10-Year Clinical Comparative Study of Ceramic and Composite Veneered Metal Crowns

The rejection of composite veneerings in fixed partial dentures is primarily caused by the inadequacy of the bonds between the metal framework and the composite veneering. The development of improved veneering composites necessitates an investigation of their clinical suitability compared with ceramic materials. Nineteen patients with at least two suitable, adjacent natural teeth for crowning were treated with 64 high noble alloy crowns. The adjacent crowns were veneered with ceramic (IPS inline) and composite materials (SR Adoro). Seven follow-up examinations were carried out over a period of 10 years. The crowns were investigated for mechanical defects, periodontal parameters, and discolorations. The survival rates of the ceramic veneered metal crowns (CeMCs) and composite veneered metal crowns (CoMCs) at the 10-year follow-up were 87.1 and 87.9%, respectively. The success rates of the crowns after 10 years were 83.9% for CeMCs and 51.5% for CoMCs (log-rank test, p = 0.009). No significant differences between the groups were found in the periodontal parameters (Kruskal-Wallis one-way analysis of variance, ANOVA p ⟩ 0.05). After 10 years, discoloration patterns of the two materials differed significantly (Mann-Whitney-U-test, p = 0.017). Thus, despite the improvements associated with CoMCs, CeMCs remain the gold standard for veneered metal crowns.

Marking Disappearing Colorectal Liver Metastases After Complete Response to Neoadjuvant Chemotherapy via CT - A Pilot Study

BACKGROUND/AIM

The liver is a frequent site for metastases of colorectal cancer. Approximately 15% of patients have hepatic metastases at the time of diagnosis and another 50% develop them over the course of their disease. Only 10-25% of patients are candidates for liver resection. The aim of this study was to assess the benefit of preoperative computed tomography (CT)-guided wire marking of disappearing colorectal liver metastases (CRLMs) (radiological disappearance of metastases) before surgical resection.

PATIENTS AND METHODS

Between January 2011 and January 2014, 20 patients with potentially disappearing CRLMs were selected for CT-guided wire marking. Following treatment with neoadjuvant chemotherapy, disappearing CRLMs were marked via CT guidance. Afterwards, the marked sites were resected.

RESULTS

Complete histological response to neoadjuvant chemotherapy was only in 10 resected sites (18%), and 46 (82%) resected liver metastases showed metastatic tissue present. Both overall survival and the disease-free rates in patients after using our method were 55%.

CONCLUSION

This study demonstrated the usefulness of CT-guided wire marking to mark disappearing CRLMs in order to improve long-term effectiveness of surgical treatment.

The Value of Lymph Node Dissection in the Surgery of Colorectal Cancer Liver Metastases

BACKGROUND/AIM

Liver resection is the best treatment for metastatic colorectal cancer (CRC). Hepatic lymph node metastases are considered as extrahepatic disease and represent an unfavorable prognostic factor. However, extrahepatic disease, when resectable, provides no contraindication for surgical therapy. The aim of this study was to evaluate the prevalence of hepatic lymph node involvement in our patients' cohort.

PATIENTS AND METHODS

Twenty patients submitted to resection for colorectal liver metastases were studied prospectively. Three areas for lymph node dissection were defined and analyzed separately. Lymph nodes were examined by hematoxylin and eosin staining and immunohistochemistry for Pan-Keratin.

RESULTS

In average, 5 lymph nodes were harvested per patient. Macroscopic enlargement was not a definite sign for metastatic involvement. No morbidity or mortality was associated with lymphadenectomy. In our patients' collective, no cases of lymph node metastases occurred.

CONCLUSION

There is no evidence of a survival benefit after lymph node dissection in patients with CRC liver metastases in the literature. Systematic lymphadenectomy can, however, provide a prognostic tool to better plan further treatment.

Laparoscopic versus open appendectomy for complicated appendicitis in high risk patients

INTRODUCTION

Laparoscopic appendectomy is widely used for the treatment of complicated appendicitis. Its use in patients with high operative risk is still on debate. The aim of the presented study was to investigate the benefits of laparoscopic appendectomy in patients with high peri- and postoperative risk factors.

METHODS

We performed a retrospective analysis of all patients who underwent appendectomy in our center between 2006 and 2013. Patients were classified according to their preoperative risk (classification of the American Society of Anesthesia--ASA score). Only patients with ASA 3 and 4 were included and were divided into two groups--open appendectomy (OA group) and laparoscopic appendectomy (LA group).

