K. T. E. Beckurts

How safe is high intrathoracic esophagogastrostomy

AbstractThe surgical results of transthoracic en bloc esophagectomy and high intrathoracic esophagogastrostomy performed on 109 consecutive patients are presented. Adenocarcinoma was present in 59 patients, squamous cell carcinoma in 45 patients, and other neoplastic lesions of the esophagus in 5 patients: 29.5% of the patients received neoadjuvant radiochemotherapy or chemotherapy alone. In 35% of the patients, the preoperative risk was classified as normal, whereas in 42% and 23% of the patients the preoperative status was compromised or severely impaired, respectively. On average 33 lymph nodes were dissected from each specimen. The postoperative course was uneventful in 60% of the patients and prolonged or severe in 40% of the patients. The hospital mortality was 5.5% (six patients). Nine patients (8.2%) developed anastomotic leakage.Six of these nine patients were discharged after rethoracotomy and reanastomosis (n=3) or endoscopic treatment with fibrin glue (n=3).Three patients died despite rethoracotomy and reanastomosis. Only 2 of 103 discharged patients (1.9%) underwent postoperative endoscopic bougienage two or three times because of an anastomotic stenosis. High intrathoracic esophagogastrostomy is a safe anastomosis, which nevertheless requires diligent postoperative management.Zusammenfassung An einer konsekutiven Serie von 109 Patienten mit Ösophaguskarzinom (59 Adenokarzinome, 45 Plattenepithelkarzinome, 5 andere Malignome) werden die Ergebnisse der standardisierten transthorakalen En-bloc-Ösophagektomie und hoch intrathorakalen Ösophagogastrostomie analysiert. Mit Radiochemotherapie oder Chemotherapie waren 29,5% der Patienten vorbehandelt worden; 35% der Patienten hatten in der präoperativen Risikoanalyse ein normales, 42% ein mittleres und 23% ein hohes Risiko. Im Mittel wurden 33 Lymphknoten pro Patient entfernt. Der postoperative Verlauf von 60% der Patienten war normal, während 40% einen protrahierten bzw. schweren Verlauf hatten. Insgesamt verstarben 6 Patienten postoperativ entsprechend einer Hospitalmortalität von 5,5%. Anastomoseninsuffizienzen traten bei 9 Patienten (8,2%) auf, von denen 3 nach Reanastomosierung und 3 nach endoskopischer Fibrinklebung ausheilten, während 3 Patienten trotz Rethorakotomie verstarben. Nur 2 von 103 entlassenen Patienten (1,9%) mussten im weiteren Verlauf wegen einer Anastomosenstenose 2- bis 3-mal endoskopisch bougiert werden. Die hoch intrathorakale Ösophagogastrostomie ist eine sichere Anastomose, die jedoch ein konsequentes postoperatives Management erfordert.

