[Hepaticojejunostomy after pancreatic head resection - technical aspects for reconstruction of small and fragile bile ducts with T-tube drainage]. / Die Technik der Hepatikojejunostomie mit T-Drainage bei der Rekonstruktion schmalkalibriger Gallengänge nach Pankreaskopfresektion.

BACKGROUND: After pancreatic head resection the reconstruction of small and fragile bile ducts is technically demanding, resulting in more postoperative bile leaks. One option for the reconstruction is the placement of a T-tube drainage at the site of the anastomosis. MATERIAL AND METHODS: Standard reconstruction after pancreatic head resection was an end-to-side hepaticojejunostomy with PDS 5.0, 15-25 cm distally from the pancreaticojejunostomy. For patients with a small bile duct diameter (≤ 5 mm) or a fragile bile duct wall the reconstruction was performed with PDS 6.0 and a T-tube drainage at the side of the anastomosis. RESULTS: The reconstruction with a T-tube drainage at the site of the anastomosis is technically easy to perform and offers the opportunity for immediate visualisation of the anastomosis in the postoperative period by application of water soluble contrast medium. If a bile leak occurs, biliary deviation through the T-tube drainage can enable a conservative management without revisional laparotomy in selected patients. Whether or not a conservative management of postoperative bile leaks will lead to more bile duct strictures is a subject for further investigations. CONCLUSION: A T-tube drainage at the site of the anastomosis can probably not prevent postoperative bile leaks from a difficult hepaticojejunostomy, but in selected patients it offers the opportunity for a conservative management resulting in less re-operations. Therefore we recommend the augmentation of a difficult hepaticojejunostomy with a T-tube drainage.

Pancreatic resections for advanced M1-pancreatic carcinoma: the value of synchronous metastasectomy.

BACKGROUND: For M1 pancreatic adenocarcinomas pancreatic resection is usually not indicated. However, in highly selected patients synchronous metastasectomy may be appropriate together with pancreatic resection when operative morbidity is low. MATERIALS AND METHODS: From January 1, 2004 to December, 2007 a total of 20 patients with pancreatic malignancies were retrospectively evaluated who underwent pancreatic surgery with synchronous resection of hepatic, adjacent organ, or peritoneal metastases for proven UICC stage IV periampullary cancer of the pancreas. Perioperative as well as clinicopathological parameters were evaluated. RESULTS: There were 20 patients (9 men, 11 women; mean age 58 years) identified. The primary tumor was located in the pancreatic head (n = 9, 45%), in pancreatic tail (n = 9, 45%), and in the papilla Vateri (n = 2, 10%). Metastases were located in the liver (n = 14, 70%), peritoneum (n = 5, 25%), and omentum majus (n = 2, 10%). Lymphnode metastases were present in 16 patients (80%). All patients received resection of their tumors together with metastasectomy. Pylorus preserving duodenopancreatectomy was performed in 8 patients, distal pancreatectomy in 8, duodenopancreatectomy in 2, and total pancreatectomy in 2. Morbidity was 45% and there was no perioperative mortality. Median postoperative survival was 10.7 months (2.6-37.7 months) which was not significantly different from a matched-pair group of patients who underwent pancreatic resection for UICC adenocarcinoma of the pancreas (median survival 15.6 months; P = .1). CONCLUSION: Pancreatic resection for M1 periampullary cancer of the pancreas can be performed safely in well-selected patients. However, indication for surgery has to be made on an individual basis.

[Distal pancreatectomy: radical or spleen-preserving?]. / Pankreaslinksresektion: Wann radikal, wann milzerhaltend?

During recent years, spleen-preserving distal pancreatectomy (SPDP) has broadened the operative spectrum in pancreatic surgery. The rationale for spleen-preserving procedures comprises prevention of overwhelming postsplenectomy infection syndrome (OPSI) and possibly an advantage regarding reduced carcinogenesis. Although there are no prospective randomized trials, SPDP and distal pancreatectomy with splenectomy (DPSx) seem to be equivalent in terms of blood loss, operative time, mortality and frequency of reoperation. Concerning pancreatic fistulas and other major surgical complications, current data from the literature are conflicting. Long-term effects of SPDP, such as development of gastric varices due to portal hypertension, are still insufficiently investigated. However, SPDP should always be considered in patients with benign tumors of the pancreatic tail and chronic pancreatitis. Spleen-preserving distal pancreatectomy can also be combined with resection of the splenic vessels (DPSx-SVx) if the blood supply of the spleen via the small gastric vessels and the gastro-epoploic arcade is sufficient. In the presence of malignant tumors, DPSx is necessary for oncological reasons.

