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Introduction: Fundoplication techniques for treatment of gastroesophageal reflux are discussed concerning impairments and success. This randomized trial was conducted to compare Nissen’s wrap and the anterior partial technique (Dor) concerning patients’ quality of life (QoL) and functional data after a mid-term follow-up. Methods: In a 24-month period, 64 patients were equally randomized into group A (Nissen’s fundoplication) and group B (180° anterior partial fundoplication). After a mean follow-up of 18 months, all patients were examined and interviewed using standardized QoL questionnaires (Gastrointestinal Quality of Life Index), Visick score, 24-hour pH-metry and esophageal manometry. Data of 57 patients (group A: 27, group B: 30) could be analyzed. Results: After partial fundoplication, 9 patients (30%) stated the operative results were worse than perfect. Only 2 patients (7%) evaluated the outcome after Nissen’s fundoplication as unsuccessful (p = 0.04). However, postoperative Gastrointestinal Quality of Life Index showed no differences between groups (p = 0.5). Additionally, functional data were not different (DeMeester 10 vs. 12, p = 0.17, and lower esophageal sphincter pressure 13 vs. 12 mm Hg, p = 0.5). Conclusion: The anterior partial fundoplication technique did not lead to disadvantages in postoperative QoL, physiological function and reflux control when compared to Nissen’s approach in a mid-term follow-up.

We used a solid tumor model to evaluate the influence of laparotomy versus laparoscopy on tumor growth after curative resection for rectal cancer in rats.Colon tumor cells (DHD/K12/TRb) were administered intraperitoneally in 15 rats, which were used as solid tumor donors. Twenty-one days later, a 20-mg piece was then implanted in the rectal submucosa of the study rats (n=45). Animals were randomized into 3 groups for rectal resection either open or laparoscopic using either carbon dioxide (CO2) or helium for pneumoperitoneum. Autopsy took place 21 days after resection and tumor recurrence was evaluated.Port-site metastasis was observed after laparoscopy with CO2 (1 animal) and helium (1), whereas intraperitoneal tumor growth was detected in 2 and 3 animals of these groups. No tumor recurrence was observed after open surgery.Our solid tumor model is a novel neoplastic model that might simulate the clinical situation of an upper rectal carcinoma. It might be helpful to develop new protocols in studying solid tumor biology and different surgical procedures for cancer to address problematic issues in oncologic research.

We set up a pilot study to evaluate the efficacy of telerobotic surgery using the da Vinci system for several procedures for which traditional laparoscopy (or thoracoscopy) is a standard approach in a single institution.We performed fundoplications (hiatal hernia repair and antireflux surgery, n=112), upside-down stomach (14), cholecystectomy (16), gastric banding (3), colectomy (5), esophagectomy (4), sub/total gastrectomy (2), gastrojejunostomy (2), along with thymectomy (100), thoracic symatectomy (11), lobectomy (5), mediastinal parathyroidectomy (5), and left pancreatic resection (1).The median set up time for all procedures was reduced from 25.0 to 10.4 minutes. Conversion to traditional laparoscopy or thoracoscopy occurred in 12 cases and in open surgery in 11 cases. There was no morbidity related to the telerobotic system.Robotically assisted laparoscopic and thoracoscopic surgery is feasible and safe for a variety of procedures in general, visceral, and thoracic surgery.

Surgical therapy of peritoneal surface malignancy from colorectal origin in combination with Hyperthermic Intraoperative Peritoneal Chemotherapy (HIPEC) has now become an established treatment approach in very few specialised centres. A peritonectomy procedure is possible to perform with additional HIPEC in patients. An experimental model to simulate peritonectomy procedure and HIPEC does not exist so far in rats. Nevertheless, animal models seem to be very important for evaluation of new therapeutic opportunities and toxicity of different multimodal therapies. In a first step we analysed the surgical tumour debulking of peritoneal surface malignancy in rats. A peritoneal surface malignancy from colonic origin was induced in 75 male BD IX rats. Twenty one days after induction of peritoneal surface malignancy rats were randomised and animals intend to create an operation with surgical tumour debulking. There was no tumour growth in two animals. The aim of the peritonectomy procedure was the complete tumour reduction. In this study the results of the surgical approach will be described. A complete tumour reduction (R0) was achieved in 34 animals. In 39 rats a macroscopic tumour deposit was left behind (R2). The intraoperative experimental Peritoneal Cancer Index (ePCI) was used to describe tumour weight and number of tumour inoculations. Both parameters were found to be dependent factors of complete tumour reduction. Six animals died due to therapeutical interventions. Surgical tumour debulking in rats with peritoneal surface malignancy is possible with high reliability and a low mortality rate. This animal model could be an important step for investigation of multimodal treatment options and toxicity in treatment regimens of peritoneal surface malignancy.

Hintergrund: Die gastroosophageale Refluxkrankheit stellt mit einer Inzidenz von 10% der Gesamtbevolkerung ein bedeutendes medizinisches wie auch zunehmend okonomisches Problem in d

Background/Aim: Chemotherapy can induce serious leukopenia. The aim of our study was to investigate the effects on leukopoiesis when the antineoplastic agent taurolidine (TRD) is administered by a bolus injection or during repetitive treatment (21 cycles) over 7 days in rats. Methods: Rats were intravenously treated with a single injection (A) or by a 7-day treatment (B) with increasing doses of TRD versus control (isotone sodium) in a standardized animal model. Hematological adverse effects on leukopoiesis were analyzed in peripheral blood. Results: (A) Neither the highest TRD concentration (3%) nor 1 or 2% caused a significant difference between the control and TRD groups (p > 0.085) in the perioperative course after bolus administration. (B) The administration of TRD 3% led to a slight change of granulocyte and monocyte counts compared to the control group particularly on postoperative day 7, but this difference was not significant. In both protocols a slight postoperative increase in leukocytes was observed. Conclusion: We report that TRD administered intravenously in an antitumor dose does not affect leukopoiesis in rats. Thus, the agent offers a promising and safe means in cancer treatment. The effects are currently investigated in incurable cancer patients.

