework for physicians. The curriculum follows a "blended learning" concept with modular attendance courses and associated preparatory online courses. The didactics follows the principles of adult learning and are characterised by learner-centred, self-directed learning processes in small groups with feedback. The initial implementation phase was accompanied by a detailed evaluation of the general concept as well as the quality of content and didactics of the attendance courses.

RESULTS

Seven of the planned 12 attendance courses have been designed, 6 courses have been implemented2q1. Altogether 562 participants from hospitals of all levels of patient care took part in the attendance courses, some of them in several courses. The gender distribution was almost balanced with a slight female surplus. The majority of participants were supported by their clinics through exemption from clinical work or financial sponsoring. 80 % of the participants completed the evaluation of the attendance courses. The data show a high degree of participant satisfaction with the content and didactic concept of the courses, as well as with the surrounding conditions and the commitment of the trainers.

CONCLUSIONS

The evaluation data on the attendance courses implemented reveal a high acceptance among participants concerning the overall concept of the modular postgraduate training programme as well as the support of the programme by surgeons responsible for postgraduate training.

Quality of life after restorative proctocolectomy and ileal pouch-anal anastomosis in patients with familial adenomatous polyposis: a matter of adjustment

AIM

Favourable outcomes for health-related quality of life (HRQL) have been reported in patients with familial adenomatous polyposis (FAP) after restorative proctocolectomy and ileal pouch-anal anastomosis (RPC). However, less is known about patients' subjective experience and adjustment to postoperative impairment. Using a multidimensional psychometric assessment, we investigated patient-reported HRQL to determine the impact of the patient's subjective experience together with medical, functional and psychosocial factors on HRQL.

METHOD

In this cross-sectional study, 116 FAP patients who had undergone RPC on average 8 years earlier completed standardized and study-specific questionnaires and participated in a personal interview. The impact of medical, functional and psychosocial factors on patients' HRQL was determined by regression analyses.

RESULTS

When using a generic psychometric measure, FAP patients' overall HRQL was comparable with that of the general population. Impaired HRQL, however, was found in patients reporting poor pouch function in contrast to those reporting good or moderate functional outcome. Findings from a personalized interview also suggested that a good functional result does not necessarily translate into good HRQL. Personal resources predicted patients' physical and psychological well-being, whereas little variance of HRQL was explained by medical factors and function.

CONCLUSION

Patients' HRQL is, to a substantial degree, the result of adjustment to the adverse impact of RPC. By using personal resources the majority of patients may achieve satisfactory HRQL levels even when bowel function is impaired. A multidimensional assessment that comprises medical, functional and psychosocial aspects is required to ascertain an adequate evaluation of FAP patients after RPC.

Functional outcome after restorative proctocolectomy in pigs: comparing a novel transverse ileal pouch to the J-pouch and straight ileoanal anastomosis

BACKGROUND

Restorative proctocolectomy followed by an ileoanal J-pouch procedure is the therapy of choice for patients with familial adenomatous polyposis and ulcerative colitis. After low anterior rectal resection, the authors have reported on a novel, less complex pouch configuration, a transverse coloplasty pouch. The aim of the present work was to apply this new design to the ileal pouch construction, to evaluate feasibility, and to measure functional results in comparison with the J-pouch and the straight ileoanal anastomosis using the pig as an animal model.

METHODS

Twenty-three pigs underwent restorative proctocolectomy followed by reconstruction with straight ileoanal anastomosis (IAA; n = 5), J-pouch (n = 7), and a transverse ileal pouch (TIP; n = 11). Pigs were followed for 6 days postoperatively. Peristaltic function was assessed by manometry proximal to the pouch, in the reservoir, and at the level of the ileoanal anastomosis. Functional outcome was monitored by semiquantitative assessment of the general condition of the animals, postoperative feeding habits, and stool frequency and consistency. A Fourier analysis was performed in order to compare peristalsis in the ileal reservoirs. The reservoir volume was measured in situ by triple contrast computed tomography scan with 3D reconstruction.

