Alloplastic bypass material below the knee: actual rationale.

AIM: The greater saphenous vein is considered as material of first choice for a below-knee bypass. A high number of below knee synthetic, polytetrafluoroethylene or knitted polyester, bypass grafts in the institution of the senior author formed the basis to analyze factors for outcome of below-knee synthetic grafts. METHODS: A total of 533 patients (327 men, 206 women; age: 71.2 ± 10.3 years), who had their first below knee bypass, were followed-up for up-to 9 (4.1 ± 2.6) years. Survival, primary and secondary patency, and limb salvage were compared between vein bypasses and synthetic grafts by Kaplan Meier analysis. Within the group of 377 patients with synthetic grafts comorbidities, previous interventions, indications, graft diameter, and technical aspects were related to outcome including univariate (log-rank) and multivariate (Cox Proportional Hazard Ratio) statistics. RESULTS: The greater saphenous vein was superior to synthetic graft in primary and secondary patency as well as limb salvage (5 year limb salvage 73.3% vs. 56.7%, P=0.001). In patients with a synthetic bypass, relevant preoperative factors for higher patency rates were hypertension, coronary heart disease and no previous endovascular intervention. Patency and limb salvage was significantly improved for anastomoses not to a single crural vessel. Adding a St. Mary's Boot as cuff technique did not improve the results. In multivariate analysis, independent factors for higher primary patency were no previous endovascular intervention, low severity of peripheral arterial occlusive disease, coronary heart disease and age above 65. Additionally, femoropopliteal and tibioperoneal anastomoses were related to better limb salvage. CONCLUSION: The greater saphenous vein reveals the best results for below-knee bypass grafts. However, if a vein is not available, synthetic grafts appear to be an valuable alternative especially in patients with no previous radiologic intervention, coronary heart disease, and age over 65.

[Comment on the article "Operative Techniques and Outcomes in Metabolic Surgery: Sleeve Gastrectomy"]. / Kommentar zum Artikel "Operative Techniken und deren Outcome in der metabolischen Chirurgie: Sleeve-Gastrektomie" von T.P.Hüttl et al.

The review article "Operative Techniques and Outcomes in Metabolic Surgery: Sleeve Gastrectomy" by Hüttl et al. is concerned with laparoscopic sleeve stomach operations ("sleeve gastrectomy") for the surgical treatment of morbid obesity (Zentralblatt für Chirurgie 2009; 134: 24-31). After an analysis of the available literature and own results, the authors concluded that the laparoscopic sleeve operation is established today as an effective standard procedure in the therapy for obesity.We would like to comment on the content of this article.

[Metastasis of an esophageal carcinoma at a PEG site--case report and review of the literature]. / PEG-Implantationsmetastase eines Osophaguskarzinoms--Fallbericht und Literaturübersicht.

We describe the case of a 54-year-old man with a tumour of the proximal esophagus (cT3-4,N1,M0), who underwent percutaneous endoscopic gastrostomy (PEG) for enteral feeding. Primary radiochemotherapy was initiated shortly after PEG insertion. Five months after PEG insertion the patient detected a nodule at the site. The general practitioner diagnosed this nodule as a brotic reaction. Another six weeks later, ulceration that had grown along the PEG probe at the PEG site was observed on gastroscopy. The primary tumour was not visible. Histological examination showed an abdominal wall metastasis of the esophageal cancer. Despite subtotal gastrectomy with en-bloc resection of the tumour, distant metastasis developed. The patient died six months after surgery. About 47 cases of abdominal wall metastases as late complications at the site have been reported until now. The mechanism of tumour spread of PEG site is a subject of controversial discussion. As direct mechanical tumour implantation is the most likely mechanism, an alternative method like operative (laparoscopic) or radiological PEG placement should be considered in cases with advanced, stenotic tumours.

Tumor cell dissemination in a human colon cancer animal model: orthotopic implantation or intraportal injection?

