Igors Iesalnieks

Intraabdominal septic complications following bowel resection for Crohn’s disease: detrimental influence on long-term outcome

BackgroundA number of studies deal with factors affecting postoperative recurrence; however, they do not analyze the influence of postoperative morbidity on the long-term outcome. This was the aim of the present study.Materials and methodsTwo hundred eighty-two patients underwent 331 intestinal resections for primary or recurrent Crohn’s disease between 1992 and 2005. Closure of ileostomy or colostomy, isolated stricturoplasty, abdominoperineal resection for perianal disease, and reoperations for postoperative complications were excluded. “Surgical recurrence” was defined as a development of stricturing or perforating disease necessitating repeat surgical therapy.ResultsAnastomotic leak, intraabdominal abscess, enterocutaneous fistula (intraabdominal septic complications, IASC) occurred after 46 operations (16%). Four patients died (1.2%). By multivariate analysis, articular disease manifestation (p = 0.03), duration of symptoms leading to surgery (p = 0.009), and weight loss (p = 0.03) were associated with occurrence of postoperative complications. Surgical recurrence occurred following 86 bowel resections, and 36 occurred during the first postoperative year. The following factors were associated with an increased risk of surgical recurrence by multivariate analysis: postoperative IASC (p = 0.0002) and previous bowel resections (p = 0.002). Patients suffering IASC had statistically significantly higher 1-, 2-, 5-, and 10-year surgical recurrence rate (25%, 29%, 50%, and 57%) than patients without IASC (4%, 7%, 19%, and 38%, p = 0.0003).ConclusionThe incidence of the postoperative IASC is predominantly determined by preoperative disease severity. IASC have a detrimental influence on the long-term outcome following intestinal resections in patients with Crohn’s disease, leading to increased number of repeat resection surgery.

Thyroid Metastases of Renal Cell Carcinoma: Clinical Course in 45 Patients Undergoing Surgery. Assessment of Factors Affecting Patients' Survival

BACKGROUND Metastases of renal cell carcinoma (RCC) to the thyroid gland are uncommon. There is no clear consensus regarding the role of surgery in metastatic disease to the thyroid since most clinical studies include small numbers of patients. Also, risk factors associated with disease progression following thyroidectomy are not yet defined. We examined the determinants of the outcome in patients undergoing surgery for thyroid metastases of RCC. METHODS The medical records of 45 patients undergoing resection of thyroid metastases of RCC at 15 institutions in Germany and Austria were reviewed retrospectively. The outcome parameters assessed were overall survival and tumor-related survival. Factors associated with disease progression following thyroid surgery have been calculated. RESULTS The overall 5-year survival rate following thyroid metastasectomy was 51%. Nineteen patients died during the study: 14 of disseminated disease and 5 of non-tumor-related causes. In the multivariate analysis, the prognosis was significantly worse in patients older than > or = 70 years and in patients who had undergone nephrectomy for metastases in the contralateral kidney during the course of the disease. Nine patients developed a thyroid recurrence following surgery. No local disease relapse occurred if resection margins were documented to be free of the tumor. Of the 45 patients with thyroid metastases, 14 (31%) developed pancreatic metastases during the course of disease. Ten of these patients also underwent pancreatic surgery with a 5-year survival rate of 43% in this subgroup. CONCLUSIONS The overall survival of patients undergoing thyroidectomy for metastases of RCC is affected rather by general health status than by tumor-related factors. There is a significant coincidence of thyroid and pancreatic metastases of RCC.