So far, the impact of telematic surgical approach in Gastroesophageal Reflux Disease (GERD) is still obscure. In this prospective study, we analyzed the Da Vinci® Intuitive Surgical robotic system for antireflux surgery. In April 2003, we set up a pilot study to evaluate the efficacy of laparoscopic telerobotic surgery using the three-arm Da Vinci® system. Optimal trocar positions, operating and setup times, conversion rate, intraoperative complications, and perioperative morbidity, as well as mortality rate, were analyzed. The median age was 53 years (range 25–74) in 118 patients (52 female/66 male). In 17 patients, an upside-down stomach- and in 101 GERD was surgical indication. The median operating time has been reduced from 105 min to 91 min after 40 procedures and setup time from 24.5 min to 10.4 min after 10 procedures. The system is safe and it seems to be superior to traditional laparoscopy during dissection in the esophageal hiatus region. This compensates long setup- and operating times. Disadvantages are the high costs, the time to master the setup/system and the necessity of exact trocar positioning.

Background The antitumor agent taurolidine (TRD) affects tumor growth in animals. Thus far, no animal studies have been published concerning the systemic or local toxicity and the effectiveness of long-term intraperitoneal (i.p.) and intravenous (i.v.) administration on advanced tumor growths. Materials and methods In a first experiment (A) the systemic toxicity of the liver and kidneys was examined only after i.v. treatment in 40 rats (BD IX). For local toxicity the superior vena cava (SVC) was histologically analyzed. In a second study (B) 20,000 colon adenocarcinoma cells (DHD/K12/TRb) were initially applied i.p. after laparotomy in 80 rats (BD IX). After 28 days a port catheter system was placed in the SVC and left for 1 week. The animals were randomized into eight groups (n = 10) and received a 7-day treatment (eight hourly, 1 ml): 1, 2, 3% TRD or Ringer’s solution (control group) either i.p. or i.v. Total i.p. tumor weight was measured 4 weeks after the end of the therapy. Side effects on differential blood counts and animal weight changes were examined. Results No organ lesions were detected in liver, kidneys, and SVC in experiment A. The i.v. administration of 2% TRD (P = 0.034) and 3% TRD (P = 0.05) as well the i.p. application of 2% TRD (P = 0.05) decreased the development of advanced i.p. tumor lesions. No changes of differential blood count nor relevant animal weight changes resulted. Three port catheter-related infections were examined. Conclusions TRD does not impair the liver tissue, kidneys, SVC, and leucopoiesis. The intravenous therapy of 2% TRD is safe and anti-tumorigenic in advanced local tumor growth in rats.

Recently introduced telerobotic surgical systems attempt to elude the inherent limitations of traditional laparoscopic surgery. Four patients (3 male, 1 female) with mixed hiatal and paraesophageal hernias with fixed intrathoracic partial or complete displacement of the stomach were operatively treated using the Da Vinci robotic system. Tissue dissection, hiatoplasty, and anterior hemifundoplication (Dor) were performed with the telerobotic system. There were no surgical complications. The system broke down in the fourth patient due to a software defect. Advantages were seen in terms of the intrathoracic dissection of displaced stomach through a narrow hiatus, intracorporeal suturing due to 6 degrees of freedom plus grasping. At the moment, lack of the appropriate robotic instruments for abdominal surgery as well as the enormous functional cost of the robotic system are considered to be the most significant current impediment to the adoption of robotic abdominal surgery. The continuous evolution and upgrade of the system is quite promising so far. Telerobotic-assisted hiatal hernia operation is feasible with many advantages compared with the traditional laparoscopic approach, especially during the dissection in the mediastinum in patients with intrathoracic stomach. A prospective, randomized trial will be performed later to evaluate the advantages and limitations of robotic compared with traditional laparoscopy. Technological evolution will perhaps diminish the current problems and the cost associated with robotic surgery.

Pneumatosis intestinalis (PI) is characterized by multiple gas cysts in the wall of the gastrointestinal tract. Primary PI is extremely rare. In most of the cases PI is due to an underlying disease (traumatic and mechanical, inflammatory and autoimmune diseases, infectious and pulmonary diseases, drug induced, immunosuppression, transplantation, or neoplasm). A 69-year-old woman was treated with mixed connective tissue disease and PI twice operatively and once conservatively in our department. Review of the english literature showed 13 more cases of PI with underlying mixed connective tissue disease. Most published cases of pneumatosis intestinalis with radiological finding of pneumoperitoneum were treated conservatively and should have not been considered as a reason for surgery. Therefore, the treatment of PI can present as a major dilemma for the surgeon.

Hintergrund: Iatrogene Lasionen der Trachea oder der Hauptbronchien sind sehr selten. Der Verlauf wird masgeblich durch fruhzeitige Erkennung, Verletzungsausmas und adaquate Versorgung bestimmt. Bei grosen Defekten konnte der kombinierte Einsatz neuer Materialien die Sicherheit primarer Nahte erhohen. Patienten und Methoden: Es wurden drei konsekutive iatrogene Tracheal- oder Bronchialverletzungen nach primarer Naht (Polydioxanon) zusatzlich mit resorbierbarem Soft PGA Mesh® (resorbierbares Polyglykol- Vlies) und Fibrin versorgt. Eine Patientin hatte bei einer notfallmasigen, orotrachealen Intubation eine langstreckige tracheale Verletzung der Pars membranacea erlitten. Bei einer weiteren Patientin (Ileus bei fortgeschrittenem Kolonkarzinom) war es durch mehrfache perkutane Tracheotomie bei Verlagerung der Trachea durch eine Arteria lusoria zu mehreren Defekten sowie einer grosen osophagotrachealen Fistel gekommen. Diese wurde erst am Folgetag identifiziert. Bei der dritten Patientin war bei stumpfer Dissektion eines fortgeschrittenen Osophaguskarzinoms ein erheblicher Defekt im Bereich der Bifurkation und des linken Hauptbronchus entstanden. Die therapeutischen Verlaufe wurden prospektiv erfasst und ausgewertet. Ergebnisse: Die jeweilige tracheale Versorgung blieb auch unter langwierigen Beatmungssituationen suffizient. Die erste Patientin blieb tetraparetisch und wurde nach 48 Tagen zur Rehabilitation verlegt. Die zweite Patientin verstarb am 15. postoperativen Tag unter dem Bild einer Urosepsis. Die dritte Patientin wurde 10 Tage lang intensivtherapeutisch behandelt und am 23. Tag von der Normalstation entlassen. Bronchoskopische und computertomographische Verlaufskontrollen sicherten adaquate lokale Ergebnisse. Schlussfolgerung: Nach suffizienter primarer Naht kann die zusatzliche Versorgung groser Verletzungen der Trachea und der Hauptbronchien mit resorbierbarem Material im Sinne eines Patches zu einer zusatzlichen Sicherung des Operationsergebnisses durch Ableitung auftretender Krafte (Cuff-Druck des Tubus, Beatmungsdruck) fuhren.

