Intraoperative localization of occult colorectal tumors during laparoscopic surgery by magnetic ring markers-a pilot study.

PURPOSE: Intraoperative localization of small tumors or malignant polyps has been an important issue in laparoscopic colon surgery. We have developed a new method for preoperative endoscopic tumor marking using a ring-shaped magnetic marker. METHODS: In a pilot study, 28 patients with small colonic (n = 23) or rectal tumors (n = 5) underwent endoscopic magnetic clipping prior to laparoscopic resection. A cap carrying a high-power neodymium ring magnet was mounted on the tip of a colonoscope. Near the lesion, the ring magnet was released and clipped to the colorectal wall. Standard laparoscopic instruments were used to find the magnet intraoperatively. RESULTS: Endoscopic fixation of a ring magnet next to the tumor by clipping was technically feasible in all 28 patients. Intraoperative localization of the marked lesions was successful in 27 of 28 patients (96 %). All patients underwent magnet-guided radical laparoscopic resection of the tumor with an average proximal and distal resection margin of 101 and 63 mm, respectively. In one case, the magnet could not be found due to preoperative migration. Surgical complications related to magnetic clip application or intraoperative tumor localization were not observed. However, there was one case with an intraoperative perforation of the colon by the magnet, which was obviously caused by unchecked action with a laparoscopic instrument. CONCLUSIONS: Preoperative endoscopic labeling of colonic lesions with on-the-scope magnetic markers is simple and safe. Intraoperative tumor localization during laparoscopic colorectal surgery can be achieved reliably without additional equipment such as ultrasound or fluoroscopy.

Natural orifice transluminal endoscopic surgery in surgical oncology: analysis of indications and feasibility in cancer patients.

BACKGROUND/AIMS: Natural orifice endoscopic surgery (NOTES) is an emerging technique that has been postulated as a promising alternative to laparoscopy in the field of minimal invasive surgery. Until now appropriate indications, safe access routes and general feasibility of this approach have not been defined exactly in surgical oncology. METHODOLOGY: A total of 474 patients undergoing cancer surgery were analyzed regarding possible applications of transluminal endoscopic surgery. Patient with potential indications underwent intraoperative endoscopy to evaluate technical aspects, indications and intraoperative feasibility. RESULTS: A potential indication for transluminal surgery was found in 54 of 474 patients (11%) undergoing abdominal cancer surgery. Staging of gastrointestinal tumors was considered the main indication (45%) followed by splenectomy (11%) and diagnostic excision (11%). As a potential access route the transgastric approach was considered in 42 patients (66%) and the transcolonic approach in 18 patients (28 %). Of these 42 patients, 19 (30%) presented with significant intra-abdominal adhesions which would have resulted in a more complicated procedure. Accurate transluminal orientation was considered impossible in 13 cases (20%). CONCLUSIONS: Although some indications for NOTES procedures in surgical oncology have been identified in this study these techniques have to be assessed cautiously. Implementation of NOTES in surgical oncology is currently difficult because of technical problems, lack of intraoperative orientation and abdominal adhesions.

Matched-pair analysis of postoperative morbidity and mortality for pancreaticogastrostomy and pancreaticojejunostomy using mattress sutures in soft pancreatic tissue remnants.

BACKGROUND: After pancreaticoduodenectomy, the incidence of postoperative pancreatic fistula remains high, especially in patients with "soft" pancreatic tissue remnants. No "gold standard" surgical technique for pancreaticoenteric anastomosis has been established. This study aimed to compare the postoperative morbidity and mortality of pancreaticogastrostomy and pancreaticojejunostomy for "soft" pancreatic tissue remnants using modified mattress sutures. METHODS: Seventy-five patients who had undergone pancreaticogastrostomy and 75 who had undergone pancreaticojejunostomy after pancreaticoduodenectomy between 2002 and 2008 were retrospectively compared using matched-pair analysis. A modified mattress suture technique was used for the pancreaticoenteric anastomosis. Patients with an underlying "hard" pancreatic tissue remnant, as in chronic pancreatitis, were excluded. Both groups were homogeneous for age, gender, and underlying disease. Postoperative morbidity, mortality, and preoperative and operative data were analyzed. RESULTS: There were no significant differences between the groups for the incidence of postoperative pancreatic fistula (10.7% in both). Postoperative morbidity and mortality, median operation time, median length of hospital stay, intraoperative blood loss, and the amount of intraoperatively transfused erythrocyte concentrates also did not significantly differ between the groups. Patient age >65 years (P=0.017), operation time >350 minutes (P=0.001), and intraoperative transfusion of erythrocyte concentrates (P=0.038) were identified as risk factors for postoperative morbidity. CONCLUSIONS: Our results showed no significant differences between the groups in the pancreaticogastrostomy and pancreaticojejunostomy anastomosis techniques using mattress sutures for "soft" pancreatic tissue remnants. In our experience, the mattress sutures are safe and simple to use, and pancreaticogastrostomy in particular is feasible and easy to learn, with good endoscopic accessibility to the anastomosis region. However, the location of the anastomosis and the surgical technique need to be individually evaluated to further reduce the incidence of postoperative pancreatic fistula.

Contrast enhanced ultrasound cholangiography via T-tube following liver transplantation.

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

Repeated liver resection for recurrent hepatocellular carcinoma.