RESULTS

Seventeen animals survived for 1 week. There was no difference in the general condition or the feeding habits of the groups. A significant number of pigs with the TIP pouch (7/10) had semisolid or formed stools as opposed to liquid stools after J-pouch (6/6) and IAA (4/5; p = 0.01). TIP animals had a lower stool frequency (3.2 +/- 1.14 per day) on day 6 after the operation than pigs with J-pouch, 5.33 +/- 1,03, and IAA, 4.6 +/- 1.82 (p = 0.0036). The in situ volume of the pouches did not differ significantly. The Fourier analysis demonstrated a disruption of peristalsis by the J-pouch and the TIP reconstruction but not after IAA.

CONCLUSION

The function of ileoanal reservoirs after proctocolectomy may result from the disruption of properistaltic waves after pouch formation. The mechanism of peristalsis disruption is independent of the in situ volume of the pouch.

A ‘Nonsense’ Mutation Leads to Aberrant Splicing of hMLH1 in a German Hereditary Non-polyposis Colorectal Cancer Family

Hereditary Non-polyposis Colorectal Cancer (HNPCC) is an autosomal dominant cancer predisposition syndrome caused by germline mutations in at least four genes encoding integral components of the cellular DNA mismatch repair (MMR) system. The spectrum of genetic alterations encompasses missense- and nonsense mutations, intronic mutations affecting splice donor or acceptor sites as well as small-scale deletions and insertions. We have identified a 'nonsense' mutation that activates a cryptic splice site generating an in frame deletion of the last 17 codons of exon1 of the hMLH1 gene causing HNPCC in a German family. We present a comprehensive genetic analysis of this family that demonstrates important aspects of HNPCC pathogenesis.

Evaluation der traditionellen studentischen Ausbildung in der Chirurgie

BACKGROUND

The medical faculty of Heidelberg University implemented a new problem-based clinical curriculum (Heidelberg Curriculum Medicinale, or Heicumed) in 2001. The present study analyses the evaluation data of two student cohorts prior to the introduction of Heicumed. Its aim was to specify problems of the traditional training and to draw conclusions for implementation of a new curriculum.

METHODS

The evaluation instrument was the Heidelberg Inventory for the Evaluation of Teaching (HILVE-I). The data were analysed calculating differences in the means between defined groups, with the 13 primary scales of the HILVE I-instrument as dependent variables.

RESULTS

Teaching method and subject had no systematic influence on evaluation results. Thus, didactic lecture in orthopedic surgery achieved better results than small group tutorials, while the data on vascular and general surgery showed opposite results. Major factors for success were continuity and didactic training of lecturers and tutors. This is convincingly reflected by the results of the lecture course "Differential diagnosis in general surgery". The good evaluation data on small group tutorials resulted largely from the "participation" and "discussion" scales, which represent interactivity in learning.

CONCLUSION

The results of the present study suggest the importance of two major pedagogic ideas: continuity and didactic training of lecturers and tutors. These principles were widely implemented in Heicumed and have contributed to the success of the new curriculum.

Prophylaktische Chirurgie der familiären adenomatösen Polyposis coli

Familial adenomatous polyposis coli (FAP) may not be considered a single disease entity with standardized guidelines for operative treatment. However, prophylactic colectomy after the manifestation of polyps but prior to the development of colorectal cancer is essential. The optimal timing of prophylactic surgery remains a clinical decision taken independently of mutation analysis. In case of the classic FAP phenotype, restorative proctocolectomy and ileal pouch-anal anastomosis is the procedure of choice. The development of reliable guidelines for attenuated FAP variants requires further evidence from clinical studies on surgical strategy and the advantages of prophylactic surgery over regular endoscopic screening with removal of polyps.

Die Technik der pankreaserhaltenden Duodenektomie

Even in pancreatic surgery, as in other organs, there is a tendency towards subtle organ-preserving techniques. Benign duodenal tumors which cannot be resected transduodenally or multiple dysplastic duodenal adenomas in patients with familial adenomatous polyposis (FAP) usually require partial pancreaticoduodenectomy. However, pancreas-preserving duodenectomy may represent a viable alternative. This technique allows for the resection of the entire duodenum without resection of the pancreatic head. Large duodenal adenomas, multiple adenomas with dysplasia in patients with FAP, and based on the literature extended duodenal injury after trauma may represent indications for this surgical technique. Compared with duodenopancreatectomy, this intervention can be performed with a comparably low morbidity and leads to good functional results. Beside the preservation of pancreatic parenchyma and the reduction of the number of anastomoses, this technique offers the advantage of uncomplicated endoscopic follow-up. In this article we describe the surgical technique of pancreas-preserving duodenectomy and our experience with this intervention.

