Embolization of Hemorrhoidal Arteries: A Novel Endovascular Therapy Option for the Treatment of Hemorrhoidal Disease

BACKGROUND

 Hemorrhoids are a widespread disease. Treatment options range from dietary measures to open surgery. A novel treatment approach is the embolization of the hemorrhoidal arteries.

METHOD

 A review was performed based on a selective literature search in PubMed representing the current state of research. The keywords "hemorrhoid" and "embolization" and "emborrhoid" were used. In addition, technical details of the hemorrhoidal embolization procedure are explained.

RESULTS AND CONCLUSION

 Embolization of hemorrhoidal arteries is a safe treatment, which allows efficient symptom control even in patients with contraindications for open surgery.

KEY POINTS

  · Embolization of hemorrhoidal arteries is a new approach to the treatment of hemorrhoids.. · Embolization of hemorrhoidal arteries is feasible in patients with contraindications for open surgery such as hypercoaguable states and contraindications for general anesthesia.. · The endovascular approach causes no rectal and anal trauma and associated complications can be avoided.. · The treatment of bleeding hemorrhoids seems to be particularly effective.. · No ischemic complications have been reported so far when coils as well as particles were used..

CITATION FORMAT

· Feyen L, Freyhardt P, Schott P et al. Hämorrhoidenembolisation: Eine neue minimalinvasive endovaskuläre Therapieoption bei Hämorrhoidalleiden. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1662-5487.

Verrucous carcinoma of the esophagus - a case report and literature review

BACKGROUND

 Verrucous carcinoma of the esophagus is a rare disease leading to dysphagia, chest pain, and weight loss. The diagnosis is difficult because even repeated biopsies are often without tumor evidence. We present a patient with verrucous carcinoma of the esophagus and a literature review.

CASE REPORT

 A 64-year-old patient with dysphagia and sore throat received esophagogastroduodenoscopy illustrating segmental circumferential verrucous inflammation and Candida esophagitis in the middle part of the esophagus. Repeated mucosal biopsies revealed reactive hyperkeratosis of the squamous epithelium with minimal atypia but without ulcera, eosinophilic esophagitis, or suspicion of cancer. Mucosal infection with adenovirus, herpes simplex virus 1, human papilloma virus types, and cytomegaly virus was ruled out. Veruccous carcinoma was detected finally by endoscopic mucosal resection. The patient was successfully treated by esophageal resection. Tumor stage was G1, pT1b, pN0, L0, V0, Pn0, R0.

CONCLUSION

 The results suggest that macroscopic suspicion of verrucous esophageal carcinoma should lead to resections of larger tissue specimens by EMR to confirm the diagnosis.

Laparoscopic right hemicolectomy with CME: standardization using the "critical view" concept

Background

Complete mesocolic excision is gradually becoming an established oncologic surgical principle for right hemicolectomy. However, the procedure is technically demanding and carries the risk of serious complications, especially when performed laparoscopically. A standardized procedure that minimizes technical hazards and facilitates teaching is, therefore, highly desirable.

Methods

An expert group of surgeons and one anatomist met three times. The initial aim was to achieve consensus about the surgical anatomy before agreeing on a sequence for dissection in laparoscopic CME. This proposal was evaluated and discussed in an anatomy workshop using post-mortem body donors along with videos of process-informed procedures, leading to a definite consensus.

Results

In order to provide a clear picture of the surgical anatomy, the “open book” model was developed, consisting of symbolic pages representing the corresponding dissection planes (retroperitoneal, ileocolic, transverse mesocolic, and mesogastric), vascular relations, and radicality criteria. The description of the procedure is based on eight preparative milestones, which all serve as critical views of safety. The chosen sequence of the milestones was designed to maximize control during central vascular dissection. Failure to reach any of the critical views should alert the surgeon to a possible incorrect dissection and to consider converting to an open procedure.

Conclusion

Combining the open-book anatomical model with a clearly structured dissection sequence, using critical views as safety checkpoints, may provide a safe and efficient platform for teaching laparoscopic right hemicolectomy with CME.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-6267-0) contains supplementary material, which is available to authorized users.

Minimally Invasive Techniques and Hybrid Operations for Esophageal Cancer

Background

Minimally invasive esophagectomy (MIE) is slowly gaining acceptance due to advantages in short-term outcome. While evidence is slowly increasing, the discussion about MIE is still controversial.

Methods

A literature review was performed to compare MIE with open esophagectomy (OE). Current studies are summarized in view of short- and long-term outcome as well as oncological accuracy.

Results

The majority of studies show that MIE is associated with a significant reduction of pulmonary complications, blood loss, and shorter length of stay on the intensive care unit. Pulmonary complications are reduced by 14-65%. MIE shows an improved quality of life 6 weeks after surgery. There is some evidence that the endoscopic reintervention rate may be higher after MIE than after OE. Mortality rates do not differ. Regarding oncological results, the rate of R0 resections is comparable between MIE and OE, as is the number of retrieved lymph nodes. Long-term survival seems to be comparable. A few single center trials suggest oncological advantages of MIE over OE concerning the number of lymph nodes, R0 resection rate, and 1-year survival.

Conclusion

Current evidence supports that MIE has advantages over OE in the short-term outcome. Oncological results are comparable to those achieved by OE. As a result, MIE has already been included in current guidelines for the treatment of esophageal cancer.