Fistula-associated anal adenocarcinoma in Crohn's disease

Background: Adenocarcinoma arising from perianal fistulae in patients with Crohns disease (CD) is rare. The literature consists mainly of case reports and small series making characterization of this clinical entity difficult. We present 6 patients with CD and fistula‐associated anal adenocarcinoma (FAAA) and a systematic review of published series. Methods: Retrospective charts were reviewed of 6 consecutive patients with FAAA in CD treated from 1992 through 2007. All available variables of our patients and of all available published cases were included for statistical analysis. Results: All patients treated at our institution had severe perianal CD at presentation. The average age at time of diagnosis was 45.5 years. All patients underwent abdominoperineal resection (APR) and 4 received chemoradiation. Four patients died with metastatic disease, 1 is alive with pelvic recurrence at 55 months, and 1 is alive without evidence of disease at 19 months follow‐up. A total of 23 publications including 65 patients (37 female, mean age 53 years) with FAAA were reviewed in our systematic review. The average fistula duration was 14 years. Mean delay of cancer diagnosis was 11 months. APR was performed in 56 patients with an overall 3‐year survival rate of 54%. Thirteen of 15 patients with node‐positive tumors died with recurrent disease following surgery. Conclusions: Adenocarcinoma arising from long‐standing perianal CD fistulae is being increasingly reported. The outcome is poor following operative treatment, especially if perirectal lymph nodes are involved. Periodical cancer surveillance should be performed in all patients with long‐standing perianal CD fistulae. Inflamm Bowel Dis 2010

Factors Associated With Disease Progression in Patients With Gastrointestinal Stromal Tumors in the Pre-Imatinib Era

The aim of this study was to determine the predictors of survival in 38 patients with curatively resected gastrointestinal stromal tumors (GISTs). The tumor was located in the stomach in 23 cases, the small bowel in 13, and the colon in 2. In 23 patients (61%), a mutation in exon 11 of the kit gene was detected. In 7 cases, all small gastric tumors, a mutation in the platelet-derived growth factor receptor a (PDGFRA) gene was detected. The overall 5-year survival rate was 70%. In 9 patients, GISTs relapsed, leading to an actuarial 5-year disease-free survival of 78%. By multivariate analysis, the presence of distant metastases, the proliferative (MIB-1) index, and deletional mutation in codons 557 and/or 558 of kit exon 11 correlated significantly with poor outcome. None of the PDGFRA mutant GISTs relapsed. These findings suggest a strong relationship between various tyrosine kinase receptor mutations and survival outcome in patients with GISTs.

Surgical treatment of substernal goiter: An analysis of 59 patients

PurposeSubsternal goiter is defined as a thyroid mass of which more than 50% is located below the thoracic inlet. In this article we report the diagnosis, symptoms, thyroid function, treatment, and postoperative complications of 59 patients with substernal goiter.MethodsBetween 1992 and 2005, 59 patients underwent surgery for substernal goiter at our institution. The indications for surgery were multinodular goiter in 46 cases, follicular adenoma in two cases, and Hashimoto’s thyroiditis in one case. Ten patients were operated on for recurrent thyroid disease.ResultsThe leading preoperative symptoms were dyspnea (49.2%), dysphagia (13.6%), hyperhidrosis (10.2%), and cardiac dysfunction (6.8%). All but two thyroid glands could be removed through a Kocher transverse collar incision. The most common postoperative complications were persistent (5.1%) or temporary (3.4%) paresis of the recurrent laryngeal nerve, transient hypocalcemia (3.4%), and hematoma (3.4%). A tracheotomy was required in one patient with bilateral vocal cord paresis (1.7%).Conclusions(1) We conclude that a subtotal thyroidectomy is also the treatment of choice for asymptomatic benign substernal goiter. (2) Transverse collar incision should be the standard approach for most patients. (3) The visual identification of at least two parathyroid glands is essential to prevent permanent postoperative hypoparathyroidism.

Benefit of Kupffer cell modulation with glycine versus Kupffer cell depletion after liver transplantation in the rat: effects on postischemic reperfusion injury, apoptotic cell death graft regeneration and survival*

