Leber, Magen, Darm最新文献

Patients and methods: In a prospective protocol 86 consecutive patients with a diffuse peritonitis were treated in the Surgical Clinic of the RWT-University in Aachen (FRG) from January 1992 to June, 1994. According to the "Mannheim Peritonitis-Score" three different stages were treated with different procedures. Stage-I-peritonitis (mild forms, MPS 0-20) was treated with the so-called standard procedure, Stage-II-cases (MPS: 21-29) with the closed postoperative lavage and severe stage-III-cases (MPS > 29) with the so-called "Etappenlavage" (multiple reexplorations and intraoperative lavage).

Results: 36 patients showed stage-I-, 29 stage-II-, and 21 stage-III-peritonitis. Mortality was 3% (1/36) in stage-I-, 24% (7/29) in stage-II-, and 33% (7/21) in stage-III-groups. The overall mortality of the whole group was 17% (15/86). The statistically expected mortality was 38% according to the MPS and 33% related to the APACHE-II-Score.

Photodynamic therapy (PDT) is a new local, endoscopically controlled therapeutic concept based on the selective sensitization of malignant and precancerous lesions prior to light-induced tissue destruction. The first therapeutic experiences with the conventional photosensitizer dihematopor-phyrineter in the treatment of Barrett's esophagus without or with severe dysplasia and mucosal carcinomas of the esophagus demonstrate the efficacy and the curative potential of photodynamic therapy. The unwanted skin photosensitivity and only relative selectivity of the haematoporphyrins however, are somehow unsatisfactory and therefore, an optimization of the method of PDT is necessary. The endogenous photosensitizer aminolaevulinic acid with its high mucosa specificity without phototoxic side effects of the skin which can be administered orally was successfully used by our group for the treatment of patients with severe dysplasia of Barrett's esophagus and superficial squamous cell carcinomas. In patients with severe dysplasia/carcinoma in situ of Barrett's esophagus and early squamous cell carcinomas who pose high surgical risk, photodynamic therapy might be an effective alternative treatment modality in the future.

To define the role of operative treatment of intraabdominal abscesses, we retrospectively reviewed 106 patients, who were operated for intraabdominal abscesses between January 1988 and October 1994. 49 patients had had a primary abscess, 57 patients had an anteceding operation. In both groups appendix and bilio-pancreatic tract were the mostly involved organs. 81 (76,4%) abscesses were single, whereas 17 patients had 2 and 8 patients had 3 synchronous abscesses. All abscesses fulfilled the criteria of complicated abscesses. Successful drainage was achieved in 83%, 17% of cases had to be reoperated or percutaneously drained for recurrence of abscess or abscess related complications. The procedure related morbidity was 37,7% (40/106), half of these were minor complications. 5 patients died, conferring to a mortality of 4,7%. We conclude, that operative drainage plays an important role in the therapeutic regimes of intraabdominal complicated abscesses and can be performed with low morbidity and mortality.

Actually, the therapeutic goal in a metastasized carcinoid tumor is rather symptomatic than curative. Here we report the case of a 53 year old woman with a hepatic and pulmonal metastasized carcinoid tumor of the small intestine. We will discuss current therapeutic options and the approach to the individual patient. After treatment with the standard therapeutics Octreotide and Interferon alpha we could achieve a remarkable and persistent remission by applying the rather unusual drug Dacarbacine in this patient. This is an example for the frequently occurring clinical situation in the treatment of patients with rare tumors requiring the application of individually modified therapeutic regimens. Furthermore, the potency of Dacarbacine in the treatment of carcinoid tumors seems to be underestimated up to now.

The Alagille syndrome which is also known as arterio-hepatic dysplasia is an autosomal dominant inherited disorder. In several cases cytogenetic studies revealed an interstitial deletion of the short arm of chromosome 20. The hypoplasia or paucity of the interlobular bile ducts causes a chronic intrahepatic cholestasis. The association with facial dysmorphia, embryotoxon posterior, pulmonary stenosis and vertebral deformities are required for the diagnosis of the complete Alagille syndrome. The occurrence of hepatocellular carcinoma as a late complication of the Alagille syndrome was recognized only 11 years after the first publication by Alagille et al. So far 15 cases complicated by hepatocellular carcinoma have been reported. There is one family where all four siblings suffered from hepatocellular carcinoma. Our own case concerns a 31 year old man who died of hepatocellular carcinoma. The postmortem study of his medical history reaching back to childhood allowed the diagnosis of an unrecognized Alagille syndrome.

The case of a female patient aged 34 suffering from abdominal actinomycosis is reported. She underwent emergency surgery for an abscess-forming tumour infiltrating the lateral abdominal wall and giving rise to the clinical picture of acute abdomen. The casuistry is complemented by two further case histories of actinomyces infections in patients with fistulas of the anal region and pilonidal sinus respectively. Abdominal actinomycosis presents itself as a rare chronic bacterial inflammation, usually located in the right lower abdomen, with local abscess or fistula formation as well as tumour-like infiltration of the surrounding tissues. Exceptionally, the diagnosis is ascertained prior to surgery. Postoperative antibiotic therapy with penicillin for several months ist essential.