R Schöfl

Stage-dependent Therapy of Rectal Carcinoid Tumors

Abstract. Although malignant behavior of rectal carcinoid tumors is rare, the risk of metastases and death does exist. Adaptation of therapy according to the estimated malignancy seems necessary. To develop a stage-dependent therapy, 31 patients with rectal carcinoid tumors measuring 5 to 50 mm in diameter were analyzed retrospectively. Malignancy was estimated according to tumor size, infiltration depth, and histopathology. There were 18 tumors within the mucosa and submucosa (T1), 7 tumors with muscularis propria invasion (T2), and carcinoid tumor penetrating the full rectal wall (T3) or spreading to surrounding tissue (T4) in 6 patients. Altogether 20 patients (65%) were treated with a minimally invasive intervention: endoscopic polypectomy (EP) in 12 and transanal excision (TE) in 8 patients. In 11 patients (35%) aggressive surgical procedures—anterior resection (AR) in 4 and abdominoperineal resection (APR) in 7—were performed. After a mean ± SD follow-up of 86.0 ± 61.3 months, tumor recurrence was not seen in any of the 20 patients with minimally invasive treatment, and all were still alive. No severe complications associated with surgical procedures were detected. In contrast, 5 of the 10 patients with advanced tumor stage died from their disease despite aggressive surgery (AR, APR). In conclusion, depending on tumor stage, treatment of rectal carcinoids includes EP, TE, or extended resection. Minimally invasive techniques are safe treatments for small to medium-size T1/T2 rectal carcinoids. Extended surgery cannot improve the overall survival of those with advanced tumors (T3/T4, N1, M1) but can be beneficial for preventing local complications.

The relationship between juxtapapillary duodenal diverticula and biliary stone disease.

Objective: To assess the relationship between juxtapapillary duodenal diverticula (JDD) and common bile duct stones and biliary stone disease in general. Design: A retrospective study. Methods: We analysed 1115 patients who underwent consecutive endoscopic retrograde cholangiopancreatography examinations. The patients were subdivided into three groups: the first group (group I; n = 482) had no biliary stone disease, the second one (group II; n = 329) had common bile duct stones, and the third group (group III; n = 304) had biliary stone disease of the gallbladder but without evidence of common bile duct stones. Additionally, the patients were subdivided into age groups of <50, 50‐59, 60‐69, 70‐79, and ≥ 80 years of age. Logistic regression was applied for statistical analysis. Results: Juxtapapillary duodenal diverticula were diagnosed in 111 (10.0%) patients. The incidence of JDD was 6.9% in group I, 14.3% in group II and 10.2% in group III. Age was the most dominant influence factor for JDD, common bile duct stones, and biliary stone disease (P<0.0001). Sex was also a factor, female patients having a higher risk for common bile duct stones (P=0.01) and biliary stone disease (P< 0.0001). After adjustment for age and sex, JDD was found to have a noticeable, but not statistically significant (P= 0.073), influence on common bile duct stones and no influence on biliary stone disease (P=0.15). Conclusion: Our data support only moderately the existence of a relationship, which had been conjectured in a part of the literature, between JDD and common bile duct stones. No noticeable influence on biliary stone disease was found.

The VITRO Score (Von Willebrand Factor Antigen/Thrombocyte Ratio) as a New Marker for Clinically Significant Portal Hypertension in Comparison to Other Non-Invasive Parameters of Fibrosis Including ELF Test

Background Clinically significant portal hypertension (CSPH), defined as hepatic venous pressure gradient (HVPG) ≥10 mmHg, causes major complications. HVPG is not always available, so a non-invasive tool to diagnose CSPH would be useful. VWF-Ag can be used to diagnose. Using the VITRO score (the VWF-Ag/platelet ratio) instead of VWF-Ag itself improves the diagnostic accuracy of detecting cirrhosis/ fibrosis in HCV patients. Aim This study tested the diagnostic accuracy of VITRO score detecting CSPH compared to HVPG measurement. Methods All patients underwent HVPG testing and were categorised as CSPH or no CSPH. The following patient data were determined: CPS, D’Amico stage, VITRO score, APRI and transient elastography (TE). Results The analysis included 236 patients; 170 (72%) were male, and the median age was 57.9 (35.2–76.3; 95% CI). Disease aetiology included ALD (39.4%), HCV (23.4%), NASH (12.3%), other (8.1%) and unknown (11.9%). The CPS showed 140 patients (59.3%) with CPS A; 56 (23.7%) with CPS B; and 18 (7.6%) with CPS C. 136 patients (57.6%) had compensated and 100 (42.4%) had decompensated cirrhosis; 83.9% had HVPG ≥10 mmHg. The VWF-Ag and the VITRO score increased significantly with worsening HVPG categories (P<0.0001). ROC analysis was performed for the detection of CSPH and showed AUC values of 0.92 for TE, 0.86 for VITRO score, 0.79 for VWF-Ag, 0.68 for ELF and 0.62 for APRI. Conclusion The VITRO score is an easy way to diagnose CSPH independently of CPS in routine clinical work and may improve the management of patients with cirrhosis.