Wie sicher ist die hoch intrathorakale Ösophagogastrostomie

AbstractThe surgical results of transthoracic en bloc esophagectomy and high intrathoracic esophagogastrostomy performed on 109 consecutive patients are presented. Adenocarcinoma was present in 59 patients, squamous cell carcinoma in 45 patients, and other neoplastic lesions of the esophagus in 5 patients: 29.5% of the patients received neoadjuvant radiochemotherapy or chemotherapy alone. In 35% of the patients, the preoperative risk was classified as normal, whereas in 42% and 23% of the patients the preoperative status was compromised or severely impaired, respectively. On average 33 lymph nodes were dissected from each specimen. The postoperative course was uneventful in 60% of the patients and prolonged or severe in 40% of the patients. The hospital mortality was 5.5% (six patients). Nine patients (8.2%) developed anastomotic leakage.Six of these nine patients were discharged after rethoracotomy and reanastomosis (n=3) or endoscopic treatment with fibrin glue (n=3).Three patients died despite rethoracotomy and reanastomosis. Only 2 of 103 discharged patients (1.9%) underwent postoperative endoscopic bougienage two or three times because of an anastomotic stenosis. High intrathoracic esophagogastrostomy is a safe anastomosis, which nevertheless requires diligent postoperative management.Zusammenfassung An einer konsekutiven Serie von 109 Patienten mit Ösophaguskarzinom (59 Adenokarzinome, 45 Plattenepithelkarzinome, 5 andere Malignome) werden die Ergebnisse der standardisierten transthorakalen En-bloc-Ösophagektomie und hoch intrathorakalen Ösophagogastrostomie analysiert. Mit Radiochemotherapie oder Chemotherapie waren 29,5% der Patienten vorbehandelt worden; 35% der Patienten hatten in der präoperativen Risikoanalyse ein normales, 42% ein mittleres und 23% ein hohes Risiko. Im Mittel wurden 33 Lymphknoten pro Patient entfernt. Der postoperative Verlauf von 60% der Patienten war normal, während 40% einen protrahierten bzw. schweren Verlauf hatten. Insgesamt verstarben 6 Patienten postoperativ entsprechend einer Hospitalmortalität von 5,5%. Anastomoseninsuffizienzen traten bei 9 Patienten (8,2%) auf, von denen 3 nach Reanastomosierung und 3 nach endoskopischer Fibrinklebung ausheilten, während 3 Patienten trotz Rethorakotomie verstarben. Nur 2 von 103 entlassenen Patienten (1,9%) mussten im weiteren Verlauf wegen einer Anastomosenstenose 2- bis 3-mal endoskopisch bougiert werden. Die hoch intrathorakale Ösophagogastrostomie ist eine sichere Anastomose, die jedoch ein konsequentes postoperatives Management erfordert.

Intraoperative Radiofrequency Ablation Using a 3D Navigation Tool for Treatment of Colorectal Liver Metastases

Background: Resection as the only potential cure for colorectal liver metastasis is limited by the size and the intrahepatic localization of lesions. Radiofrequency ablation (RFA) may extend the limitations of surgery. Patients and Methods: 23 consecutive patients suffering from a total of 128 colorectal liver metastases were treated by resection and intraoperative RFA. All of these patients were irresectable by standard surgery due to volume and distribution of the lesions. 17 patients were treated by chemotherapy before RFA, with only 1 patient showing partial regression of liver metastases. In 12 lesions a new 3D navigation tool was used, that allows a virtual overlay of the RFA probe in real-time. Results: 60 metastases were resected, 68 metastases were treated by RFA. There was no mortality, and complications occurred in 4 patients only (1??temporary encephalopathy, 3x cholangitis). Local tumor control according to CT scan was achieved by RFA in 93% of lesions up to 30 mm diameter (n = 45) and in 44% of lesions larger than 30 mm (n = 23). All ablations using the navigation tool were successful. After a mean follow-up of 8 ± 5 months 12 patients are free of disease, 8 patients have either recurrent or new metastases, and 3 patients died of progressive disease. The estimated median survival time is 18 months (95% confidence interval 13–22 months). Conclusions: Intraoperative RFA of colorectal liver metastases in combination with hepatic resection is safe. Up to a lesion size of 30 mm a reliable treatment with RFA is possible. The navigation aid increases the reproducibility of the procedure.

Successful treatment of radiofrequency-induced biliary lesions by interventional endoscopic retrograde cholangiography (ERC)

Background: Radiofrequency ablation (RFA) of malignant liver lesions is considered a procedure with low morbidity. However, RFA performed close to hilar structures carries the risk of heat-induced biliary tract damage and subsequent septic episodes. Methods: We performed an analysis of complications in 42 patients with 211 liver lesions treated with a combined approach of liver resection and RFA. Results: One patient died due to postoperative liver failure. There was one case of temporary liver dysfunction, one vena cava thrombosis, and six febrile episodes. Four of the six febrile episodes were related to bile duct injuries. They became evident 3–5 weeks after the procedure. All four patients were treated successfully by the placement of stents within the biliary tract. None of the patients developed a hepatic abscess. Conclusion: Biliary tract damage is a complication that can occur weeks after RFA. Immediate endoscopic intervention can obviate the occurrence of prolonged septic complications.

