Georg Werkgartner

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

PURPOSE: Nitric oxide is an important neurotransmitter mediating internal anal sphincter relaxation. Patients suffering from fissure-in-ano were treated with topical nitroglycerine. The clinical evidence for therapeutic adequacy was examined in a prospective, randomized study. METHODS: The study included 35 patients with acute and chronic anal fissures. In Group A, including 20 patients with the clinical diagnosis of acute (12 patients) and chronic (8 patients) anal fissures, treatment consisted of topical nitroglycerine. Group B, consisting of 15 patients (10 acute and 5 chronic fissures), received topical anesthetic gel during therapy. Manometry was performed before and on days 14 and 28 in the course of topical application of either 0.2 percent glyceryl trinitrate ointment or anesthetic gel (lignocaine). Anal pressures were documented by recording the maximum resting and squeeze pressures. RESULTS: In 60 percent of cases treated with topical nitroglycerine (Group A, 11 acute (91.6 percent) and 1 chronic (12.5 percent)), anal fissure healed within 14 days, in contrast to Group B in which no healing was observed. The healing rate after one month was 80 percent (11 acute (91.6 percent); 5 chronic (62.5 percent)) in Group A and was significantly superior to Group B (healing rate, 40 percent: 5 acute (50 percent); 1 chronic (20 percent)). DISCUSSION: Previously increased maximum resting pressures decreased from a mean value of 110 to 87 cm H2O. This represents a mean reduction of 20 percent (P=0.0022). We also noted a significant decrease in squeeze pressures (from 177.8 to 157.9 cm H2O (11 percent)). However, anal pressures did not decrease significantly in the four chronic fissure patients from Group A, whose fissures only healed after 28 days. Similarly to these Group A chronic fissure patients, no significant anal pressure reduction was observed in any Group B patients. Except for mild headache (20 percent), no side effects of treatment were reported. CONCLUSIONS: Topical application of nitroglycerine represents a new, easily handled, and effective alternative in the treatment of anal fissures. All of our patients reported a dramatic reduction in acute anal pain. However, it should be noted that a lack of sphincter tone reduction is a likely reason for the great tendency of chronic anal fissures to recur.

Hemostatic Methods for the Management of Spleen and Liver Injuries

Abstract. The spleen and liver are the most frequently injured organs during blunt and penetrating abdominal trauma. Emergency laparotomy is crucial for early control of bleeding and to prevent “secondary” injury as a result of physiologic splanchnic vasoconstriction and free oxygen radicals. Altogether 98 patients with spleen and liver injuries were treated over an 8-year period. Primary orthotopic spleen preservation could be achieved in 46 of 63 patients. In 58 patients with hepatic trauma, hemostatic treatment was chosen based on the severity of the injury. Nonoperative management was used for four splenic and seven hepatic trauma patients. The most commonly used techniques were fibrin sealing, suturing, and débridement for hepatic injury and mesh splenorrhaphy, fibrin glue, and partial resection with a TA stapler for splenic injury. The death of patients with complex injuries was mainly due to preclinical massive blood loss and multiple organ failure.

Treatment of Patients with Pyogenic Liver Abscess

Background: Pyogenic liver abscess (PLA) remains a serious disease with a mortality of 6–14%. Methods: Clinical data of 76 patients with PLA were analyzed. Treatment options comprised antibiotics, percutaneous puncture/drainage, endoscopic papillotomy/stenting and/or surgery as indicated. Results: Fifty-eight patients (76%) had single and 18 patients multiple PLA (right lobe: 65%; both lobes: 22%). The most frequent etiologies were: biliary (38%), hematogenous and posttraumatic (11%). Factors associated with the need for surgery included gallbladder empyema, biliary fistulas, malignancy, perforation, multicentricity, vascular complications and foreign bodies (e.g. infected ventriculo-peritoneal shunt, toothpick). Conclusions: Microbiological testing provides important information for treatment monitoring and modification. Complementary assessment of risk factors for a complicated course is crucial for timely identification of patients requiring additional treatment.

