Erik Schlöricke

Metachronous metastasis- and survival-analysis show prognostic importance of lymphadenectomy for colon carcinomas

BackgroundLymphadenectomy is performed to assess patient prognosis and to prevent metastasizing. Recently, it was questioned whether lymph node metastases were capable of metastasizing and therefore, if lymphadenectomy was still adequate. We evaluated whether the nodal status impacts on the occurrence of distant metastases by analyzing a highly selected cohort of colon cancer patients.Methods1,395 patients underwent surgery exclusively for colon cancer at the University of Lübeck between 01/1993 and 12/2008. The following exclusion criteria were applied: synchronous metastasis, R1-resection, prior/synchronous second carcinoma, age < 50 years, positive family history, inflammatory bowel disease, FAP, HNPCC, and follow-up < 5 years. The remaining 421 patients were divided into groups with (TM+, n = 75) or without (TM-, n = 346) the occurrence of metastasis throughout a 5-year follow-up.ResultsFive-year survival rates for TM + and TM- were 21% and 73%, respectively (p < 0.0001). Survival rates differed significantly for N0 vs. N2, grading 2 vs. 3, UICC-I vs. -II and UICC-I vs. -III (p < 0.05). Regression analysis revealed higher age upon diagnosis, increasing N- and increasing T-category to significantly impact on recurrence free survival while increasing N-and T-category were significant parameters for the risk to develop metastases within 5-years after surgery (HR 1.97 and 1.78; p < 0.0001).ConclusionsBesides a higher T-category, a positive N-stage independently implies a higher probability to develop distant metastases and correlates with poor survival. Our data thus show a prognostic relevance of lymphadenectomy which should therefore be retained until conclusive studies suggest the unimportance of lmyphadenectomy.

Endoscopic negative-pressure therapy for duodenal leakage using new open-pore film and polyurethane foam drains with the pull-through technique

Few reports have described the use of endoscopic vacuum therapy (EVT) for duodenal defects [1–4]. We treated a complicated duodenal leak with EVT using the pull-through technique with a new type of open-pore polyurethanefoam drain (OPD) [5] and a novel type of open-pore film drain (OFD). Construction of an OFD is shown in ▶Video1. First the distal ends of two drainage tubes (Ventrol; 12–18Fr × 120cm; Covidien, Argyle, Ireland) are connected. This coupling segment is then wrapped with open-pore polyurethane-foam or a very thin double-layered film (Suprasorb CNP drainage film; Lohmann & Rauscher, Germany) (▶Fig. 1). The diameter of the OPD is 1.5–3 cm and of the small-bore OFD is 4–6mm (▶Fig. 2). Both drain types can be placed by the pull-through technique along an intestinal–cutaneous fistula. The oral end is passed out nasally and a vacuum is applied to drain the intraluminal secretions; the distal end is passed out cutaneously (▶Fig. 3). We report a 53-year-old patient who presented for endoscopic examination with a persisting duodenocutaneous fistula after a very complicated course including multiple operations. Duodenal secretions were running along an intraabdominal drain placed next to the duodenum and a 2-cm transmural defect of the duodenal wall was found near to the papilla of Vater. The operative drain could be seen through this defect. An OPD was inserted using the pullthrough technique following the course of the operative drain. The foam was pulled into the internal opening of the duodenal fistula. Application of negative pressure with an electronic vacuum device (KCI Activac; setting 125mmHg, continuous, intensity high) resulted simultaneously in closure of the defect around the tube, collapse of the duodenal lumen, and internal drainage of duodenal secretions. The drainage of secretions cutaneously stopped immediately. Video 1 Construction of an open-pore film drain (OFD) for the pull-through method is demonstrated. Different types of pull-through drains are illustrated. Insertion of an openpore polyurethane-foam drain (OPD) is shown using the pull-through technique in a patient with duodenal leakage.

Laparoscopic spleen preserving distal pancreatectomy

PurposeFor a long time, laparoscopic pancreatic surgery was simply a matter of extended diagnostics without a simultaneous resection.MethodsThe increase of experience in complex laparoscopic procedures combined with a substantial improvement in technical equipment has led to the possibility of performing pancreatic resections laparoscopically.ResultsIn contrast to the experimental laparoscopic pancreaticoduodenectomy, laparoscopic distal pancreatectomy has proved its safety and efficacy.ConclusionIn order to avoid splenectomy-associated complications, such as the OPSI-syndrome or formation of abscesses in the splenic area, the spleen-preserving technique is more favorable. Due to ischemia caused by the resection of the splenic vessels, as well as portal hypertension in the long-term follow-up, those vessels should remain untouched. The following article and video describe our approach for laparoscopic spleen-preserving distal pancreatectomy with sparing of the splenic vessels.

Endovascular Treatment of Aneurysms of the Popliteal Artery By a Covered Endoprosthesis

Purpose The current gold standard of popliteal artery aneurysm (PAA) treatment is saphenous vein bypass grafting. The aim of this retrospective single-center study is to investigate the safety and efficacy in the treatment of PAA by an endovascular implanted covered endoprosthesis. Materials and Methods Ten patients, mean age 64.6 (range, 52-78) years, with PAA were treated with an expanded Polytetrafluoroethylen (ePTFE)-covered stent graft (Viabahn®, W.L. Gore and Associates Inc, Flagstaff, AZ, USA). In median, 1.4 prostheses were implanted with a median length of 180 mm. Follow-up visits included determination of ankle-brachial index (ABI) and color-coded duplex sonography. Results The technical success rate was 100% (10/10). Clinically, there was an increase in ABI from 0.62 ± 0.17 to 0.91 ± 0.15 postinterventionally and to 0.89 ± 0.16 after an average follow-up of 24.7 months. During the follow-up period, 2 (20%) stent occlusions occurred; both of them were treated with a bypass graft. Conclusion The treatment of PAA with covered endoprosthesis is a safe and effective alternative to open surgical therapy, where open surgical therapy is contraindicated or patient refused open surgery.