[CAMIC Recommendations for Surgical Laparoscopy in Non-Obstetric Indications during Pregnancy]

In the operative surgical primary care, the laparoscopic surgical technique has firmly established itself in recent years. Meanwhile, in the normal population over 90 % of all cholecystectomies and over 80 % of all appendectomies are performed in a minimally invasive manner. The proven benefits of the laparoscopic surgical technique, compared with conventional open surgery, are a comparatively rapid early postoperative recovery with early resumption of the general physical and occupational activity. As these benefits are equally applicable for necessary interventions during pregnancy, in recent years laparoscopy has become the preferred treatment for non-obstetric indications in the gravid patient. Overall, it can be assumed that such interventions have to be performed in approximately 2 % of all pregnant patients. Numerous studies have proven here that the use of laparoscopic techniques, in particular for the expectant mother, is safe and not associated with an increased risk. On the other hand, the current pregnancy makes necessary an adapted approach to the solution of surgical problems to ensure the protection of the unborn child. On the basis of currently available data situation, recommendations are formulated which can be used as a decision-making support for a variety of clinical situations.

[Options and Limitations in Endovascular Therapy for Acute and Chronic Mesenteric Arterial Occlusions]

BACKGROUND

The significance of endovascular therapy for mesenteric ischaemia (MI) is being debated. Despite initially lower mortality and morbidity, inconsistent early and late results led to questions concerning indications and technical applications of the procedure.

METHODS

91 patients with MI underwent endovascular treatment in a period of 11 years. In 78 (85.7 %) patients a stent was deployed and in 13 (14.3 %) an angioplasty was performed, principally of the superior mesenteric artery (n = 81/91, 89 %). Follow-up consisted of a clinical and an ultrasound examination in all cases. Mean follow-up was 4.2 years. Our results were compared to those in the literature.

RESULTS

Endovascular treatment of the intestinal arteries accounted for 0.6 % of all vascular procedures. Seven of 91 patients (7.7 %) died after an initial PTA/stenting. The overall peri-interventional morbidity was 6.6 % (n = 6/91). Medium- to long-term complications were encountered in 20 patients (22 %), primarily during the first year (85 %). Six of 91 patients developed an in-stent stenosis (6.6 %) and 14/91 patients (15.4 %) stent occlusion. Additionally 2 dislocated stents (2.2 %) and an arterial perforation with bleeding into the mesentery (1.1 %) were seen. Although 3 of these 20 patients were successfully treated with an additional PTA or stenting (15.0 %; n = 3/91, 3.3 %), surgical conversion was necessary in 9 (n = 9/20, 45 %; n = 9/91, 9.9 %). The postoperative mortality was respectively 22.2 % (n = 2/9; n = 2/91, 2.2 %). In the case of acute MI, endovascular procedures are only indicated for patients without peritonitis. In chronic MI, the indication for endovascular treatment depends on the type of occlusion and the vascular anatomy. Despite favourable early results, the outcome of endovascular treatment deteriorates with time reaching a 1-year patency rate of 63 % in a multicentre analysis. This leads to secondary procedures in 30 %. A surgical conversion carries a high mortality.

CONCLUSION

The endovascular treatment of intestinal artery disease cannot be considered the treatment of choice, it is rather an alternative method in patients with functional or local contraindications to surgery. Life-long follow-up is necessary to prevent stent complications with fatal consequences. A prospective randomised study concerning the evaluation of the advantages and disadvantages of surgical and endovascular therapy of intestinal artery occlusive disease is required.

[Scope and limitations of minimally invasive resections of the oesophagus and stomach]

BACKGROUND

Although minimally invasive surgery is being increasingly performed for the treatment of upper gastrointestinal cancers, the discussion on potential advantages and oncological accuracy is still controversial.

MATERIAL AND METHODS

In the framework of a literature survey, current trials on minimally invasive oesophageal resection and laparoscopic abdominal surgery have been analysed.

RESULTS

Minimally invasive oesophagectomy and laparoscopic gastric resections for cancer are safe. Minimally invasive resections result in an improved short-term outcome postoperatively in view of less pain, less blood loss and shorter duration of hospital stay. While mortality is equal, morbidity following minimally invasive surgery is reduced. Especially pulmonary complications decrease on the application of minimally invasive oesophagectomy. Minimally invasive operations last longer than open procedures. The oncological results seem to be equal between open and minimally invasive operations. A few studies have shown that laparoscopic gastric resections may result in a reduced number of lymph nodes harvested. The long-term survival between open and laparoscopic resections did not differ in any study.

CONCLUSION

Minimally invasive resections for oesophageal and gastric cancer are safe and show several advantages in short-term outcome. Oncological long-term results seem to be comparable. The potential risk of a reduced number of harvested lymph nodes during laparoscopic gastrectomy has to be addressed by an adequate surgical technique.

Role of transarterial chemoembolization for hepatocellular carcinoma before liver transplantation with special consideration of tumor necrosis

Several authors suggest that local ablative therapies, specifically transarterial chemoembolization (TACE), may control tumor progression of hepatocellular carcinoma (HCC) in patients who are on the waiting list for liver transplantation (orthotopic liver transplantation, OLT). There is still no evidence if TACE followed by OLT is able to prevent recurrence of tumor, to prolong survival rate of the patients on the waiting list, or to improve the survival after OLT. We report 27 patients with HCC who underwent OLT. From these patients, 15 were pre-treated with TACE alone or in combination with percutaneous ethanol injection (PEI) or laser-induced thermo therapy (LITT). Mean time on the waiting list was 214 d for treated patients and 133 d for untreated patients. Comparing pre-operative imaging and histopathological staging post-transplant, we found 13 patients with tumor progression out of which five were treated with TACE. In two of the TACE patients a decrease of lesions could be achieved. In a single patient, there was no evidence of any residual tumor. Only one patient displayed tumor progression prior to OLT despite undergoing TACE. Comparison of outcome in patients undergoing TACE or having no TACE was not statistically significant (p = 0.5). In addition, our analysis showed that progression either in the total study population or in the TACE group alone is associated with a significant poorer outcome concerning overall survival (p = 0.02 and p = 0.02).

