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Purpose: Interferon-induced protein with tetratricopeptide repeats 3 (IFIT3) gene from IFITs family is one gene among hundreds of IFN-stimulated genes. The potential role of IFIT3 in cancer is scarcely understood. In addition, the clinical relevance of IFIT3 is not yet known in pancreatic ductal adenocarcinoma (PDAC). We evaluated the prognostic significance of this gene in PDAC patients., Methods: The expression of IFIT3 was analyzed in pancreatic cancer cell lines with different metastatic potential (FG and L3.6pl) and one established gemcitabine resistant cell variant-L3.6plGres. Second, we analyzed the protein expression in tissue microarrays (TMA) from specimens of 254 radically resected patients with pancreatic adenocarcinoma. The prognostic relevance of IFIT3 was evaluated by the Kaplan-Meier and Cox regression analysis., Results: L3.6pl cells with an aggressive capacity showed a significant higher expression of IFIT3 as compared to FG cells. IFIT3 was accumulated in gemcitabine resistant cells. Overexpression of IFIT3 increased the resistance of apoptosis against gemcitabine treatment. Patients who had high expression of IFIT3 (32%) and received chemotherapy had a statistically significant reduced survival in multivariate analysis., Conclusions: High expression of IFIT3 enhances anti-apoptotic activity and chemotherapy resistance of PDAC cells. High expression of IFIT3 was independently correlated to shorter patients' survival and may serve as a prognostic marker.

Purpose: Besides classical colorectal adenocarcinomas (AC), mucinous adenocarcinomas (MAC) and signet-ring cell carcinomas (SC) occur. Controversy remains regarding their prognostic role. Aim of this study was to define prognostic and histopathological specifications of mucinous and signet-ring cell colorectal cancer., Methods: A total of 28,056 patients with AC, MAC, and SC between 1998 and 2012 in the catchment area of the Munich Cancer Registry were analyzed. Time to locoregional recurrence and distant recurrence was calculated by cumulative incidence. Survival was analyzed by the Kaplan-Meier method, calculation of relative survival, and Cox proportional hazards regression., Results: AC occurred in 25,172 patients (90 %), MAC in 2724 (9.7 %), and SC in 160 (0.6 %). AC were less frequently localized in the proximal colon (34 %) compared to MAC (57 %, p < 0.001) and SC (76 %, p < 0.001). Both, MAC and SC had higher T, N, and M categories, lymphatic invasion, and worse grading (p < 0.001 for each). There were significant differences regarding the 10-year cumulative incidence of locoregional recurrence (p < 0.001), and distant recurrence (p < 0.001). For AC, the 5-year overall survival was 59 % (95 % confidence interval 58.0; 59.3), for MAC 52 % (50.2; 54.2), and for SC 40 % (32.1; 48.5; p < 0.001). However, MAC or SC did not remain independent prognostic factors for overall survival compared to AC upon multivariable analysis (p = 0.981)., Conclusion: This large cohort reveals specific histopathological and recurrence patterns for patients with colorectal AC, MAC, and SC. MAC and SC are diagnosed at more advanced tumor stages and therefore entail reduced survival rates.

Background: Gastric cancer accounts for 5 % of cancer deaths. Successful implementation of guideline-recommended treatment procedures should result in population-based outcome improvements despite the still poor prognosis. In this context, the objective of this study was to compare the outcome of gastric cancer by different levels of hospital care., Materials and Methods: Total of 8,601 patients with invasive gastric cancer documented between 1998 and 2012 by the Munich Cancer Registry were evaluated. Tumour and therapy characteristics and outcome were analysed in regard to five levels of hospital care: three levels were defined for general hospitals (level I-III), while university hospitals and speciality hospitals were grouped as separate classes. Survival was investigated using the Kaplan-Meier-method, computing relative survival, and by multivariate Cox proportional hazard regression., Results: The average age differed between 66 years in university hospitals and 75 years in hospitals providing a basic level of care (level I). No survival differences were found for patients treated in different levels of hospital care in 75 % of the patient cohort, namely the M0 patients. A better survival could only be shown for patients with M1 at diagnosis when treated in a university or level III hospital compared to those treated in other hospitals., Conclusion: The outcome difference of M1 patients is most likely caused by selection effects concerning health status differences and not by processes of health care attributable to level of hospital care. Thus, this study demonstrates and confirms appropriate treatment and care of gastric cancer over all levels of hospital care.

