Roger Kuhn

Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents

BACKGROUND Surgery, as well as conservative treatment, in patients with clinically apparent intrathoracic esophageal anastomotic leaks often is associated with poor results and carries a high morbidity and mortality. The successful treatment of esophageal anastomotic insufficiencies and perforations when using covered, self-expanding metallic stents is described. METHODS The feasibility and the outcome of endoscopic treatment of intrathoracic anastomotic leakages when using silicone-covered self-expanding polyester stents were investigated. Twelve consecutive patients presented with clinically apparent intrathoracic esophageal anastomotic leak caused by resection of an epiphrenic diverticulum (n = 1), esophagectomy for esophageal cancer (n = 9), or gastrectomy for gastric cancer (n = 2), were endoscopically treated in our department. The extent of the dehiscences ranged from about 20% to 70% of the anastomotic circumference. After endoscopic lavage and debridement of the leakage at 2-day intervals (mean duration, 8.6 days), a large-diameter polyester stent (Polyflex; proximal/distal diameters 25/21 mm) was placed to seal the leakage. Simultaneously, the periesophageal mediastinum was drained by chest drains. OBSERVATIONS All 12 patients were successfully treated endoscopically without the need for reoperation. A complete closure of the leakage was obtained in 11 of 12 patients after stent removal (median time to stent retrieval, 4 weeks, range 2-8 weeks). In one patient, a persistent leak was sealed endoscopically after stent removal by using 3 clips. Distal stent migration was obtained in two patients. CONCLUSIONS The placement of silicone-covered self-expanding polyester stents seems to be a successful minimally invasive treatment option for clinically apparent intrathoracic esophageal anastomotic leaks.

Outpatient Therapy with Gemcitabine and Docetaxel for Gallbladder, Biliary, and Cholangio-Carcinomas

AbstractPurpose. The prognosis of patients withbiliary tree carcinomas is very poor. Thediagnosis often occurs at an advancedstage, when curative resection is notpossible. We combined gemcitabine anddocetaxel to optimize the palliativetherapy for patients with gallbladder,biliary, and cholangio-carcinomas on anoutpatient basis. Patients and methods. Patients withhistologically proven biliary treecarcinomas and a WHO performance status<2 received gemcitabine 1000 mg/m2followed by docetaxel 35 mg/m2 weekly for 3weeks followed by 1 week of rest. Results. Forty-three patients, 14males/29 females, with an average age of63.3 years (range, 41 to 78) have beenenrolled since 1998; 37 have completedtreatment. So far, 168 cycles (range, 1 to16) have been administered. All 43 patientswere included in the response and toxicityassessments. There are no completeremissions; however, 4 (9.3%) patientsachieved partial remission, 1 (2.3%) had aminimal remission, and 24 (55.8%)reached disease stabilization for a medianperiod of 5.2 months. Fourteen (32.6%)patients progressed. The median overallsurvival rate is currently 11.0 months. Grade 3 hematologic toxicities wereinfrequent, and there were no grade 4hematologic toxicities. Grade 3 leukopeniawas reported in 4 (9.3%) patients, grade 3thrombozytopenia in 1 (2.3%) patient, andgrade 3 anemia in 1 (2.3%) patient.Twenty-eight (65.1%) patients had grade3/4 alopecia, 8 (18.6%) hadnausea/vomiting, and 2 (4.6%) hadmucositis. Conclusion. The combination ofgemcitabine/docetaxel is an effective andwell tolerated therapy for patients withadvanced or metastatic gallbladder,biliary, and cholangio-carcinomas.

Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with diathermy

Background: Initially, treatment for anastomotic strictures was surgical. Currently. however, endoscopic techniques are preferred. This study aimed to investigate the efficiency and safety of endoscopic treatment using argon plasma coagulation in combination with diathermy. Methods: From 1995 to 2000, 49 patients with postsurgical anastomotic strictures of the esophagus or colon were referred for endoscopic treatment. In all cases, radiologic and endoscopic examination showed membranous or short strictures (diameter, 3–8 mm). Under direct endoscopic control, the scar tissue at the anastomotic line was incised radially with a polypectomy snare. The scar tissue between the incisions then was reduced carefully by argon plasma coagulation. Results: All 49 patients were treated successfully with this combined endoscopic technique. Only for four patients was more than one endoscopic session (mean, 3.5; range, 2–6) needed to guarantee long-term success. No complications were encountered. Conclusions: Endoscopic argon plasma coagulation in combination with diathermy is a safe and effective technique for the treatment of short postsurgical gastrointestinal anastomotic strictures.