Laparoscopic sigmoid resections for diverticulitis complicated by abscesses or fistulas

BACKGROUND AND AIMS

Treatment of choice in recurrent and complicated diverticulitis is surgical resection of the inflamed bowel. Whereas it is accepted that recurrent diverticulitis (RD) can be handled laparoscopically, this is still not generally recommended for complicated diverticulitis (CD). Therefore, we analysed our results of laparoscopic sigmoidectomies concerning intraoperative course, conversion rate, morbidity and hospital stay in RD and CD.

MATERIALS AND METHODS

Between 09/2002 and 01/2006, laparoscopic sigmoidectomies were offered to all patients suffering from recurrent or complicated diverticulitis (Hinchey I+II). All resections were performed in a four-port technique with the use of Ultracision and intraabdominal stapler anastomosis. Data were prospectively collected and retrospectively analysed in an intention-to-treat view.

RESULTS

Out of 127 laparoscopic colectomies, 58 were performed for diverticulitis (RD 32; CD 26). Eight patients with colovesical and one patient with colovaginal fistula are included. Three patients with abscesses underwent pretreatment by percutaneous drainage. Operative time was longer in CD than in RD (205+/-41 vs 147+/-34 min; p<0.001) and associated with higher blood loss, but conversion rate was low (RD, 2/32 vs CD, 3/26; p=0.64). There was one intraoperative complication in each group; postoperative major complications occurred in 3.13% (RD) vs 11.5% (CD; p=0.316). One anastomotic leakage occurred in the RD group. Length of hospital stay was shorter for RD than for CD (7.1+/-3.4 vs 10.7+/-6.4 days; p=0.02).

CONCLUSIONS

Laparoscopic resections should not be limited to recurrent diverticular disease but can be safely applied for complicated diverticulitis.

Lebermetastasen kolorektaler Karzinome - Neoadjuvante Konzepte zum präoperativen Downstaging

Liver resection for colorectal metastases disease can be performed with curative intent at low morbidity and mortality. Only 15-30 % of liver metastases are amenable to potentially curative resection. Five year survival following primary and repeat liver resection has consistently been reported as 25-40 %. Future strategies focus at widening the indication and extending therapeutic options. The aim of neoadjuvant treatment of irresectable liver metastasis is the conversion to secondary resectability either via increasing residual liver mass (portal vein embolisation/2-stage resection) and/or reducing tumor load via chemotherapy ("down-sizing"). Current data suggest resectability following neoadjuvant chemotherapy in around 8 % of cases but varying between 1-33 %.

Evaluation of Type 1 Diabetics for Simultaneous Pancreas-Kidney Transplantation With Regard to Cardiovascular Risk

The main cause of death for diabetic patients and patients on dialysis is coronary artery disease (CAD). The most common cause of graft loss following simultaneous pancreas and kidney transplantation (SPK) is death with a functioning graft due to CAD. Therefore, careful pretransplantation evaluation of CAD is mandatory. In our series, every patient undergoes a noninvasive cardiac function test like dobutamine stress echocardiography (DSE) or myocardial thallium scintigraphy using adenosine to induce medical stress. Thirty patients were evaluated for SPK: 15 patients with myocardial scintigraphy and 8 with DSE. Seven investigations showed pathological findings and we performed coronary angiograms, none of which showed coronary artery stenosis. Seven primary coronary angiograms were performed: four due to a history of CAD and three as a primary diagnostic. Following SPK one patient died at 21 days after transplantation due to myocardial infarction. He had a history of CAD with angioplasty and stent implantation. Noninvasive cardiac function tests like DSE or myocardial scintigraphy are reliable methods to evaluate CAD in patients with diabetic nephropathy awaiting SPK. In case of a suspicious finding or a history of CAD, a coronary angiogram should be performed to assess the need for revascularization. Following this algorithm we may further reduce the mortality of SPK.

Telerobotic-assisted laparoscopic spleen-preserving partial resection of the pancreatic tail for insulinoma

Laparoscopic pancreatic resection is rarely described. Telerobotic-assisted laparoscopy may offer some advantages for resection of the pancreatic tail. A 49-year-old woman was diagnosed with insulinoma located in the pancreatic tail. Telerobotic-assisted laparoscopic spleen-preserving resection of the pancreatic tail was performed. Operation time was 195 minutes. The postoperative course was uneventful. The previously described advantages of a telerobotic approach with extended range of motion and three-dimensional view make more complex operations like pancreatic resection possible and may offer extended indications for laparoscopic surgery.

Acceptance criteria of pancreas grafts: how do surgeons decide in Europe?

OBJECTIVES

Some donor factors, such as age, cause of death, and obesity, affect the outcomes of pancreas transplantation. Donors with a high-risk profile are usually not declined for pancreas donation. The purpose of our study was to investigate differences between accepted and refused pancreata after being procured and offered.

METHODS

In a retrospective study we analyzed all offered pancreata (n = 1360) in the "Eurotransplant Area" between May 25, 2002 and September 18, 2003. Included in this study were 525 pancreata transplanted (38.6%) and 608 pancreata refused for medical reasons (44.7%). A total of 227 pancreata (16.7%) refused for other than medical reasons were excluded from this analysis.