Decision analysis model of incisional hernia after open abdominal surgery.

BACKGROUND: The incidence rate of incisional hernias after open surgery has been reported to be higher than that of port site hernias after laparoscopic surgery. No studies have compared the costs for the health care system in treating those two types of hernia. METHODS: A systematic review was conducted to obtain the baseline data, and a decision analysis model was created to simulate the occurrence and recurrence of incisional and port site hernias. RESULTS: The overall risk of having incisional hernias was eight-times higher than that of having port site hernias (7.4% vs 0.9%). A cost savings of 93 British Pound per patient can be generated for the health care system in the UK. Similar results were obtained for Germany, Italy and France. CONCLUSIONS: The additional treatment costs for incisional hernia should be taken into account when the costs of a surgery performed by open approach are compared with by laparoscopy.

[Laparoscopic splenectomy: first experiences with a 3-trocar-technique and the 'hanging-spleen-maneuver']. / Laparoskopische Splenektomie: Erste Erfahrungen mit einer 3-Trokar-Technik und dem 'hanging-spleen-Manöver'.

AIMS: Laparoscopic splenectomy has been established as standard procedure for elective splenectomy and is performed for a variety of haematological diseases. However, different techniques have been used and a four- to five trocar technique is applied in most instances. We report our experience with a three-trocar technique using the triangular liver retractor and the so-called "hanging spleen" maneuver. METHODS: Data were obtained from a prospectively collected computer database of all patients who underwent elective laparoscopic splenectomy between April 2001 and July 2003. RESULTS: The study population consisted of 26 patients (14 men, 12 women, mean age: 45 years; range: 16-75 years). Median operative time was 140 min (85-310 min). There was one conversion (3.8 %) due to a suspected malignancy, which was finally not confirmed. A fourth trocar had to be placed in two cases (10 %) due to a large left lobe of the liver. In two patients a small midline incision was made to extract the spleen in toto for pathohistological examination due to a splenic metastasis. In the remaining cases the spleen was morcellated in an endobag. Accessory spleens were found in 1 patient (3.8 %). There were two bleedings following operation, which required laparotomy in one patient. There were no deaths (0 %). The median postoperative hospital stay was 7 days (range 3-17). CONCLUSIONS: Laparoscopic splenectomy can be performed safely in the vast majority of patients. The described technique using three trocars with the so-called "hanging spleen" maneuver can be used in about 90 % of cases.

Aberrant left hepatic artery in laparoscopic antireflux procedures.

BACKGROUND: The aberrant left hepatic artery (ALHA) is an anatomic variation that may present an obstacle in laparoscopic antireflux procedures. Based on our experience, we addressed the following questions: How frequent is ALHA? When or why is it divided? What is the outcome in patients after division of the ALHA? METHODS: From a prospective collected database of 720 patients undergoing laparoscopic antireflux surgery, we collected the following information: presence of an ALHA, clinical data, diagnostic workup, operative reports, laboratory data, and follow-up data. RESULTS: In 57 patients (7.9%) (37 men and 20 women; mean age, 51 +/- 15.7 years), an ALHA was reported. Hiatal dissection was impaired in 17 patients (29.8%), requiring division of the ALHA. In three patients (5.3%), the artery was injured during dissection; in one case (1.8%), it was divided because of ongoing bleeding. Ten of the divided ALHA (55.5%) were either of intermediate size or large. Mean operating time was 2.2 +/- 0.8 h; mean blood loss was 63 +/- 49 ml. Postoperative morbidity was 5.3% and mortality was 0%. None of the patients with divided hepatic arteries had postoperative symptoms related to impaired liver function. Postoperatively, two patients (11.7%) had transient elevated liver enzymes. At a mean follow-up of 28.5 +/- 12.8 months, no specific complaints could be identified. CONCLUSIONS: ALHA is not an uncommon finding in laparoscopic antireflux surgery and may be found in > or =8% of patients. Division may be required due to impaired view of the operating field or bleeding. Patients do not experience clinical complaints after division, but liver enzymes may be temporarily elevated.

