Rainer Eckhard Hintze

Extended resections for hilar cholangiocarcinoma.

OBJECTIVE To evaluate different strategies for extended resections of hilar cholangiocarcinomas on radicality and survival. SUMMARY BACKGROUND DATA Surgical resection of hilar cholangiocarcinoma is the only potentially curative treatment. Resection of central bile duct carcinomas, however, cannot always comply with the general principles of surgical oncology to achieve wide tumor-free margins with no-touch techniques. METHODS From 1988 to 1998, 95 patients underwent resection of hilar cholangiocarcinoma. Eighty patients had hilar and hepatic resections and 15 had liver transplantation and partial pancreatoduodenectomy (LTPP; i.e., eradication of the entire biliary tract using a no-touch technique). RESULTS The 60-day death rate was 8%. The overall 1- and 5-year survival rates were 67% and 22%, respectively. Five-year survival rates after R0, R1, and R2 resections were 37%, 9%, and 0%. In a multivariate analysis, surgical radicality was the strongest determinant of survival (p < 0.001). The rate of formally curative resection (R0 resection) was significantly lower in hilar resections (29%) than in liver resections (left hemihepatectomy 59%, right hemihepatectomy 55%, right trisegmentectomy 65%; p < 0.05). The highest rate of R0 resection was observed after LTPP (93%; p < 0.05). Right trisegmentectomies achieved the highest rate of 5-year survival after R0 resection (57%). In a multivariate analysis of patient survival after R0 resection, additional portal vein resection was the only significant factor. The 5-year survival rate after formally curative liver resection with portal vein resection was 65% versus 28% without. CONCLUSION Extended resections, especially right trisegmentectomies and LTPP, resulted in the highest rate of R0 resection. Right trisegmentectomy together with portal vein resection best represents the principles of surgical oncology and may be regarded as the surgical procedure of choice. Immunosuppression limits the applicability of LTPP.

Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy.

Major bile duct injuries usually need operative repair and remain a challenge even for surgeons who specialize in hepatobiliary surgery. The purpose of this study was to evaluate management and short‐ and long‐term outcomes of patients with major complications after cholecystectomy.

Einteilung und Behandlung von Gallengangverletzungen nach laparoskopischer Cholecystektomie

Abstract. Iatrogenic bile duct lesions are serious complications during laparoscopic cholecystectomy and include biliary leakage and major bile duct injury. The incidence of biliary lesions following laparoscopic cholecystectomy is up to threefold higher than that of the open procedure. A total of 108 patients with bile duct lesions after laparoscopic cholecystectomy were treated at our institution. Endoscopic treatment was successful in 68 cases, 6 patients were treated by external drainage, and 34 patients required surgical therapy. Selection criteria for the type of treatment included the etiology, anatomical situation, and diagnostic interval of the biliary lesion. We suggest a classification of bile duct injury and a proposal for diagnosis and treatment of these complications.Zusammenfassung. Die iatrogene Gallengangverletzung stellt eine schwerwiegende Komplikation der laparoskopischen Cholecystektomie dar. Sie umfaßt periphere Galleleckagen und Verletzungen des extrahepatischen Gallengangsystems. Ihre Incidenz ist im Vergleich zur konventionellen Cholecystektomie um das 2–3 fache erhöht. In unserem Zentrum wurden 108 Patienten wegen einer iatrogenen Gallengangläsion nach laparoskopischer Cholecystektomie behandelt. Während 68 Patienten erfolgreich endoskopisch therapiert werden konnten, war bei 34 Patienten eine chirurgische Intervention erforderlich. Bei 6 Patienten mit einem peripheren Galleleck war die alleinige percutane äußere Drainage ausreichend. Für die Gallengangverletzungen wird unter Berücksichtigung der Ätiologie, der Lokalisation und des diagnostischen Intervalls eine neue Klassifikation vorgeschlagen, aus der sich diagnostische und therapeutische Konsequenzen ableiten lassen.

Successful recanalization of a completely obliterated esophageal stricture by using an endoscopic rendezvous maneuver

Patients with head and neck cancer frequently develop problems with food intake and malnutrition. A common cause is non-neoplastic stricture of the proximal esophagus after radiotherapy. The proximal esophagus is known to be particularly radiosensitive; radiation-induced injury usually occurs at doses of greater than 60 Gy in about 3.4% of patientswithheadandneckcanceratamedianof6months after completion of radiotherapy. 1 Radiation-induced strictures are amenable to a single or a repeated endoscopic dilation. 2,3 Complete obliteration of the esophagus, however, poses a greater challenge. This report describes the first successful recanalization of a completely obstructed esophagus after radiotherapy by using an endoscopic rendezvous maneuver.