Obwohl die laparoskopische Resektion eines malignen Tumors impliziert, dass durch den Einsatz des minimal invasiven Verfahrens die immunologische Abwehr und das Tumorwachstum weniger beeinflusst werden als bei der konventionellen Chirurgie, ist der Stellenwert dieser Operationstechnik im Hinblick auf die Prognose der Tumorpatienten immer noch unvollstandig geklart. Ob die durch die Operation verursachte intra- und postoperative Immunsuppression nach laparoskopischen Operationen im Gegensatz zur konventionellen Technik wirklich reduziert ist und hierdurch moglicherweise die Prognose der Patienten gunstig beeinflusst werden kann, kann derzeit nicht eindeutig beantwortet werden. Zudem zeigen experimentelle Studien eher einen negativen Effekt von CO2 auf die Abwehrreaktion von Immunzellen und eine Stimulation des Wachstums von Tumorzellen. Hingegen konnten die meisten Tiermodelle einheitlich einen immunologischen Vorteil und eine geringere Stimulation des Tumorwachstums im Vergleich zur konventionellen Chirurgie nachweisen. Die klinischen Studien zeigen zwar bei kleineren chirurgischen Eingriffen eine deutlich geringere postoperative systemische Inflammation, allerdings konnte dieser Vorteil bei der Resektion von malignen Tumoren, wie dem kolorektalen Karzinom, nur bedingt bestatigt werden. Bislang konnte in allen prospektiv randomisierten Studien weder eine geringere Morbiditat noch eine Korrelation zwischen perioperativen immunologischen Veranderungen und postoperativen Komplikationen noch eine Verbesserung der Langzeitprognose nachgewiesen werden.

Although the problem of port-site metastases is mainly related to the surgeon, the technique, manipulation of the tumor-bearing organ, and some other factors related to laparoscopy itself have been shown to influence tumor growth. The different experimental studies about basic research and possible new therapeutic strategies, including instillation of cytotoxic and immune modulating agents in combination with laparoscopy, are presented and discussed.

BACKGROUND The Whipple operation (PD) is the standard operation in patients with cancer of the head of the pancreas and the periampullary region. However, the pylorus-preserving duodenopancreatectomy (PPPD) is supposed to be superior in gastrointestinal function. METHODS In a prospective randomized trial (October 1994-October 1998) PD and PPPD were compared in terms of global and gastrointestinal quality of life, operation time, duration of hospital stay, transfusions and perioperative morbidity. Quality of life was analyzed under standardized conditions (EORTC-QLQ-30) pre- and postoperatively (weeks 2, 6, 12, 24, 36, 48, and 60). RESULTS A duodenopancreatectomy was performed in 48 patients because of cancer of the head of the pancreas (n = 38) and the periampullary region (n = 10) (PD, n = 24; PPPD, n = 24). The PD and PPPD groups did not differ according to age, gender or UICC stage. Operation time was shorter in the PPPD group (206 +/- 48 vs 306 +/- 54 min) (P 0.05). While there was no difference in global quality of life, gastrointestinal quality of life was postoperatively increased in the PPPD group regarding appetite, nausea and diarrhea (P < 0.05). While the preoperative body weight was reached after 6 months in 85% of the PPPD group (n = 20), this was true in only 60% of the PD-group (n = 14) (P < 0.05). CONCLUSION PPPD seems to be associated with a better postoperative gastrointestinal quality of life than PD.

Background and aims: It has not been clarified whether there is a correlation between the tumor size and the preoperative immune function in pancreatic carcinoma. Patients/methods: In a prospective trial, the influence of tumor size and lymph-node status on different immune system factors [interleukins (IL)-6 and -10, tumor necrosis factor (TNF)-α, CD3-, CD4-, and CD8-lymphocytes, and human leukocyte antigen (HLA)-DR-monocytes] was analyzed in 28 patients with pancreatic carcinoma and compared with a control group (n=20). There were 3 pancreatic carcinomas of the T1-tumor type, 20 T2- and 5 T3-tumors; 14 patients were in stage N1. Results: In comparison with the control group, tumor patients preoperatively showed a significant increase of leukocytes (P=0.02), monocytes (P=0.04), and granulocytes (P=0.03). The total count of lymphocytes, the number of CD3-, CD4- and CD8-lymphocytes, and the expression of HLA-DR on monocytes were significantly decreased as a sign of immunosuppression in tumor patients. A multivariate analysis proved that only tumor size (T-stage) but not lymph-node status correlates with the deficiency of immune competence. Progressive tumor size correlated with decreasing expression of HLA-DR on monocytes, CD3- (P=0.04) and CD8- (P=0.02) lymphocytes. In contrast IL-6, IL-10 (P=0.04) and TNF-α (P=0.02) increased with progressive tumor size. Conclusion: Regarding the negative prognosis after resection, the preoperative immune status could be an additional help for decision between a resection or a preoperative immune stimulation in pancreatic carcinoma.