[Laparoscopic emergency surgery in perforated gastroduodenal ulcers]. / Laparoskopische Notfallchirurgie bei perforierten gastroduodenalen Ulcera.

The value of laparoscopic treatment of perforated gastroduodenal ulcers remains to be determined. To evaluate this modality the results of laparoscopic treatment of 18 patients with perforated gastroduodenal ulcers were compared with 28 patients who were operated by open access. Patients operated on conventionally had a mean ASA score of 2.9 compared to 1.8 in the laparoscopic group (p = 0.0009). Operative time revealed no difference between both groups, no patient had to be converted. Morbidity and mortality was 16.7% (3/18) and 0% in the laparoscopic group compared to 10.7% (3/28) and 35.7% (10/28) in the open group (p = 0.41 and p = 0.19). The mean postoperative hospital stay was 9.4 compared to 15.3 days (p = 0.15). The laparoscopic treatment of perforated gastrointestinal ulcers is an effective method, which can be used in suited patients with a low morbidity and mortality.

Simultaneous aortic surgery and malnutrition increase morbidity after revascularisation of the mesenteric arteries.

OBJECTIVE: To evaluate the early and late outcome of mesenteric revascularisation in patients who had had elective mesenteric revascularisation for chronic intestinal ischaemia. DESIGN: Retrospective review. SETTING: Academic clinic, United States. SUBJECT: 19 consecutive patients (7 men, 12 women; mean age 70 years, range 53-83). RESULTS: Angiography showed that 2 mesenteric vessels were affected in 7 patients and 3 in 12. Four patients had coexisting symptomatic aortoiliac occlusive disease and 1 patient had bilateral renal artery stenosis. A total of 36 visceral arteries were revascularised. One patient died postoperatively, and 8 developed serious complications. Morbidity and mortality were significantly higher in patients who had simultaneous infrarenal aortic or renal artery reconstructions (p = 0.01). Patients whose body weight before operation was less than 90% of ideal had more complications (8/11) than patients who were within 10% of their ideal body weight (1/8) (p = 0.02). Cumulative survival was 89% at 1 year, 72% at 3 years, and 57% at 5 years. The cumulative graft patency rate was 92% at 3 years and 66% at 5 years. CONCLUSIONS: Mesenteric bypass procedures for chronic mesenteric ischaemia are durable. Long-term survival and graft patency rates are excellent even in older patients. Simultaneous aortic surgery should be avoided because of the associated morbidity. More than 10% below ideal body weight was associated with higher morbidity. For these patients, early total parenteral nutrition postoperatively, or a period of total parenteral nutrition preoperatively may reduce postoperative morbidity and mortality.

Accurate placement of the esophageal pH electrode for 24-hour pH monitoring using a combined pH/manometry probe.

OBJECTIVE: Accurate placement of a pH electrode requires manometric localization of the lower esophageal sphincter (LES). Combined manometry/pH devices using water-perfused tubes attached to pH catheters and the use of an electronic "LES locator" have been reported. We investigated whether accurate placement of pH probes can be achieved using such a probe, and whether this may reduce the need for the performance of the usual stepwise pull-back manometry. METHODS: Thirty consecutive patients (15 men, 15 women; median age, 56 yr; interquartile range, 42-68 yr) referred for manometry and pH testing were included in the study. The localization of the LES was determined with standard esophageal manometry. After that, a second 3-mm pH electrode with an internal perfusion port was passed into the stomach. Using this catheter, a single stepwise pull-through manometry was performed and the LES position was noted. LES location, mean pressure, and length obtained with standard manometry were compared to data from the combined pH/manometry catheter. Additionally the time necessary to perform each of the procedures was noted and the patient's discomfort caused by the catheter was evaluated using a standardized questionnaire. RESULTS: The LES location with the pH/manometry probe was proximal to that with standard manometry in 19 patients (63%), the same in nine patients (30%), and distal in two patients (7%). The differences were <2 cm in 29 of 30 (97%) patients. The LES location with the pH/manometry probe required a median of 6.5 min (interquartile range: 3.5-8.5 min) versus a median of 21.5 min (interquartile range: 14.5-26.5 min) for standard manometry (p < 0.0001). In addition, LES evaluation using the combined pH/manometry probe provided accurate data on the resting pressure, as well as overall and intraabdominal length of the LES. All patients tolerated the combination probe better than the standard manometry probe (p < 0.001). CONCLUSIONS: Placement of the esophageal electrode for 24-h esophageal pH monitoring using a combined pH/manometry probe is accurate. The technique is simple, time-saving, and convenient for the patients. Because it is possible to accurately evaluate the LES using this technique, it may even replace conventional manometry before pH probe placement.