RESULTS

The significant differences in the donor profiles between transplanted and refused pancreata were cause of death (P < .001), donor age (P < .001), body mass index (BMI, P < .001), serum lipase and amylase (P < .05) at the time of procurement, and a history of smoking (P = .001) or alcohol abuse (P < .001). No differences were found for serum sodium (P = .188), blood leukocytes (P = .349), serum glucose at the time of procurement (P = .155), amylase and lipase at the time of admission (P = .34; P = .758), and vasopressor use at the time of admission or at the procedure (P = .802; P = .982).

CONCLUSION

Even after procuring and offering potentially good pancreata, nearly half the organs are refused for medical reasons. Acceptance criteria in the Eurotransplant region reveal a conservative attitude toward pancreas acceptance.

Does the liver ever age? Results of liver transplantation with donors above 80 years of age

INTRODUCTION

Facing an increasing shortage of donor organs, donor criteria become more extended and so-called marginal organs are accepted for transplantation. For liver donation donor age above 70 years is accepted as a risk factor concerning primary dysfunction or nonfunction. Therefore, the aim of this study was to compare the early outcome of grafts older versus younger than 80 years of age.

PATIENTS AND METHOD

Between August 2002 and February 2004, 40 adult liver transplants were performed using triple immunosuppression with tacrolimus, MMF, and low-dose corticosteroids. Recipients with HCC received low-dose rapamycin after postoperative day 14. The outcome of grafts from donors under 80 years of age (n=35) was compared with those from donors 80 years old or more (n=5). For statistical analysis Mann-Whitney-U-Test and Fisher's Exact Test were used with P < .05 considered statistically significant.

RESULTS

The average donor age of our population was 54.4 +/- 17.3 years with five donors older than 80 years (80-83 years). These donors all had additional risk factors. The recipients of the latter grafts suffered from HCC and liver cirrhosis Child A (n=2) or from viral hepatitis (n=3). One recipient had advanced cirrhosis with severe complications. The outcomes of both groups were comparable concerning intraoperative and postoperative courses. All recipients of old liver grafts left the hospital with stable graft function.

CONCLUSION

Liver grafts over 80 years can be transplanted with good results, especially if given to recipients with malignancy and otherwise stable liver function.

Influence of methicillin-resistant Staphylococcus aureus carrier status in liver transplant recipients

The prevalence of methicillin-resistant Staphylococus aureus (MRSA) has increased worldwide and MRSA has emerged as an important cause of sepsis in cirrhotic patients and liver transplant recipients. In this retrospective study, the prevalence of MRSA colonization and its influence on infections following orthotopic liver transplantation (OLT) was investigated. From August, 2002 until November, 2004, 66 primary cadaver OLT were performed for adult recipients. Antibody induction used Daclizumab (n = 49) or ATG (n = 14). Maintenance immunosuppression consisted of tacrolimus and steroids, with 30 patients receiving mycophenolate mofetil and 4, rapamune. For perioperative anti-infectious prophylaxis cefotaxime, metronidazole, and tobramycin were administered for 48 hours. The preoperatively performed routine swabs revealed MRSA colonization in 12 of 66 (18.2%) patients. The stage of cirrhosis was equivalent for MRSA(-) patients according to Child score. The mean MELD score was significantly higher for MRSA(+) patients (24.3 versus 18.7, P = .036). More MRSA(+) patients were hospitalized at the time of transplantation (14/54 versus 8/12, P = .018). The incidence of posttransplant infections was not significantly different among the two groups. Within the first year 7 of 66 (10.6%) patients died: 3 of 12 (25%) MRSA(+) and 4 of 54 (7.4%) MRSA(-). The 1-year survival was lower in the MRSA(+) group (74.1% versus 94.1%). In conclusion, this study did not show that an MRSA-positive carrier status implies an increased risk for septic complications following OLT. Mortality was increased for MRSA(+), but failed to show a significant difference. A significantly higher MELD score and pretransplant hospitalization for MRSA(+) patients may contribute to the higher mortality and reflect sicker patients.

Does telerobotic assistance improve laparoscopic colorectal surgery?

BACKGROUND AND AIMS

The laparoscopic approach is common for several surgical procedures. Although the laparoscopic approach in colorectal surgery is described as being beneficial, its use is not yet widespread. This restriction may be due to technical difficulties. The use of telerobotic assistance may simplify complex laparoscopic procedures. We compared the traditional laparoscopic and the telerobotic-assisted approaches to colorectal surgery.

PATIENTS AND METHODS

Between August 2002 and January 2004, 61 laparoscopic colorectal operations were performed. In this study we focused on sigmoid resection for benign disease. Twenty-three patients underwent sigmoid resection for diverticulitis using traditional laparoscopy, and 4 using telerobotic-assisted laparoscopy. The DaVinci system was used for telerobotic assistance. Four patients underwent resection rectopexies, 2 with traditional and 2 with telerobotic-assisted laparoscopy.

RESULTS

The DaVinci device worked well during all operations. No robot-related complications occurred. The conversion rate was 3 out of 23 with traditional laparoscopy and 1 out of 4 in the telerobotic-assisted group. The incidence of postoperative complications was 5 out of 23 after traditional laparoscopic and 1 out of 4 following telerobotic-assisted laparoscopic resection. Operation time was significantly longer using the telerobotic-assisted approach (236.7+/-5.8 vs. 172.4+/-38 min, p<0.05).