Neither experimental nor clinical data confirm the repeatedly published opinion that video-endoscopic surgery promotes tumor growth or the occurrence of implantation metastases in cancer patients. On the contrary, alterations due to pneumoperitoneum by the application of different gases, pressures, and temperatures might provide the basis for a new therapeutic approach to cancer surgery. Oncologically adequate resections defined by such terms as "no touch isolation" and "monobloc resection" can be performed video-endoscopically in a variety of intraabdominally or intrathoracically located cancers if a standardized technique is used. The benefit of video-endoscopic surgery is limited in large tumors, especially if they have reached the organ surface. There is still a major deficit in the clinical evaluation of video-endoscopic interventions in most oncologic diseases. Randomized studies comparing video-endoscopic and conventional surgery have been reported only for the resection of colorectal carcinoma. They show that laparoscopic resections can be performed with a minimum of postoperative complications to the same extent as conventional resections and offer several advantages during the early postoperative period. No reliable data from comparative trials are as yet available on the long-term results.

Increased intraperitoneal pressure and insufflation of carbon dioxide during laparoscopy may cause sepsis by promoting systemic inflammation in patients with intra-abdominal inflammatory diseases. The influence of carbon dioxide and helium during laparoscopy on bacteremia, endotoxemia, the plasma concentration of tumor necrosis factor-alpha (TNF-alpha), TNF-alpha secretion ex vivo by peripheral blood mononuclear cells (PBMCs), and intraperitoneal abscess formation was investigated in an animal model. A standardized fecal inoculum was injected intraperitoneally, and rats underwent laparoscopy with either carbon dioxide (N = 20) or helium (N = 20) or no further manipulation (control group; N = 20). Bacteremia was significantly more common 1 hour after laparoscopy with CO2 than in animals receiving helium or the control group. Furthermore, helium use led to a significant decrease of bacteremia 1 week after intervention. Fecal inoculation caused significant leukocytopenia in all groups within 1 hour after intervention, with complete recovery only in the helium-treated group (p0.05). The TNF-alpha plasma concentration was significantly lower in the helium-treated group, and suppression of ex vivo production recovered only in the animals undergoing laparoscopy with helium (p0.05). The number of intraperitoneal abscesses was significantly lower after laparoscopy with helium (2+/-1.5) than after CO2 laparoscopy (6.3+/-5.1) or in the control group (5.2+/-4.8). Laparoscopy with CO2 increased systemic inflammation only slightly, while helium use was associated with a significant lower incidence of bacteremia and local and systemic inflammation compared with the control group.

BACKGROUND In a prospective trial (October 1996-April 1998) the effect of octreotide and tamoxifen on the recurrence of pancreatic carcinoma after R0 resection was evaluated. METHODS Patients with a local recurrence after curative resection of ductal adenocarcinoma of the pancreas were treated with 100 micrograms of octreotide three times a day and tamoxifen 20 mg once daily. The median survival time, quality of life (EO-RTC-QLQ-30) and side effects of the octreotide-tamoxifen group were compared with a historic cohort (n = 14) of patients treated in our department (9/95-9/96) according to the "best supportive care" concept. RESULTS Recurrences were diagnosed after R0 resection in a mean time of 13 +/- 6.8 months. Patients treated with octreotide and tamoxifen had a significantly (P < 0.05) longer median survival time (7 months; range: 3-12) vs 3.5 months; range: 1.5-5). The octreotide-tamoxifen group suffered less from lack of appetite, nausea, fatigue, and pain and needed fewer analgesics. The only side effect of the octreotide-tamoxifen therapy was moderate diarrhea in 2 patients at the beginning of the therapy. CONCLUSION Since combined therapy with octreotide and tamoxifen can be administered comfortably for outpatient treatment, this seems to represent progress in the palliative therapy of pancreatic cancer.

Background: Abdominal hernia repair with implantation of synthetic meshes using the sublay technique has resulted in low recurrence rates and high patient satisfaction. Aim: The purpose of this experimental animal study was to investigate whether mesh fixation is necessary in abdominal hernia repair using a polypropylene mesh in the sublay technique. Methods: Forty-five rats were divided into three groups after creating an abdominal wall defect (CG control group, no mesh implantation; NoFixG mesh implantation without fixation group; SG mesh with suture fixation group) with 15 animals in each group. Endpoints were clinical herniation pressure, hydroxyproline (HP) concentration, mesh shape and number of fibroblasts/collagen fibres of the anchor zone 7, 14 and 90 days after implantation. Results: Herniation pressure, HP content and number of fibroblasts were similar between NoFixG and SG, although significantly higher in these groups than in the CG (P

Background: Although tension-free techniques of hernia repair using synthetic meshes revealed encouraging results, the best method of inguinal hernia repair is still unclear. Methods: In a prospective randomized phase-II-B study, early postoperative results of laparoscopic transabdominal preperitoneal repair (n = 80), open plug and patch repair (n = 80), and Shouldice’s operation (n = 80) were compared. Postoperative pain and patient’s comfort were defined as main endpoints. Results: The laparoscopic approach had significantly longer operation time and was more expensive (61 ± 12 minutes; $1,211) than plug and patch repair (36 ± 14 minutes; $124) and Shouldice’s operation (47 ± 17 minutes; $69). Main postoperative complications were wound hematomas, seromas, and superficial wound infection, without significant difference between the groups. Postoperative pain, analgesia requirements, limitation of daily activities, and return to work did not differ between laparoscopic and open tension-free repair but were significantly lower in both groups compared with Shouldice’s operation. So far, no recurrence was observed after a mean follow-up of 25 months. Conclusion: Open plug and patch repair is a promising technique of hernia repair in adults, because it offers the same excellent patient comfort as the laparoscopic repair but is less expensive and can be performed under local anesthesia.