BACKGROUND: The development of therapeutic strategies for treatment of metastasized colorectal carcinoma requires biologically relevant and adequate animal models generating both metastases and the dissemination of tumor cells. METHODS: To prove the efficiency of orthotopic implantation concerning induction of minimal residual disease (MRD) colorectal cancer tissue from 10 patients was transplanted orthotopically into nude mice. In the intraportal injection model 1 x 10(6) HT-29 human colon cancer cells were injected. We investigated by histological studies and CK-20 RT-PCR the occurrence of hematogenous metastases and the dissemination of human colon cancer cells in bone marrow. RESULTS: Following orthotopic implantation of human colon cancer tissue the lymph node and hepatic metastasis rates were low. MRD as reflected by CK-20 positivity of the bone marrow was present in 22.2%. The intraportal injection of 1 x 10(6) HT-29 human colon cancer cells produced hepatic metastases in up to 89% of all animals. The intraportal injection of 1 x 10(6) cells also generated MRD in the bone marrow in 63% of animals. CONCLUSIONS: The intraportal injection model represents a biologically relevant and adequate animal model for the induction of both reproducible hepatic metastasis and MRD in the bone marrow. In this regard it seems to be superior to the orthotopic implantation model.

Ten-year outcome of laparoscopic antireflux surgery.

BACKGROUND: Reflux recurrence is the most common long-term complication of fundoplication. Its frequency was independent from the type of fundoplication in randomized studies. Results for different techniques of laparoscopic antireflux surgery were retrospectively evaluated after 10 years. METHODS: From 1992 to 1997, 120 patients had primary laparoscopic fundoplication with a "tailored approach" (type of wrap chosen according to esophageal peristalsis): 88 received a Nissen, 22 an anterior, and 10 a Toupet fundoplication. Follow-up of 87% of the patients included disease-related questions and the gastrointestinal quality-of-life index (GIQLI). RESULTS: Of the patients, 89% would select surgery again. Heartburn was reported by 30% of the patients. Regurgitations were noted from 15% of patients after a Nissen, 44% after anterior fundoplication, and 10% after a Toupet (p = 0.04). Twenty-eight percent were on acid-suppressive drugs again. Following Nissen fundoplication, proton pump inhibitors were less frequently used (p = 0.01) and on postoperative pH-metry reflux recurrence rate was lower (p = 0.04). The GIQLI was 110 +/- 24 without significant differences for the type of fundoplication. DISCUSSION: Ten years after laparoscopic fundoplication, overall outcome is good. A quarter of the patients are on acid-suppressive drugs. Nissen fundoplication appears to control reflux better than a partial fundoplication.

[Less reflux recurrence following Nissen fundoplication : results of laparoscopic antireflux surgery after 10 years]. / Weniger Refluxrezidive nach Nissen-Fundoplikation : 10-Jahres-Ergebnisse der laparoskopischen Antirefluxoperation.

BACKGROUND: Reflux recurrence is the most common long-term complication following fundoplication. Results for different techniques of laparoscopic antireflux surgery were retrospectively compared after 10 years. METHODS: From 1992 to 1997, the 120 patients studied had laparoscopic fundoplication with 'tailored' approaches: 88 Nissen, 22 anterior, and ten Toupet fundoplications. Follow-up of 87% of these patients included disease-related questions and the gastrointestinal quality of life index (GIQLI). RESULTS: Of the patients, 89% would select surgery again. Regurgitations after fundoplication were noted from 15% of patients after Nissen, 44% after anterior, and 10% after Toupet types (P=0.04). Twenty-eight percent were on acid suppression therapy. Proton pump inhibitors were used less frequently following Nissen fundoplication (P=0.01). The GIQLI score was 110+/-24 without significant differences for type of fundoplication. DISCUSSION: Overall results are satisfactory after 10 years of experience with fundoplication. Total fundoplication appears to control reflux better than partial fundoplication.

[Antibody treatment in colorectal cancer--what the surgeon needs to know]. / Antikörpertherapie beim metastasierten kolorektalen Karzinom--was der Chirurg wissen sollte.