RESULTS

The operation time was slightly longer in the LA group (p = 0.05), but hospital stay was shorter (p = 0.05). Complications graded according to the Clavien Dindo classification were slightly more frequent in patients after LA, whereas severe complications occurred more frequently in patients after OA (p = 0.01). The postoperative WBC decreased steadily and significantly in patients after OA, whereas the decrease in patients after LA was delayed (p = 0.03). CRP slightly increased after OA and decreased thereafter, whereas it steadily decreased after LA (p = 0.05).

CONCLUSION

Laparoscopic appendectomy can be recommended for patients with complicated appendicitis even with higher risk categories.

Effectiveness of porcine dermal collagen in giant hernia closure in patients with deleterious fascia constitution after orthotopic liver transplantation

Incisional hernias (IHs) occur universally after orthotopic liver transplantation (OLT). This study aimed to investigate the effectiveness of porcine dermal collagen (PDC) as a closing aid in giant hernias after OLT in a prospective trial. If direct closure (DC) was not feasible due to the hernia size and abdominal wall constitution, a PDC mesh was implanted. All patients from the PDC and DC groups were followed prospectively for 24 months. IH recurrence rates served as the primary endpoint, and the development of infections and wound healing disorders served as the secondary endpoints. Recurrence rate was 21% (4/19) in DC patients and 12% (2/16) in PDC patients (P = 0.045). Implant site infections occurred in five of PDC and one of DC patients (P < 0.05). All of them were managed with antibiotics; two of the PDC patients required surgical drainage. Histological analysis of PDC mesh biopsies indicated good angiogenesis and integration of the PDC into the abdominal wall. PDC was effective in our study for incisional hernia repair, and our results compared favourably with those of patients in whom direct hernia closure was feasible.

Hepatobiliary transporter expression and post-operative jaundice in patients undergoing partial hepatectomy

BACKGROUND AND AIMS

Post-operative hyperbilirubinaemia in patients undergoing liver resections is associated with high morbidity and mortality. Apart from different known factors responsible for the development of post-operative jaundice, little is known about the role of hepatobiliary transport systems in the pathogenesis of post-operative jaundice in humans after liver resection.

METHODS

Two liver tissue samples were taken from 14 patients undergoing liver resection before and after Pringle manoeuvre. Patients were retrospectively divided into two groups according to post-operative bilirubin serum levels. The two groups were analysed comparing the results of hepatobiliary transporter [Na-taurocholate cotransporter (NTCP); multidrug resistance gene/phospholipid export pump(MDR3); bile salt export pump (BSEP); canalicular bile salt export pump (MRP2)], heat shock protein 70 (HSP70) expression as well as the results of routinely taken post-operative liver chemistry tests.

RESULTS

Patients with low post-operative bilirubin had lower levels of NTCP, MDR3 and BSEP mRNA compared to those with high bilirubin after Pringle manoeuvre. HSP70 levels were significantly higher after ischaemia-reperfusion (IR) injury in both groups resulting in 4.5-fold median increase. Baseline median mRNA expression of all four transporters prior to Pringle manoeuvre tended to be lower in the low bilirubin group whereas expression of HSP70 was higher in the low bilirubin group compared to the high bilirubin group.

DISCUSSION

Higher mRNA levels of HSP70 in the low bilirubin group could indicate a possible protective effect of high HSP70 levels against IR injury. Although the exact role of hepatobiliary transport systems in the development of post-operative hyper bilirubinemia is not yet completely understood, this study provides new insights into the molecular aspects of post-operative jaundice after liver surgery.

Management of pancreatic trauma and its consequences--guidelines or individual therapy?

BACKGROUND/AIMS

Diagnosis of pancreatic trauma and its complications may be difficult due to non-specific signs and symptoms and treatment recommendations are not unequivocal.

METHODOLOGY

Clinical data of a series of 47 patients with pancreatic trauma were analyzed; most of them were polytraumatized and treated by an interdisciplinary team.