BACKGROUND AND AIM: Tumor recurrence after liver resection occurs in the majority of patients with hepatocellular carcinoma (HCC). This study was conducted to clarify the safety and effectiveness of repeated liver resection as a curative option for intrahepatic HCC recurrence. METHODS: Between July 1990 and January 2009, 483 patients underwent 514 curative hepatic resections for HCC in our institution. Among this collective, 27 patients underwent 31 repeated resections due to recurrent HCC (27 s resections, three third resections and one forth resection). The outcome of these patients was retrospectively reviewed using a prospective database. RESULTS: Perioperative morbidity and mortality was 11% (three of 27) and 0%. Six patients showed multiple liver lesions, 23 underwent minor liver resections (fewer than three segments) and five patients underwent major resections (three or more segments). The majority of the patients showed no signs of chronic liver disease (16 of 27). The median tumor free margin was 1.5 mm (range: 0 to 20 mm). The median tumor diameter was 40 mm (range: 10 to 165 mm). Tumor dedifferentiations at time of tumor recurrence were not observed. The 1-, 3- and 5-year overall survival rates after second liver resection were 96%, 70% and 42%. CONCLUSIONS: Repeated liver resection is a valid and safe curative therapy option for recurrent HCC and results in significant prolongation of survival in comparison to interventional treatment strategies in selected patients. However, due to impaired liver function, multifocal intrahepatic or extrahepatic recurrence repeated resection is only feasible in a minority of patients.

Safety of pancreatic surgery in patients with simultaneous liver cirrhosis: a single center experience.

BACKGROUND/AIMS: Pancreatic surgery is associated with an increased risk of postoperative complications. We therefore investigated the impact of an additional liver function disorder on the postoperative outcome using a case-control study of patients with or without liver cirrhosis who underwent pancreatic surgery at our department. METHODS: Between 1998 and 2008, 1,649 pancreatic resections were performed. Of these, 32 operations were performed in patients who also suffered from liver cirrhosis (30× Child A, 2× Child B). For our case-control study, we selected another 32 operated patients without cirrhosis who were matched according to age, sex, diagnosis and tumor classification. The following parameters were compared between both groups: operating time, number of transfusions, duration of ICU and hospital stay, incidence of complications, rate of reoperation, mortality. RESULTS: Patients with cirrhosis experienced complications significantly more often (69 vs. 44%; p = 0.044), especially major complications (47 vs. 22%; p = 0.035) requiring reoperation (34 vs. 12%; p = 0.039). These patients also had a prolonged hospital stay (27.9 vs. 24.3 days) and a significantly longer ICU stay (8.6 vs. 3.7 days; p = 0.033), and required twice as many transfusions. Overall, 3 patients died following surgery, 1 with Child A (3% of all Child A patients) and 2 with Child B cirrhosis. CONCLUSION: Pancreatic surgery is associated with an increased risk of postoperative complications in patients with liver cirrhosis, and is therefore not recommended in patients with Child B cirrhosis. In Child A cirrhotic patients the mortality is, however, comparable to noncirrhotic patients. Due to the demanding medical efforts that these patients require, they should be treated exclusively in high-volume centers. and IAP.

Distal pancreatectomy with en bloc resection of the celiac trunk for extended pancreatic tumor disease: an interdisciplinary approach.

PURPOSE: Infiltration of the celiac trunk by adenocarcinoma of the pancreatic body has been considered a contraindication for surgical treatment, thus resulting in a very poor prognosis. The concept of distal pancreatectomy with resection of the celiac trunk offers a curative treatment option but implies the risk of relevant hepatic or gastric ischemia. We describe initial experiences in a small series of patients with left celiacopancreatectomy with or without angiographic preconditioning of arterial blood flow to the stomach and the liver. MATERIALS AND METHODS: Between January 2007 and October 2009, six patients underwent simultaneous resection of the celiac trunk for adenocarcinoma of the pancreatic body involving the celiac axis. In four of these cases, angiographic occlusion of the celiac trunk before surgery was performed to enhance collateral flow from the gastroduodenal artery. Radiologic and surgical procedures, findings, and outcome were analyzed retrospectively. RESULTS: Complete tumor removal (R0) succeeded in two patients, whereas four patients underwent R1-tumor resection. After surgery, one of the two patients without angiographic preparation experienced an ischemic stomach perforation 1 week after surgery. The other patient died from severe bleeding from an ischemic gastric ulcer. Of the four patients with celiac trunk embolization, none presented ischemic complications after surgery. Mean survival was 371 days. CONCLUSION: In this small series, ischemic complications after celiacopancreatectomy occurred only in those patients who did not receive preoperative celiac trunk embolization.

Late-fluorescence mammography assesses tumor capillary permeability and differentiates malignant from benign lesions.

Using scanning time-domain instrumentation we recorded fluorescence projection mammograms on few breast cancer patients prior, during and after infusion of indocyanine green (ICG), while monitoring arterial ICG concentration by transcutaneous pulse densitometry. Late-fluorescence mammograms recorded after ICG had been largely cleared from the blood by the liver, showed invasive carcinomas at high contrast over a rather homogeneous background, whereas benign lesions did not produce (focused) fluorescence contrast. During infusion, tissue concentration contrast and hence fluorescence contrast is determined by intravascular contributions, whereas late-fluorescence mammograms are dominated by contributions from protein-bound ICG extravasated into the interstitium, reflecting relative microvascular permeabilities of carcinomas and normal breast tissue. We simulated intravascular and extravascular contributions to ICG tissue concentration contrast within a two-compartment unidirectional pharmacokinetic model.