Evaluation of Bethesda guidelines in relation to microsatellite instability

PURPOSE

The Bethesda guidelines were developed for selection of patients whose tumors should be tested for high microsatellite instability. This study examined the validity of the different Bethesda criteria in relation to microsatellite instability status to simplify their use in clinical practice.

METHODS

A total of 164 patients with colorectal or hereditary nonpolyposis colorectal cancer-associated cancers were registered on the basis of the Amsterdam criteria without age limitations (11 cases), multiple tumors (2 cases), the accumulation of colorectal cancer in the family (no first-degree relatives affected or the index patient's age up to 50 years; 45 cases), an early age at onset up to 50 years (13 cases), morphologic and histopathologic manifestations (right-sided colorectal cancer, mucinous undifferentiated histology; 1 case), and the Bethesda criteria (92 cases). The microsatellite instability status of tumors was determined using the International Collaborative Group on Hereditary Non-Polyposis Colorectal Cancer marker reference panel.

RESULTS

When applying all Bethesda criteria, high microsatellite instability tumors were identified in our hereditary nonpolyposis colorectal cancer registry with a sensitivity of 87 percent. Twenty-nine percent (27/92) of the Bethesda-positive patients displayed high microsatellite instability compared with 6 percent of patients (4/72) not meeting these criteria (P < 0.001). Only Bethesda Criteria 1, 3, and 4 showed a significantly different distribution of the microsatellite instability status when compared with those of the remaining patients registered (P < or = 0.001). These three criteria detected high microsatellite instability tumors in 48 percent (10/21), 50 percent (18/36), and 31 percent (21/67) of patients, respectively. When applying these criteria only, a cumulative detection rate of 77 percent of all (24/31) high microsatellite instability cases was found, thereby identifying 89 percent of high microsatellite instability tumors among the Bethesda-positive patients. Patients matching Criteria 1, 3, and 4 frequently showed hMSH2 or hMLH1 germline mutations and tumor-specific loss of protein expression.

CONCLUSION

In our hereditary nonpolyposis colorectal cancer registry the complete Bethesda criteria showed the highest sensitivity to identify patients with high microsatellite instability tumors. However, for general medical practice outside academic centers, three criteria are reasonably accurate for adequate high microsatellite instability tumor selection.

Duodenal adenomatosis in familial adenomatous polyposis coli. A review of the literature and results from the Heidelberg Polyposis Register

Familial adenomatous polyposis coli (FAP) is an autosomal dominant genetic disorder caused by mutations of the APC gene on the long arm of chromosome 5. While multiple colorectal adenomas usually developing in early adolescence represent the most conspicuous phenotypic feature, the disease represents a generalized hyperproliferative disorder with various extracolonic manifestations. Duodenal cancer and desmoids are the leading causes of death in FAP patients after prophylactic colectomy. The prevalence of duodenal adenomatosis among FAP patients varies from 50% to greater than 90%, while only few patients (3-5%) develop duodenal cancer. Periampullary adenomas seem to carry a high risk of malignant transformation. The sensitivity of endoscopic procedures for early detection of severely dysplastic or malignant duodenal lesions is low, and the prognosis of duodenal cancer is poor. Thus the question arises whether it is possible to define a subgroup of high-risk patients for duodenal malignancy, and whether severe duodenal adenomatosis should lead to an aggressive prophylactic surgical approach. This contribution discusses the current literature and presents the experience of the Heidelberg Polyposis Register based on gastroduodenoscopy findings in 231 FAP patients. In 135 cases (58.4%) macroscopic duodenal adenomas were observed. The majority of patients displayed numerous lesions throughout the duodenum, while adenomas were restricted to the periampullary region in ten. Four patients suffered from duodenal cancer. Twenty-two required an endoscopic or operative intervention. Five were treated by laparotomy and duodenotomy, while ampullary excision was indicated in six cases. Eight patients underwent partial pancreaticoduodenectomy for severe duodenal adenomatosis.