Advances in the medical treatment of colorectal cancer patients have resulted in considerable improvements through the introduction of new cytotoxic drugs. The significant progress in molecular and tumour biology has produced a great number of targeted, tumour-specific, monoclonal antibodies that are now in various stages of clinical development. Two of these antibodies, cetuximab (Erbitux) und bevacizumab (Avastin), directed against the epidermal growth factor receptor (EGFR) and the vascular epithelial growth factor (VEGF), respectively, have recently been approved for use in metastatic colorectal cancer. The combination of well-known and newly developed cytotoxic agents with monoclonal antibodies makes the medical treatment of colorectal cancer patients considerably more complex, but also provides additional therapeutic strategies for patients in advanced stages of disease.

[Intrapancreatic accessory spleen: a differential diagnosis of pancreatic tumour]. / Intrapankreatische Nebenmilz als Differentialdiagnose des Pankreasschwanzkarzinomes.

BACKGROUND: According to autoptic studies, accessory spleens may be found in 10-15% of the population and most of them are usually located at or near the splenic hilum. Only in 1-2% they are located in the pancreatic tail. We report a rare case of intrapancreatic accessory spleen which radiologically mimicked a tumor in the tail of the pancreas. PATIENT: A 54-year-old man was diagnosed with a tumor at the pancreatic tail. In the preoperative computed tomography (CT), there was a lesion (2.6 cm in diameter) in the pancreatic tail and two locoregional lesions (1 and 1.5 cm in diameter), which had intensive contrast enhancement. The diagnosis of a nonfunctioning endocrine pancreatic tail carcinoma with lymph node metastasis was made. RESULTS: Intraoperative examination showed two accessory spleens nearby the pancreatic tail. As pancreatic cancer could not be excluded because of the local findings, an oncological left pancreatectomy was performed. Histological examination excluded cancer and revealed an intrapancreatic accessory spleen and two accessory spleens nearby the pancreatic tail. CONCLUSION: Intrapancreatic accessory spleen should be included in the differential diagnosis of pancreatic neoplasm.

Importance of duodenogastric reflux in gastro-oesophageal reflux disease.

BACKGROUND: Bile in the oesophagus occurs frequently in patients with gastro-oesophageal reflux disease (GORD) and has been linked to Barrett's metaplasia and cancer. Although duodenogastric reflux is a prerequisite for bile in the oesophagus, little is known about its importance in GORD. METHODS: Some 341 patients with GORD were assessed by simultaneous 24-h gastric and oesophageal bilirubin monitoring. Definitions of increased bilirubin exposure were based on the 95th percentiles in healthy volunteers. The relationship between gastric and oesophageal bilirubin exposure and the correlation with disease severity were analysed. RESULTS: Of the 341 patients with GORD, 130 (38.1 per cent) had increased gastric and 173 (50.7 per cent) had increased oesophageal bilirubin exposure. Of the 173 patients with bile in the oesophagus, 89 (51.4 per cent) had normal and 84 (48.6 per cent) had increased gastric bilirubin exposure. Of these 84 patients, 75 (89 per cent) had oesophagitis or Barrett's oesophagus (P = 0.003). These effects were mainly related to differences in supine reflux. CONCLUSION: Bile in the oesophagus originates from either normal or increased gastric bilirubin exposure. Patients with increased duodenogastric reflux are more likely to have oesophagitis or Barrett's oesophagus. These findings highlight the role of duodenogastric reflux as an additional factor in the pathogenesis of GORD.

Laparoscopic Nissen repair: indications, techniques and long-term benefits.