Liver Transplantation and Interventional Techniques

For a transplanted liver to function, arterial perfusion and venous drainage have to be sufficient and biliary drainage must not be blocked. Anastomoses of vessels and biliary ducts have to be open and must not leak. The success of liver transplantation in recent years has been based to a significant degree on improvements in surgical techniques. Not the least important of these improvements concern the anastomoses.

Partial or total resection of the biliary tract — Surgical strategies for hilar cholangiocarcinoma

SummaryBackground: Surgical resection provides the only chance of cure for patients suffering from hilar cholangiocarcinoma. Although appropriate procedures are not agreed upon, an increase in radicality has been observed during the past 20 years.Methods: The literature as well as our own experience after 80 resections of hilar cholangiocarcinomas were reviewed retrospectively.Results: Tumor-free margins represent the most important prognostic parameter. Hilar resections as least radical resective procedure will generate rates of formally curative resections of less than 50%. Curative resection and 5-year survival rates after additional hemihepatectomy generally do not exceed 65% and 25% in the more promising reports, respectively. In our series, the best 5-year survival rate was achieved after right trisegmentectomy with 59%. After conventional liver transplantation, 5-year survivors can only exceptionally be observed. Although extended bile duct resection or abdominal organ cluster transplantation may significantly increase the rate of formally curative resections, long term survival is still disappointing.Conclusions: In our hands, right trisegmentectomy will provide the most pronounced benefit, if this procedure is applicable with respect to tumor extension and functioning hepatic reserve. Extended bile duct resections cannot be evaluated definitely at this stage. However, patterns of recurrence clearly demonstrate the need for adjuvant treatment protocols.ZusammenfassungGrundlagen: Resektionen stellen die einzigen potentiell kurativen Therapieoptionen beim zentralen Gallengangskarzinom dar. In den vergangenen 20 Jahren konnte eine Zunahme der Radikalität in der chirurgischen Therapie beobachtet werden, ohne daß einheitliche Therapiekonzepte bestünden.Methodik: Retrospektive Untersuchung der Literatur sowie unserer eigenen Erfahrung nach 80 Resektionen zentraler Gallengangskarzinome.Ergebnisse: Formal kurative Resektabilität stellt den wichtigsten Prognosefaktor dar. Hilusresektionen als Verfahren mit der geringsten Radikalität sind in weniger als 50% der Fälle formal kurativ. Die Raten formal kurativer Resektionen sowie des 5-Jahres-Überlebens nach zusätzlicher Hemihepatektomie übersteigen auch in günstigeren Serien in der Regel 65% bzw. 25% nicht. Im eigenen Krankengut wurde mit 59% die höchste 5-Jahres-Überlebensrate nach rechtsseitiger Trisegmentektomie beobachtet. Nach konventioneller Lebertransplantation kommt es nur in Ausnahmefällen zu einem Langzeitüberleben. Erweiterte Gallengangsresektionen sowie auch abdominelle „Cluster-Transplantationen“ können zwar die Rate formal kurativer Resektionen signifikant steigern, führen aber nicht zu einer höheren 5-Jahres-Überlebensrate.Schlußfolgerungen: Nach unserer Erfahrung können die günstigsten Ergebnisse nach Trisegmentektomien beobachtet werden, wenn Tumorausmaß oder Parenchymreserve diese Verfahrenswahl zulassen. Erweiterte Gallengangsresektionen können derzeit nicht abschließend beurteilt werden. Das Rezidivmuster verdeutlicht die Notwendigkeit adjuvanter Therapieansätze.

ERCP in the sitting position--an alternative technique with potential benefits (with video).

The authors describe a new technique of performing endoscopic retrograde cholangiopancreatography in the sitting position with special emphasis on methods of stabilization of the duodenoscope during the procedure. The article is accompanied by an instructional video. The benefits of this comfortable alternative to the standard standing position and its potential limitations are discussed.

