Sascha S. Chopra

Management of esophageal anastomotic leaks, perforations, and fistulae with self-expanding plastic stents

OBJECTIVE Esophageal anastomotic leaks, perforations, and fistulae are associated with considerable morbidity and mortality. The aim of the present study was to assess the efficacy of self-expanding plastic stents in the treatment of esophageal leaks. METHODS From 2001 to 2009, 41 patients with postoperative anastomotic leaks (n = 30), esophageal perforations (n = 6), or fistulae (n = 5) were treated by endoscopic insertion of self-expanding plastic stents. The clinical outcome of the patients was analyzed, including leak healing, morbidity, and mortality. RESULTS Self-expanding plastic stents were successfully inserted in all 41 patients without procedure-related complications. Non-ventilated patients received oral feeding an average of 3.9 days after stent placement. Complete leak healing was obtained in 27 of 30 patients (90%) with anastomotic leaks and 5 patients (83%) with perforation. Sealing of fistulae by the stents was achieved in all 5 patients, and closure of the fistula was observed in 2 patients (40%). The mean healing time was 30 days for anastomotic leaks, 15 days for esophageal perforations, and 16 days for fistulae. Stent migration occurred in 14 cases, but endoscopic reintervention and new stent placement were successful in all cases. In-hospital mortality after treatment of esophageal leaks with stents was 10%. CONCLUSIONS In combination with effective interventional or surgical drainage, stenting is a viable option for the treatment of esophageal anastomotic leaks and perforations, but the success in tracheoesophageal fistula is limited.

The effect of endoscopic treatment on healing of anastomotic leaks after anterior resection of rectal cancer

BACKGROUND Despite surgical advances, anastomotic leaks remain a major complication after rectal resection. Endoscopic techniques are increasingly used as an alternative or in addition to conventional operative therapy of anastomotic leakage. We have analyzed the impact of endoscopic treatment on the outcome of patients with leaks after resection of rectal cancer. METHODS From January 2000 to December 2005, rectal resection was performed in 274 patients with rectal cancer. Anastomotic leakage was observed in 29 patients (11%). Nine of these patients received a protective ileostomy. The remaining 20 patients underwent either conventional operative or endoscopic treatment. Both groups were analyzed regarding complications, necessity of operative reintervention, hospitalization, anastomotic healing time, and stoma reversal rate. RESULTS The endoscopic group included 13 patients who underwent endoscopic debridement in combination with stenting, endoluminal vacuum therapy, or fibrin injection. The remaining 7 patients underwent reoperation-secondary ileostomy creation (n = 4), Hartmann procedure (n = 2), or anastomotic repair (n = 1). Stoma creation was necessary in 7 of 13 patients (54%) in the endoscopic group and in 6 of 7 patients (86%) in the operative group. There were no significant differences regarding postoperative septicemia (39 vs 43%), duration of intensive care (13 vs 11 days), or time of hospitalization (25 vs 26 days) for endoscopic and conventional therapies. Mean healing time of the anastomotic leak in the endoscopic and conventional group was 105 and 173 days, respectively. The stoma reversal rate was similar in both groups (50 vs 57%), but the overall rate of patients without colostomy was higher in the endoscopic group (77 vs 57%). CONCLUSION Endoscopic therapy in combination with effective operative drainage may support healing of anastomotic leaks after rectal resection. However, the majority of patients require operative reintervention with bowel diversion despite endoscopic treatment.

Low-dose computed tomography to detect body-packing in an animal model

OBJECTIVE To assess the possible extent of dose reduction for low-dose computed tomography (CT) in the detection of body-packing (ingested drug packets) as an alternative to plain radiographs in an animal model. MATERIALS AND METHODS Twelve packets containing cocaine (purity >80%) were introduced into the intestine of an experimental animal (crossbred pig), which was then repeatedly examined by abdominal CT with stepwise dose reduction (tube voltage, 80 kV; tube current, 10-350 mA). Three blinded readers independently evaluated the CT datasets starting with the lowest tube current and noted the numbers of packets detected at the different tube currents used. In addition, 1 experienced reader determined the number of packets detectable on plain abdominal radiographs and ultrasound. RESULTS The threshold for correct identification of all 12 drug packets was 100 mA for reader 1 and 125 mA for readers 2 and 3. Above these thresholds all 3 readers consistently identified all 12 packets. The effective dose of a low-dose CT scan with 125 mA (including scout view) was 1.0 mSv, which was below that of 2 conventional abdominal radiographs (1.2 mSv). The reader interpreting the conventional radiographs identified a total of 9 drug packets and detected 8 packets by abdominal ultrasound. CONCLUSIONS Extensive dose reduction makes low-dose CT a valuable alternative imaging modality for the examination of suspected body-packers and might replace conventional abdominal radiographs as the first-line imaging modality.