Folate Absorption in Crohn’s Disease

An oral folate absorption test was performed in 100 consecutive patients with Crohns disease (CD) and 20 healthy individuals to investigate the frequency of abnormal folate absorption in regard to the site of the disease and to investigate the possibility of defining a subgroup of patients requiring parenteral folate supplementation. The described oral folate absorption test can be performed quickly on an outpatient basis and is capable of distinguishing patients with altered folate absorption from those with normal folate absorption. In 25 patients, abnormal folate absorption was detected. 16 patients showed impaired folate absorption as indicated by a marked but insufficient increase in serum folate levels after oral folate intake, whereas no increase of the serum folate levels was detected in the remaining 9 patients. Abnormal folate absorption was not correlated with disease extent or activity. In patients with only impaired folate absorption, it might be sufficient to increase dietary intake of folates. In the remaining patients with no measurable increase of serum folate levels after oral folate intake, i.e. about 10% of all patients with CD, parenteral folate supplementation could be considered.

Transient and long-term feeding by means of percutaneous endoscopic gastrostomy in neurological rehabilitation

In 28 patients of a neurological rehabilitation unit of a hospital the use of enteral nutrition via percutaneous endoscopic gastrostomy (PEG) tubes was reviewed. During a total observation period of 5,172 days no life-threatening complications occurred. Minor complications were observed in 12 patients (43%) in the first 2 weeks after the insertion and in 5 patients (18%) afterwards. The nutritional status stabilized in all subjects. Transient PEG feeding was performed in 11 patients (39%) with a mean duration of 150 days. We conclude that hesitation in the application of PEG feeding in neurological rehabilitation should be abandoned. The timing and monitoring of PEG feeding in patients undergoing neurological rehabilitation for acute remitting neurological disorders is discussed.

Endoscopic versus surgical management of biliary complications – Outcome analysis after 1188 orthotopic liver transplantations

BACKGROUND AND AIM After liver transplantation, the endoscopic approach has become the standard treatment modality for biliary complications. Aim of this study was to compare primary endoscopic with primary surgical management. PATIENTS AND METHODS A retrospective review on 1188 consecutive liver transplant patients between 1989 and 2009 was performed. Management strategies (endoscopic, surgical or combined approach) were evaluated for treatment success as well as patient survival. RESULTS Biliary complications after liver transplantation were diagnosed in 211 (18%) patients. Initial endoscopic approach (N=162, 77%) was successful in 97 of 162 (60%) patients. In 80% of patients, success was achieved within a median of four ERCPs. Sixty-one patients (38%) were referred to surgery after non-successful ERCP. Initial surgical approach was performed in 49/211 patients (23%) with successful management in 38/49 (78%) of patients. Patients presenting with intraluminal objects needed a significantly higher number of ERCPs to reach treatment success (median 3 versus 2 interventions, p=0.001) but had an equal endoscopic success rate (p=0.427). Patients with successful endoscopic treatment showed lower mortality compared to patients with primary surgical treatment (p=0.029). CONCLUSIONS Endoscopic management should be considered as the primary approach for biliary complications after liver transplantation.

Endoskopische Submukosadissektion – Ergebnisse eines österreichischen Zentrums

Gastrointestinaltrakt als Standardtherapie. Die endoskopische Mukosaresektion (EMR) ist eine etablierte und sichere Technik. Allerdings hat diese Technik Limitationen: Eine enbloc-Resektion ist nur bis zu einer Tumorgröße von 20 mm möglich. Die Piecemeal-EMR hat eine beträchtliche Rezidivrate und gilt bei malignen Läsionen nicht als kurativ. Die endoskopische Submukosadissektion (ESD) erlaubt enbloc-Resektionen unabhängig der Größe. Sie ist technisch deutlich anspruchsvoller und hat eine höhere Komplikationsrate. Wir berichten über die Ergebnisse der ESD an unserer Abteilung. In den letzten 3 Jahren wurden 40 ESDs von einem Untersucher (A. Z.) durchgeführt.