Clinical utility of routine screening for abdominal aortic aneurysm during echocardiography.

BACKGROUND: The aim of this study was to determine the clinical utility of transthoracic echocardiography (TTE) as a screening method for the detection of abdominal aortic aneurysms (AAA). PATIENTS AND METHODS: Each patient who was referred to the echocardiography laboratory TTE was included into the study. After complete cardiac assessment the abdominal aorta was evaluated. Patients with a known, a clinically suspected, or a previously operated AAA were excluded. RESULTS: During the study period, 14,876 patients underwent TTE. 13,166 (88.5%) of the patients were 50 years and older. Of these 6953 (52.8%) were men and 6213 (47.2%) were women. A total of 108 (0.82%; 95% confidence interval (CI) 0.67-0.99) clinically unsuspected AAA of at least 3 cm in diameter (range 3 cm-6.8 cm) were detected. There were 93 (86.1%) men and 15 (13.9%) women with a mean age of 73.8 years (range 59-90). In 7 patients an AAA was suspected by TTE but not verified on subsequent abdominal ultrasound, as the diameter of the abdominal aorta was less than 3 cm. The prevalence of an AAA in patients 50 years and older was 1.34% (95% CI 1.08-1.64) for men and 0.24% (95% CI 0.14-0.40) for women. In patients less than 50 years old no aneurysm was detected. Seventeen patients who were found to have an AAA with a mean diameter of 4.4 cm (range 3-6 cm) underwent successful elective conventional AAA repair after a mean interval of 13.9 months (range 0.2-49 months) following the initial diagnosis. CONCLUSIONS: TTE performed in a highly selected cardiac patient group in a tertiary referral center is not a useful tool to screen for clinically unsuspected abdominal aortic aneurysms due to the low prevalence. The detection of an aneurysm should be confirmed by conventional abdominal ultrasound.

Clostridium difficile infection: risk factors, medical and surgical management.

BACKGROUND: Clostridium difficile has become recognized as a cause of nosocomial infection which may progress to a fulminant disease. METHODS: Literature review using electronic literature research back to 1966 utilizing Medline and Current Contents. All publications on antibiotic-associated diarrhea, antibiotic-associated colitis, and pseudomembranous colitis as well as C. difficile infection were included. We addressed established and potential risk factors for C. difficile disease such as an impaired immune system and cost benefits of different diagnostic tests. An algorithm is outlined for diagnosis and both medical and surgical management of mild, moderate and severe C. difficile disease. RESULTS: Diagnosis of C. difficile infection should be suspected in patients with diarrhea, who have received antibiotics within 2 months or whose symptoms started after hospitalization. A stool specimen should be tested for the presence of leukocytes and C. difficile toxins. If this is negative and symptoms persist, stool should be tested with 'rapid' enzyme immunoabsorbent and stool cytotoxin assays, which are the most cost-effective tests. Endoscopy and other imaging studies are reserved for severe and rapidly progressive courses. Oral metronidazole or vancomycin are the antibiotics of choice. Surgery is rarely required for selected patients refractory to medical treatment. The threshold for surgery in severe cases with risk factors including an impaired immune system should be low. CONCLUSION: C. difficile infection has been recognized with increased frequency as a nosocomial infection. Early diagnosis with immunoassays of the stool and prompt medical therapy have a high cure rate. Metronidazole has supplanted oral vancomycin as the drug of first choice for treating C. difficile infections.