Background: Intra-abdominal adhesions following surgery are a major source of morbidity and mortality including abdominal pain and small bowel obstruction. This study evaluated the safety of PVA gel (polyvinyl alcohol and carboxymethylated cellulose gel) on intestinal anastomoses and its potential effectiveness in preventing adhesions in a clinically relevant large animal model., Methods: Experiments were performed in a pig model with median laparotomy and intestinal anastomosis following small bowel resection. The primary endpoint was the safety of PVA on small intestinal anastomoses. We also measured the incidence of postoperative adhesions in PVA vs. control groups: group A (eight pigs): stapled anastomosis with PVA gel compared to group B (eight pigs), which had no PVA gel; group C (eight pigs): hand-sewn anastomosis with PVA gel compared to group B (eight pigs), which had no anti-adhesive barrier. Animals were sacrificed 14 days after surgery and analyzed., Results: All anastomoses had a patent lumen without any stenosis. No anastomoses leaked at an intraluminal pressure of 40 cmH2O. Thus, anastomoses healed very well in both groups, regardless of whether PVA was administered. PVA-treated animals, however, had significantly fewer adhesions in the area of stapled anastomoses. The hand-sewn PVA group also had weaker adhesions and trended towards fewer adhesions to adjacent organs., Conclusion: These results suggest that PVA gel does not jeopardize the integrity of intestinal anastomoses. However, larger trials are needed to investigate the potential of PVA gel to prevent adhesions in gastrointestinal surgery.

Background: High-quality biospecimens of human origin with annotated clinical and procedural data are an important tool for biomedical research, not only to map physiology, pathophysiology and aetiology but also to go beyond in translational research. This has opened a new special field of research known as 'biobanking', which focuses on how to collect, store and provide these specimens and data, and which is substantially supported by national and European funding., Purpose: An overview on biobanking is given, with a closer look on a clinical setting, concerning a necessary distinction from clinical trials and studies as well as a comparison of prospective sample collection with secondary use of archived samples from diagnostics. Based on a summary of possible use and scientific impact of human tissue in research, it is shown how surgical expertise boosts the scientific value of specimens and data. Finally, an assessment of legal and ethical issues especially from a surgical perspective is given, followed by a model of interdisciplinary biobanking within a joint 'centre' that as synergistic structure merges essential input from surgery as well as laboratory medicine, pathology and biometry., Conclusion: Within the domain of biobanking, surgeons have to develop a better awareness of their role within translational research, not only on the level of medical faculties but also as nationally and internationally funded initiatives. Therefore, the authors suggest a platform for biobanking within the German association of surgeons in analogy to the existing special interest group for clinical trials.

Purpose: The purpose of this study was to assess the impact of surgical training and surgeon's experience on surgical quality and early outcome parameters., Methods: The outcomes of 184 deceased donor kidney transplant procedures were retrospectively reviewed. Intraoperative quality parameters, complication rates, and early outcome parameters were analyzed with respect to surgeon's experience. Surgeons were grouped according to their level of experience: trainees (n = 5), who were senior residents in their transplant rotation; low-experience surgeons (n = 4), who had an individual caseload of at least 30 supervised procedures; medium-experience surgeons (n = 5), who had an individual caseload of a minimum of 30 unsupervised (+30 supervised) procedures; and high-experience surgeons (n = 2), who had an individual caseload of more than 200 procedures., Results: Surgical training was offered in 20 % of all cases. Surgeons with a high experience in kidney transplantation had a significantly lower warm ischemic time (30 versus 35 min, p = 0.01) and total operation time (135 versus 155 min, p = 0.43) as compared to the other study groups. However, this did not translate into a better outcome after transplantation. The complication rate and early outcome parameters such as length of hospital stay, serum creatinine at discharge, and graft and patient survival at 3 months post TX did not show any significant difference between the groups., Conclusion: We conclude that hands-on training of residents in kidney transplantation is feasible and surgical experience can be safely gained within a staged surgical training program.

Background: The objective of this retrospective study was to assess the survival of patients after resection of hepatic and pulmonary colorectal metastases to identify predictors of long-term survival., Methods: Patients receiving chemotherapy alone were compared to patients receiving surgery and chemotherapy in a matched-pair analysis with the following criteria: UICC stage, grading, and date of initial primary tumor occurrence., Results: A total of 30 patients with liver and lung metastases of colorectal carcinoma underwent resection. In 20 cases, complete resection was achieved (median survival, 67 months). Incomplete resection and preoperatively elevated carcinoembryonic antigen (CEA) levels are independent risk factors for reduced survival. Patients developing pulmonary metastases prior to hepatic metastases had the worst prognosis. Surgical resection significantly increased survival compared to chemotherapy alone in matched-pair analysis (65 vs. 30 months, p = 0.03)., Conclusions: Incomplete resection and elevated CEA levels are predictors of poor outcome. Matched-paired analysis confirmed that surgical resection in combination with chemotherapy appears to be superior to chemotherapy alone.

Background: Angiogenesis, the formation of new blood vessels from the endothelium of the existing vasculature, describes a crucial process in tumor growth, disease progression, and metastasis. Therefore, the upcoming strategy of inhibiting tumor angiogenesis has generated different treatment modalities, which have been transferred into clinical practice in recent years. Currently, this concept is applied to target the vasculature of different visceral tumors and intensive clinical research has just started., Materials and Methods: This review summarizes the modifications of systemic treatment of visceral tumors by targeting the vasculature in the past years. Moreover, novel targets and treatment strategies will be discussed to evaluate future directions., Results: Leading antiangiogenic drugs combined with systemic chemotherapy have been applied with increasing success during the last years. Therefore, the concept of combining vascular targeting agents with established chemotherapeutic regimens has been increasingly adopted into the therapies of different visceral tumors., Conclusion: Targeting the vasculature of visceral tumors in combination with established standard tumor therapies includes major clinical potential for future therapy concepts.