Purpose: The genesis of anastomotic leakage and late stenosis of esophagogastrostomy is still unknown, although minimal blood flow and tissue hypoxia of the gastric tube are discussed as main reasons. However, the changes in tissue oxygen tension (PtO 2 ) on esophagogastric anastomoses have not yet been evaluated in the perioperative course. Methods: Submucosal tissue oxygen tension (PtO 2 ) was measured in 33 patients with cervical esophagogastrostomy during resection of esophageal carcinoma and reconstruction by a gastric tube. Measurements were taken close to the projected resection line and latter anastomosis using a Clark-type oxygen electrode. Results: Mean baseline PtO 2 was 55.1 ± 10.4 mmHg. Following the ligature of the vasa gastricae brevis and the left gastroepiploic artery (46.1 ± 9.7 mmHg), the left gastric artery (34.8 ± 9.8 mmHg), and the pull up of the gastric tube, PtO 2 decreased to 25.8 ± 9.4 mmHg. Anastomotic leakage occurred in 6 patients and late stenosis in 10 patients. During the operation there was no significant evidence of decreased PtO 2 levels in these two groups. Postoperative PtO 2 levels showed a significant increase in patients with anastomotic leakage. Conclusion: A disorder in oxygen consumption may cause a significant increase of PtO 2 in anastomotic tissue, which is associated with anastomotic leakage.

Hintergrund: Zur Zeit existiert keine einheitlich akzeptierte Therapie zur Verhinderung von Trokarmetastasen bei laparoskopischen Operationen von malignen Tumoren. Methode: Um ein intraperitoneales Tumorwachstum und Trokarmetastasen bei laparoskopischen Operationen zu verhindern, wurden die Effekte von Taurolidin und Heparin auf das Wachstum von Kolonkarzinomzellen (DHD/K12/TRb) in vitro sowie im Rattenmodell untersucht. In vitro erfolgte zunachst nach Inkubation der Zellen mit Heparin, Taurolidin oder beiden Substanzen die Bestimmung der Wachstumskinetiken der Zellen. In einem 2. Experiment erfolgte dann bei Ratten (n = 60) die intraperitoneale Applikation der Tumorzellen und anschliesend der Aufbau eines Pneumoperitoneums fur 30 min. Die Ratten wurden in 4 Gruppen randomisiert (I: Tumorzellen; II: Tumorzellen und Heparin; III: Tumorzellen und Taurolidin; IV: Tumorzellen und Taurolidin + Heparin). Ergebnisse: Wahrend das Tumorzellwachstum in vitro durch Heparin nicht beeinflust wurde, konnte durch Taurolidin und Taurolidin/Heparin eine signifikante Supprimierung des Wachstums erreicht werden. In vivo hingegen war das intraperitoneale Tumorgewicht gegenuber der Kontrollgruppe (596 ± 278 mg) sowohl bei der Instillation von Heparin (298 ± 155 mg) als auch von Taurolidin (149 ± 247 mg) vermindert. Die Kombination beider Substanzen verursachte eine weitere Verminderung des Tumorgewichts auf durchschnittlich (21,5 ± 36 mg). Die Entwicklung von Trokarmetastasen konnte hingegen nur durch die Instillation von Taurolidin oder die Kombination von Taurolidin und Heparin signifikant supprimiert werden. Schlusfolgerung: Wahrend durch Heparin das intraperitoneale Tumorwachstum nur geringgradig beeinflust wurde, konnten durch die Instillation von Taurolidin und Taurolidin/Heparin sowohl das intraperitoneale Tumorwachstum als auch die Entwicklung von Trokarmetastasen fast vollstandig verhindert werden.

Hintergrund: Laparoskopische Operationen werden auch in zunehmendem Mas bei Patienten mit einer Peritonitis oder anderen intraabdominalen entzundlichen Prozessen durchgefuhrt, obwohl der erhohte intraabdominale Druck eine Sepsis durch eine gesteigerte Bakteriamie und systemische Inflammation begunstigen konnte. Methode: In einer experimentellen Studie wurde deshalb der Einflus einer Laparotomie und einer Laparoskopie auf die bakterielle Translokation sowie auf die Plasmaspiegel von TNFα und Endotoxin analysiert. Hierzu wurde zunachst bei Ratten eine standardisierte humane Stuhlprobe intraperitoneal appliziert und anschliesend eine Laparotomie (n = 20), eine Laparoskopie (n =20) oder keine weitere Manipulation in der Kontrollgruppe (n = 20) durchgefuhrt. Ergebnisse: Eine Stunde nach der Intervention kam es in allen Gruppen zu einer Bakteriamie, welche nach Laparotomie und Laparoskopie signifikant gegenuber der Kontrollgruppe gesteigert war (p = 0,01). Die Stuhlapplikation verursachte weiterhin in allen Gruppen eine signifikante Erhohung der TNFα- und Endotoxinplasmaspiegel. Bereits 1 h postoperativ stiegen die TNFα- und Endotoxinplasmaspiegel an, mit signifikant hoheren Werten nach Laparotomie (p < 0,05). Die durchschnittliche Zahl der intraperitonealen Abszesse war ebenfalls nach Laparotomie (n = 10) signifikant hoher (p < 0,05) als nach Laparoskopie (n = 8) und in der Kontrollgruppe (n = 5). Schlusfolgerung: Die Laparotomie und die Laparoskopie fuhren im Vergleich zur Kontrollgruppe zu einer transienten Steigerung der Bakteriamie und systemischen Inflammation. Die systemische Inflammation sowie die Entwicklung von intraperitonealen Abszessen war allerdings in diesem Modell nur nach einer Laparatomie signifikant gegenuber einer Laparoskopie und der Kontrollgruppe gesteigert.

The effects of laparotomy and laparoscopy with different gases on subcutaneous and intraperitoneal tumor growth have not been evaluated yet.Tumor growth of colon adenocarcinoma DHD/K12/TRb was measured in rats after laparotomy, laparoscopy with CO2 or air, and in control group. Cell kinetics were determined after incubation with carbon dioxide or air in vitro and tumor growth was measured subcutaneously and intraperitoneally after surgery in vivo.In vitro, tumor cell growth increased significantly after incubation with air and CO2. In vivo, intraperitoneal tumor weight was increased after laparotomy (1,203 +/- 780 mg) and after laparoscopy with air (1,085 +/- 891 mg) and with CO2 (718 +/- 690 mg) compared to control group (521 +/- 221 mg) (p0.05). Subcutaneous tumor growth was promoted after laparotomy (71 +/- 35 mg) and even more after laparoscopy with air (82 +/- 45 mg) and CO2 (99 +/- 55 mg) compared to control group (36 +/- 33 mg).Insufflation of air and CO2 promote tumor growth in vitro. In vivo, intraperitoneal tumor growth seems to be promoted primarily by intraperitoneal air and subcutaneous tumor growth by CO2.