Tools for augmented-reality-based liver resection planning

Surgical resection has evolved to an accepted and widely-used method for the treatment of liver tumors. In order to elaborate an optimal resection strategy, computer-aided planning tools are required. However, measurements based on 2D cross sectional images are difficult to perform. Moreover, resection planning with current desktopbased systems using 3D visualization is also a tedious task because of limited 3D interaction. For facilitating the planning process, different tools are presented allowing easy user interaction in an Augmented Reality environment. Methods for quantitative analysis like volume calculation and distance measurements are discussed with focus on the user interaction aspect. In addition, a tool for automatically generating anatomical resection proposals based on knowledge about tumor locations and the portal vein tree is described. The presented methods are part of an evolving liver surgery planning system which is currently evaluated by physicians.

Endocavitary Ir-192 radiation and laser treatment for palliation of obstructive rectal cancer.

Endoscopic laser therapy (ELT) either alone or combined with endocavitary Ir-192 radiation is performed for advanced, inoperable rectal cancer and when patients are ineligible for surgery due to severe concomitant medical illness. During the period from January 1984 to January 1997 we treated 81 patients (51 males, 30 females). Sixty-seven patients had ELT only using a ND-Yag Laser system. Twenty-five patients (average age: 80.5 years) were ineligible for surgery (Group I). Forty-two patients (74.1 years) had an advanced locally inoperable tumour (Group II). Fourteen patients (76.5 years) underwent a combined therapeutic regime with endocavitary Ir-192 afterloading following ELT (Group III). Adequate desobliteration was achieved in 100% (groups I and III) and 97% (group II) of the patients. The average interval to aftertreatment was 8.4 weeks in group I and 9.4 weeks in group II, compared to 11.5 weeks in group III. Serious complications (perianal abscess, rectovaginal fistula) occurred in 3.7%, minor complications (laser-induced bleedings, unclear fever) in 12.3%. All laser-induced bleedings could be dealt with using laser therapy. The frequency of treatment was governed by tumour mass and the patients survival. The results suggest that additional endocavitary radiation significantly prolongs the maintenance of normal bowel function compared with laser therapy alone.

Long-term quality of life of liver transplant recipients beyond 60 years of age

Due to ameliorated surgery as well as better immunosuppression, the recipient age after liver transplantation has been extended over the past years. This study aimed to investigate the health related quality of life after liver transplantation in recipients beyond 60 years of age. The SF-36 was used to evaluate the recipients’ health-related quality of life as standardized tool. It comprises 36 items that are attributed to 8 subscales attributed to 2 components: the physical component score and the mental component score. Differences in the health-related quality of life between the included aged recipients and age-matched general population as well as among female and male recipients. Aged recipients showed significantly lower scores in physical functioning (29 vs. 76, p = 0.001), role physical (42 vs. 73, p = 0.003), bodily pain (34 vs. 71, p = 0.003), general health (28 vs. 59, p = 0.001), vitality (25 vs. 61, p = 0.001), social functioning (36 vs. 87, p = 0.001), role emotional (46 vs. 89, p = 0.001) as well as the physical component score (28 vs. 76, p = 0.001). Aged female recipients showed lower results as compared to males in social functioning, physical functioning, role physical, and social functioning (p = 0.03 respectively) but comparable results in the remaining. Quality of life seems to be an issue among aged recipients and should be assessed on a regular basis.

Virtual dissection of the colon: technique and first experiments with artificial and cadaveric phantoms

Virtual dissection refers to a display technique for polyp detection, where the colon is digitally straightened and then flattened using multirow detector Computed Tomograph (CT) images. As compared to virtual colonoscopy where polyps may be hidden from view behind the folds, the unravelled colon is more suitable for polyp detection, because the entire inner surface of the colon is displayed in a single view. The method was tested both on artificial and cadaveric phantoms. All polyps could be recognized on both phantoms. This technique for virtual dissection requires only a minimum of operator interaction.

Virtual Liver Surgery Planning

Liver tumors account for a considerable number of deaths every year (World Health Organization, 2004). One of type of primary liver tumors is hepatocellular carcinoma, which arises frequently as a complication of liver cirrhosis. Additionally, almost any tumor can seed metastasis within the liver, colorectal cancer being at the top of the list.