Laparoscopic Pylorus- and Spleen-Preserving Duodenopancreatectomy for a Multifocal Neuroendocrine Tumor

Background: In contrast to laparoscopic left pancreatic resection, laparoscopic total duodenopancreatectomy is a procedure that has not been standardized until now. It is not only the complexity that limits such a procedure but also its rare indication. The following article demonstrates the technical aspects of laparoscopic pylorus- and spleen-preserving duodenopancreatectomy. Case Report: The indication for intervention in the underlying case was a patient diagnosed with a multiple endocrine neoplasia (MEN) I syndrome and a multifocal neuroendocrine tumor (NET) infiltrating the duodenum and the pancreas. The patient was post median laparotomy which was necessary after jejunal perforation due to a peptic ulcer. The resection was carried out entirely laparoscopically, and the reconstruction, which included a biliodigestive anastomosis and a gastroenterostomy, was carried out by means of a median upper abdomen laparotomy of 7 cm in length through which the resected specimen was also removed. The total operative time was 391 min. The blood loss accounted for 250 ml. The postoperative course was uneventful, and the patient was discharged on the eighth postoperative day. Conclusion: Laparoscopic pancreatectomy is a treatment option in carefully selected indications. The complexity of the operation demands a high level of expertise in the surgical team.

Long-term outcome of laparoscopic and open surgery in patients with Crohn’s disease

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Acute and Chronic Infections of the Gastrointestinal Tract.

within community care. These studies have identified the cultural anthropological dimension of uncertainty avoidance (UA) as being particularly relevant in explaining why doctors in some European countries have a greater propensity to prescribe antibiotics for predominantly viral conditions, such as colds, flu, and sore throat, in the face of clear scientific evidence. UA is described in the Geert Hofstede model of cultural dimension as a construct estimating the extent to which a society tolerates uncertainty and ambiguity. Such cultures often try to counteract the unease created by situations of uncertainty through the adoption of dogmatic and excessive measure, even when there is no evidence of cost-effectiveness or risk attenuation. There is no evidence to support postoperative prophylaxis.

Hinweise für Autoren

A rare case of hibernoma about the nipple in a 9-year-old boy is presented: the tumour was peculiar not only for the age and region, but also for its superficial, subepidermal site.

Thromboseprophylaxe und perioperative Therapie mit Antikoagulantien

Die perioperative Thromboseprophylaxe wird in Deutschland zumeist mit niedermolekularem Heparin (NMH) durchgeführt. Bei der Anwendung von NMH muss auf die Nierenfunktion geachtet werden und gegebenenfalls die Dosis bei eingeschränkter Nierenfunktion angepasst werden. Auch beim sog. Bridging, dem Unterbrechen einer Therapie mit Vitamin-K-Antagonisten, sollte bevorzugt NMH verwendet werden. Hierbei zeigen neueste Daten, dass bis dato wahrscheinlich viel zu hoch während der Überbrückungsphase antikoaguliert wurde. Bei niedrigem und mittlerem Risiko scheint eine Gabe der Thromboseprophylaxedosierung des NMH ausreichend zu sein, wenn die orale Antikoagulation zügig wieder aufgenommen wird. Bei der Pausierung einer dualen oder singulären antithrombozytären Therapie muss ein besonderes Augenmerk auf stattgefundene Stentimplantationen oder ein akutes Koronarereignis gelegt werden. Das unkritische Pausieren der Thrombozytenaggregationshemmer kann deletäre Folgen haben.

Gastrointestinaler Notfall in der Onkologie

ZusammenfassungDer gastrointestinale Notfall in der Onkologie besitzt eine enorme Bandbreite an Manifestation, Ursache und Schwere sowie u.U. Dramatik. Die Therapie sollte somit immer im interdisziplinären Konsens zwischen Chirurgen, Onkologen, Gastroenterologen und Intensivmediziner erfolgen. Hierbei ist insbesondere der individuelle Zustand des Patienten (Alter, Vorerkrankungen, bisher durchgeführte Therapie, Organfunktionen, Prognose etc.) in der Therapieentscheidung zu berücksichtigen. Grundsätzlich sollte das Primum movens jeglichen therapeutischen Handelns die Sanierung der Komplikationsursache sein und darüber hinaus den Prinzipien der onkologischen Radikalität Rechnung tragen. Die klinische Manifestation der Perforation und Blutung wird in Abhängigkeit ihrer Ursache und der entsprechenden Organlokalisation diskutiert. Die sich hieraus ableitenden diagnostischen und therapeutischen Maßnahmen erlauben im interdisziplinären Konsens die notwendige Individualisierung der Therapie.AbstractGastro-intestinal emergencies in oncology requiring surgical intervention exhibit an enormous variety of manifestations and causations and are likely to evolve into challenging situations. Therapeutic strategies should therefore be an interdisciplinary consensus between surgeons, oncologists, gastro-enterologists and intensive care medicine. Furthermore, the consideration of the individual patient’s condition regarding age, organ function, prognosis and current treatment is of paramount importance. In general, the aim of all therapeutic interventions should be guided by treatment of the underlying cause and especially consider the principles of oncologic surgery. This review outlines the manifestation of perforation and bleeding in oncology patients depending on the underlying cause and the corresponding organ affected. The subsequent diagnostic and therapeutic interventions should therefore allow for a mandatory individualization of therapy.