Purpose: Different suture techniques and various suture materials are in use to close midline incisions after primary laparotomy. The ISSAAC study aimed to assess the safety and efficacy of the new ultra-long-term absorbable, elastic monofilament suture material MonoMax® for abdominal wall closure., Methods: This is a single-arm, multicentre prospective study that included 150 patients undergoing a primary elective midline incision. The control group consists of 141 patients from the INSECT study who received MonoPlus® or PDS® for abdominal wall closure. The incidences of burst abdomen and wound infection until the day of discharge were defined as the primary composite endpoints. The rate of incisional hernias 1 year after surgery, the length of postoperative hospital stay and safety parameters served as secondary endpoints. The study has been registered under www.clinicaltrials.gov [NCT005725079]., Results: Eleven patients in the ISSAAC study [7.3%; 95% CI = (3.9; 13.1%)] experienced wound infection or burst abdomen until the day of discharge as compared to 16 [11.3%; 95% CI = (6.6; 17.8%)] patients in the INSECT control group (p = 0.31). The length of postoperative hospital stay was comparable in both study groups. One year after surgery, incisional hernias were observed in 21 ISSAAC patients (14.0%) in contrast to 30 hernias (21.3%) in the INSECT control group., Conclusions: The ultra-long-term absorbable, elastic monofilament suture material MonoMax® is safe and efficient for abdominal wall closure.

Background: To date, only limited data are available regarding the routine surgical management of patients with exocrine pancreatic cancer (PC) in German community and university hospitals., Methods: With the use of a standardized questionnaire, a national survey on surgical and oncological treatment concepts for PC in Germany was conducted on behalf of the Chirurgische Arbeitsgemeinschaft Onkologie and Arbeitsgemeinschaft Internistische Onkologie. The surgical part of that questionnaire contained 25 questions on criteria regarding resectability, surgical techniques, perioperative patient management, and palliative surgical procedures in advanced PC. Data were collected centrally and analyzed using the SPSS(®) software. Additionally, predefined subgroup analyses, classifying the results by the professional site of the responding physician and the local annual number of treated patients, were carried out., Results: One-hundred and two questionnaires on the surgical survey section were returned. For the majority of the survey respondents, arterial infiltration is the most important criterion for non-resectability of PC (common hepatic artery, 69.9%; superior mesenteric artery, 85.3%; celiac trunk, 86.3%), whereas only 17.6% would define non-resectability based on portal vein infiltration; 69.9% consider extrapancreatic tumor manifestations as a criterion of surgical non-resectability. Of the survey participants, 53.9% perform a biliary drainage in case of preoperative cholestasis, whereas 43.1% reject this preoperative endoscopic-interventional approach. For cancers of the pancreatic head, 24.5% of surgical units recommend a classical Kausch-Whipple procedure, 52.9% prefer the pylorus-preserving partial pancreatoduodenectomy, and 20.6% use both procedures; 74.5% routinely perform a standard lymphadenectomy, whereas 16.7% prefer an extended procedure. A radical pancreatic resection would be performed by 63.7% of survey respondents also if a single liver metastasis would be found intraoperatively., Conclusion: Surgical treatment of PC in Germany is heterogeneous; future efforts to implement an evidence-based and standardized surgical management will be necessary.

Background: Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstone disease. Cultural as well as organisational differences can result in significant variations of postoperative length of stay. AIM OF THE PRESENT STUDY: The aim of this study is to evaluate whether differences in postoperative length of stay and early postoperative outcome can be observed by comparison of an Australian rural centre and a German university hospital., Results: Between February 2006 and August 2007 (18 months), 359 patients (140 Australia, 219 Germany) underwent laparoscopic cholecystectomy. Mean patient age was 50.4 +/- 1.5 and 53.5 +/- 1.0 years, respectively. Seventy-seven percent of the Australian and 62% of the German patients were female. Twenty-one percent and 20% of the procedures were emergencies, respectively. Median American Society of Anaesthesiologists score of all patients was two. The conversion rate was 8% in both centres. A 4% complication rate was observed in Australia (N = 5, 3x bile leak, 1x postoperative bleeding and 1x wound infection) as opposed to 3% in Germany (N = 7, 2x bile leak, 2x postoperative bleeding and 3x wound infection). Postoperative length of stay in Australia was 1.8 +/- 0.1 days (median 1 day) and was significantly longer in patients after emergency surgery (1.6 +/- 0.1 versus 2.6 +/- 0.3 days, p < 0.018). Postoperative length of stay in Germany was 3.7 +/- 0.2 days (median 3 days), and no significant differences were observed when elective and emergency procedures were compared (3.5 +/- 0.2 versus 3.9 +/- 0.5 days, p > 0.05). Comparison of treatment results indicates a significantly shorter postoperative stay in Australia (3 days versus 1 day, p < 0.001)., Discussion/conclusion: In rural Australia, a median postoperative stay of 1 day after laparoscopic cholecystectomy can be safely achieved. Postoperative length of stay is significantly longer in the German setting with otherwise comparable patients and surgical techniques. Simple changes of pre- and postoperative management of elective as well as emergency laparoscopic cholecystectomy will allow, for substantial cost savings, for the German health system.