Seprafilm-induced peritoneal inflammation: a previously unknown complication. Report of a case.

INTRODUCTION: Various substances and agents have been evaluated to prevent postoperative adhesion formation. Recently a sodium hyaluronate-based bioresorbable membrane was introduced with promising clinical results. Its application was regarded as safe and efficient. METHODS: We present the first reported case of a severe inflammatory reaction to a bioresorbable membrane and give a review of the related literature. CONCLUSION: Bioresorbable membranes are increasingly used by general surgeons and gynecologists to reduce postoperative adhesion formation. Bioresorbable membranes may produce extensive inflammatory reactions.

Use of intraoperative duplex ultrasonography and routine patch angioplasty in patients undergoing carotid endarterectomy.

OBJECTIVE: To determine the value of routine patch angioplasty and intraoperative duplex ultrasonography (US) during carotid endarterectomy (CEA) for high-grade internal carotid artery stenosis. PATIENTS AND METHODS: The charts of 102 consecutive patients who underwent CEA with routine patching and intraoperative duplex US for treatment of high-grade carotid stenosis between June 1991 and January 1997 were reviewed retrospectively. Recurrent stenosis was defined as a narrowing in the common or internal carotid artery of more than 40%. RESULTS: Of 102 patients, 65 (63.7%) were men, and 37 (36.3%) were women (mean age, 72.4 years). Thirteen patients (12.7%) had bilateral CEAs. Intraoperative duplex US revealed abnormalities during 29 (25.2%) of 115 CEAs; 14 abnormalities (12.2%) were major and underwent immediate revision. No perioperative neurologic events or deaths occurred. Mean length of follow-up was 21.3 months (range, 1.3-72.6 months). Late neurologic events occurred in 2 patients, and 5 patients died during follow-up. All neurologic events and deaths were unrelated to the patients' carotid surgery. Twelve patients (11.8%) developed moderate restenosis (40%-69%). In 4 of these patients restenosis resolved during further follow-up. No patient developed severe recurrent carotid stenosis. CONCLUSION: Morbidity and mortality following CEA with routine patch angioplasty and intraoperative duplex US appear to be low. Routine intraoperative duplex US detects correctable technical problems that subsequently lead to a low incidence of symptomatic stenosis. The low incidence of recurrent stenosis suggests that routine postoperative follow-up may not be necessary or cost-effective unless the patient has symptoms or a contralateral stenosis.

Minimally invasive surgical techniques for the treatment of gastroesophageal reflux disease.

Open antireflux surgery produces good long-term control of disease, but new interest in the surgical management of gastroesophageal reflux disease has been stimulated by the introduction of minimally invasive techniques to perform standard antireflux procedures. In the past some scepticism existed among gastroenterologists who quoted the poor surgical results they had seen. These bad results, however, were largely due to inappropriate surgery in poorly worked-up patients or antireflux surgery performed by inexperienced surgeons. Since the introduction of minimally invasive surgery for gastroesophageal reflux disease, excellent results have been reported with over 5 years of follow-up. The most common and successfully used laparoscopically antireflux procedures are reviewed and results analyzed.

Paraesophageal herniation as a complication following laparoscopic antireflux surgery.

Paraesophageal herniation of the stomach is a rare complication following laparoscopic Nissen fundoplication. We retrospectively reviewed our experience with 720 patients undergoing laparoscopic Nissen fundoplications. Seven patients were found to have postoperative paraesophageal hernias requiring reoperation. The clinical presentation, diagnostic workup, operative treatment, and outcome were evaluated. There were no deaths or procedure-related complications. Clinical presentation was recurrent dysphagia in four, nonspecific abdominal symptoms in one, and acute abdomen in one. One additional patient was asymptomatic. Preoperatively the correct diagnosis was able to be confirmed in four of six patients by barium esophagogram. Four patients underwent successful laparoscopic repair. Two patients had a thoracotomy including one conversion from laparoscopy to thoracotomy. One patient had a lap-arotomy to reduce an intrathoracic gastric volvulus. At a mean follow-up of 2.5 months no patient had further complications. Paraesophageal herniation is a rare complication following laparoscopic Nissen fundoplication and a definitive diagnosis is often difficult to establish. Early dysphagia after surgery should alert the surgeon to this complication. Redo laparoscopic surgery is feasible but an open procedure may be necessary.

