Herwig Cerwenka

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.

Working conditions and trainee shortage in operative disciplines—is our profession ready for the next decade?

BackgroundIncreasing concern has been expressed worldwide on the problem of finding young doctors to enter a training programme in an operative speciality.Materials and methodsA survey comprising 22 questions on working conditions and job satisfaction was placed on the homepage of the Austrian Society of Surgery; 667 questionnaires were completed.ResultsThe question whether surgery is threatened by a trainee shortage was answered with “yes” by 68%. Only 37% were satisfied with their working conditions. The majority (61%) specified documentation as making up between 20% and 40% of their workload, 22.5% estimated an even higher percentage. Only 17.7% were satisfied with payment. A clear majority works 60 to 80xa0h per week or more. Only 32.5% stated that they can leave the hospital in the morning after weekend duty; for night duty during the week, this percentage decreased to just 4.2%. As for surgical training, 33.3% were satisfied. Regular assessments between the trainees and their department heads were confirmed by only 34%. A clear majority (96%) is in favour of rotations in other hospitals during residency for the sake of broader experience.ConclusionWorking hour restrictions are essential, but not enough: Substantial improvements in the professional profile and in training are required.

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.

Bile duct cyst in adults: Interventional treatment, resection, or transplantation?

Cystic dilatations of the bile ducts may be found along the extrahepatic biliary tree, within the liver, or in both of these locations simultaneously. Presentation in adults is often associated with complications. The therapeutic possibilities have changed considerably over the last few decades. If possible, complete resection of the cyst(s) can cure the symptoms and avoid the risk of malignancy. According to the type of bile duct cyst, surgical procedures include the Roux-en-Y hepaticojejunostomy and variable types of hepatic resection. However, the diffuse forms of Todani type V cysts (Caroli disease and Caroli syndrome) in particular remain a therapeutic problem, and liver transplantation has become an important option. The mainstay of interventional treatment for Todani type III bile duct cysts is via endoscopic retrograde cholangiopancreatography. The diagnostic term bile duct cyst comprises quite different pathological and clinical entities. Interventional therapy, hepatic resection, and liver transplantation all have their place in the treatment of this heterogeneous disease group. They should not be seen as competitive treatment modalities, but as complementary options. Each patient should receive individualized treatment after all of the clinical findings have been considered by an interdisciplinary team.