CONCLUSION

Colorectal surgery using the DaVinci system is safe and feasible. Compared to traditional laparoscopy, we did not see any relevant practical advantages of the supportive features of the telerobotic assistance that simplified the operation significantly. However, it would be useful to evaluate the telerobotic-assisted approach for other kinds of laparoscopic procedures.

Predicting creatinine clearance by a simple formula following live-donor kidney transplantation

The outcome after live-donor kidney transplantation is influenced by many parameters. The aim of our study was to establish a multivariate prognostic model for calculating the recipient's creatinine clearance after transplantation. Basic immunological, donor-, recipient- and process-related variables were assessed in a series of 18 live-donor kidney transplant patients with an uncomplicated postoperative course. Multivariate analysis was carried out with automated forward and backward selection. The following four parameters were included in the predictive model: recipient age, recipient BMI, graft clearance and degree of relationship. The coefficient of determination (R(2)) was 0.67. It could be shown that a significant prediction of creatinine clearance after living related kidney transplantation can be made, based on simple variables. Therefore, this formula could help to detect early complications in the post-transplantation course if the recipient's creatinine clearance drops below the predicted result.

[Acute pancreatitis]

Acute pancreatitis is an acute inflammatory process of the pancreas mainly due to biliary obstruction or alcohol consumption. Most episodes of acute pancreatitis are mild and resolve under conservative treatment. Severe forms of acute pancreatitis, especially the necrotising form, still have a high mortality rate and can be difficult to treat. The problem today is to identify the few cases that should be treated operatively. Infected necroses are well accepted as an indication for operative treatment. Surgery consists of débridement and necrosectomy followed by closed or open lavage. In biliary pancreatitis, ERCP is performed early in cases of biliary obstruction, with or without cholangitis. In these patients cholecystectomy should be performed electively after clinical recovery.

Mangan-enhanced MR imaging for the detection and localisation of small pancreatic insulinoma

Insulinoma is the most common pancreatic endocrine tumor. Localization of small tumors remains a diagnostic challenge. Recently, Mangafodipir-enhanced MR imaging using a whole-body coil has been shown to be effective in the detection and staging of pancreatic cancer [3]. Localization of even small tumors is improved and surgical techniques, such as robotic-assisted surgery, have been made possible.

High levels of C-reactive protein after simultaneous pancreas-kidney transplantation predict pancreas graft-related complications and graft survival

BACKGROUND

Although pancreas graft-related complications are frequent after simultaneous pancreas-kidney transplantation (SPK), there are no parameters predicting the risk for these complications.

METHOD

A two-center retrospective study was performed in 97 patients who underwent SPK to investigate the peak serum value of c-reactive protein (CRP) during the first 72 hr after SPK in view of graft-related complications and graft survival.

RESULTS

Mean peak CRP was 115.6 +/- 71.5 mg/L. Mean peak CRP was higher in patients needing relaparotomy (n=31) (136.4 vs. 105.8 mg/L, P=0.048), especially when postoperative bleeding was excluded (P=0.015); in patients with graft pancreatitis (P=0.03); and in patients with graft loss (n=19; P<0.001) compared with patients without these complications. With a cut-off of peak CRP at the level of mean plus 1 SD (187.05 mg/L), there was a significantly higher incidence of relaparotomies (P=0.01; bleedings excluded: P=0.003), graft pancreatitis (P=0.03), and pancreas graft loss (P<0.0001) in patients with high peak CRP compared with patients with low peak CRP. No differences were noticed with regard to rejection rate, mortality, and kidney graft loss.

CONCLUSION

Our findings suggest that peak CRP is a helpful parameter in predicting pancreas graft-related complications and pancreas graft survival after SPK. Our results also stress the importance of early graft damage in pancreas transplantation.

Prothrombotic disorders in uremic type-1 diabetics undergoing simultaneous pancreas and kidney transplantation

BACKGROUND

Although prothrombotic disorders (PTD) are known to increase the risk of graft failure in kidney transplantation only, there are no data on PTD in simultaneous pancreas and kidney transplantation (SPK).

METHODS

Forty-seven SPK performed between September 2000 and July 2002 underwent routine screening for PTD. Data were retrospectively analyzed in view of complications (relaparotomy, graft thrombosis, pancreatitis, rejection) and graft function (HbA1c, serum creatinine) 3 months posttransplantation.

RESULTS

Twenty-five of forty-seven (53.2%) patients had 30 PTDs. Homozygous mutations of the MTHFR gene (C677T) were found in six, factor-V Leiden mutation (homo- or heterozygous G1691A) in seven, and prothrombin mutation (20210A) in one patient (group 1). Group 2 consists of deficiencies of protein C (n=1), of protein S (n=12), of antithrombin (n=1), and antiphospholipid syndromes (n=2). Overall, PTD had no influence on graft thrombosis (P=0.36) or rejection (P=0.56). In patients with homozygous mutations, relaparotomies were more often necessary than in patients without mutations (42.9% vs. 11.8%, P=0.046). In group 1, there was a trend toward a higher incidence of graft pancreatitis than in patients without mutations (38.5% vs. 14.7%, P=0.075). Three months posttransplantation, HbA1c was 6.0% in patients with and 5.5% in patients without PTD (P=0.023). With regard to serum creatinine, no significant differences were observed.

CONCLUSION

PTD are frequent in type-1 diabetics receiving SPK and may have a role in relaparotomies, graft pancreatitis, and pancreas graft function.