Das Leiomyom des oberen Gastrointestinaltrakts ist ein seltener benigner Tumor. In der Klinik fur Chirurgie der Charite wurden von 1984–1994 24 Leiomyome des oberen Gastrointestinaltrakts (Osophagusn=4, Magenn=18, Ileumn=2) reseziert. In Abhangigkeit von der Grose des Tumors erfolgten insgesamt 11 lokale Enukleationen bzw. Exzisionen und 13 resezierende Operationen. Bei einer durchschnittlichen Nachbeobachtungszeit von 36–84 Monaten traten weder Rezidive noch tumorbedingte Todesfalle auf. Die Enukleation und, wenn notwendig, die lokale Resektion sind die Therapie der Wahl bei Leiomyomen und fuhren zu guten Langzeitergebnissen.

Fracture of the distal clavicle type II (Neer) is an indication for surgical intervention. We report our experience in 12 patients with acute clavicular fractures and operative treatment with polydioxanone suture (PDS) tension band wiring. The patients were assessed 6 and 12 weeks postoperatively by radiological and clinical evaluation and with the Constant Murley score. All 12 patients had an excellent functional result 12 weeks postoperatively. The Constant Murley score was excellent in all patients. The PDS band can be considered as an alternative osteosynthesis. In the context of the current literature, the advantages and disadvantages of this new procedure are discussed.

The surgical therapy of the rupture of a distal biceps tendon and a modified postoperative treatment is described. Mainpoint is the early treatment in anaclisis of Kleinert as it is standardized in the treatment of ruptures of the flexor tendons of the hand. A forearm orthesis with a simply ROM-joint without reboundmechanism was used. Possible benefits are shown and further industrial evolution seems to be indicated.

Background Castleman's disease is a rare lymphoproliferative syndrome. Its etiology and pathogenesis are unclear. The disease can be occasionally associated with a paraneoplastic pemphigus (PNP), an autoimmune mucocutaneous disorder commonly seen in neoplasms of lymphocytic origin. Case presentation We present a case of a 63-year old male patient who was referred for surgical treatment of a lately diagnosed retroperitoneal pelvic mass. The patient had been already treated for two years due to progressive diffuse cutaneous lesions histologically consistent with lichen ruber verucosus and pemphigus vulgaris. Intraoperatively a highly vascularized solid mass occupying the small pelvis was resected after meticulous vascular ligation and hemostasis. After surgery and following immunosuppressive treatment a clear remission of the skin lesions was observed. Conclusion Castleman's tumor should be always suspected when a retroperitoneal mass is combined with PNP. In a review of the literature we found 37 additional cases. Complete surgical resection of the tumor can be curative in most of the cases.

Background The tumor suppressive agent taurolidine (TRD) inhibits tumor growth of more than 30 cell lines in vitro and reduces tumor load in early and advanced stages of neoplastic disease in animals. TRD has been shown to induce apoptosis of melanoma cells in vitro . Therefore, the effects of TRD on disseminated melanoma were evaluated in a mice model. Methods After general anesthesia, a midline laparotomy was performed and 1.5 million malignant melanoma cells (B78-D14) were applied in the spleen and 1 million cells at the back (C57BL/6). Animals were randomized and either treated intraperitoneally (i.p., n = 40, 7 days, 12 hourly) or intravenously (i.v., n = 40, 2 days, 12 hourly) with 1%, 2%, or 3% TRD or with Ringer’s solution (control group). On day 28, all animals were sacrificed and the total tumor weight and the number of metastatic lesions were determined by two investigators blinded for randomization. Results The i.p. therapy caused a dose-dependent inhibition of total tumor growth ( P = 0.003) and i.p. tumor growth ( P = P = 0.132) compared with the i.p. control group. The i.v. therapy reduced the total tumor growth ( P = 0.013) and the s.c. tumor growth ( P = 0.016), whereas the i.p. tumor load was not reduced ( P = 0.122) compared with the control group. Both i.p. and i.v. therapy with 3% TRD significantly decreased the total number of metastatic lesions. The animal weight was not affected. Conclusions The i.p. and i.v. therapies reduce total tumor weight and number of metastatic lesions of disseminated malignant melanoma in a dose-dependent fashion in mice. Our encouraging findings should be further confirmed in clinical studies examining the influence of TRD in patients with disseminated malignant melanoma for whom prognosis still remains dismal.

Primary amyloidosis isolated in the mediastinum is rarely encountered in thoracic surgery and few such cases have been reported. We present a case of primary isolated hilar amyloidosis of the mediastinum to illustrate the difficulties in differentiating this disorder preoperatively from central bronchial carcinoma, carcinoid tumor, and mediastinal lymphoma. Usually, a definitive diagnosis can only be made by open biopsy during thoracoscopy or thoracotomy. In conclusion, amyloidosis should be considered in the differential diagnosis of patients when calcifications are found, bearing in mind that radiologic findings are inconclusive and transbronchial biopsy can be negative.