Can APC mutation analysis contribute to therapeutic decisions in familial adenomatous polyposis? Experience from 680 FAP families

BACKGROUND AND AIMS

In familial adenomatous polyposis (FAP), correlations between site of mutation in the adenomatous polyposis coli (APC) gene and severity of colonic polyposis or extracolonic manifestations are well known. While mutation analysis is important for predictive diagnosis in persons at risk, its relevance for clinical management of individual patients is open to question.

METHODS

We examined 680 unrelated FAP families for germline mutations in the APC gene. Clinical information was obtained from 1256 patients.

RESULTS

APC mutations were detected in 48% (327/680) of families. Age at diagnosis of FAP based on bowel symptoms and age at diagnosis of colorectal cancer in untreated patients were used as indicators of the severity of the natural course of the disease. A germline mutation was detected in 230 of 404 patients who were diagnosed after onset of bowel symptoms (rectal bleeding, abdominal pain, diarrhoea). When these patients were grouped according to the different sites of mutations, mean values for age at onset of disease differed significantly: patients carrying APC mutations at codon 1309 showed a disease onset 10 years earlier (mean age 20 years) compared with patients with mutations between codons 168 and 1580 (except codon 1309) (mean age 30 years), whereas patients with mutations at the 5' end of codon 168 or the 3' end of codon 1580 were diagnosed at a mean age of 52 years. Within each group of patients however large phenotypic variation was observed, even among patients with identical germline mutations. A higher incidence of desmoids was found in patients with mutations between codons 1445 and 1580 compared with mutations at other sites, while no correlation between site of mutation and presence of duodenal adenomas was observed.

CONCLUSIONS

As age at manifestation and course of the disease may be rather variable, even in carriers of identical germline mutations, therapeutic decisions should be based on colonoscopic findings in individual patients rather than on the site of mutation. However, in patients with mutations within codons 1445-1580, it may be advisable to postpone elective colectomy because desmoids may arise through surgical intervention.

Combined molecular and clinical approaches for the identification of families with familial adenomatous polyposis coli

OBJECTIVE

Using an interdisciplinary clinical and molecular approach, the authors identified APC germline mutations in families with familial adenomatous polyposis (FAP). Correlation of mutation site with disease manifestation and the impact of molecular data on clinical proceedings were examined.

SUMMARY BACKGROUND DATA

Germline mutations in the APC gene predispose to FAP. Established and proposed genotype-phenotype correlations as well as the influence of mutation site on surgical procedures have been reported. The predictive value of APC mutation analysis for disease manifestation and therapeutic decision making needs to be investigated further.

METHODS

One hundred twenty-three kindreds of the local FAP registry were included in this study. CHRPE phenotype was defined as at least one large characteristic lesion or a total of four lesions in both eyes. APC mutations were identified by protein truncation test and automated DNA sequencing from patient lymphocyte DNA and RNA.

RESULTS

APC germline mutations were identified in 85/123 families with FAP. They were located between codons 213 and 1581 of the APC gene and displayed distinct genotype-phenotype correlations. CHRPE status facilitated mutation analysis by discriminating regions of interest within the APC coding region. Severe manifestations of desmoids were restricted to mutations between codons 1444 through 1581. Whereas 91% (75/82) of at-risk persons were excluded as mutation carriers, APC germline mutations were detected before clinical examination in 9% (7/82) of at-risk persons. One patient agreed to endoscopy only after mutation detection.

CONCLUSIONS

This study supports the feasibility of combined molecular and clinical screening of families with FAP and may provide a guideline for routine presymptomatic molecular diagnostics in a clinical laboratory.

[Long-term results after restorative proctocolectomy and ileoanal pouch in children with familial adenomatous polyps]

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) is considered the therapy of choice for the prophylactic treatment of FAP in adults, while straight ileoanal endorectal pull-throughs were often favored in children. However, our experience with five children undergoing an ileoanal J-pouch procedure under the age of 15 years (7-15) due to early onset of a severe symptomatic FAP phenotype suggests results which are superior to those after direct ileoanal anastomosis. Even after a primary straight ileoanal pull-through with local complications and a high defecation rate, secondary IPAA should be considered.

[Modification of surgical strategy in HNPCC by molecular and clinical aspects]

Because of the positive correlation between Amsterdam criteria and positive MSI analysis, a subtotal colectomy with ileorectal anastomosis seems to be indicated in patients with positive Amsterdam criteria to eliminate the high risk of metachronous colon cancer. In patients with an identified mutation in one of the known mismatch repair genes, a subtotal colectomy is indicated as well. In patients with positive Bethesda criteria, apart from the Amsterdam criteria, a subtotal colectomy seems only to be indicated if a positive MSI analysis is available.