Value of donor swabs for intra-abdominal infection in simultaneous pancreas-kidney transplantation

BACKGROUND

Simultaneous pancreas-kidney transplantation (SPK) has a higher rate of surgical complications compared with other whole organ transplantations. Graft thrombosis and intra-abdominal infections are the most frequent causes for relaparotomy. We evaluated risk factors for abdominal infections after SPK, with emphasis on the value of the routinely taken intraoperative swabs.

METHODS

Between June 1994 and December 2000, 177 SPK were performed. Immunosuppression consisted of antithymocyte globulin induction and triple-drug maintenance therapy. Routine swabs were taken from the graft perfusion solutions, from the donors' duodenum, and from the recipients' bladder and jejunum (in case of enteric drainage).

RESULTS

A total of 19 (10.7%) of 177 patients underwent 41 relaparotomies as a result of intra-abdominal infections. Positive microbial results from any donor site and positive duodenal swabs were significant risk factors for intra-abdominal infections after SPK (P=0.01, P=0.02). There was a significantly higher incidence of abdominal infections when Candida was found in the donor duodenal swab (P=0.0048). Patient survival was significantly lower in cases with abdominal infection (P=0.02). Survival rates of patients with and without abdominal infection were 89.5% and 97.4% at 1 year and 72.3% and 92.8% at 5 years, respectively.

CONCLUSIONS

The results of this study confirm that abdominal infections significantly reduce patient survival and thus jeopardize the success of SPK. Positive donor duodenal swabs have been revealed to be a significant risk factor for a subsequent intra-abdominal infection, especially when Candida was found.

Laparoscopic compared with conventional treatment of acute adhesive small bowel obstruction

BACKGROUND

Although laparoscopy may be associated with fewer intra-abdominal adhesions and quicker recovery of bowel function, it remains unclear whether patients with acute small bowel obstruction (SBO) might benefit from laparoscopic techniques.

METHOD

The results of patients with acute SBO treated laparoscopically (LAP; n = 52) and conventionally (CONV; n = 52) were compared in a retrospective matched-pair analysis. Conversions were included in the laparoscopic group.

RESULTS

Complete laparoscopic treatment was performed in 25 patients (48.1 per cent). Major intraoperative complications occurred in 15 patients in the LAP group and eight in the CONV group (P = 0.156). Intraoperative perforations were more frequent in patients who had undergone more than one previous laparotomy (P = 0.066). Postoperative complications occurred in ten patients (19.2 per cent) in the LAP group and in 21 patients (40.4 per cent) who had conventional surgery (P = 0.032). Bowel movements started 3.5 days after operation in the LAP group and 4.4 days after conventional operation (P = 0.001). The length of hospital stay was 11.3 and 18.1 days respectively (P < 0.001).

CONCLUSION

Laparoscopic treatment of acute SBO was feasible in about half of these patients. Postoperative recovery was improved after laparoscopic procedures but the risk of intraoperative complications increased. A laparoscopic approach seems justified in a subset of patients.

[Morbidity following simultaneous pancreas/kidney transplantation]

BACKGROUND

Simultaneous pancreas-kidney transplantation (SPK) is still associated with the highest rate of morbidity among solid organ transplantations. Although improved long-term survival following SPK has been proven in IDDM patients, a further decrease in morbidity would be desirable.

METHODS

A retrospective, single-center study was performed to investigate the morbidity following SPK and to compare the results to kidney transplantation alone (KTA). Parameters included the rates of relaparotomies, septic complications (urinary tract infection, wound infection, pneumonia), and graft function.

RESULTS

Between September 2000 and August 2001, 99 patients underwent transplantation (34 SPK, 63 KTA, 2 pancreas transplants alone). Relaparotomies were performed in six SPK patients (17.6%), mostly due to complications related to the pancreatic graft (n=5). Three reoperations (4.8%) were necessary in KTA patients (p=0.085). Septic complications occurred more often in SPK than in KTA patients (55.9% vs 30.2%, p<0.05). This difference resulted from the high rate of wound infections in SPK patients (35.3%). No intra-abdominal infection or sepsis occurred in any patient. There was one hospital death in SPK and KTA patients, respectively. The rejection rate was similar in SPK (17.6%) and KTA (12.7%, p=0.72). At discharge 91.2% of SPK patients were insulin free and 97.1% free of dialysis. At discharge 96.8% of KTA patients were free of dialysis.

CONCLUSION

SPK is still associated with a higher morbidity (relaparotomies, septic complications) than KTA, although life-threatening complications were rare. There was no increased mortality following SPK.

High duodeno-jejunal anastomosis as a safe method of enteric drainage in simultaneous pancreas and kidney transplantation

One of the key issues in successful pancreas transplantation is uncomplicated drainage of pancreas exocrine secretion.

OBJECTIVE

The aim of the study is to present results of side-to-side high duodeno-jejunal anastomosis as routine method of enteric drainage in simultaneous pancreas kidney transplantation (SPK).

METHODS

30 diabetic patients underwent SPK at the Department of Surgery, Ruhr University Bochum in 2001. The pancreas was drained using a portion of duodenal segment anastomosed to the first loop of jejunum about 20-40 cm distal to the Treitz ligament.

RESULTS

Early relaparotomy was required in 20% patients. The mean time of first relaparotomy was 5.5 (range 1-11) days after transplantation. In 10% of cases graft pancreatectomy was necessary. Perioperative mortality was 3.3%. Currently 83.3% patients are insulin-free and 86.6% patients are free of dialysis.

CONCLUSIONS

These data suggest, that side-to-side high duodeno-jejunal anastomosis is a safe method of drainage of pancreas exocrine secretion in SPK.