RESULTS

The most common causes were traffic accidents and sport injuries with 66% and 15%, respectively. Concomitant injuries were seen in 96% (nonpancreatic intra-abdominal injuries 85% including spleen 38% and liver 34%, extra-abdominal injuries 70%). Concomitant liver injuries were treated conservatively in 31% and operatively in 69% (including hepatic packing in 38%). Concomitant splenic injuries were usually very severe and could be managed conservatively in only 11%. All patients with pancreatic injuries grade III, IV or V (17%) according to the American Association of Surgical Trauma Classification required surgery, endoscopic treatment or interventional radiology. The most common posttraumatic complications were necrotizing pancreatitis (15%), pseudocyst formation (9%), abscesses (6%) and fistulas (4%).

CONCLUSIONS

The status of the pancreatic duct is the crucial point for management of pancreatic trauma and should be assessed as early as possible. Treatment has to be tailored to the individual situation, especially in patients with severe concomitant injuries or prolonged course.

Prospective study comparing standard and robotically assisted laparoscopic cholecystectomy

BACKGROUND AND AIMS

Laparoscopic surgery has become the treatment of choice for cholecystectomy. Many studies showed that while this approach benefits the patient, the surgeon faces such distinct disadvantages as a poor ergonomic situation and limited degrees of freedom with limited motion as a consequence. Robots have the potential to overcome these problems. To evaluate the efficiency and feasibility of robotically assisted surgery (RAC), we designed a prospective study to compare it with standard laparoscopic cholecystectomy (SLC).

MATERIALS AND METHODS

Between 2001 and 2003, 26 patients underwent SLC and 20 patients underwent RAC using the ZEUS system. The feasibility, safety, and possible advantages were evaluated. To assess the efficacy, the total time in the operating room was divided into preoperative, operative, and postoperative time frames.

RESULTS

For RAC in comparison with SLC, the preoperative phase including equipment setup was significantly longer. In the intraoperative phase, the cut-closure time and camera and trocar insertion times were significantly longer. It is interesting to note that the net dissection time for the cystic artery, duct, and the gall bladder was not different from SLC.

CONCLUSIONS

The study demonstrates the feasibility of robotically assisted cholecystectomy without system-specific morbidity. There is time loss in several phases of robotic surgery due to equipment setup and deinstallation and therefore, presents no benefit in using the robot in laparoscopic cholecystectomy.

Accuracy of preoperative routine MRI for hepatic lesion detection

BACKGROUND

The outcome of liver resections depends on complete removal of all detectable foci. Our aim was to determine the value of preoperative routine magnetic resonance imaging (MRI) for complete detection of hepatic lesions.

METHODS

We compared 271 lesions seen on MRI in 182 patients to intraoperative findings (including intraoperative ultrasonography) and histology.

RESULTS

The overall rate of lesions was 7% each for segments 2 and 3, as compared to 14-17% each for segments 5, 6, 7, and 8. Twenty-three additional lesions were found intraoperatively, two thirds of them in the left lobe (mean size: 1.4 cm; mean total number of lesions in those patients: 2.2). In segments 2 and 3, the relative frequency for intraoperative diagnosis of additional lesions was 17% and 20%, respectively. On the other hand, most of the 15 MRI lesions not verified intra- or postoperatively had been described in the right hepatic lobe (maximum: segment 6).

CONCLUSION

MRI provided reliable preoperative lesion detection. Special attention should be paid to segments 2 and 3, which showed a lower total number of lesions but an elevated relative frequency of intraoperatively detected additional foci.

Treatment of patients with pyogenic liver abscess

BACKGROUND

Pyogenic liver abscess (PLA) remains a serious disease with a mortality of 6-14%.

METHODS

Clinical data of 76 patients with PLA were analyzed. Treatment options comprised antibiotics, percutaneous puncture/drainage, endoscopic papillotomy/stenting and/or surgery as indicated.

RESULTS

Fifty-eight patients (76%) had single and 18 patients multiple PLA (right lobe: 65%; both lobes: 22%). The most frequent etiologies were: biliary (38%), hematogenous and posttraumatic (11%). Factors associated with the need for surgery included gallbladder empyema, biliary fistulas, malignancy, perforation, multicentricity, vascular complications and foreign bodies (e.g. infected ventriculo-peritoneal shunt, toothpick).

CONCLUSIONS

Microbiological testing provides important information for treatment monitoring and modification. Complementary assessment of risk factors for a complicated course is crucial for timely identification of patients requiring additional treatment.

Surgical therapy options in polycystic liver disease

INTRODUCTION

Polycystic liver disease (PLD) is a rare affliction frequently observed in association with polycystic kidney disease. Only symptomatic patients require treatment, which can be conservative or surgical, i.e. laparoscopic or conventional. We report the results of our experience in the surgical management of polycystic liver disease.