BACKGROUND: The Nissen fundoplication or total 360 degrees fundoplication is probably the most frequently used anti-reflux procedure throughout the world. With the advent of laparoscopic surgery the popularity among surgeons to perform a laparoscopic Nissen fundoplication has even increased. AIM: The purpose of this paper is to provide an overview of the experience of laparoscopic Nissen fundoplication over the past 15 years. METHOD: We performed an extensive review of the literature in order to ascertain the representative papers. In addition, available consensus papers, especially with regard to indication and technique, were assessed. Indication for a laparoscopic Nissen fundoplication should depend on documentation of the presence of disease as well as objective testing of the functional disorders and the complications. The technique of Nissen fundoplication is discussed controversially. Consensus exists with regard to floppiness of the wrap, necessary closure of the crurae and the use of a calibration method during the performance of the wrap. RESULTS: The laparoscopic technique creates a learning curve, which needs to be respected. Large prospective series in recent years have shown a complication rate between 5% and 10%, depending on the definition of the complication. In these last prospective series good and excellent results have been reported, of between 85% and 95%. Reflux recurrence is reported as between 1% and 8.5%, with a concomitant dysphagia rate of 0%-10%. CONCLUSIONS: The Nissen fundoplication is currently performed throughout the world, most frequently in a minimally invasive technique. Several randomized trials that have been performed in the past years document that the Nissen fundoplication is an effective procedure for the treatment of pathological gastro-oesophageal reflux disease when a critical indication is used for well-defined patients.

Randomized clinical trial comparing quality of life after straight and pouch coloanal reconstruction.

BACKGROUND: Functional results after rectal resection with straight coloanal anastomosis are poor. While most functional aspects are improved with coloanal J pouch anastomosis, it is still unclear whether this translates into better quality of life. The aim of this trial was to investigate health-related quality of life as a primary endpoint in patients undergoing sphincter-saving rectal resection. METHODS: Sixty-four patients were randomized to either straight (n = 32) or coloanal J pouch (n = 32) anastomosis. Patients were studied before operation, at the time of stoma reversal and at 3-month intervals for 1 year thereafter. Quality of life was measured using two generic (Gastrointestinal Quality of Life Index and European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30) and one disease-specific (EORTC QLQ-CR38) instruments. Functional results using a standardized score as well as manometric variables were recorded. RESULTS: Thirty-nine patients (19 with a pouch and 20 with a straight anastomosis) completed the trial. There was a marked difference between the two groups with regard to quality of life profile. Patients with a pouch reconstruction had a significantly better quality of life, particularly in the early postoperative period. CONCLUSION: Patients undergoing low anterior rectal resection and coloanal J pouch reconstruction may expect not only better functional results but also an improved quality of life in the early months after surgery compared with patients who receive a straight coloanal anastomosis.

[Is duodeno-gastro-esophageal reflux just a bystander of acid reflux?]. / Ist duodeno-gastro-ösophagealer Reflux nur eine Begleiterscheinung des sauren Refluxes?

BACKGROUND & AIM: Duodeno-gastro-esophageal reflux (DGER) as measured with bilirubin monitoring is observed in many patients with reflux disease especially in Barrett's esophagus. As acid suppression is an effective therapy of reflux disease, DGER is frequently just considered as a bystander of acid reflux. To define the importance of DGER, reflux of duodenal contents was evaluated by bilirubin monitoring in the stomach. METHODS: 100 patients with reflux disease were evaluated (62 m, 38 f, 50 (12) years). 26 patients had Barrett's esophagus, 57 had esophagitis and 17 non- erosive reflux disease (pH pos.). All patients were evaluated with simultaneous 24-hour bilirubin monitoring in the esophagus and stomach. Results were compared to 35 measurements of healthy volunteers in the esophagus and 41 measurements in the stomach. RESULTS: Normal values: DGER - Exposure time esophagus > 11.8 % using an absorbance value > 0.14, duodenogastric reflux (DGR) - Exposure time stomach >24.8 % using an absorbance value > 0.25. 56 % of the patients had DGER, 41 % had DGR. 29 of the 41 patients with DGR had DGER (71 %), while 27 of the 56 patients with DGER had physiologic duodenogastric reflux (48 %). DISCUSSION: About 30 % of the patients with reflux disease show DGER combined with excessive DGR. Therefore, DGER is not just a bystander of acid reflux. The excessive DGR in some patients adds additional potentially dangerous substances to the esophageal reflux.

How long should a long-term esophageal motility study be?