[Heidelberg polyposis register. Experiences with ileoanal pouch in familial adenomatous polyposis coli (FAP): the ileoanal anastomosis problem zone]

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) is the therapy of choice for the prophylactic treatment of FAP. Despite maximal radicality, we frequently observed remaining rectal mucosa and in some cases even adenomas at the pouch-anal anastomosis. Therefore, we changed our postoperative care by adding a yearly proctoscopy to regular pouchoscopies.

[Mutation localization as a guide for surgical approach in familial adenomatous polyposis?]

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) is considered the operative therapy of choice for the prophylactic treatment of FAP. Recently, Vasen and coworkers [5] after correlating the incidence of metachronous rectal cancer with the site of the causative APC mutation suggested subtotal colectomy and IRA to be the primary treatment in patients with mutations proximal to codon 1250, whereas IPAA should be performed in those with mutations beyond this codon. Mutation analysis in our patients after IRA, however, shows the majority of APC mutations to be located proximal to codon 1250 even in those patients with severe rectal polyposis and metachronous rectal cancer, thus not supporting the therapeutic recommendations of Vasen and coworkers.

Mucosal tenascin C content in inflammatory and neoplastic diseases of the large bowel

PURPOSE

Tenascin C is a glycoprotein of the extracellular matrix. It is upregulated during embryologic development, wound healing, and under conditions of normal and neoplastic growth. Most available data on tenascin C expression in tissues is based on immunohistologic studies. The present study was designed to quantify tissue concentrations in patients with inflammatory and neoplastic diseases of the large bowel.

METHODS

Fifty patients with ulcerative colitis, 19 patients suffering from familiar adenomatous polyposis without malignant transformation, and 69 patients with colorectal carcinoma were investigated. Tenascin C concentrations in tissue extracts were determined by semiquantitative Western blotting.

RESULTS

The tenascin C tissue concentration of normal mucosa was 2.6 +/- 3.4 microg/mg (n = 55), 2.9 +/- 2.1 microg/mg in colorectal adenomas (n = 19), 7.5 +/- 4.7 microg/mg in ulcerative colitis (n = 50), and 18 +/- 15 microg/mg in colorectal carcinomas (n = 69; mean +/- standard deviation). In ulcerative colitis, the mucosal tenascin C content correlated with histopathologic disease activity. No differences were found between subgroups of adenomas or carcinomas.

CONCLUSIONS

Tenascin C tissue concentrations were not altered in adenomas, slightly elevated in ulcerative colitis, and substantially increased in colorectal carcinomas. Although less useful as a diagnostic parameter, tenascin C tissue levels serve as an instrument for assessing the activity of stromal remodeling in large-bowel diseases generally. Specifically, they may reflect disease activity in ulcerative colitis.

Tenascin-C tissue concentration in inflammatory and neoplastic diseases of the colon mucosa

BACKGROUND

Tenascin-C is a gycoprotein of the extracellular matrix with predominantly antiadhesive qualities. In the colon mucosa tenascin-C has been found to be induced in inflammatory and neoplastic diseases by immunohistology. This study aimed at quantitating mucosal tenascin-C induction.

MATERIALS AND METHODS

Mucosal tenascin-C concentration was determined by Western blotting quantified by densitometry in fresh frozen specimens of the colon from patients with ulcerative colitis, familial polyposis, and colorectal carcinomas.

RESULTS

The tenascin-C concentration in normal mucosa was 2.6 micrograms/mg protein (SD +/- 3.4 micrograms/mg). Colorectal adenomas displayed an equal tissue concentration of 2.8 micrograms/mg protein (SD +/- 2.0 micrograms/mg). In ulcerative colitis statistically significant elevated tissue content of 7.5 micrograms/mg protein (SD +/- 4.7 micrograms/mg) was found. Colorectal carcinomas had a tissue tenascin-C level of 18.0 micrograms/mg protein (SD +/- 14.6 micrograms/mg), which was significantly different from the other groups.

