Hans-Jörg Mischinger

Percutaneous endoscopic gastrostomy (PEG). 8 years of clinical experience in 232 patients.

AbstractBackground: Percutaneous endoscopic gastrostomy (PEG) is now a standard method for providing long-term enteral nutrition in patients who are unable to swallow. The aim of our study was to document clinical data that would allow prediction of a possible complicated clinical course. Methods: The study was carried out retrospectively. Clinical data of patients having received a PEG tube by a single endoscopic technique were analyzed. Results: Some 5.17% of 232 patients showed complications requiring surgery including a mortality rate of 0.43%. Patients with complications had a significantly lower body mass index and there was a significantly higher complication rate in patients having obstructive malignancies compared with benign diseases. Conclusions: Low body mass index and advanced malignancies are predictors for complications after PEG application. Early installation should help prevent further nutritional deterioration and the related risk of complications.

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.

Significant Increase in Breast Conservation in 16 Years of Trials Conducted by the Austrian Breast & Colorectal Cancer Study Group

ObjectiveTo confirm evidence that breast-conserving treatment (BCT) does not impair the prognosis in breast cancer patients as compared to mastectomy and to argue that it be regarded as the treatment of choice in stage I and II disease. Summary Background DataScientifically, survival rates in breast cancer have been shown to be stage-dependent, but independent of the extent of surgical breast tissue removal, as long as the resection margins are free of tumor infiltration. MethodsBetween 1984 and 1997, six different trials conducted by the Austrian Breast & Colorectal Cancer Study Group accrued a total of 4,259 women with hormone-responsive disease. The authors selected and compared three patient groups (n = 3,316) according to pathologic stage, age, and the surgical procedure applied. ResultsOver this interval, the BCT rate in the premenopausal node-positive subgroup experienced a highly significant increase from 27.2% to 73.2% overall. In the group of postmenopausal node-negative patients, the BCT rate grew significantly by 37.3% to 77.3% in total. With an overall BCT rate growing from 22.5% to 56.8% in postmenopausal node-positive women, those presenting with T1 tumors saw a significant increase from 35.1% to 65.9%. Mortality and local recurrence rates proved stable or even decreased considerably over time and in all subgroups. ConclusionsThe presented outcome of BCT rates, significantly improved over this 16-year period and in no way counterbalanced by higher local recurrence or death rates, reflects an excellent example of surgical quality control. BCT can safely be regarded as the standard of therapy for T1 and increasingly for T2 disease. Especially in multi-institutional adjuvant breast cancer trials, the highest priority should be given to breast-conserving procedures.

A prospective randomised trial to study the role of levamisole and interferon alfa in an adjuvant therapy with 5-FU for stage III colon cancer.

The purpose of this trial was to examine the efficacy of the addition of levamisole (LEV) or interferon alfa (IFN) to an adjuvant chemotherapy with 5-fluorouracil (5-FU) in patients with stage III colon cancer. According to a 2 × 2 factorial study design, 598 patients were randomly assigned to one of four adjuvant treatment arms. Patients in arm one received 5-FU weekly for 1 year, patients in arm two 5-FU plus LEV, in arm three 5-FU plus IFN and patients in arm four 5-FU, LEV and IFN. The relative risk of relapse and the relative risk of death were significantly higher for patients treated with LEV compared with those without LEV treatment (HR 1.452, 95% CI 1.135–1.856, P=0.0028; HR 1.506, 95% CI 1.150–1.973, P=0.0027, respectively). No significant impact on survival was observed for therapy with IFN in the univariate analysis. The addition of LEV to adjuvant 5-FU significantly worsened the prognosis of patients with stage III colon cancer. Interferon alfa had no significant influence on survival when combined with adjuvant 5-FU, but increased the toxicity of therapy substantially.

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.