Background: Therapeutic strategies to prevent port site recurrences in laparoscopy surgery of malignancies have not been investigated until now. Methods: The effects of taurolidine, heparin, and povidone iodine on the growth of rat and human colon adenocarcinoma as well as gallbladder carcinoma were investigated in vitro. Furthermore, cytokine release of growth-stimulating IL-1β by peritoneal macrophages was measured after incubation with carbon dioxide and additional incubation with the different agents. In the third experiment, prevention of intra- and extraperitoneal metastases by intraperitoneal instillation of the different agents during laparoscopy was investigated in a colon carcinoma model in the rat. Tumor cells were administered intraperitoneally in 100 rats, and pneumoperitoneum (8 mm Hg) was established over 30 min with carbon dioxide. Rats received either tumor cells, cells + heparin, cells + povidone iodine, cells + taurolidine, or cells + taurolidine + heparin. Results: In vitro, tumor cell growth decreased after incubation with taurolidine, taurolidine/heparin, and povidone iodine. Cytokine release was stimulated by incubation with carbon dioxide and could only be suppressed by incubation with taurolidine in vitro. In vivo, intraperitoneal tumor weight was lower in rats receiving heparin (251 ± 153 mg) and povidone iodine (134 ± 117 mg) compared to the control group (541 ± 291 mg), but even less when taurolidine (79 ± 82 mg) or taurolidine/heparin (18.3 ± 30 mg) were instilled. Conclusion: Heparin slightly inhibits intraperitoneal tumor growth in vivo, while povidone iodine and taurolidine cause a significant decrease in tumor cell growth in vitro as well as intraperitoneal tumor growth in vivo. Cytokine release of peritoneal macrophages is only suppressed by taurolidine. Total tumor take and trocar metastases are only suppressed by taurolidine and taurolidine/heparin.

Background and aim: K-ras oncogene is the most promising molecular marker of pancreatic cancer. However, the incidence of single and combined K-ras mutations in stool and pancreatic tissue is unknown, and it is not clear whether detection of the K-ras oncogene in stool could be employed in screening tests. Patients/methods: Stool and pancreatic tissue of patients with ductal adenocarcinoma (n = 36), cystadenocarcinoma (n = 1), periampullary carcinoma (n = 7), endocrine tumour (n = 2) and chronic pancreatitis (CP, n = 5) were analysed for mutated K-ras sequences prospectively. DNA of stool and pancreatic tissue was amplified by polymerase chain reaction and K-ras status was analysed by hybridisation. Results: K-ras mutations were detected in the pancreatic tissue of 28 patients with ductal adenocarcinoma (78%), in 1 patient with cystadenocarcinoma, in 1 patient with periampullary carcinoma (14%) and in 1 patient with CP (20%). In 1 patient with an endocrine tumour, no K-ras mutations were diagnosed. K-ras mutations were detected in stool in 7 patients with ductal adenocarcinoma (20%), in 1 patient with cystadenocarcinoma and in 2 patients with CP (40%). Sensitivity of K-ras mutations for pancreatic cancer was 78% in tissue and 20% in stool. Conclusion: K-ras mutations lack specificity to discriminate malignant pancreatic disease from chronic inflammation in tissue and stool.

Background: The pathogenesis of port site recurrences after laparoscopic surgery for malignant disease is still unknown. Whether different gases used to establish pneumoperitoneum have an influence on immunologic function and therefore on promotion of tumor growth has not yet been investigated. Methods: Tumor growth of colon adenocarcinoma DHD/K12/TRb was evaluated in a rat model after insufflation either with CO2 (n = 25) or helium (n = 25) and in a control group (n = 25). Tumor growth was measured subcutaneously and intraperitoneally 5 weeks after insufflation. Beside tumor growth, immunologic changes (peripheral leukocyte subpopulations, plasma levels of TNFα and IL-10) were evaluated during the perioperative course in all animals. Results: Subcutaneous tumor growth was promoted by the CO2 (99 ± 55 mg; p < 0.01) compared to the helium (40 ± 41 mg) and control groups (36 ± 33 mg). Total intraperitoneal tumor weight was 718 ± 690 mg in the CO2 group compared to the helium (549 ± 233 mg) and control groups (521 ± 221 mg). While peripheral leukocyte subpopulations only differed between the laparoscopic groups and the control group during the perioperative course, TNFα plasma levels were significantly decreased and IL-10 plasma levels significantly increased in the CO2 group compared to the helium and control groups in the postoperative course. Conclusion: The insufflation of CO2 promotes tumor growth compared to the helium and control groups in a rat model. In addition, increased tumor growth was associated with a significant increase in IL-10 and a decrease in TNFα plasma levels.

Background The pathogenesis of portsite recurrences after laparoscopic surgery is still unknown, and a generally accepted approach to prevent tumor implantation does not exist. Methods The effect of taurolidine and heparin on growth of colon adenocarcinoma DHD/K12/ TRb was measured in vitro and in vivo. After incubation of the cells with heparin or taurolidine or both substances, cell kinetics were determined. In a rat model (n = 60), tumor cells were administered intraperitoneally, and pneumoperitoneum was established over 30 minutes. Rats received tumor cells, tumor cells + heparin, tumor cells + taurolidine, or tumor cells + taurolidine + heparin. Results In vitro, tumor cell growth decreased after incubation with taurolidine and taurolidine/ heparin. In vivo, intraperitoneal tumor weight was lower in rats receiving heparin (298 ±155 mg) and taurolidine (149 ± 247 mg) compared with the control group (596 ± 278 mg) but even less when both substances were combined (21.5 ± 36 mg). Conclusion Heparin inhibits intraperitoneal tumor growth in vivo slightly, while taurolidine causes significant decrease of tumor cell growth in vitro as well as tumor take and intraperitoneal tumor growth in vivo.

Port-site recurrences have often been reported after laparoscopic surgery for malignant disease, and the pathogenesis is unknown. Whether different gases used to establish pneumoperitoneum have an influence on tumor cell growth has not been investigated.Tumor growth of colon adenocarcinoma DHD/K12/TRb was measured in a rat model after insufflation with either carbon dioxide or helium and in a control group. Tumor growth was evaluated in three experiments: (1) in vitro (n = 60), (2) ex vivo (n = 60), and (3) in vivo (n = 60). After insufflation, cell kinetics were determined in the first two experiments. In the third experiment, tumor growth was measured subcutaneously and intraperitoneally 5 weeks after insufflation.Tumor cell growth increased significantly after insufflation with carbon dioxide in vitro (p0.03) and ex vivo (p0.05) compared with the control group, whereas helium did not stimulate cell growth. In vivo, subcutaneous tumor growth was promoted by carbon dioxide (131 +/- 55 mg) (p0.01) compared with helium (35 +/- 34 mg) and the control group (36 +/- 33 mg). Total intraperitoneal tumor weight was 717 +/- 320 mg in carbon dioxide group compared with helium (549 +/- 231 mg) and control group (570 +/- 321 mg).The insufflation of carbon dioxide promotes tumor growth compared with helium and control in a rat model. Further studies should confirm these results before alternative gases should be recommended in laparoscopic surgery for malignant diseases.