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

Surgical therapy options in polycystic liver disease

SummaryINTRODUCTION: Polycystic liver disease (PLD) is a rare affliction frequently observed in association with polycystic kidney disease. Only symptomatic patients require treatment, which can be conservative or surgical, i.e. laparoscopic or conventional. We report the results of our experience in the surgical management of polycystic liver disease. METHODS: Between 1994 and 2003, 19 patients (16 female, 3 male) were referred to our center for the management of PLD. Their median age was 50xa0years (range, 33–72). All were symptomatic and their cysts had a median diameter of 11xa0cm (range, 5–22). RESULTS: Laparoscopic management was undertaken in eight patients, with one conversion to open technique because of bleeding from a superficial hepatic vein. An open procedure was performed in 11 patients: one left hemihepatectomy, deroofing in two patients, segment resection 2/3 plus deroofing in six patients, and segment resection 5/6 plus deroofing in two patients. Four patients had complications: one case of biliary leakage was managed conservatively; two patients had pneumothorax caused by the cava catheter inserted for anesthesia, and one patient’s abdominal drain tore off and had to be removed by relaparotomy on the fourth postoperative day. Median follow-up of all patients was 49 months (range, 7–98). In one patient there was symptomatic recurrence with hepatomegaly and compression of the inferior vena cava 84 months after the first operation. CONCLUSIONS: Careful selection of patients and meticulous surgical technique are recommended in the management of PLD. The treatment of choice for symptomatic Gigot or Morino type 1 PLD is laparoscopic surgery, and for advanced-stage PLD, combined hepatic resection and cyst fenestration.ZusammenfassungEINLEITUNG: Die polyzystische Lebererkrankung ist selten und häufig mit polyzystischer Nierenerkrankung assoziiert. Nur symptomatische Patienten benötigen eine Therapie. Wir berichten über unsere Erfahrungen und Ergebnisse mit der chirurgischen Therapie der polyzystischen Lebererkrankung. METHODIK: Zwischen 1994 und 2003 wurden 19 Patienten (16 Frauen, 3 Männer) wegen einer polyzystischen Lebererkrankung an unserer Abteilung operiert. Das mittlere Alter der Patienten war 50xa0Jahre (33–72xa0Jahre). Alle Patienten waren symptomatisch. Der mittlere Durchmesser der Zysten war 11xa0cm (5–22xa0cm). ERGEBNISSE: Ein laparoskopisches Vorgehen wurde bei 8 Patienten durchgeführt, mit einer Konversion zur Laparotomie wegen einer Blutung aus einer oberflächlichen Lebervene. Der offene Zugang wurde bei 11 Patienten gewählt: eine linke Hemihepatektomie, Deroofing in 2 Patienten, Segmentresektion 2/3 plus Deroofing bei 6 Patienten, Segmentresektion 5/6 plus Deroofing bei 2 Patienten. Komplikationen traten bei 4 Patienten auf. Bei einem Patienten kam es zu einer Gallefistel, welche konservativ abheilte. Zwei Patienten hatten einen Pneumothorax, bedingt durch eine Pleuraverletzung durch einen Cavakatheter seitens der Anästhesie. Bei einem Patienten kam es zu einem Abriss des Bauchdrains, welches am 4 postoperativen Tag per Relaparotomie entfernt werden musste. Die mittlere Nachbeobachtungszeit aller Patienten war 49xa0Monate (7–98xa0Monate). Ein symptomatisches Rezidiv trat 84xa0Monate nach der Erstoperation auf. SCHLUSSFOLGERUNGEN: Die exakte Patientenselektion ist ein wichtiger Punkt im chirurgischen Management dieser Erkrankung. Das laparoskopische Vorgehen sollte bei Zysten Type 1 nach Gigot oder Morino gewählt werden, bei fortgeschrittener Erkrankung eine Kombination aus Leberresektion und Zystenfenestration.

Neuroendocrine liver metastases: contributions of endoscopy and surgery to primary tumor search.

Neuroendocrine tumors (NETs) are diagnosed with increasing frequency and patients often present with liver metastases at the time of diagnosis. Apart from treatment of the metastases, resection of the primary tumor at an early phase is recommended to prevent complications, although it may be difficult to locate, especially in patients with functionally inactive NETs. Small and multifocal tumors in the jejunum and ileum represent a particular challenge. Primary hepatic neuroendocrine carcinoma is extremely rare and is diagnosed only after exclusion of other primary tumors. Therefore, some uncertainty may remain, as small non-hepatic primary tumors may escape detection. Diagnostic work-up in these patients includes biochemical assays and imaging modalities (also comprising specific techniques of scintigraphy and positron emission tomography). This editorial highlights the contributions of endoscopy and operative exploration to the search for the primary tumor. Besides esophago-gastro-duodenoscopy, endoscopic ultrasonography, colonoscopy and bronchoscopy, special endoscopic techniques such as balloon enteroscopy or capsule endoscopy are used with growing experience. Compared with balloon enteroscopy, capsule endoscopy is non-invasive and better tolerated, but it cannot localize a lesion precisely and does not allow biopsy or removal of lesions. Before proceeding to surgery, a discussion of the findings by a tumor board should be a standard procedure. Improvements in diagnostic tools have created new perspectives for the detection of obscure primary tumors in patients with neuroendocrine liver metastases, and these searches are best coordinated by a multidisciplinary team.

Intraoperative ultrasonography during planned liver resections remains an important surgical tool.