METHODS

Between 1994 and 2003, 19 patients (16 female, 3 male) were referred to our center for the management of PLD. Their median age was 50 years (range 33-72). All were symptomatic and their cysts had a median diameter of 11 cm (range 5-22).

RESULTS

Laparoscopic management was undertaken in eight patients, with one conversion to open technique because of bleeding from a superficial hepatic vein. An open procedure was performed in 11 patients: one left hemihepatectomy, deroofing in two patients, segment resection 2/3 plus deroofing in six patients, and segment resection 5/6 plus deroofing in two patients. Four patients had complications: one case of biliary leakage was managed conservatively; two patients had pneumothorax caused by the cava catheter inserted for anesthesia, and one patient's abdominal drain tore off and had to be removed by relaparotomy on the fourth postoperative day. Median follow-up of all patients was 49 months (range 7-98). In one patient there was symptomatic recurrence with hepatomegaly and compression of the inferior vena cava 84 months after the first operation.

CONCLUSIONS

Careful selection of patients and meticulous surgical technique are recommended in the management of PLD. The treatment of choice for symptomatic Gigot or Morino type 1 PLD is laparoscopic surgery, and for advanced stage PLD combined hepatic resection and cyst fenestration.

Minimally invasive management of dysontogenetic hepatic cysts

BACKGROUND

Liver cysts occur with a prevalence of 4%-7% in the general population. Laparoscopic surgery is effective for solitary cysts and in selected patients with polycystic liver disease (PLD). We present our experience in the laparoscopic management of dysontogenetic cysts.

PATIENTS AND METHODS

Between 1994 and 2002, 36 patients were referred to our centre for the management of dysontogenetic cystic liver disease. Management was laparoscopic in 16 cases. Indications were solitary giant cysts (n=9) and PLD (n=7).

RESULTS

Laparoscopic procedures were completed in 15 patients. Mean operating time was 90 min. There were no deaths. In one case there was an intraoperative complication: bleeding from a superficial hepatic vein necessitated conversion to an open procedure. There were two postoperative complications: one patient with biliary leakage, which was managed conservatively, and one patient with a pneumothorax caused by the cava catheter installed for anaesthesia. Median follow-up was 36 months. There was no symptomatic recurrence.

CONCLUSION

Laparoscopy can be recommended as the procedure of choice for symptomatic solitary giant cysts and PLD Gigot type I.

Endoskopische Palliation der malignen Magenausgangsstenose durch selbstexpandierbare Metallstents

INTRODUCTION

Malignant gastric outlet stenosis is caused by tumour obstruction and restricts the oral intake of food, resulting in a seriously reduced quality of life. Endoscopic implantation of self expanding metal stents (SEMS) can clear stenosis in the GI-tract and reestablish and preserve the passage in the GI-tract.

PATIENTS AND METHODS

Between October 2001 and April 2003 seven patients with malignant gastric outlet stenosis have been treated by the implantation of SEMS. Four patients had malignant stenosis in the upper duodenum or gastric antrum, two patients had stenosis because of tumour recurrence in the efferent loop of the jejunum after gastric resection because of gastric carcinoma and one patient had an obstruction 20 cm distal of the oesophagus after gastrectomy because of gastric cancer.

RESULTS

In all patients obstruction was cleared by the implantation of SEMS, and oral intake of food was possible in all patients after two days. No serious complications occurred during or after stent implantation.

CONCLUSION

Stent implantation for the treatment of malignant gastric outlet stenosis is a cost effective procedure, associated with low risk and low stress for the patient, and provides excellent palliation of symptoms in patients with malignant gastric outlet stenosis.

Is intraoperative ultrasonography during partial hepatectomy still necessary in the age of magnetic resonance imaging?

BACKGROUND/AIMS

The aim of our study was to determine if intraoperative ultrasonography is still necessary in the time of magnetic resonance imaging.

METHODOLOGY

Our prospective study comprised 122 patients (82% with malignant tumors) undergoing partial hepatectomy with preoperative magnetic resonance imaging, done at the same institution using a standardized liver protocol as well as intraoperative ultrasonography performed in a systematic fashion.