Objective The effects of the different surgical approaches (transhiatal esophagectomy and right-sided transthoracic esophagectomy) on perioperative cardiopulmonary function in the surgical treatment of esophageal carcinoma are discussed controversially and have not yet been evaluated. Methods In a prospective randomized study including 32 patients, we investigated the effects of the surgical approach (blunt dissection (n = 16) versus transthoracic en-bloc resection (EB) (n = 16)) in the treatment of esophagus carcinoma on perioperative cardiopulmonary function. The following parameters were measured in all patients: cardiac index (CI), mean arterial pressure (MAP), central venous pressure (CVP), mean pulmonary artery pressure (MPAP), pulmonary capillary wedge pressure (PCWP), intrapulmonary shunt (QS/QT), arterio-alveolar (aaDO2), arterio-venous oxygen pressure difference (avDO2), and blood gas analyses. Time of measurement were: after induction of anesthesia, beginning and end of esophagus resection, end of surgery, 1 h postoperatively, and then every 12 h until the third postoperative day. Results Compared to blunt dissection, en-bloc esophagectomy was found to be associated with a transient deterioration of pulmonary function during one-lung ventilation in the left-lateral position, which could already be compensated for during the intervention. No other significant differences in cardiopulmonary effects were seen between the two surgical techniques. The incidence of postoperative complications was identical in both groups. Conclusions The results of our study show that en-bloc resection is only associated with an increased intraoperative pulmonary strain that is completely compensated during the operation and that there is no difference in cardiopulmonary functions between the two techniques in the postoperative course.

Submucosal tissue oxygen tension (PtO2) was measured in 20 patients with cervical esophagogastrostomy after resection of esophageal carcinoma, using a Clark-type oxygen electrode. The mean gastric baseline PtO2 was 54.6 +/- 10.7 mm Hg. Following ligature of the vasa brevia and the left gastroepiploic artery PtO2 decreased to 45.8 +/- 9.9 mm Hg, ligature of the left gastric artery caused a decrease to 34.2 +/- 9.7 mm Hg and resection of the lesser curvature and pulling up of gastric tube led to 25.5 +/- 9.0 mm Hg. Clinical value and practicability of intraoperative PtO2 measurements could be proven.

Postoperative radiation therapy following curative resection of squamous cell carcinoma of the esophagus was investigated in a prospective randomized study. A group of 33 patients received postoperative radiation therapy and were compared to a control group of 35 patients treated by surgery alone. No statistically significant differences were noted between the two treatment groups concerning overall and disease-free survival rates. Postoperative irradiation significantly increased the incidence of fibrotic strictures of the esophagogastric or esophagocolonic anastomoses and caused a delayed recovery of patients quality of life. Based on these results, we believe that postoperative radiation therapy alone cannot be advocated as a adjuvant therapy following curative resection of squamous cell carcinoma of the esophagus.

Background Taurolidine (TRD) is a novel agent with multimodal antineoplastic effects. We present the case of a tumor remission after intravenous administration of taurolidine in a patient with gastric cancer re-recurrence. Case presentation A 58 years old male patient suffering from a gastric adenocarcinoma was submitted to partial gastrectomy and partial liver resection (pT2, pN1, pM1L (liver segment 2), N0, V0). 24 months later a local recurrence was diagnosed and the patient was reoperated. Postoperatively the patient underwent a palliative chemotherapy with eloxatin, FU, and leucovorin. A subsequent CT-revealed a liver metastasis and a recurrence adjacent to the hepatic artery. After successful radiofrequency ablation of the liver metastasis the patient was intravenously treated with 2% taurolidine. The patient endured the therapy well and no toxicity was observed. CT-scans revealed a stable disease without a tumor progression or metastatic spread. After 39 cycles the patient was submitted to left nephrectomy due to primary urothelial carcinoma and died 2 days later due to myocardial infarction. Postmortem histology of the esophageal-jejunal anastomosis and liver revealed complete remission of the known metastasized gastric adenocarcinoma. Conclusion The intravenous treatment with 2% taurolidine led to a histological remission of the tumor growth without any toxicity for the patient.

Background The effect of additional treatment strategies with antineoplastic agents on intraperitoneal tumor stimulating interleukin levels are unclear. Taurolidine and Povidone-iodine have been mainly used for abdominal lavage in Germany and Europe. Methods In the settings of a multicentre (three University Hospitals) prospective randomized controlled trial 120 patients were randomly allocated to receive either 0.5% taurolidine/2,500 IU heparin (TRD) or 0.25% povidone-iodine (control) intraperitoneally for resectable colorectal, gastric or pancreatic cancers. Due to the fact that IL-1beta (produced by macrophages) is preoperatively indifferent in various gastrointestinal cancer types our major outcome criterion was the perioperative (overall) level of IL-1beta in peritoneal fluid. Results Cytokine values were significantly lower after TRD lavage for IL-1beta, IL-6, and IL-10. Perioperative complications did not differ. The median follow-up was 50.0 months. The overall mortality rate (28 vs. 25, p = 0.36), the cancer-related death rate (17 vs. 19, p = .2), the local recurrence rate (7 vs. 12, p = .16), the distant metastasis rate (13 vs. 18, p = 0.2) as well as the time to relapse were not statistically significant different. Conclusion Reduced cytokine levels might explain a short term antitumorigenic intraperitoneal effect of TRD. But, this study analyzed different types of cancer. Therefore, we set up a multicentre randomized trial in patients undergoing curative colorectal cancer resection. Trial registration ISRCTN66478538