Simultaneous pancreas-kidney transplantation in patients with antiphospholipid syndrome

BACKGROUND

Graft thrombosis is one of the main reasons of graft loss following simultaneous pancreas-kidney transplantation (SPK). Although antiphospholipid syndrome (APLS) is known as a high risk for graft thrombosis in kidney transplants alone, little is known about APLS in SPK.

METHODS

Between September 2000 and December 2001, 45 SPK were performed. The treatment and clinical course of 2 patients with APLS is presented.

RESULTS

In one patient, APLS was known before transplantation. After SPK, she was treated by systemic heparin followed by coumarin. Both grafts are doing well 5 months posttransplant. The second patient underwent SPK without knowledge of APLS. The patient developed a deep vein thrombosis 5 weeks posttransplant. Hypercoagulability screening revealed APLS. Treatment consisted of systemic anticoagulation. Grafts were not affected.

CONCLUSION

SPK can successfully be performed in APLS patients if anticoagulation is performed consistently. To reduce the risk of graft thrombosis, a pretransplant screening for APLS would probably be of benefit.

Incidence of minor and major amputations after pancreas/kidney transplantation

Among other complications, diabetes mellitus leads to peripheral vascular disease with the risk of limb amputation. This retrospective study analyzed the incidence of amputations after simultaneous pancreas-kidney transplantation (SPK). Between June 1994 and February 2001, 200 SPKs, nine pancreas-after-kidney- (PAK) and one pancreas transplantation alone (PTA) were performed. The overall 5-year patient, pancreas-, and kidney-graft survival rates were 92.4%, 80.2% and 85.6%, respectively. Mean age at transplantation was 38.7 years, mean duration of diabetes was 26.9 years, mean duration of dialysis was 26.7 months. Nineteen (9.5%) patients after SPK (seven female/12 male) underwent 33 amputations, on average 18.7 months after transplantation. Longer duration of dialysis and a previous history of amputation were significant risk factors for an amputation after SPK ( P=0.014, P<0.001). Thus, early referral for SPK before dialysis initiation may be beneficial in preventing amputation.

[Transplantation and outcome quality]

Organ transplants are procedures which require intensive personal and material resources. The results of organ transplants have continuously improved during recent decades. International data bases (registries) have documented the continuous evolution of organ transplantation. On the basis of the German Transplant Law guidelines for "Requirements regarding quality control for procedures related to organ procurement and transplantation" have been formulated by the German Medical Chamber. Thus, monitoring of outcome quality will become a requirement for all German transplant centers. In this paper, the guidelines for the different organ transplants (kidney, pancreas, liver, heart, lung) are discussed as well as quality control for living donor transplantation. Studies from the USA and Europe demonstrated volume-outcome relationships in organ transplantation. In addition, in kidney transplantation a centre-effect could be demonstrated which influences outcome more than the immunological match between donor and recipient. The introduction of required quality control may have far reaching consequences for the future structure of organ transplantation in Germany.

Do complications related to laparoscopic cholecystectomy influence the prognosis of gallbladder cancer?

BACKGROUND

Laparoscopy is thought to worsen the prognosis of gallbladder cancer (GBC) discovered unexpectedly at laparoscopic cholecystectomy (LC). However, laproscopy has never been shown to have an influence on patient survival in clinical series.

METHODS

We Performed a two-center retrospective analysis of 28 patients with GBC (11 previously known, 17 unexpectedly discovered by LC) to determine whether laparoscopy and complications related to LC had any influence on the prognosis of GBC. Resectability for cure after LC, survival, and recurrence related to both the procedure itself and complications associated with LC were analyzed.

RESULTS

Of the 17 patients with unexpected GBC, 16 were considered resectable for cure at the time of LC. Advanced disease was detected in eight patients by re staging (n = 5) or exploration (n = 3). Seven patients (43.8%) underwent reoperation for cure. Mean survival of patients with unexpected GBC was 26.5 months. Mean survival was shorter when complications (bile spillage, injury of common bile duct, or tumor violation) occurred during LC (10.2 vs 33 months, p = 0.016). If bile spillage was the only complication at LC, there was also a trend to shorter survival (12 vs 33 months, p = 0.061).

CONCLUSION

Complications during LC significantly worsen the prognosis of GBC. Therefore, bile spillage and excessive manipulation of the gallbladder should be avoided.

[Pyoderma gangrenosum after TAPP hernioplasty. A rare differential necrotizing wound infection diagnosis]

Pyoderma gangrenosum is an aseptic skin disease that occasionally complicates operative incisions and mimics postoperative necrotising wound infection. So far there are only a few case reports about bacterial necrotising infections following laparoscopy; no report exists about postoperative pyoderma gangrenosum after minimally invasive surgery. Differential diagnosis of both these diseases with potentially high morbidity and mortality is, however, essential, as they require opposite therapeutic regimens. Here we present the case of a patient who developed pyoderma gangrenosum after laparoscopic hernioplasty. Pathophysiological, clinical and therapeutic aspects of the disease are discussed.

Results of laparoscopic vs. conventional appendectomy in complicated appendicitis

BACKGROUND

Although many trials show some advantages of laparoscopic appendectomy over open appendectomy, the value of laparoscopic appendectomy is still controversial. Specifically the question of whether there are benefits of laparoscopic appendectomy over open appendectomy in complicated appendicitis remains to be answered.