RESULTS

Seventeen additional malignant lesions in 16/122 patients (13.1%) were found intraoperatively [7 visible, 2 palpable, 8 (6.6%) diagnosed by intraoperative ultrasonography only; mean size: 1.5 cm; left:right lobe = 11:6]. This caused a change in surgical strategy in 14 patients (11.5%), including 6 patients (4.9%) with lesions seen on intraoperative ultrasonography only. The average total number of lesions in those patients was 3.4. Ten lesions (7 benign, 3 malignant) described on magnetic resonance imaging were not found on intraoperative ultrasonography, but no unnecessary operations resulted from this. In one patient additional micrometastases seen neither on magnetic resonance imaging nor on intraoperative ultrasonography were found histologically.

CONCLUSIONS

Intraoperative ultrasonography is still worthwhile as it remains unsurpassed in the ultimate determination of the number of lesions, tumor extension and anatomical resolution. However, in the course of time its benefits may decrease further due to ongoing improvement of preoperative imaging.

Pyloric obstruction caused by prolapse of a hyperplastic gastric polyp

Hyperplastic gastric polyps account for the majority of benign gastric polyps and are generally diagnosed by routine gastroscopy as they rarely become symptomatic. We report a 79-year-old woman who presented with intermittent attacks of bloating, belching, nausea and vomiting. Endoscopy showed a pedunculated polyp in the gastric antrum prolapsing through the pylorus, thus obstructing the gastric outlet. The polyp was repositioned with an endoscopic forceps and then removed at its pedicle by endoscopic snare excision. Histologic examination showed a hyperplastic polyp without dysplasia or malignancy. The significance of gastric polyps is discussed from the clinical point of view.

Pancreatitis-associated protein (PAP) in patients with pancreatic cancer

BACKGROUND

Pancreatitis-associated protein (PAP) is known as a marker for pancreatitis and cystic fibrosis. The aim of our study was to evaluate PAP in patients with pancreatic cancer, to assess its correlation to the extent of the disease and to compare it to CA19-9.

PATIENTS AND METHODS

This prospective study comprised 75 individuals. Thirty had pancreatic cancer, 30 were healthy controls and 15 had benign lesions of the pancreas. PAP was determined by enzyme-linked immunosorbent assay. Statistical analysis was by Wilcoxon test and Spearman correlation coefficients.

RESULTS

As compared to healthy individuals and using a cut-off of 18 micrograms/l corresponding to a sensitivity of 90%, the specificity of PAP for pancreatic cancer was 82.8%. PAP elevation in cancer patients could not be explained by concomitant pancreatitis (p = 0.649). PAP did not show correlation to tumour size (p = 0.14), T-stages (p = 0.706) or tumour grading (p = 0.105), but was significantly correlated to the overall extent of the disease according to the UICC stages (p = 0.002). No correlation between PAP and CA19-9 was seen. Jaundice was not found to influence PAP values (p = 0.4).

CONCLUSION

Elevation of PAP in patients with pancreatic cancer is not merely explainable by concomitant pancreatitis, but seems to be due to increased PAP production by the cancer cells and is also correlated to tumour load as expressed by the UICC stages.

Liver ischemia, catecholamines and preoperative condition influencing postoperative tachycardia in liver surgery

The aim of our study was to assess the influence of intraoperative hypoxic stress -unavoidably brought about by so called Pringle maneuver - on free and conjugated catecholamines during major hepatic resection. Judging from earlier results of fatigue-experiments in rats we also wanted to check the relationship between of poor general preoperative condition and conspicuously low triglyceride serum concentrations. The study included 26 patients with primary and secondary liver tumors. The mean age was 54 years (range 27-79). Twenty-one patients had segmental liver resections, 3 had hemihepatectomies and 2 hydatid cysts were treated by cystectomy. Blood samples were taken 2 days before and throughout surgery. Catecholamine plasma values were determined by high performance liquid chromatography. Statistical comparisons were made by t-test, ANOVA and chi square test. Free plasma catecholamines increased significantly during prolonged intraoperative ischemia (Pringle time 50-125 minutes). Patients with elevated intraoperative catecholamines had a significant correlation to postoperative episodes of tachycardia, and prolonged hospital stay. On the other hand, we could also see postoperative tachycardias in patients with short Pringle times (18-49 minutes) but with decreased preoperative serum triglycerides as an indicator of chronic stress and reduced general condition. Intraoperative hypoxic stress is associated with increased catecholamine values. Elevated catecholamines may well cause postoperative sinus-tachycardias (mean 20 hours) and are strongly related to postoperative liver failure and prolonged hospital stay.