CONCLUSIONS

Tenascin-C concentration is elevated in inflammatory and neoplastic diseases of the colorectal mucosa. The distinct increase in the tenascin-C content in colorectal carcinomas in contrast to normal levels in colorectal adenomas reflects an association of tenascin-C induction with malignant disease.

[Desmoid tumors in patients with familial adenomatous polyposis (FAP). Clinical and therapeutic observations from the Heidelberg polyposis register]

The life-threatening event of early colorectal cancer in FAP patients may effectively be prevented by prophylactic colectomy. Desmoid tumors and periampullary carcinoma are now becoming the most frequent causes of death in FAP patients. Since the establishment of the Heidelberg polyposis registry in January 1991 we evaluated the frequency of desmoid tumors in 171 prospectively reexamined FAP patients. 29 patients (17%) with desmoid tumors were identified. In our series R0-resection with a wide security margin was performed in 12 cases, 3 of which developed a desmoid recurrence, 8 are free of desmoids and one treated for an intraabdominal desmoid states being well but refuses a radiological reevaluation. Tumor debulking was performed in 6 patients and led to an aggressive desmoid progression in 4 patients despite additional postoperative administration of tamoxifen and sulindac. Nonsurgical treatment with tamoxifen and sulindac seemed beneficial in 5 of 7 patients, 4 showed a stagnation of tumor growth, a reduction of an abdominal wall desmoid was documented in one female with a further intraabdominal desmoid. In life-threatening cases chemotherapy and radiation therapy may be considered. In two females radiation therapy resulted in a remarkable tumor reduction. The operative trauma of previous colectomy is considered the most relevant predisposing external factor inducing desmoid growth in FAP patients. 50% (11/22) of the desmoid tumors in our series were diagnosed within the first two years postoperatively, and 72% (18/22) of the desmoids developed within the first four years after colectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Restorative proctocolectomy with ileoanal J-pouch in symptomatic children with familial adenomatous polyposis coli (FAP). Indications and results]

Familial adenomatous polyposis (FAP) is a genetic disorder leading to the early development of numerous polyps of the entire colorectum. First polyps usually emerge in puberty and cause symptoms in the third and fourth decade of life when a malignant transformation of the adenomas via an adenoma-carcinoma-sequence has often already occurred. Extracolonic manifestations and age of onset of the disease show a wide range of variability rendering the establishment of unequivocal standards for the timing of diagnostic, prophylactic and therapeutic modalities difficult. We report the cases of two unrelated children who presented with severe symptomatic, pancolonic polyposis already at the age of 3. Molecular diagnostics revealed a 'new mutation' in one case, the other child had a family history for FAP. Rapid progression of the disease with anemia and slight growth retardation were the indications for prophylactic surgery at the age of 7. The operative procedure performed was restorative proctocolectomy followed by an ileal pouch-anal anastomosis. Both children developed small bowel adhesions that forced us to perform an early closure of the protective ileostomy 3 weeks postoperatively. The subsequent course was uneventful. The children are now thriving and lead a normal social life. After only 3 months their stool frequency ranged between 2 and 5 times daily.

Familial adenomatous polyposis: desmoid tumours and lack of ophthalmic lesions (CHRPE) associated with APC mutations beyond codon 1444

An earlier study has shown that FAP patients with mutations in codons 136-302 of the APC gene do not develop congenital hypertrophy of the retinal pigment epithelium (CHRPE), whereas those with mutations in codons 463-1387 regularly do. Here we present data on 36 patients from 20 families with mutations in codons 1445-1578. These patients lack CHRPE. Furthermore, with the exception of three prepubertal children all patients with mutations in codons 1445-1578 developed desmoid tumours. This relationship between certain extracolonic manifestations and site of the APC mutation points to a specific role of the APC protein in different tissues.