Intraperitoneal Versus Intravenous CPT-11 Given Intra- and Postoperatively for Peritoneal Carcinomatosis in a Rat Model

PurposePeritoneal recurrence after resection of colorectal carcinoma is still a major concern. We investigated whether the novel cytostatic drug, CPT-11 (Irinotecan), delivered intraperitoneally (i.p.) and intravenously (i.v.), could inhibit intraperitoneal tumor spread in a rat model.MethodsWe induced intraperitoneal tumor growth using a tumor cell transfer model (106 cells) and divided the rats into the following five groups of eight: group IP1, given CPT-11 i.p. immediately after intraperitoneal tumor cell transfer; group IV1, given CPT-11 i.v. immediately after intraperitoneal tumor cell transfer; group IP2, given CPT-11 i.p. on postoperative days (PODs) 5, 10, and 15; group IV2, given CPT-11 on PODs 5, 10, and 15; and a control group. The rats were killed 30 days after tumor cell transfer, and the tumor weight, number of nodes in the greater omentum and peritoneum, presence of metastases in the liver and lungs, and ascites volume were determined.ResultsCPT-11 inhibited peritoneal tumor growth significantly. The direct intraoperative intraperitoneal application induced a more pronounced effect than the early postoperative intraperitoneal application, but both these application modes were superior to the intravenous route, which had no significant effect.ConclusionCPT-11 was highly efficacious against peritoneal carcinomatosis in this experimental model. The combination of CPT-11 with other cytostatic agents and drugs generating different effector mechanisms may diminish or even prevent intraperitoneal tumor growth.

Retroperitoneoscopic and laparoscopic removal of periadrenally located bronchogenic cysts – a systematic review

UNLABELLED Retroperitoneal bronchogenic cysts (BC) are rare clinical entities and may mimic an adrenal mass. Laparoscopic and retroperitoneoscopic approach is widely-used in adrenal surgery. However minimally-invasive resection of a periadrenally located BC has been reported rarely. MATERIAL AND METHODS A systematic review of PubMed has been performed using the following search strategy: bronchogenic cyst AND (adrenal OR retroperitoneal OR subdiaphragmatic). 18 BC being removed via minimally invasive approach have been found. Including our own case 7 were removed retroperitoneoscopically and 12 laparoscopically. RESULTS An index case of a 50 year old male is presented. CT revealed 2 masses above the left adrenal area. A control demonstrated an increase in size. Retroperitoneoscopic resection was performed. Pathologic finding showed a multilocular cystic lesion with a diameter of 4cm. The cysts were lined by pseudostratified ciliated epithelium. The wall contained hyaline cartilage, seromucous glands and smooth muscle. CONCLUSIONS Because exact preoperative diagnosis of hormonally inactive adrenal masses is not possible surgical resection is recommended in case of tumor growth, symptoms and to obtain definitive histological diagnosis. Minimal invasive approach seems to be a safe way for resection of BC in experienced hands. There is no clear evidence if laparoscopic or retroperitoneoscopic approach is favourable.

Effect of Intraperitoneal Application of an Endotoxin Inhibitor on Survival Time in a Laparoscopic Model of Peritonitis in Rats

Gram-negative sepsis due to fecal peritonitis is a hazardous disease with a high percentage having a lethal course. The inflammatory effects are induced by endotoxin release. We performed this study to evaluate the potential of direct intraperitoneal application of an endotoxin inhibitor in a laparoscopic peritonitis model in rats. The human feces specimen was prepared, and a standard fecal specimen (0.5 ml/kg b.w.) was applied via minilaparotomy. The rats were randomized to two studies. First, rats were randomized to three groups to define the survival time: (1) rats without further manipulation; (2) rats with laparoscopic lavage using NaCl; (3) rats with laparoscopic lavage using endotoxin inhibitor. Second, rats underwent the same procedure used in the first part of the study and an additional group with only NaCl lavage without peritonitis was randomized. To evaluate the immunologic or biochemical effects, animals were killed at a standard time of 20 hours until the postmortem examination was established. Interleukins 6 and 10 (IL-6, IL-10), malondialdehyde, and protein carbonyl group levels in plasma and particularly in peritoneal fluid were assayed. The first part of the experiment showed significantly increased survival after endotoxin inhibitor lavage. In the second part, administration of endotoxin inhibitor intraperitoneally caused a significant reduction of IL-6 in the peritoneal fluid, in contrast to that in the other groups. Laparoscopic application of endotoxin inhibitor intraperitoneally thus produced a beneficial effect on survival and reduction of IL-6 in peritoneal fluid. Hence, it is possible to influence the inflammation cascade by causing intraperitoneal endotoxin inhibition.