Bronchogenic cyst appearing as a hepatic mass

Because bronchogenic cysts may be found in or near any organ derived from the embryonic foregut, they sometimes pose considerable diagnostic difficulties. We describe the plain chest X-ray, computed tomographic, and angiographic findings in a patient with elevated CA 19-9 and upper quadrant abdominal pain due to a cystic tumor appearing as a hepatic mass. Surgery and histology showed a bronchogenic cyst located in the lower lobe of the right lung.

Normothermic liver ischemia and antioxidant treatment during hepatic resections

The purpose of our study was to evaluate the clinical impact of reperfusion injury after normothermic ischemia during major liver resections and the effect of an intraoperative antioxidant infusion. This prospective randomized study comprised 50 patients; half of them (treatment group) were given an antioxidant infusion containing tocopherol and ascorbate immediately prior to reperfusion onset. Venous blood samples for the determination of MDA-TBARS (malondialdehyde-thiobarbituric acid reactive substances) by a HPLC-based test as a marker of lipid peroxidation were taken prior to ischemia, 30 min after reperfusion onset and at the end of the operation. In the control group there was a significant increase of MDA-TBARS (p = 0.001) at 30 min after reperfusion onset. At the end of the operation the values had returned to the initial level. The treatment group showed only a marginal increase (p-value for the difference between the two groups: 0.007). After exclusion of the patients with histologically proven advanced cirrhosis the increase in the control group (p < 0.001) and the difference between the increase in the two groups (p = 0.001) became more significant. Prothrombin time was also significantly better in the treatment group (p = 0.003). Postoperative complications such as prolonged liver failure, bleeding disorders and infections were seen more often in the control group. In our study MDA-TBARS was increased after liver ischemia, but in patients with advanced cirrhosis the effect was smaller or even absent. This increase and possible clinical consequences of reperfusion injury could be reduced by intraoperative administration of an antioxidant infusion.

Use of anal endosonography in diagnosis of endometriosis of the external anal sphincter: report of a case

PURPOSE

Perianal endometriosis is an infrequent form of extragenital endometriosis and is usually situated in episiotomy scars.

METHODS

We report a rare case involving the external anal sphincter in a 24 year-old female. The precise anatomical location of the endometriotic lesion was confirmed using preoperative and intraoperative anal endosonography.

CONCLUSION

We believe this procedure to be essential when history, digital examination, and proctoscopy are not conclusive in the differential diagnosis of perianal pain or mass. Although hormonal suppression often is the therapy of choice in extrapelvic endometriosis, we think surgical excision, respecting the anatomical fiber architecture of the anal sphincter, is the best treatment for perianal endometriosis. Surgical excision is required for histological diagnosis, which is imperative in view of the albeit rare development of malignancy in extragenital endometriosis.

Primary biliary cystadenocarcinoma perforating the duodenum and left intrahepatic biliary tree--mimicking a hydatid cyst

We report the case of a 76-year-old woman with biliary cystadenocarcinoma perforating the left biliary tree and exhibiting intra-tumoral gas bubbles resulting from invasion of the duodenum. The clinical history included subfebrile temperatures of 3 months duration, and pains associated with an abdominal mass in the right upper quadrant. Blood tests showed leucocytosis, and radiological studies revealed the features of a partially calcified septated tumor with nodular components combined with multiple gas-fluid levels, mimicking an infected hydatid cyst. Intraoperative ultrasonography, cholangiography and frozen section histology were necessary to prove the malignant nature of this cystic tumor. Provided that complete resection with strict adherence to oncological precepts is possible, the prognosis of cystadenocarcinoma is better than in hepatocellular or cholangiocellular carcinoma.

TUM2-PK (pyruvate kinase type tumor M2), CA19-9 and CEA in patients with benign, malignant and metastasizing pancreatic lesions

The diagnostic value of the tumor marker pyruvate kinase type tumor M2 was evaluated in patients with benign, malignant and metastasizing pancreatic lesions and compared to the reference markers CA19-9 and CEA. This prospective study comprised 166 individuals; 66 patients had various pancreatic pathologies (38 histologically proven pancreatic cancer, 28 benign pancreatic lesions such as pseudotumorous pancreatitis, pseudocysts or pancreatic (cyst)adenoma) and 100 healthy blood donors served as controls. With a cut-off value of 28 U/ml (corresponding to a specificity of 90%) the sensitivity of TUM2-PK for pancreatic cancer (as related to the control group) was 79% (CA19-9: 65%, CEA: 22%). There was a good correlation between the TUM2-PK levels and tumor metastasis (p < 0.001 for no versus distant metastasis, p = n.s. for CA19-9 and CEA). However, TUM2-PK was also elevated in 64.3% of the patients with benign pancreatic pathologies. In our study TUM2-PK had good diagnostic qualities for pancreatic cancer and also showed better correlation to metastasis than CA 19-9 and CEA.