Incidence, risk factors and management of incisional hernia in a high volume liver transplant center

BACKGROUND Incisional hernia after liver transplantation is a common complication with an incidence between 5% and 34%. This prospective study analyzed risk factors, surgical management and long-term results after hernia repair. MATERIAL AND METHODS From February 2002 until August 2009, 810 liver transplantations were performed. 77 patients (9.5%) underwent incisional hernia repair after a median time of 21.1 months (4.6-76.7) following transplant. These patients were compared to patients without hernia (n=733). RESULTS No statistically significant differences between the groups were observed with respect to gender, underlying liver disease, Child-Pugh classification, MELD-Score and preoperative renal failure (p=NS). Multivariate analysis revealed advanced age (p=0.014), body mass index (p=0.016), and re-laparotomies (p<0.001) as independent risk factors for incisional hernias. Pre-existing diabetes mellitus and immunosuppression with mycophenolate mofetil reached significance only in the univariate analysis (p<0.001). Recurrent hernia was observed in 12 of 77 patients (15.6%) at a median time of 7.9 months (4.8-46.8) after primary surgical repair. The recurrence rate after intraperitoneal onlay mesh implantation was lower compared to other mesh techniques (7.7% vs. 21.4%). CONCLUSIONS The risk factors for the development of incisional hernias in liver transplant patients are similar to patients with prior abdominal surgery for other reasons. Intraperitoneal onlay mesh implantation may lead to a decrease of hernia recurrences. The role of immunosuppression in the genesis of incisional hernias requires further elucidation.

Evaluation of Laparoscopic Liver Resection with Two Different Nd:YAG Lasers for Future Use in a High-Field Open MRI

OBJECTIVE Laparoscopic liver surgery is a safe and feasible technique for the treatment of benign and malignant liver tumors and has been well established at many specialized centers. Many different techniques of tissue dissection have been developed. As an alternative various lasers have been applied to conventional liver resections. Laser surgery is potentially beneficial for laparoscopic liver resection, allowing parenchymal dissection and vessel coagulation. A second advantage is the non-ferromagnetic character of this instrument, which facilitates magnetic resonance (MR)-guided interventions. In this study two different Nd:YAG lasers were evaluated for laparoscopic liver resection in a porcine model. In other studies this technique will be transferred into an interventional open MRI for image-guided liver resection. MATERIALS AND METHODS We used 1064-nm and 1318-nm Nd:YAG lasers for laparoscopic wedge, segmental, and left lateral liver lobe resection. During the intervention blood loss, resection time, and cardiopulmonary parameters were quantified. The resected specimen underwent histomorphometric analysis for thermal tissue effects, including parenchymal carbonization, necrosis, and vessel coagulation. RESULTS The resected volume showed a positive correlation with intraoperative blood loss, which increased from wedge resection (245 mL, SD +/- 71 mL) and segment resection (325 mL), to left lateral resection (455 mL). Total parenchymal dissection was slightly faster with the 1064-nm Nd:YAG laser (9 min, SD +/- 5 min) compared with the 1318-nm Nd:YAG laser (11 min, SD +/- 4 min). Thermally-induced vessel sealing was shown for liver veins and arteries to a maximum diameter of 2 mm. CONCLUSION Laparoscopic liver resection with both Nd:YAG lasers is a safe and feasible technique, allowing parenchymal dissection and coagulation. The 1064-nm Nd:YAG laser showed increased tissue damage with more effective coagulation capability than the 1318-nm Nd:YAG laser. Because of its non-ferromagnetic characteristics, laser-based laparoscopic liver resection is potentially useful for image-guided surgery in an open MRI.

Results of liver resection in combination with radiofrequency ablation for hepatic malignancies.