Small bowel pancreatitis.

t s b A otherwise healthy woman presented with recurrent abdominal pain of 8-years’ duration. She recalls he pain staring after a hysterectomy. The pain was described as ttacks of recurrent, sharp, colicky, periumbilical pain that adiated to the left flank and groin. She had visited her primary are physician, several gastroenterologists, and the emergency oom on several occasions for these pains. The patient had been iagnosed with “irritable bowel syndrome.” The clinical examnation was unremarkable except for epigastric tenderness on eep palpation. The laboratory data were within reference anges, except for a repeatedly mildly elevated lipase (83 U/L; ormal 13– 60 U/L). A computed tomography scan performed t an outside facility was reported as completely normal. Varius endoscopies including an esophagogastroduodenoscopy, leocolonoscopy, and double-balloon enteroscopy were unrearkable. We reviewed the outside computed tomography scan f the abdomen, which demonstrated a suspected calcified esion in the left upper quadrant (Figure A). During exploratory laparotomy, a subserosal ectopic pancreas of the upper jejunum was discovered (Figure B). Adjacent to the ectopic pancreas, there was a white cauliflower-like structure representing saponification and calcification of fat which had likely been induced by the exudate of pancreatic enzymes during each “attack of pancreatitis” (Figure C). The involved segment of small bowel was removed. The resected specimen contained normal pancreas parenchyma with lobulated acinar tissue and islets of Langerhans, ductular structure, and areas of adipose tissue. The patient has not had any similar episodes of pain during an 8-month follow-up period. Ectopic pancreas is defined as pancreatic tissue found outside its usual anatomical position, with no ductal or vascular communication with the native pancreas.1,2 Ectopic pancreas can occur anywhere in the gastrointestinal tract and is usually an incidental finding at endoscopy, surgery, or autopsy.1,2 Alhough these lesions are generally silent, they may become ymptomatic as a result of complications such as obstruction, leeding, pancreatitis, and malignant transformation.2 This case is interesting for several reasons. First, we show that ectopic pancreatitis should be kept in the differential diagnosis of chronic, recurrent, abdominal pain. Second, this case shows that submucosal lesions may be missed during deep enteroscopy. Third, we show that careful review (ie, “second look”) of x-ray studies should be attempted in any patient with unclear abdominal pain. If a second x-ray examination is not possible, obtaining new imaging tests should be strongly pursued. In summary, in a patient with recurrent, unclear abdominal pain, even in the absence of elevated serum amylase/lipase, ectopic pancreatitis should be included in the differential diagnosis.

Intraperitoneale Applikation von Gefitinib inhibiert das Tumorwachstum der Kolonkarzinomzelllinie CC 531 im laparoskopischen Rattenmodell

Moglicherweise stellt die von uns gewahlte direkte Applikation eine zusatzliche Alternative im Behandlungskonzept des Kolonkarzinoms dar. Die Potenz von Tyrosinkinaseinhibitoren beim Kolonkarzinom ist unklar und sollte unbedingt weiter evaluiert werden. Ansatzpunkte sind die Prufung einer optimalen Dosierung, der Intervalle und die Kombination mit zytostatischen Substanzen.

Kann eine Heparinapplikation das Tumorwachstum reduzieren

Background: Growth, metastasis, adhesion and invasion of tumor cells involve a cascade of complex phenomena which potentially can be affected. We studied the influence of a low-molecular weight heparin, reviparin natrium, on the intraabdominal tumor growth in rats undergoing laparoscopy. We used adenocarcinoma cells CC531 to study cytotoxicity, adhesive and anti-invasive effects of reviparin in vitro, and tumor growth in vivo. Methods: In vitro assays: Adhesion of 1 × 105 CC531 cells into microtiter plates coated with 10 μg/ml collagen type I or 10 μg/ml Matrigel was significantly reduced by 5,52; 11,04; 27,6 mg/ml reviparin vs. 0,9% saline (p < 0.001). The cytotoxicity on 1 × 104 adenocarcinoma cells was studied in a similar assay. Transwell dual chamber with polycarbonate filters coated with 100 μm/cm2 Matrigel were used to investigate the effect of 0.27; 0.55; 1.10; 2.76 mg reviparin per well on the invasion of adenocarcinoma cells.