Mucinous biliary cystadenocarcinoma containing gas bubbles secondary to duodenal invasion

Biliary cystadenocarcinoma is a rare, usually intrahepatic neoplasm. A case is described in which an intrahepatic cystadenocarcinoma invaded the duodenum. This resulted in intratumoral gas.

Antioxidant treatment during liver resection for alleviation of ischemia-reperfusion injury

BACKGROUND/AIMS

Many experimental studies on ischemia-reperfusion injury in animals suggest a preventive effect of antioxidants, but the clinical significance of these findings is still unclear. The aim of our study was to evaluate the effect of antioxidant treatment with vitamins on liver function parameters during liver resection.

METHODOLOGY

Our prospective randomized study comprised 58 patients undergoing major liver surgery, including the Pringle maneuver. In the treatment group 32 patients received a multivitamin infusion (Omnibionta) which included 10 mg of alpha-tocopherol acetate, 2 mg of DL-alpha-tocopherol and 1 g of ascorbate. The control group consisted of 26 patients. Various parameters associated with liver function, such as transaminases, lactate, ammonia, bilirubin, cholinesterase and clotting parameters were measured preoperatively, at the beginning of liver ischemia, 15, 30 and 60 minutes after reperfusion onset and every 12 hours after the operation.

RESULTS

The Mann-Whitney-Wilcoxon-Test showed statistically significant differences in the postischemic changes between the treatment group and the control group for the Quick test (prothrombin time): p = 0.01. The transaminases were also markedly better in the treatment group (splitting-up slightly more delayed than with the Quick test). A smaller effect was seen with cholinesterase. Lactate, however, increased intraoperatively with a strong correlation to the duration of ischemia and returned quickly to baseline values without any remarkable influence of the antioxidant treatment.

CONCLUSION

In our study, antioxidant treatment with a multivitamin infusion showed a positive effect on postischemic liver function parameters.

[The effect of heparin on the course of some organ complications in experimental acute pancreatitis in rats]

The aim of this study was to present whether the heparin has on influence on course of experimental acute pancreatitis (AP) and some organ complications. The research referred to histological changes in liver, lungs and kidneys. The study was conducted on 69 rats divided into 5 groups: I--operated, without induction AP, II--control, induction of AP without treatment, III--induction of AP and immediate administration of heparin, IV--induction of AP and administration of heparin 3 hours after, V--induction of AP and administration of heparin 6 hours after. AP was induced by administration 5% sodium taurocholate. In all groups the animals were anesthetised after the period of 3, 6 and 12 hours from the induction of AP respectively. The specimens of mentioned organs were formalinized and stained with hematoxylin/eosin, and in addition specimens of the liver with p.a.S, Sudan IV and Brachets methods. In group I we observed pulmonary oedema after 6 and 12 hours but kidneys and liver were unchanged. In group II pathological changes were most evident in lungs, while we observed on acute passive hyperaemia, pulmonary emphysema and single coagulative thrombosis in vessels. In the liver number of lining cells was increased and minor or major droplets of lipids in hepatocytes were present. Using Brachets method we revealed regular staining of hepatocytes, and p.a.S. method regular staining of their cytoplasm. In group III examined organs do not show any significant differences as compared with group II, except for lungs where the coagulative thrombosis was not present. In groups IV and V changes were similar to those described in group II. This study showed decreased inflammatory and thrombotic process in lungs in experimental AP in rats after heparin treatment.

Preoperative differential diagnosis of benign and malignant pancreatic lesions--the value of pancreatic secretory trypsin inhibitor, procarboxypeptidase B, CA19-9 and CEA

BACKGROUND/AIMS

Pancreatic secretory trypsin inhibitor (PSTI). Procarboxypeptidase B (PCPB or Human pancreas-specific protein HPASP), CA19-9 and CEA were evaluated for their performance in preoperative differential diagnosis of benign and malignant pancreatic lesions.