Competition Between Native Liver and Graft in Auxiliary Liver Transplantation in a Rat Model

The competition between the native and the grafted liver in heterotopic auxiliary liver transplantation (HALT) with portal vein arterialization (PVA) was investigated in a rat model. The experimental groups were: HALT with flow-regulated PVA and 70% resection of a native liver and graft (n = 32; group I) versus 70% liver resection (n = 32; group II). After HALT, the weight of the native liver increased until the sixth postoperative week (431% +/- 55% of the intraoperative weight), whereas, the graft weight was only 76% +/- 31% of the intraoperative weight at this time. In group II, liver weight increased continuously to 529% +/- 30% of the intraoperative weight after 6 weeks. On postoperative day 2, there was significantly increased proliferative hepatocellular activity in all groups. This was highest in the resected livers of group II, followed by the native livers of group I, and the grafts of group I (301 +/- 126 vs 262 +/- 97 vs 216 +/- 31 Ki-67-positive hepatocytes/10 visual fields). However, the differences between the groups were not significant. With regard to hepatocellular apoptosis, the livers were similar among all groups and at all time points, M30-positive hepatocyte counts were <or=1/10 visual fields, which was equivalent to normal values. After HALT with flow-regulated PVA, the native liver regenerated and the graft showed atrophy, most likely caused by the lack of hepatotrophic factors in the arterialized graft portal vein blood. Regeneration of the 70% resected native liver in the presence of an arterialized heterotopic auxiliary liver graft was less pronounced than the regeneration of a 70% resected liver without HALT. Native liver regeneration seemed negatively influenced by a graft, suggesting a competition between the 2 livers.

POSTOPERATIVES REZIDIVULCUS NACH MAGENRESEKTION : ERGEBNISSE DER CHIRURGISCHEN BEHANDLUNG

Summary. Within a 10-year period, 50 patients with postoperative ulcer recurrence after gastric resection were treated; 31 of these had one, 8 two, 5 three and 6 four previous gastric operations. Ulcer recurrence was attributed to surgery-related causes in 78 % of the cases: excessively large gastric remnant 56 %, anastomotic stenosis 18 %, loop problems 4 %. Some 22 % of the patients had causes independent of previous surgery: abuse of non-steroidal antirheumatics (NSAR) 10 %, hyperacidity of normal gastric remnant 6 %, Zollinger-Ellison-Syndrom 6 %. The most important co-factor of ulcer genesis was chronic abuse of NSAR (38 % of the total series). The interval between onset of complaints of ulcer disease and the last ulcer-dependent operation amounted on average to 13.8 (0.5–36) years. The definitive treatment of recurrent ulceration was surgery in 34 cases – indicated by ulcer complications (73.5 %) or failure of medical therapy (26.5 %) – and conservative treatment in 16 cases. Surgery comprised 21 re-resections, 7 thoracic truncal vagotomies, 4 total gastrectomies, 1 Whipple procedure and 1 enucleation of gastrinoma (hospital mortality 0 %). During the follow-up period (median 7.1 years, follow-up rate 96 %), the cumulative ulcer re-recurrence rate was 57 % for the conservatively treated group and 17.6 % for the patients treated by surgery (p < 0.05). In none of the eight patients who died during long-term follow-up was the cause of death ulcer-related.Zusammenfassung. In einem 10-Jahres-Zeitraum wurden 50 Patienten mit postoperativem Rezidivulcus nach Magenresektion behandelt, von denen 31 einmal, 8 zweimal, 5 dreimal und 6 viermal am Magen voroperiert worden waren. Das Rezidivulcus ließ sich in 78 % der Fälle auf operationsabhängige Ursachen zurückführen: zu großer Restmagen 56 %, Anastomosenstenose 18 %, Schlingenprobleme 4 %. Dagegen bestanden in 22 % der Patienten operationsunabhängige Ursachen: Abusus nichtsteroidaler Antirheumatica (NSAR) 10 %, Hyperacidität des normal großen Restmagens 6 %, Zollinger-Ellison-Syndrom 6 %. Als wichtigster Cofaktor der Ulcusgenese fand sich in 38 % der Gesamtgruppe ein chronischer NSAR-Abusus. Das Intervall zwischen dem Beschwerdebeginn der Ulcuskrankheit und dem letzten ulcusbedingten Eingriff betrug im Mittel 13,8 (0,5–36) Jahre. Die definitive Behandlung der Rezidivulcera war 34mal operativ – indiziert durch Ulcuskomplikationen (73,5 %) bzw. Versagen der medikamentösen Therapie (26,5 %) – und 16mal konservativ. Die Operationen umfaßten 21 Nachresektionen, 7 thorakale trunculäre Vagotomien, 4 Gastrektomien, 1 Operation nach Whipple und 1 Gastrinomenucleation (Operationsmortalität 0 %). Bei einem medianen Follow-up von 7,1 Jahren, und einer Follow-up-Rate von 96 % betrug die kumulative Rerezidivulcusrate für die konservativ behandelte Gruppe 57 % und für die operierten Patienten 17,6 % (p < 0,05). Keiner der 8 im Langzeitverlauf verstorbenen Patienten hatte eine ulcusbedingte Todesursache.