Purpose: Since the discovery of cancer cells with stem-like characteristics in hematopoietic malignancies and, more recently, in solid tumors, enormous attention has been paid to the stem-cell nature of pancreatic cancer. Among the most important properties of cancer stem cells their high capacity for tumorigenicity as well as their ability to metastasize is under special research interest today., Methods: Here, we give a brief overview of main components used to confirm the stem-cell-like behavior of putative cancer stem cells and discuss markers and methods for identifying them in pancreatic cancer. Finally, the review provides some new suggestions as to how specifically target these cells and improve current therapy regimens., Results: The cancer stem-cell hypothesis is a fundamentally different model of carcinogenesis composed of two separate but dependent on each other characteristics of stem cells--aberrant activation of their tightly regulated processes of self-renewal and differentiation and their resistance towards chemo- and radiotherapy. The cancer stem cells may further be identified based on their expression of cell surface markers or their functional characteristics. The concept of molecular targeting of such highly tumorigenic cancer cells aimed to sensitize tumors toward conventional therapies and effectively abrogate tumor growth and metastasis., Conclusions: The presence of cancer stem cells in pancreatic tumors has prognostic relevance and influences therapeutic response. Evidence suggests that metastatic potential may be conferred to these highly tumorigenic cells as well. A better understanding of the biological behavior of these cells may further improve therapeutic approaches and outcomes in patients with this devastating disease.

Background/aims: Soft tissue sarcomas (STS) are rare tumors. General treatment is difficult while multimodality treatment strategies are more and more common. In these strategies, surgical resection of the primary tumor is essential to achieve local control of the tumor. In certain cases, complex resections (CR) including multivisceral and/or vascular resection are needed to achieve resection with tumor-free margins. In this study, we evaluated retrospectively the overall prognosis, morbidity, and mortality of patients treated for STS at our university hospital., Patients/methods: Between 1992 and 2000, 24 of 154 patients with STS received multivisceral resection and four of 154 underwent vascular resection. To determine the influence of CR on overall prognosis, we compared n = 19 patients after CR with a matched control group after simple tumor resection (SR). To determine surgical morbidity and mortality the whole study group was used (n = 154, SR n = 126, CR n = 28)., Results: The median follow up for all patients was 6.89 years (mean 5.64 years SD 4.3) with no difference between the groups (CR vs SR: 5.4 SD 4.8 vs 5.9 SD 3.9 years; p = 0.711). Patients receiving CR had a similar overall prognosis (mean survival 9.9 years), morbidity (10.7%) and mortality (0%) compared to patients with SR (mean survival 8.5 years; morbidity 10.3%; mortality 3.96%)., Conclusions: Multivisceral resection and/or vascular resection with tumor-free margins can be achieved with the same overall prognosis, same morbidity and mortality as SR. This has to be taken into account when evaluating the treatment strategy in patients with STS.

Introduction: Gender-specific immune responses have been found after trauma-hemorrhage. Male and female sex hormones seem to be responsible for this gender dimorphism. Alterations in sex hormone receptor expression in mice appear to contribute to the immunomodulatory effect of sex hormones after blood loss. The effect of surgical trauma on the expression of sex hormone receptors in peripheral blood mononuclear cells (PBMCs) from patients, however, remains unknown., Materials and Methods: PBMCs were obtained from 14 patients (7 men and 7 women) undergoing major abdominal surgery preoperatively and 2 h postoperatively. The expression of the androgen and the estrogen alpha- and beta- receptors were determined by reverse transcriptase polymerase chain reaction (RT-PCR). beta-Actin was used as housekeeping gene., Results: The results indicate that surgical trauma has no influence on the expression of the androgen receptor and the estrogen receptors alpha and beta in male and female patients., Discussion: The data demonstrate that, in contrast to mice, no alterations in the expression of androgen and estrogen hormone receptors were evident after surgery in patients. Thus, differences in the expression of sex hormone receptors do not appear to be responsible for the gender-specific immune response after surgery.