METHODOLOGY

Our prospective study included 92 patients with pancreatic lesions diagnosed by imaging techniques. In 45 of them (group I), the lesions turned out to be malignant tumors (35 pancreatic cancer, 10 other carcinoma of the pancreatic region); 47 patients (group II) had benign lesions (38 inflammatory disease of the pancreas, 9 other benign lesions).

RESULTS

Statistical analysis showed significant differences between these two groups for PSTI, PCPB and CA19-9, but not for CEA. When only pancreatitis versus pancreatic cancer was analyzed, differences were more significant for PSTI and PCPB, but less significant for CA19-9. Because of a strong trend toward false positive values in patients with pancreatic inflammation, the specificity of CA19-9 in our selected patient group was only 67%, but in combination with normal PSTI (< 13.5 ng/ml), it reached 96%.

CONCLUSION

In our study, PSTI and PCPB were useful markers for pancreatitis. PSTI also showed good correlation with the severity of the inflammation and provided additional preoperative information, in combination with CA19-9.

Local nitroglycerin for treatment of anal fissures: an alternative to lateral sphincterotomy?

PURPOSE

Nitric oxide is an important neurotransmitter mediating internal anal sphincter relaxation. Patients suffering from fissure-in-ano were treated with topical nitroglycerine. The clinical evidence for therapeutic adequacy was examined in a prospective, randomized study.

METHODS

The study included 35 patients with acute and chronic anal fissures. In Group A, including 20 patients with the clinical diagnosis of acute (12 patients) and chronic (8 patients) anal fissures, treatment consisted of topical nitroglycerine. Group B, consisting of 15 patients (10 acute and 5 chronic fissures), received topical anesthetic gel during therapy. Manometry was performed before and on days 14 and 28 in the course of topical application of either 0.2 percent glyceryl trinitrate ointment or anesthetic gel (lignocaine). Anal pressures were documented by recording the maximum resting and squeeze pressures.

RESULTS

In 60 percent of cases treated with topical nitroglycerine (Group A, 11 acute (91.6 percent) and 1 chronic (12.5 percent)), anal fissure healed within 14 days, in contrast to Group B in which no healing was observed. The healing rate after one month was 80 percent (11 acute (91.6 percent); 5 chronic (62.5 percent)) in Group A and was significantly superior to Group B (healing rate, 40 percent: 5 acute (50 percent); 1 chronic (20 percent)).

DISCUSSION

Previously increased maximum resting pressures decreased from a mean value of 110 to 87 cm H2O. This represents a mean reduction of 20 percent (P = 0.0022). We also noted a significant decrease in squeeze pressures (from 177.8 to 157.9 cm H2O (11 percent)). However, anal pressures did not decrease significantly in the four chronic fissure patients from Group A, whose fissures only healed after 28 days. Similarly to these Group A chronic fissure patients, no significant anal pressure reduction was observed in any Group B patients. Except for mild headache (20 percent), no side effects of treatment were reported.

CONCLUSIONS

Topical application of nitroglycerine represents a new, easily handled, and effective alternative in the treatment of anal fissures. All of our patients reported a dramatic reduction in acute anal pain. However, it should be noted that a lack of sphincter tone reduction is a likely reason for the great tendency of chronic anal fissures to recur.

Intrahepatic hematoma with secondary Salmonella infection via biliary fistula

Usually liver hematoma after blunt trauma is treated conservatively as long as clinically possible, in order to avoid infection via drainage. We report a patient who developed a huge liver abscess after a minor blunt trauma caused by a piece of wood that hit his hepatic region during work with a circular saw. Neither conservative treatment nor percutaneous drainage was successful and intraoperatively a biliary fistula was identified as the route of infection by salmonella. Cholecystectomy (here meaning removal of the salmonella reservoir) and consequent drainage of the gall flow via T-drain were the crucial therapeutic steps and the fistula finally closed after three months. Therapeutic possibilities in the management of blunt liver trauma, and biliary and septic complications are discussed.

[Spontaneous splenic rupture during portal triad clamping]

A 45-year-old woman underwent a resection for a hepatic metastasis of the liver caused by a carcinoma of the colon. Shortly after the Pringle maneuver severe hemorrhage from the upper left quadrant of the abdomen was observed. Exploration revealed a spontaneous parenchymal laceration of the spleen.