Is laparoscopic reoperation for failed antireflux surgery feasible?

HYPOTHESIS: Laparoscopic techniques can be used to treat patients whose antireflux surgery has failed. DESIGN: Case series. SETTING: Two academic medical centers. PATIENTS: Forty-six consecutive patients, of whom 21 were male and 25 were female (mean age, 55.6 years; range, 15-80 years). Previous antireflux procedures were laparoscopic (21 patients), laparotomy (21 patients), thoracotomy (3 patients), and thoracoscopy (1 patient). MAIN OUTCOME MEASURES: The cause of failure, operative and postoperative morbidity, and the level of follow-up satisfaction were determined for all patients. RESULTS: The causes of failure were hiatal herniation (31 patients [67%]), fundoplication breakdown (20 patients [43%]), fundoplication slippage (9 patients [20%]), tight fundoplication (5 patients [11%]), misdiagnosed achalasia (2 patients [4%]), and displaced Angelchik prosthesis (2 patients [4%]). Twenty-two patients (48%) had more than 1 cause. Laparoscopic reoperative procedures were Nissen fundoplication (n = 22), Toupet fundoplication (n = 13), paraesophageal hernia repair (n = 4), Dor procedure (n = 2), Angelchik prosthesis removal (n = 2), Heller myotomy (n = 2), and the takedown of a wrap (n = 1). In addition, 18 patients required crural repair and 13 required paraesophageal hernia repair. The mean +/- SEM duration of surgery was 3.5+/-1.1 hours. Operative complications were fundus tear (n = 8), significant bleeding (n = 4), bougie perforation (n = 1), small bowel enterotomy (n = 1), and tension pneumothorax (n = 1). The conversion rate (from laparoscopic to an open procedure) was 20% overall (9 patients) but 0% in the last 10 patients. Mortality was 0%. The mean +/- SEM hospital stay was 2.3+/-0.9 days for operations completed laparoscopically. Follow-up was possible in 35 patients (76%) at 17.2+/-11.8 months. The well-being score (1 best; 10, worst) was 8.6+/-2.1 before and 2.9+/-2.4 after surgery (P<.001). Thirty-one (89%) of 35 patients were satisfied with their decision to have reoperation. CONCLUSIONS: Antireflux surgery failures are most commonly associated with hiatal herniation, followed by the breakdown of the fundoplication. The laparoscopic approach may be used successfully to treat patients with failed antireflux operations. Good results were achieved despite the technical difficulty of the procedures.

Arteriovenous fistula of the thyroid gland associated with spontaneous bleeding from a flow-induced aneurysm of the inferior thyroid artery.

A case of acute, spontaneous cervical hemorrhage caused by a ruptured aneurysm of the inferior thyroid artery is described. This lesion was accompanied by an arteriovenous fistula within the thyroid gland that caused a flow-induced aneurysm. Diagnosis and treatment were successfully performed by selective angiography with endovascular occlusion and embolization. Both diagnostic and therapeutic management are discussed, and the related literature is reviewed. To our knowledge, this is the first reported case of an aneurysm of a thyroid artery in conjunction with an intraparenchymatous arteriovenous fistula of the thyroid gland.

Small-intestinal enteroliths--unusual cause of small-intestinal obstruction: report of three cases.

PURPOSE: The aim of this study was to report on a rare cause of small-intestinal obstruction caused by small-intestinal enteroliths. METHODS: We present three different cases of enterolith formation in the small intestine. One occurred after nontropical sprue, one patient had multiple jejunal diverticula, and another patient had enterolith formation in a blind loop after a small-bowel side-to-side anastomosis. RESULTS: After initial conservative therapeutic approach all patients underwent surgery. In two patients the enteroliths were removed by ileotomy or jejunostomy. In the third patient the bowel anastomosis had to be revised after removal of the enterolith. CONCLUSION: Small-intestinal enteroliths may cause small-bowel obstruction. The first therapeutic approach is nonsurgical; however, if obstruction proceeds, surgical removal with or without revision of underlying pathology is necessary. We discuss the causes and therapeutic management of enteroliths and give a review of related literature.