Inhibition or destruction of Kupffer cells (KC) may protect against ischemia‐reperfusion (IR) induced primary graft nonfunction (PNF) in liver transplantation. Besides KC activation, PNF is characterized by microvascular perfusion failure, intrahepatic leukocyte accumulation, cell death and hepatocellular dysfunction. KCs can be inactivated by different agents including gadolinium chloride (GdCl3), methyl palmitate (MP) and glycine. The effects of three KC inactivators on IR‐injury after rat liver transplantation were compared in the present study. Lewis liver donors were treated with GdCl3, MP, glycine or saline (control). Liver grafts were transplanted following 24 h storage (UW solution). KC populations and IR damage were assessed by histologic analysis, quantitative real‐time polymerase chain reaction (RT‐PCR) and intravital microscopy. The number of hepatic ED‐1 positive macrophages was diminished after GdCl3 (114.8 ± 4.4/mm2 liver tissue) and MP treatment (176.0 ± 5.0), versus the glycine (263.9 ± 5.5) and control (272.1 ± 5.6) groups. All three treatment modalities downregulated phagocytic activity for latex particles, paralleled by reduced microvascular injury (acinar perfusion index, GdCl3: 0.75 ± 0.03; MP: 0.83 ± .03; glycine: 0.84 ± 0.03; 0.63 ± 0.03). Quantitative RT‐PCR revealed elevated myeloperoxidase mRNA after glycine versus GdCl3 and MP pretreatment (3.2‐ and 3.4‐fold, P = 0.011, respectively), without difference to controls (2.9‐fold of glycine). TNFα‐mRNA was reduced after glycine‐ (5.2‐fold), GdCl3‐ (19.7‐fold), MP‐treatment (39.5‐fold) compared with controls. However, profound prevention of intrahepatic cell death and liver graft failure was solely achieved with glycine preconditioning. Different than GdCl3 and MP, glycine modulates rather than destroys KCs. Glycine appears to preserve cell viability and to TNFα/leukocyte dependent organ regeneration capacity, which is related to increase graft survival following liver transplantation.

Single-Incision Retroperitoneoscopic Adrenalectomy and Single-Incision Laparoscopic Adrenalectomy

OBJECTIVE Single-incision surgery is by now practicable in many fields of surgery, including surgery of the adrenal gland. We report on first experience with laparoscopic transperitoneal and retroperitoneoscopic single-incision adrenalectomy. PATIENTS AND METHODS Between September 2009 and February 2010, eight patients underwent single-incision adrenalectomy. Four patients received single-incision retroperitoneoscopic adrenalectomy, and four patients transperitoneal single-incision laparoscopic adrenalectomy. Technical feasibility and perioperative data are presented. RESULTS All patients had benign adrenal tumors (Conns adenoma, n = 7; pheochromocytoma, n = 1). Tumor size ranged between 1.2 and 2.4 cm. Mean operation time was 76 minutes for single-incision retroperitoneoscopic adrenalectomy and 82 minutes for single-incision laparoscopic adrenalectomy. Blood loss was irrelevant in both groups. CONCLUSIONS Single-incision adrenalectomy is safe and feasible in appropriate operation time, both by the retroperitoneoscopic technique and by the laparoscopic technique. It is also associated with good cosmetic outcome.

Perforating Crohn's ileitis: Delay of surgery is associated with inferior postoperative outcome

Background: A perforating phenotype is associated with an increased postoperative morbidity in patients with Crohns disease undergoing ileocolic resection. Sequential conservative treatment attempts applied to patients with unrecognized perforating complications may lead to a delay of surgery and a further increase in morbidity. Methods: In all, 197 patients underwent 231 bowel resections for perforating ileitis between 1992 and 2009. The duration or clinical deterioration was calculated from the onset of clinical exacerbation unresponsive to any medical treatment to the date of surgery. Results: The median duration of clinical deterioration leading to surgery was 5 months. Patients with preoperative exacerbation lasting for >5 months had a higher number of structures involved in the inflammatory mass (3.3 versus 2.8 structures, P = 0.013), and had a higher probability to take immunosuppressive drugs (26% versus 14%, P = 0.042), budesonide (29% versus 14%, P = 0.009), and a multiple‐drug combination (31% versus 16%, P = 0.015) at the time of surgery. Patients with symptoms lasting >5 months prior to surgery had a higher incidence of postoperative septic complications (31% versus 13%, P = 0.002), both by univariate and multivariate analysis. There was a significant increase in duration of preoperative clinical deterioration, size of the inflammatory mass, incidence of preoperative weight loss, intake of immunosuppressants and multiple‐drug combination, and postoperative morbidity during the last 5 years of the study. Conclusions: Delay of surgery in patients presenting with symptoms attributable to perforating ileitis is associated with an increased postoperative risk. (Inflamm Bowel Dis 2010)