Underestimation of nodules while staging hepatocellular carcinoma prior to neoadjuvant treatment on waiting list for transplantation

Neoadjuvant therapy of hepatocellular carcinoma (HCC) has increasing importance for patients awaiting liver transplantation, as waiting time increases. The therapeutic options (ethanol injection, radiofrequency ablation, chemoembolization) are only effective locally. Therefore, occult carcinomas can overcome the efficacy of these therapies. To evaluate the impact of occult nodules, we analyzed the staging results and histology from 21 HCC patients. The average pretransplant waiting time was 5.2 +/- 3.2 months. The staging before transplantation was reliable concerning the maximum diameter of the HCC. The number of HCC nodules increased from 30 at the time of clinical staging to 59 in histology, hence from 1.4 +/- 1.5 to 2.8 +/- 1.9 per patient. Patients with pT1/2 HCCs experienced an even larger increase (from 1.3 to 3.2 nodules) than patients suffering of pT3/4 HCCs (2.6 to 3.4 nodules). All occult HCCs were less than 2 cm in diameter and showed no prognostically negative histological features such as vascular invasion. The 3-year survival of the patients with small HCCs was 86% compared to 34% for those with advanced cancer. The survival of patients with small HCCs was similar to the survival of patients receiving a transplant for a nonmalignant indication. Only after neoadjuvant therapy with radiofrequency ablation or ethanol injection but not with chemoembolization, was significant necrosis of HCC observed. Considering the current average waiting time, repetitive staging and treatment of new nodules seems justified to achieve a low dropout rate during the waiting time.

Anisoperistaltische Roux-Schlinge: Seltene Ursache rezidivierender Cholangitiden nach Hepaticojejunostomie

Summary. Stenosis of the hepatico-intestinal anastomosis after hepaticojejunostomy is a common cause for recurrent cholangitis. In the following report a patients history of recurrent cholangitis after hepaticojejunostomy performed because of bile duct injury is presented. Preoperative imaging revealed a stricture of the hepatico-intestinal anastomosis and a massive dilatation of the Roux-en-Y loop, so that a draining disorder was assumed. Laparotomy showed an anisoperistaltic Roux-en-Y loop. When assessing the differential diagnosis of recurrent cholangitis after hepaticojejunostomy, anisoperistaltic reconstruction should be considered.Zusammenfassung. Beim Auftreten einer Cholangitis nach Hepaticojejunostomie ist die häufigste Ursache eine Stenose der biliodigestiven Anastomose. Die vorliegende Kasuistik beschreibt die Krankengeschichte eines Patienten, bei dem eine Hepaticojejunostomie infolge einer Gallengangsverletzung bei Mirizzi-Syndrom angelegt worden war, und der postoperativ unter rezidivierenden Cholangitiden litt. Die präoperative bildgebende Diagnostik zeigte eine Stenose der biliodigestiven Anastomose und eine massiv erweiterte Roux-Schlinge, so daß zusätzlich der Verdacht auf eine Stenose dieser Schlinge im Mesocolonschlitz bestand. Intraoperativ fand sich jedoch eine anisoperistaltisch angeschlossene Roux-Schlinge. Diese Konstellation sollte als seltene Ursache rezidivierender Cholangitiden nach Hepaticojejunostomie differentialdiagnostisch berücksichtigt werden.