Traumatic aortic rupture is a life-threatening injury which is frequently associated with blunt thoracic trauma or found coincidentally in heavily traumatized patients. Depending on the degree of disruption of the damaged aortic wall, vascular injury is associated with a high primary mortality rate and a significant risk of secondary aortic rupture. Early clinical signs which may indicate a ruptured thoracic aorta are left sided thoracic pain, reduced ventilation, tachycardia and dyspnoe as well as hypotension in the lower extremities. The primary aim for emergency treatment is to maintain vital organ function and to hemodynamically stabilize the patient. Surgical treatment was previously performed by either direct aortic suture or segmental alloplastic graft interposition using the clamp and sew technique with or without extra-anatomic shunts or extracorporeal circulation. However, endovascular stent graft implantation has now become another treatment option for traumatic aortic rupture. According to the reported data and our own experience there is increasing evidence that endovascular aortic repair might become the treatment of choice for patients with traumatic aortic rupture, with the option of an early, less invasive intervention thus avoiding thoracotomy. Regular follow-up is necessary to detect possible stent graft migration or leakage which could require additional endovascular or open surgical re-interventions.

Background and Aims: Significant progress in surgical technique and perioperative management has substantially reduced the mortality rate of pancreatic surgery. However, morbidity remains considerably high, even in expert hands and leakage from the pancreatic stump still accounts for the majority of surgical complications after pancreatic head resection. For that reason, management of the pancreatic remnant after partial pancreatoduodenectomy remains a challenge. This review will focus on technique, pitfalls, and complication management of pancreaticoenteric anastomoses., Materials and Methods: A medline search for surgical guidelines, prospective randomized controlled trials, systematic metaanalysis, and clinical reports was performed with regard to surgical technique and complication management of pancreatic anastomoses., Results: Pancreaticojejunostomy appears to be most widely performed, but pancreaticogastrostomy is a reasonable alternative. Postoperative treatment with octreotide can be recommended only for patients with soft pancreatic tissue, and neither stents of the pancreatic duct nor drainages have proven to effectively reduce anastomotic complications. Gastroparesis remains the most common complication after pancreatic surgery and should be treated conservatively. However, it may be a symptom of other local complications, such as anastomotic leakage, pancreatic fistula or abscess. All septic complications may finally result in late postoperative hemorrhage, which requires immediate diagnostic workup and therapy. Today, interventional radiology has emerged as a standard tool in the management of local septic complications and bleeding. Therefore, relaparotomy has become less frequent and salvage pancreatectomy is now a rare procedure in case of local complications., Conclusion: The surgeon's experience with one or the other technique of pancreatic anastomosis appears to be more important than the technique itself.

Background: Fast-track rehabilitation after elective colon resection is an interdisciplinary multimodal procedure, which combines surgical and anesthesiological aspects. This leads to an improved and accelerated recovery and avoids perioperative complications. This survey focuses on the extent and use of such concepts in Germany., Methods: In January 2006, a questionnaire was sent to 1270 anesthesiology departments in Germany in which they were asked to describe the standard anesthesia procedures based on a conventional sigmoid resection., Results: The response rate was 385 out of 1270 (30.3%). Preoperative fasting of solid food 12 h before the operation was practiced in 52% and for 6 h in 44% of the clinics. For fluid intake the fasting time was 6 h in 47% and 2 h in 41%. Prophylactic measures for postoperative nausea and vomiting (PONV) were administered in 33% of clinics. Propofol (68%) was the leading narcotic, fentanyl (56%) and sufentanil (48%) were the most commonly used intraoperative analgesics and 75% of clinics used epidural analgesia., Conclusion: In Germany the anesthesiological treatment after elective colon surgery adheres broadly to the evidence-based recommendations for fast-track concepts.

ACTH-independent macronodular bilateral adrenal hyperplasia (AIMAH) is a rare cause of endogenous Cushing's syndrome. Here, massive bilateral adrenal enlargement is accompanied by ACTH-independent hypercortisolism. The detection of ectopic hormone receptors which, according to a new concept, control the cortisol production in AIMAH, offers the opportunity of normalizing the hypercortisolism by pharmacologically influencing the receptor or its ligand. We here present the case of a 46 year old male patient. Using clinical and pharmacological tests we found evidence of ectopic receptors in the AIMAH. After suspicion was erroneously raised that a malignant lesion could be inside of the right adrenal mass, the decision was made to resect both adrenals instead of trying to treat the hypercortisolism by pharmacological means. This surgical approach (bilateral adrenalectomy) has been the standard way of treatment for AIMAH until the new concept of the ectopic receptors was developed.

Background: Angiogenesis, the formation of new blood vessels from the endothelium of the existing vasculature, is fundamental in tumor growth, progression, and metastasis. Inhibiting tumor angiogenesis is a promising strategy for treatment of cancer and has been successfully transferred from preclinical to clinical application in recent years. Whereas conventional therapeutic approaches, e.g. chemotherapy and radiation, are focussing on tumor cells, antiangiogenic therapy is directed against the tumor supplying blood vessels., Materials and Methods: This review will summarize important molecular mechanisms of tumor angiogenesis and advances in the design of antiangiogenic drugs. Furthermore, clinical implications of antiangiogenic therapy in surgical oncology will be discussed., Results: First antiangiogenic drugs have been approved for treatment of advanced solid tumors in several countries. Leading antiangiogenic drugs are designed to inhibit vascular endothelial growth factor-mediated tumor angiogenesis. Combining antiangiogenic agents with conventional chemotherapy or radiation is currently investigated clinically with great emphasis to realize a multimodal tumor therapy, targeting both the tumor cell and tumor vascular compartment., Conclusion: Antiangiogenic tumor therapy represents a promising strategy for treatment of cancer and will most likely exhibit its clinical potential in combination with established standard tumor therapies in the future.