Virtual Dissection and Automated Polyp Detection of the Colon Based on Spiral CT – Techniques and Preliminary Experience on a Cadaveric Phantom

SummaryBackground: CT colonography was found to be sensitive and specific for detection of colonic polyps and colorectal cancer (CRC). Depending on the software used, CT colonography requires a certain amount of operator interaction, which limits it’s widespread usage. The goal of this papers is to present two novel automated techniques for displaying CT colonography: virtual dissection and automated colonic polyp detection. Methods: Virtual dissection refers to a technique where the entire colon is virtually stretched and flattened thus simulating the view on the pathologist’s table.Colonic folds show a ‘global outward bulging of the contour’, whereas colonic polyps exhibit the inverse (‘local inward bulging’). This feature is used to map areas of ‘local inward bulging’ with colours on 3D reconstructions. A cadaveric phantom with 13 artificially inserted polyps was used for validation of both techniques. Results: On virtual dissection all 13 inserted polyps could be identified. They appeared either as bumps or as local broadening of colonic folds. In addition, the automated colonic polyp detection algorithm was able to tag all polyps. Only 10 min of operator interaction were necessary for both techniques. Conclusions: Virtual dissection overcomes the shortcomings of CT colonography, and automated colonic polyp detection establishes a roadmap of the polyps.ZusammenfassungGrundlagen: Die CT-Kolographie ermöglicht die Detektion von Kolonpolypen und kolorektalen Karzinomen. In Abhängigkeit von der verwendeten Software ist ein unterschiedlich großer Zeitaufwand notwendig, der die breite klinische Anwendung limitiert. Zweck der vorliegenden Arbeit ist die Präsentation zweier neuer Darstellungsverfahren für die CT-Kolographie: virtuelle Dissektion und automatische Detektion von Dickdarmpolypen. Methodik: Die virtuelle Dissektion ist eine Technik, bei der das gesamte Kolon aus den Spiral-CT-Daten extrahiert, artifiziell gestreckt, in seiner Längsrichtung aufgeschnitten und ausgebreitet wird, ähnlich der Ansicht auf dem Seziertisch. Die automatische Detektion von Dickdarmpolypen basiert auf der unterschiedlichen Kurvatur des normalen Kolon und der von Polypen. Die Falten des Kolons zeigen eine uniform nach extern gerichtete Kurvatur, während Polypen eine lokal nach endoluminal gerichtete Kurvatur zeigen. Diese unterschiedliche Kurvatur wird benutzt, um polypenverdächtige Areale farbig zu markieren. Die Validierung beider Methoden erfolgte anhand von 13 Polypen, die künstlich in einem Dickdarmsegment einer Leiche implantiert wurden. Ergebnisse: Auf Rekonstruktionen mittels virtuellen Dissektion konnten alle Polypen entweder als knopfartige Verdickungen oder als lokale Faltenverdickungen erkannt werden. Der Algorithmus zur automatischen Detektion von Kolonpolypen konnte alle 13 Polypen entsprechend farbig markieren. Der Benutzer-Zeitaufwand für beide Methoden betrug 10 Minuten. Schlußfolgerungen: Die virtuelle Dissektion vermeidet die Nachteile bisherigen 3D-Rekonstruktionen und ein Zeitaufwand von 10 Minuten erscheint auch in der klinischen Routine vertretbar. Die Methode zur automatischen Erkennung von Dickdarmpolypen erlaubt farbige Landkarten polypenverdächtiger Areale zu erzeugen.

Spontane Milzruptur bei Einflußokklusion der Leber

A 45-year-old woman underwent a resection for a hepatic metastasis of the liver caused by a carcinoma of the colon. Shortly after the Pringle maneuver severe hemorrhage from the upper left quadrant of the abdomen was observed. Exploration revealed a spontaneous parenchymal laceration of the spleen.ZusammenfassungBei einer 45jährigen Patientin wurde wegen einer Metastase nach einem Kolonkarzinom an der Leber eine Segmentresektion in Einflußokklusion durchgeführt. Kurz nach dem Pringle-Manöver trat eine massive spontane Blutung aus dem linken Oberbauch auf. Als Ursache zeigte sich eine spontane Ruptur der Milz.