Stent migration necessitating surgical intervention

BACKGROUND

Internal drainage with transhepatically or endoscopically placed endoprostheses has been used for many years as a temporary or definitive treatment for biliary tract obstruction. As a late complication, stent migration may occur.

METHODS

We reviewed our records to identify patients who were operated on for a migrated endoprosthesis that was causing complications. In all, five such patients were identified.

RESULTS

One patient had a large bowel perforation. Bowel penetration led to an interenteric fistula in one patient and to a biliocolic fistula formation in another. Small bowel distension was found in two patients. Surgical treatment consisted of local excision in three patients, segmental resection in one patient, and a bypass operation in the patient with biliocolic fistula. Postoperatively, four patients recovered without problems, but one patient died during a complicated postoperative course.

CONCLUSION

If a stent becomes stuck in the gastrointestinal tract and is not accessible for endoscopic removal, early operative revision is mandatory to prevent further complications.

Stent migration necessitating surgical intervention

BACKGROUND

Internal drainage with transhepatically or endoscopically placed endoprostheses has been used for many years as a temporary or definitive treatment for biliary tract obstruction. As a late complication, stent migration may occur.

METHODS

We reviewed our records to identify patients who were operated on for a migrated endoprosthesis that was causing complications. In all, five such patients were identified.

RESULTS

One patient had a large bowel perforation. Bowel penetration led to an interenteric fistula in one patient and to a biliocolic fistula formation in another. Small bowel distension was found in two patients. Surgical treatment consisted of local excision in three patients, segmental resection in one patient, and a bypass operation in the patient with biliocolic fistula. Postoperatively, four patients recovered without problems, but one patient died during a complicated postoperative course.

CONCLUSION

If a stent becomes stuck in the gastrointestinal tract and is not accessible for endoscopic removal, early operative revision is mandatory to prevent further complications.

[Resection of tumor stenoses and stent implantations in advanced neoplasms of the esophagus, stomach and duodenum]

Up to now many people demand treatment only with symptoms of a progressed cancer disease. As curative therapy is often not possible any more, endoscopy offers valuable palliative treatment options. Tumor destructive methods are mainly used for soft exophytic neoplastic tissue, whereas stent implantation is the therapy of choice in all other cases, especially if severe obstruction is present. The advantage of this method is the immediate and long lasting effect. Because of the different stent types and indications there is no optimal universal stent, so that we have to choose the individual best endoprosthesis.

[Rectal carcinoma in a patient with familial adenomatous polyposis coli after colectomy with ileorectal anastomosis and consecutive chemoprevention with sulindac suppositories]

Surgery is the definitive treatment in familial adenomatous polyposis coli (FAP). Proctocolectomy with ileal pouch anal anastomosis is recommended for the majority of FAP patients. Only in patients with attenuated FAP, is a colectomy with ileorectal anastomosis (IRA) accepted, although the risk for rectum carcinoma remains increased. Sulindac, a chemoprophylactic agent, regresses colorectal adenomas in patients with FAP. Under systemic Sulindac-therapy, three carcinomas in the rectum after colectomy with IRA have been described. We report the first known case of rectum carcinoma in a patient with FAP, 51 months after IRA and local Sulindac therapy.

[Management of biliary complications after orthotopic liver transplantation]

In this retrospective analysis we report our results after liver transplantation regarding biliary complications (bc) and the effectiveness of endoscopic therapy. In the last 4 1/2 years we found 13 biliary leaks (7 in combination with a stenosis, 3 at the T tube insertion site), 9 biliary stenosis, 3 papillary stenosis, 2 biliary aggregates and one case of ischemic type biliary lesion, resulting in an overall complication rate of 30%. 10 (36%) "bc" could be treated successfully endoscopically, whereas 8 (32%) patients are still under observation with an endoprosthesis in the biliary tract. 10 endoscopic trials were without the desired effect, requiring a surgical reintervention. In 4 cases a thrombosis of the hepatic artery was responsible for the unwanted course.

[Assessment of drain insertion in thyroid surgery?]

INTRODUCTION

Although generally recommended the benefit of suction drains in thyroid surgery is not proven.

METHODS

Therefore, we started a prospective randomized trial including all patients who were referred to our institution for resection of an euthyroid goiter (n = 52 with drains and 48 without). On the third postoperative day as well as four weeks later the patients were questioned and physically examined, including an ultrasound of the neck and, if present, the measurement of a hematoma.

RESULTS

Two patients had to be reoperated due to a hemorrhage detected by the drains. Further the study revealed that patients without drains left the hospital significantly earlier (3.9 vs 4.6 days, p = 0.006). On the other hand the hematoma size in this group was larger than in the group with drains (1.9 ml vs. 0.9 ml, p = 0.016). The other clinical parameters were comparable in both groups. Four weeks postoperatively no differences were detected.

DISCUSSION

So far neither our results nor those in the literature could prove that severe postoperative hemorrhage can be recognized or treated faster with the use of drains. Although drains reduce the size of hematomas significantly, the quantity is too small for any clinical relevance. Based on these results a general insertion of drains after resection of an euthyroid goiter is not recommended.

Electronic photography: a new age of medical imaging?

This is a critical overview of present conceptions of the introduction of electronic photography in medicine. It is not a complete list of products, rather it is a description of how the requirements of the physician have influenced medical illustration in the past and will continue to do so in the future. Video systems are widely used in medicine. Besides the learning and teaching of effects of television, minimal invasive surgery (MIS) has become reality through endoscopy, rapidly accepted worldwide. Documentation of endoscopic procedures and their effects is becoming routine. Therefore, the conversion of complex optical information into binary units is a logical development to save space for storage. The reproduction, storage and transfer of detailed images is already realized by digital camera systems, photo CD, scanners and picture archiving and communicating system (PACS). Now electronic imaging in medicine has to be regarded as a matter of routine. The real impact of accelerated editing will be shown in the future.

[Human albumin therapy and prognostic value of determining colloid osmotic pressure at the surgical intensive care station]

367 patients treated on the intensive care unit were prospectively documented during a 1-year observation period. Plasma colloid osmotic pressure (COP) was daily measured. Human albumin therapy was required only in 10% of all patients. These mainly long-term (greater than 10 days) treated patients also showed the lowest levels of COP (minimum COP means: 21 cmH2O (= 15.4 mmHg]. In the majority of all cases an extreme decrease of COP (less than 20 cmH2O (= 14.7 mmHg] was due to sepsis associated with an unfavorable prognosis. 67% of all patients with at least a single decrease of COP less than 20 cmH2O died, as compared to 15% of the patients where the COP never fell below 25 cmH2O. When a low COP was secondary to sepsis, the therapeutic benefit of an albumin therapy could not be evaluated.