I read with great interest the article ‘‘Intraoperative ultrasonography during planned liver resections: why are we still performing it?’’ (Surg Endosc 21: 1280-1283) [1] and I want to congratulate the authors on this important study. Indeed, the role of intraoperative ultrasonography (IOUS) needs to be periodically evaluated under the circumstances of constantly improving preoperative imaging modalities. In contrast to our previous study on this subject [2], the percentage of tumors additionally diagnosed by IOUS was higher in this evaluation (both for the ‘‘historic’’ and for the more recent group). A major reason for that may be that all our patients had preoperative magnetic resonance imaging (MRI), which was done at our institution following a strict liver protocol, whereas the patients in this study had mixed imaging procedures at various institutions. In our experience, there is broad variability in the quality of diagnostic procedures both in terms of imaging techniques and interpretation. Another difference is that we also included patients with benign diseases, who underwent operation because of symptoms or suspicion of malignancy. In the literature, the classification of additional lesions during operations is not always clear. We used very strict criteria and only the lesions that would really have been missed without IOUS were counted as ‘‘additional lesions diagnosed by IOUS’’, whereas those detectable by visual inspection or palpation after complete mobilization of the liver were assigned to different groups. Like Ellsmere et al. [1], we have included all patients with attempted liver resections and not only those who eventually underwent resection as we are also convinced that sparing of procedures that are not indicated or necessary from the oncological point of view is an important function of IOUS. We found that in our patients the majority of the lesions additionally diagnosed by IOUS were in the left hepatic lobe (although this is the smaller part of the liver), which might at least partly be due to problems with superposition of the heart and the stomach in preoperative imaging. In our opinion, IOUS is a veritable surgical tool not only for lesion detection but also for evaluating vascular relationship, guiding of the resection (as well as biopsies or ablative procedures), and ensuring adequate margins; thus, we believe it should be performed by the liver surgeon (after the necessary training). We also use contrastenhanced ultrasonography [3–6] with microbubbles. After their administration three phases can be discerned: the arterial phase, the portal venous phase, and the delayed or sinusoidal phase when the microbubbles are trapped in the sinusoids of normal liver parenchyma, which happens to a much lower extent in tumor tissue. However, caution with this agent is advised in patients with cardiac diseases. According to Torzilli [7], the rates of adverse reactions reported from the use of ultrasound contrast agents seem comparable to, or lower than, those observed for other imaging modalities that use contrast agents. As for alterations of operative strategy, we again found a lower percentage as we only counted changes due to additionally diagnosed lesions and not those due to other reasons such as vascular involvement. Another aspect that is briefly mentioned by Ellsmere et al. [1] is the question of pseudo-lesions – lesions seen on preoperative imaging but not confirmed intraoperatively, often due to perfusion Ellsmere J et al. (2007) Intraoperative ultrasonography during planned liver resections: why are we still performing it? Surg Endosc 21:1280–3

Minimally invasive management of dysontogenetic hepatic cysts

BackgroundLiver cysts occur with a prevalence of 4%–7% in the general population. Laparoscopic surgery is effective for solitary cysts and in selected patients with polycystic liver disease (PLD). We present our experience in the laparoscopic management of dysontogenetic cysts.Patients and methodsBetween 1994 and 2002, 36 patients were referred to our centre for the management of dysontogenetic cystic liver disease. Management was laparoscopic in 16 cases. Indications were solitary giant cysts (n=9) and PLD (n=7).ResultsLaparoscopic procedures were completed in 15 patients. Mean operating time was 90xa0min. There were no deaths. In one case there was an intraoperative complication: bleeding from a superficial hepatic vein necessitated conversion to an open procedure. There were two postoperative complications: one patient with biliary leakage, which was managed conservatively, and one patient with a pneumothorax caused by the cava catheter installed for anaesthesia. Median follow-up was 36 months. There was no symptomatic recurrence.ConclusionLaparoscopy can be recommended as the procedure of choice for symptomatic solitary giant cysts and PLD Gigot type I.

Experience with a high speed biopsy gun in breast cancer diagnosis

Pre-operative determination of histology and receptor status is important in optimizing the management of breast cancer. The purpose of our study was to evaluate the high speed biopsy gun in 109 patients with palpable breast tumours. High speed biopsies were performed using the system BIP High Speed Multi 22 with 16-gauge-needles at a speed of 30 m/s. All biopsies could be used for frozen sections and for determination of receptor status. In 81 patients (74.3%) malignant breast tumours were diagnosed, and three patients (2.8%) had highly suspicious lesions. The oestrogen receptor status was negative in 32%, progesterone receptor status negative in 41%. In one patient (0.9%) a high grade non-Hodgkins lymphoma of B-cell-type was diagnosed. In 21.1% benign tumours were found. In one patient a malignant tumour was missed at biopsy (0.9% false-negative). It was concluded that high speed biopsy is a reliable and simple method for preoperative sampling of breast lesions.