Biliary tract strictures after orthotopic liver transplantation: diagnosis and management

Biliary tract complications in 105 patients who had undergone orthotopic liver transplantation were reviewed in order to determine their incidence and localization. In addition, the possible endoscopic and percutaneous management of such complications was evaluated. Signs of cholestasis appeared in 32 of 105 (30.5%) transplant recipients after a mean of 6.5 months (range 1-19 months), and visualization of the biliary system was performed in all. Twenty biliary tract complications were observed in these 32 patients (62.5%). There were multiple strictures, both intrahepatic and extrahepatic, in 11 grafts. Five of the nine extrahepatic strictures were not confined to the site of the bile duct anastomosis, and involved the whole common bile duct of the donor liver, while the remaining four were confined. The multiple intrahepatic and extrahepatic strictures were related either to occlusion of the hepatic artery or to the fact that the graft had been in a cold ischemic state for a prolonged time. In contrast, multiple strictures and necrosis of the whole extrahepatic bile duct were attributed to local ischemia due to the harvesting procedure. Stenoses strictly confined to the site of anastomosis were thought to be due to surgical technique. Ten extrahepatic bile duct stenoses with considerably impaired bile flow were corrected endoscopically (four), percutaneously (three) and by surgery (three). In four patients with complications in the whole intrahepatic and extrahepatic system, retransplantation was necessary. Biliary tract complications in our patients occurred in up to 19% after liver transplantation on long-term follow-up. Complications of only the extrahepatic system can be treated successfully, whereas complications involving multiple stenoses of the intrahepatic bile duct system frequently require retransplantation.

Familial adenomatous polyposis: mutation at codon 1309 and early onset of colon cancer

The clinical course of familial adenomatous polyposis (FAP) varies considerably between patients. Prediction of the severity of the disease is important in the interest of effective cancer prevention. We examined whether age at diagnosis of FAP due to gastrointestinal symptoms and age at death due to colorectal cancer are related to the site of mutation in the responsible gene. 225 families with FAP were screened for mutations. The deletion of 5 base pairs at codon 1309 within exon 15 (known to be the most common mutation) was identified in 20 families; other mutations within exons 7-15 were found in 49 families. In patients with the 5 base-pair deletion at codon 1309, gastrointestinal symptoms and death from colorectal cancer occurred about 10 years earlier than in patients with other mutations. The 1309 mutation leads to development of colonic polyps at a younger age, thus giving rise to an earlier malignant transformation. This relationship should be taken into account in strategies for preventing cancer in patients with FAP.

Inhibition by cyclosporin A of adenosine triphosphate-dependent transport from the hepatocyte into bile

BACKGROUND

Immunosuppressive treatment with cyclosporin A may be associated with impaired hepatobiliary elimination of bile salts and with cholestasis. Inhibition by cyclosporin A of the primary-active adenosine triphosphate (ATP)-dependent transport systems responsible for excretion of bile salts and cysteinyl leukotrienes across the hepatocyte canalicular membrane into bile may explain the cholestatic side effect.

METHODS

ATP-dependent transport of bile salt and of cysteinyl leukotrienes was studied in human liver plasma membrane vesicles and additionally in rat liver plasma membrane vesicles enriched in canalicular membranes.

RESULTS

Inhibition of ATP-dependent taurocholate transport in human liver by 50% was measured at 3 mumol/L cyclosporin A and at 4 mumol/L fujimycin. Kinetic analyses in rat liver indicated non-competitive inhibition by cyclosporin A with respect to ATP and competitive inhibition with respect to taurocholate with inhibition constant (Ki) values of 1.0 and 0.3 mumol/L, respectively.

CONCLUSIONS

The ATP-dependent export carriers for bile salts and cysteinyl leukotrienes in the hepatocyte canalicular membrane are novel targets for inhibitory side effects of cyclosporin A. Inhibition of ATP-dependent bile salt transport may induce cholestasis.

[Familial adenomatous polyposis. Initial experiences with the Heidelberg polyposis register]

In order to enable consequent screening in at risk persons and life-long follow-up in patients, a computer-based polyposis registry was initiated in 1991. It now includes data of 130 FAP patients and 179 risk persons from 87 families, that were seen in our clinic since 1982. 20.5% of the "probands" (symptomatic patients) had a colorectal carcinoma at the time of diagnosis in contrast to none in the "call-up" group. The most reliable screening method as yet has proven to be the flexible sigmoidoscopy with histological verification of the adenomatous nature of the polyps. Congenital hypertrophy of the retinal pigment epithelium was only seen in 50% of our patients. The exact localisation of the FAP gene in August 1991 will soon significantly improve the prognostic value of molecular genetic screening procedures. The improved prognostic value of the method will enable early and even prenatal diagnosis. It will not any more be necessary to wait for the phenotypic manifestation (colorectal polyps) in order to be sure of the diagnosis FAP.