It was the aim of this study to analyze whether a shorter measuring period would render the same diagnostic information on esophageal motility as a circadian measuring period in ambulatory esophageal manometry. In an investigation on normal volunteers (n = 10), patients with gastroesophageal reflux disease without esophageal motility disorders (n = 13), and patients with esophageal motility disorders (n = 14), a comparison was performed between a 5-hr and a 24-hr motility study. An analysis was performed on inter- and intraindividual reproducibility of time periods, prandial phases, and motility sequences (Wilcoxon and Spearman test). There was no significant difference between the two analyzed measuring periods in all three groups with regard to the diagnostic information on esophageal motility in 44 of 45 comparisons for intraindividual variability. A measuring period restricted to 5 hr offers the same diagnostic information on esophageal peristaltic activity as a 24-hr motility study.

Morphologic changes of the anal sphincter musculature during and after temporary stool deviation.

BACKGROUND AND AIMS: Temporary stool deviation, using a stoma, is a well-known surgical principle to protect low colorectal or coloanal anastomoses. The purpose of this study was to evaluate any morphologic changes with regard to the anal sphincter muscles during and after temporary ileostomy. PATIENTS AND METHODS: Forty-four patients with rectal carcinomas were studied prospectively. All patients underwent low anterior resection. Reconstruction was performed using either a coloanal pouch or a straight end-to-end anastomosis. A protective stoma was fashioned in all 44 patients (ileostomy n=41; colostomy n=3). Stoma closure was carried out after a median of 85 days (41-330 days). Using a standard protocol, anal-sphincter thickness [m. puborectalis, external anal sphincter (EAS) and internal anal (IAS) sphincter] was assessed by means of endoanal ultrasonography preoperatively, at the time of stoma closure, and every 3 months thereafter for 1 year. RESULTS: The diameter of the puborectal muscle decreased from a median preoperative value of 6.3 mm to 5.7 mm at the time of stoma closure (P=0.03). After 3 months, 6.2 mm was measured. This value remained stable for the complete follow-up period. Similar results were recorded for the EAS. The IAS thickness remained stable throughout the study period, measuring between 2.1 mm and 2.4 mm. CONCLUSION: Temporary stool deviation does lead to morphologic changes of the anal sphincter. While the smooth muscle remains unchanged, the striated counterpart undergoes atrophic transformation. However, after passage reconstruction, i.e., stoma closure, a rapid regeneration of the voluntary muscles is observed.

Combination of endoscopic argon plasma coagulation and antireflux surgery for treatment of Barrett's esophagus.

Columnar-lined epithelium with specialized intestinal metaplasia of the esophagus (i.e., Barrett's esophagus) is a premalignant condition caused by chronic gastroesophageal reflux disease. Progression of intestinal metaplasia may be avoided by antireflux surgery, whereas regeneration of esophageal mucosa could be achieved by endoscopic argon plasma coagulation (EAPC). The aim of this prospective study was to show the early results of a combination of EAPC and antireflux surgery. Thirty patients with Barrett's esophagus were treated between August 1996 and December 1999. Regeneration of esophageal mucosa was achieved with several sessions of EAPC under general anesthesia. All patients were receiving a double dose of proton pump inhibitors. Endoscopic follow-up was performed 6 to 8 weeks after the last session. Antireflux surgery (Nissen [n = 26] or Toupet [n = 4] fundoplication) followed complete regeneration of the squamous epithelium in the esophagus. One year after laparoscopic fundoplication and EAPC follow-up with endoscopy and quadrant biopsies of the esophagus, 24-hour pH monitoring and esophageal manometry were performed. All 30 patients showed complete regeneration of the squamous epithelium after a median of two sessions (range 1 to 7) of EAPC. Twenty-two patients underwent 1-year follow-up studies. All showed endoscopically an intact fundic wrap. Recurrence of a 1 cm segment of Barrett's epithelium without dysplasia was present in two patients, both of whom had recurrent acid reflux due to failure of their antireflux procedure. Our results indicate that the combination of EAPC and antireflux surgery is an effective treatment option in patients with Barrett's esophagus with gastroesophageal reflux disease. Long-term follow-up of this therapy is necessary to evaluate its effect on cancer risk in Barrett's esophagus.

Quality of life following laparoscopic gastric banding in patients with morbid obesity.