Introduction: Prolonged immunosuppression has been demonstrated after trauma-hemorrhage resulting in an increased susceptibility to sepsis. The contribution of antigen-presenting cells (APC) vs T cells to this diminished immune response, however, remains unknown., Materials and Methods: To study this, male mice were trauma-hemorrhaged (35 +/- 5 mmHg for 90 min and resuscitation) or sham operated. At 24 h thereafter, spleens were harvested and T cells (via Microbeads) and APC (via adherence) were isolated. Cocultures of combined T cells and APC were established for 48 h, stimulated with ConA and LPS. The T cell-derived cytokine IFN-gamma and IL-12 for APC responses were measured in the supernatants by the multiplex assay., Results: The release of IFN-gamma was suppressed by T cells after trauma-hemorrhage irrespective of whether sham or trauma-hemorrhage APC were added. Trauma-hemorrhaged APC did not affect T cells-derived IFN-gamma release by sham T cells. In contrast, trauma-hemorrhaged T cells depressed the release of IL-12 by APC. The release of IL-12 by trauma-hemorrhaged APC was not altered when sham T cells were cocultured., Conclusion: Prolonged immunosuppression after trauma-hemorrhage appears to be predominantly due to diminished T cell function. Thus, attempts to prevent immunodysfunction should be directed towards T cells.

Based on a large single-center follow-up database, we evaluated the long-term results after curative resection of pulmonary metastases from renal cancer. During a 20-year period, 105 patients underwent a total of 150 resections with curative intention. Hospital mortality was 0.95%, 5- and 10-year survival rates were 40% and 33%, respectively. Significant prognostic relevance was shown for complete pulmonary resection, lymph node involvement upon primary resection as well as size of the resected lung metastasis. Our findings of low perioperative morbidity and mortality rates lead us to propose that in patients without additional metastases curative resection of pulmonary lesions should be considered. Moreover, recurrent pulmonary metastases should also be considered for surgical treatment since resection for cure significantly improves survival in these patients.

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.

Background: Major liver resection is a routine surgical treatment, but hemodynamic and pulmonary complications are common. We investigated the effects of hepatic resection on hemodynamics and pulmonary and liver function., Patients and Measurements: Twelve patients who underwent major liver resection due to primary liver tumor, liver metastasis, or hemangioma were investigated prospectively and consecutively. Six patients who underwent gastrectomy due to gastric cancer served as a control group. Hemodynamic parameters (cardiac index, intrathoracic blood volume, mean arterial blood pressure), extravascular lung water, and indocyanine green clearance were measured after the induction of general anesthesia, during the preparation period, during total hilar clamping ("Pringle's maneuver"), at the end of surgery, and 24 and 72 h after surgery., Results: In contrast to gastrectomy, patients who underwent liver resection developed a hyperdynamic circulatory state (cardiac index 72 h postoperatively: 4.6+/-1.2 l/m(2) vs. 3.6+/-0.6 l/m(2)). Simultaneously we observed a significant increase in extravascular lung water in the liver resection group, indicating a moderate pulmonary edema. Indocyanine green clearance did not deteriorate following liver resection., Conclusions: After liver resection the physiological response resulted in elevated cardiac output and moderate pulmonary edema. Dynamic liver function was elevated within 24 h due to an increase in perfusion and regeneration activity of the remaining parenchyma.

Diverticula in the middle and lower thirds of the esophagus are a rare disorder, frequently associated with esophageal motility disturbances. For symptomatic patients transthoracic diverticulectomy with or without Heller's myotomy is recommended. Here we report two cases of symptomatic esophageal diverticula which were both treated successfully by a laparoscopic transhiatal approach.

Background and Aims: The discharge summary is crucial for patient aftercare as it is the main document for communicating information on patient data between the hospital and the primary care practitioner. The aim of this study was to assess the completeness of hospital discharge summaries and to determine whether the inclusion or omission of specific items of clinical information may affect further patient care., Patients/methods: A population based cohort study including patients with rectal cancer from April 1996 through March 1998 in the Munich region. Five hundred and thirty-seven discharge summaries were evaluated for completeness of clinical- and tumor-related information. In addition, the association between recommendation for (discharge summary) and initiation of adjuvant therapy after discharge was evaluated., Results: Information about T and N category was given in 98%, about metastasis in 90%, and about residual tumor in 73% of all discharge summaries. Follow-up was recommended in only 68% of the summaries. No adjuvant therapy was administered to 5/5 patients with N+, T1/2 tumors nor to 14/17 patients with N+, T3/4 tumors if correspondent recommendations were missing., Conclusion: Lack of crucial information in surgical discharge summaries is not only surprisingly common, but may also negatively affect patient aftercare.