Therapie des chronischen Hepatitis C Rezidivs nach Lebertransplantation

Die HCV Reinfektion nach Lebertransplantation ist universell, wobei die Mehrzahl der Fälle einen milden Verlauf nimmt. Das cholestatischeRezidiv (CCHC) ist eine seltene, aber schwere Form des HCV Rezidivs und kann innerhalb weniger Monaten nach LT zum Verlust des Transplantats führen. Die bisherige SOC aus pegyliertem Interferon und gewichtsadaptiertem Ribavirin PegINF/RBV zeigt oft schlechte Behandlungsergebnisse weshalb wir Daten unserer Patienten, welche zusätzlich mit iv Silibinin (SIL) behandelt wurden, vorstellen.

Endoskopisches Stenting der Appendix bei perityphlitischem Abszess

Eine 63-jahrige Frau wurde wegen seit 10 Tagen bestehenden diffusen Bauchschmerzen ohne Fieber oder Durchfall aufgenommen. Trotz antibiotischer Therapie seit 5 Tagen war das CRP auf 12,8mg/dl erhoht, zudem eine LFP Erhohung mit GOT 42U/l, GPT 155U/l und GGT 371U/l. Die Sonografie des Abdomen war unauffallig. In der daraufhin durchgefuhrten Coloskopie fiel im Bereich der Appendixbasis eine entzundlich imponierende Vorwolbung auf, aus der sich bei Manipulation mit der Biopsiezange Eiter entleerte. Das CT ergab einen 5×3cm grosen perityphlitischen Abszess. Die Standardtherapie dafur ist heute eine US- oder CT-gezielte perkutane Drainage. Ob nach Abheilung des Abszesses im Intervall eine Appendektomie notwendig ist, wird kontroversiell diskutiert. Die Datenlage spricht eher fur ein symptomorientiertes individuelles Vorgehen (1). Da unsere Patientin nach der Coloskopie ein leeres Colon hatte, entschlossen wir uns zum Versuch einer endoluminalen endoskopischen Drainage durch die Appendixoffnung. Die Patientin wurde nochmals mit dem Standardcoloskop bis ins Coecum untersucht. Mit einem Fuhrungsdrahtpapillotom gelang es problemlos, die Abszesshohle zu sondieren und den Fuhrungsdraht durchleuchtungsgezielt zu platziere. Uber den Draht wurde ein 4cm langer 7 French dicker Doppel-pigtail Drain in den Abszess eingebracht. In der Literatur existieren einzelne Fallberichte uber die endoskopische Eroffnung von pericoecalen Abszessen (2–4). Unsere Vorgangsweise einer langerfristigen endoluminalen Drainage durch das naturliche Appendixlumen ist jedoch bisher nicht publiziert. Unsere Patientin war schlagartig beschwerdefrei. Unter fortgesetzter Antibiotikagabe normalisierten sich die Entzundungsparameter und auch die erhohten Leberwerte rasch. Bei einer CT Kontrolle nach 2 Wochen war der Abszess praktisch vollig ruckgebildet. Eine weitere Woche spater ging der pigtail Drain spontan mit dem Stuhl ab, noch vor der geplanten endoskopischen Entfernung. Aufgrund der Klinik und der Befundlage wurde auf die Intervall-Appendektomie verzichtet. Im weiteren Beobachtungszeitraum von 6 Monaten trat bislang kein Rezidiv der Appendizitis auf. Literatur: 1. Kaminski et al. Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis. Arch Surg. 2005;140(9):897. 2. Said M, Ledochowski M, Dietze O, et al. Colonoscopic diagnosis and treatment of acute appendicitis; Eur J Gastroenterol Hepatol. 1995;7(6):569–71. 3. Ohtaka M, Asakawa A, Kashiwagi A, et al. Pericecal appendiceal abscess with drainage during colonoscopy. Gastrointest Endosc. 1999;49(1):107–9. 4. Liu CH, Tsai FC, Hsu SJ, et al. Successful colonoscopic drainage of appendiceal pus in acute appendicitis. Gastrointest Endosc. 2006;64(6):1011.

Stellenwert der Kontrastmittelsonographie bei der Abklärung von Lebertumoren

Von Mai 2003 bis Jänner 2004 untersuchten wir 68 Patienten mit dem Echosignalverstärker Sono-Vue®‚ (Schwefel hexafluorid Mikrobläschen) zur weiteren Charakterisierung B-Bild-morphologisch nicht eindeutiger Lebertumoren bzw. zur besseren Darstellung von Lebermetastasen. Als Referenzmethoden wurden CT, MRT bzw. nuklearmedizinische Untersuchungen und Histologie eingesetzt. Ch. Deutsch, Th. Schickmair, A. Maieron, G. Schneider, R. Schöfl Interne 4, Krankenhaus der Elisabethinen Linz.