In a prospective study of 188 patients with morbid obesity, the time-dependent changes in the quality of life of individual patients were analyzed following laparoscopic gastric banding (LGB). These 188 patients (148 females and 40 males; age 19 to 59 years; body mass index 33 to 72 kg/m(2)) underwent evaluation of the LGB according to a strict protocol that included psychological testing using standardized instruments, detailed medical evaluation, upper gastrointestinal function studies, and evaluation of quality of life using the Gastrointestinal Quality of Life Index (GIQLI). Following this evaluation, 73 patients (57 females and 16 males; age 37 years [range 19 to 59 years]; body mass index 48 kg/m(2) [range 37 to 72 kg/m(2)]) underwent LGB and were followed up for 2 years focusing on weight loss, postoperative morbidity, weight-related comorbidity, and quality of life. The results demonstrate that LGB is well able to allow for a significant loss of excess weight and a significant improvement in patients' quality of life, both after a rather short period of time after surgery and at a continuous rate throughout the follow-up. The price for this success that was found in approximately 90% of patients is a complication rate of 38%; 85% of these patients, almost one third of all patients, must undergo some type of revision surgery. However, once the complications are resolved, these patients achieve the same level of weight loss and improvement in quality of life as patients with an uncomplicated postoperative course.

[Reconstruction modes following gastrectomy. Results of experimental and clinical controlled trials]. / Ersatzmagenbildung nach Gastrektomie - Ergebnisse experimenteller und klinischer, kontrollierter Studien.

Reconstruction modes following gastrectomy. Results of experimental and clinical controlled trials. In animal experiments four reconstruction methods following gastrectomy were compared: Roux-en Y reconstruction with (n = 33) and without pouch (n = 50) and isoperistaltic jejunum interposition with (n = 26) and without pouch (n = 55). The results were mostly influenced by the extent of esophagitis, documenting the reflux reduction by a pouch. Weight gain was slightly higher following jejunum interposition.Roux-en Y pouch reconstruction with jejunum interposition with pouch was compared in a randomized controlled trial. The additional operative effort of jejunum interposition did not achieve benefits in outcome. Therefore, Roux-en Y reconstruction should be advocated as standard reconstruction. The second randomized controlled trial compared Roux-en Y reconstruction with and without pouch. After more than three years, there was an advantage in life quality for patients with pouch indicating that patients with a favorable prognosis following gastrectomy should be reconstructed with a pouch.

Duodenogastric reflux and foregut carcinogenesis: analysis of duodenal juice in a rodent model of cancer.

The incidence of esophageal adenocarcinoma is increasing rapidly. In rats, surgically induced duodenoesophageal reflux is carcinogenic. One proposed mechanism of carcinogenesis is based on the reaction of physiological bile acids with nitrite to produce carcinogenic N:-nitroso amides. To test this hypothesis, duodenal juice was analyzed for endogenously formed N:-nitroso bile acids and its genotoxicity was determined. Esophagojejunostomy was performed on 15 Sprague-Dawley rats to produce duodeno-esophageal reflux. At the time of surgery and 2 and 6 weeks later, duodenal contents were aspirated and analyzed immediately. High performance liquid chromatography coupled to tandem mass spectrometry was used to detect bile acids and their nitroso derivates. Genotoxicity was assessed using a micronucleus test. The characteristic pattern of bile acid derivatives, with taurocholic acid (TCA) and glycocholic acid (GCA) as the predominant conjugates, was detected in all samples. However, even selective reaction monitoring experiments failed to demonstrate the presence of any N:-nitroso-TCA or N:-nitroso-GCA. In addition, other nitroso derivatives could not be detected in any of the samples by neutral loss experiments monitoring the loss of nitric oxide (detection limit 0.1% of the concentration of TCA). All samples were cytotoxic, but neither the preoperative nor the postoperative samples were genotoxic. Duodenal juice was cytotoxic but not genotoxic. Tumorigenesis of esophageal adenocarcinoma in the rodent model could not be linked to a specific carcinogen, especially not to nitroso bile acids. Chronic inflammation is likely to be the mechanism of carcinogenesis by duodenogastric reflux.