Laparoscopic TME in rectal cancer – electronic supplementary: op-video

BackgroundLaparoscopic total mesorectal excision (TME) for rectal cancer has been proved in various studies. The minimal invasive procedure is feasible and safe which was demonstrated in many studies. However, the results of prospective, randomized studies providing valuable evidence are still not available. Compared to conventional surgery, the laparoscopic technique has short-term advantages including less pain, shorter duration of postoperative ileus, less fatigue, better pulmonary function, and less blood loss (Leung et al., Lancet 363:1187–1192, 2004; Braga et al., Dis Colon Rectum 48:217–223, 2005; Jayne et al., J Clin Oncol 25:3061–3068, 2007; Agha et al., Surg Endosc 22:2229–2237, 2008).MethodsThe autonomic nerve sparing TME technique is the gold standard in rectal cancer resection even in conventional or laparoscopic procedure. With regard of the oncological dimension, the laparoscopic TME technique is not different compared to the open procedure. However, a standardized laparoscopic step-by-step procedure may simplify the operation and can reduce operation time.ResultsThere are no studies available which compare different types of TME procedures. Most surgeons start the operation left laterally mobilizing the sigmoid colon first. In the laparoscopic technique, we recommend the medial to lateral approach starting the operation at the right side of the rectum and sigmoid colon. A nerve sparing TME technique can be performed easier, and the identification of the left ureter may be simplified. After multiple workshops and extensive discussion with national and international experts, we developed a standardized laparoscopic “10 step TME procedure.” Reviewing the results of laparoscopic TME the studies do not allow firm conclusions as to the questions of whether the safety and efficacy of laparoscopic TME is equal or superior to open TME (Breukink et al. 2006). Actually, we are waiting for large prospective randomized studies comparing laparoscopic TME with the traditional open procedure (Bonjer et al., Dan Med Bull 56:89–91, 2009).ConclusionLaparoscopic TME appears to have clinically measurable short-term advantages in patients with primary resectable rectal cancer based on evidence mainly from nonrandomized studies (Breukink et al. 5). In nearly all published studies, the efficacy and technical feasibility of laparoscopic surgery for rectal cancer could be demonstrated regarding perioperative morbidity and oncological outcome. A standardized laparoscopic TME technique can be strongly recommended.

Low Risk of Clostridium difficile Infections in Hospitalized Patients with Inflammatory Bowel Disease in a German Tertiary Referral Center

Introduction: Many reports, mainly from the US and Canada but also a recent report from a center in Europe, have documented the increasing impact of Clostridium difficile infections in patients with inflammatory bowel disease (IBD) during the last years. To determine the prevalence of C. difficile infections in hospitalized IBD patients in a tertiary referral center in Germany, we conducted this retrospective analysis. Methods: Data of all IBD in-patients treated due to an acute flare of their IBD at the Department of Internal Medicine I of the University of Regensburg between January 1, 2001, and June 30, 2008, were analyzed. In patients with a concomitant diagnosis of C. difficile infection, further variables such as IBD-related treatment at the time of infection or outcome were examined. Results: In total, 995 in-patients with IBD were treated in this hospital [638 patients with Crohn’s disease (CD), 357 with ulcerative colitis (UC)] during the study period. Of these, 279 patients with CD and 242 patients with UC were admitted with an acute flare and suffering from diarrhea and abdominal pain. Only 10 of those were diagnosed as having a concomitant infection with C. difficile. Six patients were female and the median age was 49 years (range: 15–80). Six patients with C. difficile infections suffered from UC and 4 patients from CD, all with previous colonic involvement. Eight patients used immunosuppressive therapies; only 2 patients were treated with antibiotics before infection. Conclusion: In contrast to recent reports from other countries, only a low percentage of hospitalized patients with acute flares of their IBD were identified as having an underlying C. difficile infection in this German tertiary referral center. However, in IBD patients with an acute flare, a concomitant C. difficile infection should be excluded, especially in patients with immunosuppressive treatment and colonic involvement of their disease. Further research is needed to evaluate if regions with different risks of C. difficile infections exist and to find out more about potential reasons for this observation.