Early experience with telemanipulative abdominal and cardiac surgery with the Zeus™ robotic system

SummaryBackground: In the past 15 years, abdominal and thoracic surgery has been greatly changed by the introduction of minimally invasive techniques; these offer great advantages for the patient but pose problems for surgeons. Disadvantages due to the limited movement radius of the endoscopic instruments and the rigidity of the instrument tips can be reduced or eliminated by the use of computer-assisted telemanipulators. Methods: We report our experience with eight abdominal and seven heart operations performed between 16 March and 31 July 2001 with a Zeus™ surgical robotic system. There were four cholecystectomies, four Nissen fundoplications, five atraumatic dissections of the left internal mammary artery (ITA), and two pericardotomies. Results: All but one operation were completed successfully with the Zeus™ device. No patient suffered any peri- or post-operative complications. Due to an electronic defect in one of the manipulators, the final cholecystectomy had to be completed as a conventional laparoscopic procedure. The duration of surgery was about 40 % longer than with conventional laparoscopic technique. The specific costs related to the robotic system were EUR 910 per operation. Conclusions: Computer-assisted manipulators are at a developmental stage that allows their successful use in clinical applications. Routine use is, however, at present only possible with a limited number of procedures.ZusammenfassungGrundlagen: In den letzten 15 Jahren hat die abdominal- und thoraxchirurgische Vorgehensweise durch die Einführung der minimal invasiven Techniken sich wesentlich geändert. Neben den großen Vorteilen für den Patienten bringt diese Technik auch große Schwierigkeiten für den Chirurgen mit sich. Die Nachteile, die durch den eingeschränkten Bewegungsradius der Instrumente und durch die Starrheit des Endteiles der Instrumente auftreten, können aber durch den Einsatz von computerunterstützten Telemanipulatoren vermindert bzw. beseitigt werden. Methodik: Wir berichten über die Erfahrung von 8 abdominalen und 7 herzchirurgischen Eingriffen, welche vom 16.3.2001 bis 31.7.2001 mit Hilfe des Zeus™-Operationsroboters durchgeführt wurden. Es wurden dabei 4 Cholezystektomien, 4 Nissen-Prozeduren, 5 atraumatische Präparationen der Arteria mammaria interna sinistra (ITA) und 2 Perikardiotomien durchgeführt. Ergebnisse: Bis auf eine konnten alle Operationen mit dem Zeus™-Operationsroboter erfolgreich beendet werden. Es traten weder während noch nach den Eingriffen patientenspezifische Komplikationen auf. Die letzte Cholezystektomie konnte jedoch aufgrund eines Elektronikdefektes an einem der Manipulatoren nur noch konventionell laparoskopisch beendet werden. Die Operationsdauer war im Vergleich zu konventionell-laparoskopischen Operationen um etwa 40 % länger. Die roboterspezifischen Kosten betrugen 910 EUR pro Eingriff. Schlußfolgerungen: Die computerunterstützten Manipulatoren sind in ihrer Entwicklung bereits soweit, daß man sie im klinischen Bereich erfolgreich einsetzen kann. Nach dem derzeitigem Stand der Entwicklung ist eine routinemäßige Anwendung nur bei einigen wenigen Indikationen möglich.

Gossypiboma of the Liver: CT, MRI and Intraoperative Ultrasonography Findings

MRI, and intraoperative ultrasonography as well as the operative specimen. Histology yielded cotton remnants and necrotic material with a fi brotic capsule. Gossypibomas [‘gossypium’ (Latin) for ‘cotton’; ‘boma’ (Kiswahili) for ‘place of concealment’] are masses formed by retained surgical sponges and reactive tissue. Other A 57-year-old woman was referred for resection of a tumor with a diameter of 6 cm located in segment 6 of the liver. Apart from a cholecystectomy 30 years previously she had no history of abdominal surgery. She complained of pain and fullness in the right upper quadrant of the abdomen. Figures 1 – 4 show the fi ndings at CT, Published online: September 28, 2005

Use of anal endosonography in diagnosis of endometriosis of the external anal sphincter

PURPOSE Perianal endometriosis is an infrequent form of extragenital endometriosis and is usually situated in episiotomy scars. METHODS: We report a rare case involving the external anal sphincter in a 24 year-old female. The precise anatomical location of the endometriotic lesion was confirmed using preoperative and intraoperative anal endosonography. CONCLUSION: We believe this procedure to be essential when history, digital examination, and proctoscopy are not conclusive in the differential diagnosis of perianal pain or mass. Although hormonal suppression often is the therapy of choice in extrapelvic endometriosis, we think surgical excision, respecting the anatomical fiber architecture of the anal sphincter, is the best treatment for perianal endometriosis. Surgical excision is required for histological diagnosis, which is imperative in view of the albeit rare development of malignancy in extragenital endometriosis.