METHODS

Of 1,106 consecutive appendectomies (717 laparoscopic appendectomies, 330 open appendectomies, and 59 conversions) between 1989 and 1999, the results of 299 patients with complicated appendicitis (defined by perforation, abscess, or peritonitis) were analyzed retrospectively to compare the complications of laparoscopic appendectomy and conversion (intention-to-treat group) with those of open appendectomy.

RESULTS

Complicated appendicitis (n = 299) was treated by laparoscopic appendectomy in 171 patients, by open appendectomy in 82 patients, and by conversion in 46 patients. Laparoscopic appendectomy and conversion showed fewer abdominal wall complications than open appendectomy (13/217; 6 percent vs. 15/82; 18.3 percent; P < 0.003), which led to a decrease of the total complication rate in the intention-to-treat group (21/217; 9.7 percent vs. 19/82; 23.1 percent; P = 0.004). The rate of intra-abdominal abscess formation was nearly the same after laparoscopic appendectomy (4.1 percent) and open appendectomy (4.9 percent). The total complication rate was higher in complicated appendicitis than in acute appendicitis (P < 0.005) but was independent of the laparoscopic technique. The conversion rate was higher in complicated appendicitis than in acute appendicitis (21.2 vs. 2.3 percent; P < 0.001).

CONCLUSION

In comparison with open appendectomy, laparoscopic appendectomy (by itself and in an intention-to-treat view) leads to a significant reduction of early postoperative complications in complicated appendicitis and therefore should be considered as the procedure of choice.

Compression anastomosis (AKA-2) in colorectal surgery: results in 442 consecutive patients

BACKGROUND

The morbidity and mortality associated with colorectal surgery results partly from anastomotic leakage. Animal experiments have shown some advantages of sutureless anastomosis over conventional colorectal anastomosis. Compression anastomosis follows the same biological principles as sutureless anastomosis.

METHODS

The compression anastomosis AKA-2 was evaluated in a prospective consecutive audit of 442 patients between September 1989 and August 1998.

RESULTS

Anastomoses were performed in 372 elective and 70 emergency situations. The indication for operation was colorectal cancer (56.3 per cent) and diverticulitis (23.5 per cent). A defunctioning colostomy was performed in 110 patients (24.9 per cent). Fourteen patients died (3.2 per cent). Death was related to anastomotic complications in three patients (0.7 per cent). Twenty-four patients (5.4 per cent) developed intra-abdominal complications. There were 11 symptomatic (2.5 per cent) and six asymptomatic (1.4 per cent) leakages. Anastomoses that were more than 10 cm from the anal verge leaked in seven (2.4 per cent) of 291 cases, while anastomoses between 5 and 10 cm leaked in three (2.6 per cent) of 116 cases and those less than 5 cm from the anal verge leaked in one (3 per cent) of 35 cases.

CONCLUSION

The low incidence of anastomotic complications demonstrates good biological healing of compression anastomoses. The compression anastomosis AKA-2 is safe in both high and low anterior resection and can therefore be recommended for use in colorectal surgery.

Laparoscopic treatment of colonic perforations related to colonoscopy

BACKGROUND

Colonic perforations associated with colonoscopy are rare but major complications. Conservative treatment is less invasive than major surgery, but any case of failure leads to more extensive surgical procedures with a higher morbidity and mortality than the immediate operative repair. To reduce the invasiveness of major surgery and avoid the risk of failure, we introduced laparoscopic techniques to deal with iatrogenic colonic perforations.

METHODS

Each colonic perforation was identified by diagnostic laparoscopy. The perforation was then characterized by size and extent of thermal damage into one of three types, followed by type-dependent treatment (suture, tangential resection, segmental resection, or open procedure). Operative time, complications, clinical outcome, and patient satisfaction were recorded.

RESULTS

Seven patients underwent diagnostic laparoscopy for colonic perforations. Laparoscopic treatment was performed on five patients (one simple closure by suture, three tangential resections, and one segmental resection). Two cases required open procedures. There was one intraoperative complication that necessitated conversion. There were no postoperative complications. All laparoscopically treated patients were satisfied with their clinical outcome and cosmetic results.

CONCLUSIONS

Laparoscopic treatment seems to reduce the invasiveness and morbidity of major surgery. At the same time, it is more definitive than conservative treatment, so that we now prefer to use laparoscopic techniques to treat colonic perforations related to colonoscopy.

[Laparoscopic versus conventional appendectomy--a comparison with reference to early postoperative complications]

OBJECTIVE AND METHODS

To compare the complications of laparoscopic appendectomy (LA) and conventional appendectomy (CA) 930 consecutive patients from 1989 until 1997 were analysed retrospectively.

RESULTS

Conventional appendectomy was performed in 330 patients, laparoscopic in 554 patients and another 46 patients required conversion after laparoscopy. The groups were similar in sex ratio, age and degree of inflammation. Postoperative complications occurred in 8.78%. There were less complications in the LA-group (4.69%) than in the CA-group (13.33%) (p < 0.01), especially wound infections were found less in the LA-group (1.8% vs. 11.21%, p < 0.01). The incidence of intraabdominal abscesses was similar in the LA and CA group (1.44% vs. 1.52%). The differences between the groups are not influenced by complicating appendicitis (perforation or abscess). Systemic complications were similar for LA and CA (0.72% and 0.61%), but were seen more often after conversion (6.52%, p < 0.01).

CONCLUSIONS

This retrospective analysis shows that laparoscopic appendectomy significantly reduces postoperative complications, especially wound infections. The authors consider laparoscopic appendectomy to be the procedure of choice in patients with acute appendicitis.