Objective: In 1962, the procedure of arterial thrombembolectomy with the Fogarty catheter was established. Numerous studies have been published studying thrombembolectomies of the lower extremities. Limited information, however, is available following thrombembolectomy of the upper extremity after arterial occlusion. The aim of the present study, therefore, was to determine long-term results (3-5 years after thrombembolectomy) following thrombembolectomy of the upper extremity with the Fogarty catheter in a large retrospective clinical study., Design: In the present study, 251 patients were encountered. Over a period of 20 years, 283 thrombembolectomies with the Fogarty catheter were performed on the upper extremity at the surgical department of the University of Munich., Main Outcome Measurements: The appearance of local and general complications in the postoperative phase, as well as long-term results, were evaluated., Results: The results indicate that general complications - i.e., cardiac insufficiency, cerebral ischemia, etc. - occurred in 18 patients (7.2%). Local complications - i.e., wound infection, persistence of ischemia, or hematoma - were evident in 51 patients (20.3%). Re-occlusion following thrombembolectomy was found in 21 patients (8.8%). The affected extremity had to be amputated in five cases (2.0%), and 14 patients (5.6%) died during the postoperative phase. As a result of multimorbidity of the patients and average age at the time of surgery (73 years), 40% of the patients had died before the date of examination. Nonetheless, 111 patients of the 117 living patients showed no complaints or minor coldness and pain following heavy exercise., Conclusions: The results of the present study indicate that, in most cases, thrombembolectomy with the Fogarty catheter represents a successful surgical method for the acute treatment of arterial occlusion of the upper extremity.

Lower gastrointestinal bleeding (LGIB) is normally treated conservatively or by noninvasive techniques. Emergency operations are only necessary when patients with severe hemorrhage cannot be stabilized by emergency endoscopy or angiography. To improve the postoperative outcome it is of importance to operate on the patients without any unnecessary time delay. If the preoperative localization of the bleeding source failed, a total or subtotal colectomy should be regarded as a safe procedure. A blind segmental resection should not be done. Alternatively, several ileotomies or colotomies might be performed in order to localize and treat the bleeding site. Elective surgery is indicated with chronic or recurrent bleeding that cannot be treated conservatively. A meticulous preoperative localization of the bleeding site, including anorectoscopy, endoscopy, angiography and nuclear scan is required. With reliable knowledge of the cause and localization of the suspected hemorrhage, a directed segmental bowel resection should be performed.

Because of its unknown etiology the treatment of Crohn's disease is of a symptomatic nature. Therapeutic decisions mostly revolve around hour one can obtain the best quality of life for the patient. An active inflammatory flare-up is normally treated with steroids; there is no known remission maintenance therapy thereafter. In all other cases a surgical treatment option has to be considered, in particular with steroid dependency, refractory disease and the presence of complications. Deficiencies after surgery must be assessed. 5-Aminosalicylic acid helps in maintaining postoperative remission maintenance.

Malnutrition is correlated with an increased incidence of postoperative complications. As a consequence, preoperative hyperalimentation results in a decrease of postoperative complications in patients with malnutrition. In contrast, the beneficial effects of postoperative nutritional support are still to be proven. The majority of prospective trials have shown limited advantageous effects for patients with delayed nutritional intake after the surgical procedure. In these patients enteral nutrition has been shown to reduce the rate of infectious complications. If enteral nutrition cannot be applied, the addition of glutamine as a dipeptide is beneficial with regard to intestinal barrier function.

Recent evidence suggests that liver transplants may be immunologically protective for other simultaneously transplanted organs. One possible explanation is that the liver secretes MHC class I molecules. Here we show that these donor-specific secreted molecules can inhibit the priming effect of donor derived membrane-bound MHC antigen. Lewis rats were injected with syngeneic hepatocytes transfected with plasmids encoding either a membrane-bound or a secreted form of the RT1. A allo-MHC class I antigen of ACI rats. To test the immunologic effects of the different forms of alloantigen, ACI to Lewis liver transplants were performed 7 days after injection. As demonstrated previously, injection of hepatocytes expressing membrane-bound alloantigen sensitizes host immunity, leading to accelerated allograft rejection. However, after simultaneous injection of hepatocytes expressing the two different forms of the alloantigen, the accelerated liver allograft rejection caused by hepatocytes expressing membrane-bound molecules was no longer evident. Our results show that soluble allo-MHC class I antigen can inhibit the sensitizing effect of the same molecule in a membrane-bound form.