Barrett- und Magenkarzinom: Chirurgische Leitlinien

Das Ziel der chirurgischen Therapie des Adenocarcinoms im Barrett-Osophagus und des Magenkarzinoms ist die Erreichung einer R0-Resektion des tumortragenden Abschnittes einschlieslich des regionaren Lymphabflusgebietes. Beim Barrett-Karzinom konnen diese Anforderungen durch eine radikale transhiatale subtotale Osophagektomie mit Lymphadenektomie des unteren Mediastinums und des Compartments I und II erfullt werden. Bei hohersitzenden Adenokarzinomen der Speiserohre ist wegen der mediastinal zu erwartenden Lymphknotenmetastasierung die transthorakale en bloc Osophagektomie indiziert. Beim Magenkarzinom richtet sich das luminale Resektionsausmas nach der Lokalisation, der Infiltrationstiefe und dem Wachstumstyp nach Lauren. Danach kann beim Antrumkarzinom vom intestinalen Typ und Stadium T1, T2 (evtl. T3) und beim distalen T1-Karzinom vom diffusen Typ eine subtotale Magenresektion erfolgen. Alle anderen Karzinome erfordern die totale Gastrektomie, die bei Infiltration der Kardia auf den distalen Osophagus erweitert werden mus. Die lokale Exzision des Magenkarzinoms ist in kurativer Absicht nur beim Mucosakarzinom (pT1a) vom intestinalen Typ zu vertreten. Da Hinweise bestehen, das durch die D2-Lymphadenektomie eine Prognoseverbesserung insbesondere in den UICC-Stadien II und IIIa erreicht werden kann, ist eine D2-Lymphadenektomie zu empfehlen, um neben einem besseren Staging, zumindest fur bestimmte Untergruppen von Patienten mit beginnender Lymphknotenmetastasierung, den moglichen Prognosegewinn zu nutzen. Die prinzipielle Splenektomie erhoht bei der Gastrektomie die Morbiditat und wirkt sich eher nachteilig auf die Prognose aus, so das die Milzentfernung wegen einer entsprechenden Lymphknotenmetastasierung nur beim proximalen Magenkarzinom einen Stellenwert besitzt.

Einfluss von niedrig-dosiertem Dopexamin auf die Gewebeperfusion im Magenschlauch des Schweines

This experimental setting investigates the influence of dopexamine-hydrochloride (DOPACARD®, Medeus Pharma GmbH, Deutschland) on tissue perfusion of the gastric tube. After laparotomy and formation of a gastric tube in 13 pigs dopexamine was continuously administered in increasing concentrations of 0.5,1.0 and 2.0 µg/kg KG/min over 45 minutes each. Before (To) and during application (T1 20 min; T2 40 min) tissue perfusion was measured in the fundus, corpus and antrum using a laser-doppler imager (in perfusion units, PU). 0.5 ug dopexamine/kg KG/min induced a significant increase of tissue perfusion in the gastric fundus (To: 226 PU± 118; T1: 319 PU ± 166; p = 0.004). 1.0 jug dopexamine/kg KG/min significantly increased tissue perfusion of the entire gastric tube (To: 509 PU ± 177; T1: 570 PU ± 190, p = 0.035; T2: 614 PU ± 159, p = 0.003). This effect was not observed for 2.0 µg dopexamine/kg KG/min.