4620 Endoscopic therapy of post-pancreatitic persistent necrosis.

Introduction: Development of PPN occurs as a severe complication of necrotising pancreatitis. PPN has to be differentiated from pancreatic pseudocysts and pancreatic abscesses. So far, treatment is performed by percutaneous or surgical drainage as well as surgical resection and necrosectomy. Endoscopic treatment offers an alternative approach to surgery. Aim:We studied the short term outcome (=30 days after initiation of endoscopic treatment) of endoscopic PPN therapy. Methods: PPN was identified by means of sonography and CT. Endoscopic treatment was adapted to the findings (MRCP, ERP) in the pancreatic duct system. Endoscopic treatment modalities comprised EST of pancreatic sphincter as well as stenting and dilation of pancreatic duct stenoses and stone extractions. Furthermore, PPN were treated by endoscopic fistulation, subsequent stenting (Amsterdam stents, 10 Fr., 2-3 cm length) and sequester extraction. Fistulation was carried out either through the gastric or the duodenal wall depending on the topographic situation. Solid sequesters and debris were extracted after enlargement of the fistula hole by multiple stenting. Liquid PPN content was washed out by irrigation through nasocystic catheters. Results: 14 patients affected with PPN (8 Women; 7 Men; mean age 47 years) were treated by endoscopic drainage. Underlying causes had been alcoholic pancreatitis (n=8), biliary pancreatitis (n=4) and idiopathic pancreatitis (n=2). All patients received endoscopic therapy as mentioned above. In 71% of patients (10 out of 14) PPN completely disappeared. In contrast, 2 patients showed no improvement and 2 further patients only partial response to endoscopic drainage therapy. 2 patients refractory to endoscopic therapy received surgery in terms of partial pancreatectomy, necrosectomy and Whipples reconstruction. 1 patient recovered soon while the other one developed septic complications and finally died. Due to endoscopic therapy, 1 patient suffered from perforation of the post-pancreatitic necrosis into the peritoneum. Discussion: We treated 14 patients which were affected with PPN due to necrotizing pancreatitis. Most patients (71%) completely recovered due to endoscopic therapy. Patients suffering from PPN are usually in reduced physical condition and therefore at high risk for surgery. Endoscopic therapy of PPN offers a minimal invasive and successful alternative to surgery. It is also suggested, that surgical resection should be restricted to patients refractory to endoscopic drainage therapy.

Interdisciplinary Treatment of Bilobular Caroli’s Syndrome by Side-To-Side Choledochoduodenostomy and Subsequent Endoscopic Stone Removal

Therapy of Caroli’s syndrome usually consists of endoscopic stone removal in order to achieve adequate bile flow and to avoid secondary complications such as cholangitis or deterioration of liver function. If primary endoscopic treatment is not sufficient, liver resection or transplantation could become necessary to achieve a stone-free situation. Case Report: We herein describe a case of bilobular Caroli’s syndrome which was primarily endoscopically treated. Due to a common bile duct stricture after cholecystectomy and choledochotomy 10 years before, endoscopic stone removal was impossible. Instead of liver resection or transplantation, we performed a wide side-to-side choledochoduodenostomy which allowed subsequent endoscopic treatment with successful removal of all bile duct stones during repeated sessions. Six years after surgery, no further episodes of cholangitis have occurred, and the patient has fully recovered with normal liver function. Conclusion: Even bilobular Caroli’s syndrome refractory to primary endoscopic treatment might be removed using an interdisciplinary approach thereby successfully avoiding liver resection or transplantation.

Endoscopic Removal of Embedded Self-Expanding Esophageal Metal Stents

Endoscopic Removal of Embedded Self-Expanding Esophageal Metal Stents Wilfried Veltzke-Schlieker, Andreas Adler, Rainer Hintze, Hassan Rebeye, Bertram Wiedenmann, Thomas Rosch Background: Selfexpanding metal stents have become standard treatment for obstructing esophageal cancer as well as for sealing of esophageal and anastomotic fistulas. Removal of those stents appears desirable in some malignant conditions but also for intermittent treatment of benign strictures. We present a standardized approach for endoscopic removal of these stents. Patients and Methods: During a six year period, metal stents were placed in 172 patients, and in 20 cases stents (all Ultraflex covered stents, Boston Scientific) had to be endoscopically removed. Reasons were dysfunction in 12 cases (3 dislocations, 5 intractable pain, 4 misplacements) and in 8 cases stent removal was planned after 8-12 weeks in patients with anastomotic leaks. Two methods were applied: In firmly embedded stents, the metal mesh was longitudinally dissected using a Neodym-Yag laser, followed by extraction of the middle stent body after radial dissection at both noncovered inner ends. The remaining filaments at the proximal and distal end were then partially removed as far as tissue embedding allowed. Method 2 consisted of bougienage dislocation in less firmly fixed stents, whereby the bougie traversed the distal stent ends, thus pushing the stent distally removing it from the underlying tissue, and finally extracting it. Results: In 16 patients method 1 was successfully applied, whereas method 2 led to stent removal in two cases. In the remaining patients both methods were used in combination. In all cases stents could be removed successfully and without significant complications in 1.3 session.Only in one case oesophagus dilatation was nesseary due to stenosis. Conclusions: Endoscopic stent removal is feasible and safe even in stents embedded in the esophageal wall by ingrowth of non-covered ends. This opens further possibilities of applications in benign conditions.