The tumor suppressor gene p53 in overexpressed in 50% of colorectal carcinomas and is an interesting target for gene therapeutic approaches. Furthermore the protooncogen bcl-2 is known to inhibit p53 induced apoptosis and is expressed in some colorectal carcinomas. In this study mechanism of bcl-2 cell death inhibition after p53 induction were evaluated. The human colon carcinoma cell line RKO posses wild-type p53 and also expresses bcl-2 protein. RKO cells were treated with liposomal bcl-2 antisense oligonucleotides (AS), control oligonucleotides (CO) and empty liposomes (EL) resulting in decreased bcl-2 expression. After induction of p53 with gamma-irradiation p53 protein expression was induced in AS, CO and EL pretreated cells. Microscopy and immunoblotting was used to characterize subcellular localization of p53 protein. Further p53 subcellular localisation was examined after p53 transfer of wt p53 cDNA in three bcl-2 expressing cell lines. Most of the p53 protein remained localized in the cytosol and apoptosis was decreased in bcl-2 expressing cells assessed by flow cytometric analysis (Ao). Our data suggests that bcl-2 is able to modulate transmembrane trafficking of p53. This resulted in inhibition of cell death implicating that bcl-2 function is involved in regulation of transmembrane gradients.

Functional variables after coloanal anastomosis or anastomosis with J pouch were investigated in 40 patients in a prospective randomized study. Continence for liquids and gas control were superior after J pouch anastomosis compared with coloanal reconstruction. The neorectal capacity was higher after J pouch anastomosis. The perception threshold for stool filling was higher in patients with J pouch resembling those values observed preoperatively. Quality of life was improved in subjects with with J pouch, although differences did not reach a significant level.

The alteration of proinflammatory mediators during sepsis and SIRS results in a large variety of adaptive changes of metabolic and physiologic variables. This study investigated the alterations of hepatocellular transport in a rat sepsis model (LPS i.p.) as well as in a model inducing SIRS by sterile abscess formation (turpentine i.m.). Two bile acids (Cholyltaurine and Chemodeoxycholyltaurine) and one organic anion (Sulfolithocholyltaurine) were used as marker substrates to investigate the time course of hepatocellular transport function. Experiments were performed in isolated perfused rat livers and plasma membrane vesicles. During sepsis, both, the transport of bile acids and that of the organic anion was markedly reduced. In contrast no alteration of transport was detected during SIRS. However, biliary secretion of glutathione (+90%) and bile acid independent bile flow (%) were increased. mRNA levels of bile acid and organic anion transport proteins were reduced. The lowest values were noted 12 h after injection of LPS or turpentine. Almost unchanged kinetic parameters during SIRS pointed to a normal population of transporters with regard to quantity and substrate affinity. Therefore it seems that transcriptional regulation plays an important role for the expression of transport proteins during sepsis, whereas posttranscriptional regulation may be of importance during SIRS. The clinical phenomenon of septic cholestasis including jaundice implies endotoxemia and differenciates against SIRS.

Szintigraphy of the thyroid gland is still one of the most important preoperative diagnostic procedures. Ultrasound of the thyroid gland is a highly sensitive, but less specific method. Fine-needle aspiration as an additional diagnostic method has a higher specificity in the case of a positive result.

During the last 16 years, 15 patients with colorectal (n = 12), gastric (n = 1), renal cell (n = 1) and adrenal (n = 1) carcinoma underwent sequential resection of both hepatic and pulmonary metastases. Median survival after diagnosis of primary tumor was 80 months (range 23-183), after liver resection 23 (range 10-131), and after lung resection 18 months (range 5-87). Compared to patients with only hepatic (median survival: 38 months) or pulmonary metastases (median survival: 30 months) survival time was not significantly different (p = 0.18).

Over a period of about 17 years 251 thrombembolectomies using the Fogartycatheter on the upper extremities were performed on 220 patients. In 9.5% of the cases reoperation and in 1.8% amputation were necessary; perioperative lethality was 5.5% and 19.5% developed local complications. Due to multimorbidity and the age of patients at the time of examination 46% had already died, while of the 101 surviving patients 94.1% showed good long-term results.

In a retrospective Study on patients with type III/IV Klatskin tumors, results of liver transplantation and liver replacement in combination with a Whipple procedure and extensive lymph node dissection (six and four patients, respectively) were compared. The combined ultraradical approach was not associated with higher peri- and postoperative morbidity and mortality, and seems to offer a chance for better results in terms of tumor-free survival.

Pulmonary embolism is the most common cause of maternal death during pregnancy. CASE REPORT. We report a 28-year-old obstetric patient (35th gestational week) who was admitted to the hospital because of intermittent vaginal bleeding caused by placenta totalis et accreta. Eleven days after admission she suffered a cardiac arrest. After cardiopulmonary resuscitation, an emergency caesarian section was performed and a healthy child was delivered. Abdominal sonography (B-mode) showed a floating thrombus in the inferior vena cava. Perfusion scintigraphy and cavography were normal; a computed tomography i.v. contrast medium study confirmed the presence of the thrombus. An open thrombectomy was performed to protect the patient from further pulmonary emboli. After 8 days she left the intensive care unit without residual complications. CONCLUSION. This case emphasises the importance of bedside sonography as a diagnostic method of identifying the source of a thrombus in patients with suspected pulmonary embolism.