INTRODUCTION Liver tumors should be surgically treated whenever possible. In the case of bilobar disease or coexisting liver cirrhosis, surgical options are limited. Radiofrequency ablation (RFA) has been successfully used for irresectable liver tumors. The combination of hepatic resection and RFA extends the feasibility of open surgical procedures in patients with liver metastases and hepatocellular carcinoma (HCC). PATIENTS AND METHODS RFA was performed with two different monopolar devices using ultrasound guidance. Intraoperative use of RFA for the treatment of liver metastases or HCC was limited to otherwise irresectable tumors during open surgical procedures including hepatic resections. Irresectability was considered if bilobar disease was treated, the functional hepatic reserve was impaired or appraised marginal for allowing further resection. RESULTS Ten patients with both liver metastases and HCC, and two patients with cholangiocellular carcinoma were treated. Complete initial tumor clearance was achieved in all patients. Two patients of the metastases group and five patients of the HCC group suffered from local recurrence after a median of 12 months (1-26) (local recurrence rate 32%). Five patients of the metastases group and six patients of the HCC group developed recurrent tumors in different areas of the ablation site after a median time of 4 months (2-18) (distant intrahepatic recurrence in 55%). Survival at 31 months was 36%. CONCLUSION RFA extends the scope of surgery in some candidates with intraoperatively found irresectability.

Esophageal Stents for Leaks and Perforations

Stenting of esophageal leaks, ie, anastomotic leaks or perforations, might be a minimally invasive alternative to surgery in most clinical situations. However, it must be emphasized that surgery should be considered if stent treatment in combination with drainage and antibiotics does not improve the clinical condition of the patient. Stent insertion should be performed as soon as possible after diagnosis of the leak.

Treatment of recurrent hepatocellular carcinoma confined to the liver with repeated resection and radiofrequency ablation: A single center experience

BACKGROUND Recurrence of hepatocellular carcinoma (HCC) after surgical treatment is a common problem. It can be treated by radiofrequency ablation (RFA) or repeated hepatic resection (HR). This report compares both in a retrospective, single-institution database. PATIENTS AND METHODS A prospectively collected database was retrospectively analyzed. RFA was performed under ultrasound control using two different monopolar devices. All kinds of access were used: open surgical (n=10), percutaneous (n=13) and laparoscopic (n=4). HR was performed using an ultrasound aspiration device. Indication for a particular treatment was allocated on a case-by-case basis; the final decision was often made intraoperatively. RESULTS Survival after RFA (median 40 months) was similar compared to that after HR (48 months, p=0.641, logRank-test). Tumor-free survival was markedly impaired after RFA (15 vs. 29 months). This difference was however not significant (p=0.07, logRank-test). Both groups were different regarding occurrence of cirrhosis, maximal tumor size, time after initial diagnosis and duration of the procedure. CONCLUSION In this non-randomized retrospective trial, survival and disease-free survival was not significantly different when compared between patients treated by RFA and HR. There was however a tendency towards a longer tumor-free survival in the resected patients.

Postoperative immunosuppression after open and laparoscopic liver resection: assessment of cellular immune function and monocytic HLA-DR expression.

In an experimental setting, the authors demonstrated a trend toward improved preservation of the immune system after laparoscopic hepatic resection compared with open surgery.

Contrast enhanced ultrasound cholangiography via T-tube following liver transplantation

BACKGROUND The objective was to evaluate contrast enhanced ultrasound (CEUS) based cholangiography compared to conventional radiography as a reference method in patients after liver transplantation. MATERIAL/METHODS Contrast agents were administered through T-tubes, which were placed during the operation. Twelve patients with side-to-side choledocho-choledochostomy and standardized intraoperative T-tube placement were investigated on the 5th postoperative day (POD 5) with both techniques. All images were digitally acquired and assessed in consensus by two investigators regarding complete anatomic visualization, depiction of pathology (e.g. delayed contrast outflow, stenosis and leakage) and general image quality. RESULTS CEUS cholangiography showed comparable results in the detection of biliary pathology and overall image quality. Regarding the visualization of the extrahepatic bile duct CEUS produced limited results in 6 patients. CONCLUSIONS In conclusion, CEUS cholangiography via T-tube represents a potential bedside test for visualization of intrahepatic bile ducts of transplanted livers; its diagnostic value remains to be determined in further studies.