Embolization of Hemorrhoidal Arteries: A Novel Endovascular Therapy Option for the Treatment of Hemorrhoidal Disease. / Hämorrhoidenembolisation: Eine neue minimalinvasive endovaskuläre Therapieoption bei Hämorrhoidalleiden.

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 2022; 194: 266 - 271.

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.

Achieving high quality standards in laparoscopic colon resection for cancer: A Delphi consensus-based position paper.

AIM: To investigate the rate of laparoscopic colectomies for colon cancer using registries and population-based studies. To provide a position paper on mini-invasive (MIS) colon cancer surgery based on the opinion of experts leader in this field. METHODS: A systematic review of the literature was conducted using PRISMA guidelines for the rate of laparoscopy in colon cancer. Moreover, Delphi methodology was used to reach consensus among 35 international experts in four study rounds. Consensus was defined as an agreement ≥75.0%. Domains of interest included nosology, essential technical/oncological requirements, outcomes and MIS training. RESULTS: Forty-four studies from 42 articles were reviewed. Although it is still sub-optimal, the rate of MIS for colon cancer increased over the years and it is currently >50% in Korea, Netherlands, UK and Australia. The remaining European countries are un-investigated and presented lower rates with highest variations, ranging 7-35%. Using Delphi methodology, a laparoscopic colectomy was defined as a "colon resection performed using key-hole surgery independently from the type of anastomosis". The panel defined also the oncological requirements recognized essential for the procedure and agreed that when performed by experienced surgeons, it should be marked as best practice in guidelines, given the principles of oncologic surgery be respected (R0 procedure, vessel ligation and mesocolon integrity). CONCLUSION: The rate of MIS colectomies for cancer in Europe should be further investigated. A panel of leaders in this field defined laparoscopic colectomy as a best practice procedure when performed by an experienced surgeon respecting the standards of surgical oncology.

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.

Increased serum levels of C-reactive protein precede anastomotic leakage in colorectal surgery.

BACKGROUND: Anastomotic leakage (AL) is a severe complication following colorectal surgery. C-reactive protein (CRP) is considered to be an indicator of postoperative complications. MATERIALS AND METHODS: Between August 2002 and August 2005 342 colorectal resections with primary anastomosis were performed at the Department of General and Vascular Surgery. Johann Wolfgang Goethe-University Frankfurt. For this retrospective study serum CRP was measured daily until postoperative day 7, and in cases of AL it was excluded from statistical analysis beginning with the day on which the AL was diagnosed. RESULTS: Twenty-six of 342 (7.6%) patients developed AL at a mean of 8.7 days postoperatively. The in-hospital mortality was 3.5% for all patients and was significantly higher in the AL group (11.5 versus 2.8%). The CRP level in the two groups showed a peak on day 2.5 and day 2.2, respectively. In case of postoperative AL the CRP level did not show a marked decline during the next few days. Compared to the cases where AL did not develop, there was a significantly higher increase in CRP from the preoperative level to the levels measured on postoperative day 3, 5, 6 and 7. Higher CRP levels were observed in patients experiencing pneumonia or urinary tract infection, but the decrease of CRP values was not as slow as in cases of AL. CONCLUSIONS: This study shows serum CRP level to be a relevant marker in detecting postoperative complications in colorectal surgery. Prolonged elevation and a missing decline in CRP level precede the occurrence of AL.

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).

Octreotide attenuates impaired microcirculation in postischemic pancreatitis when administered before induction of ischemia.

BACKGROUND: Ischemia-reperfusion injury of the pancreas causes impairment of microcirculation leading to pancreatitis. Postischemic pancreatitis is the most common reason for graft failure in pancreas transplantation. In animal models, octreotide has been described to have beneficial effects on acute pancreatitis by reducing pancreatic enzyme release and edema formation by preventing the increase of macromolecular extravasation. In contrast to earlier experimental setups, this study investigated the influence of octreotide on ischemia-reperfusion pancreatitis when administered before induction of ischemia. METHODS: Sprague-Dawley rats were randomly assigned to three groups: (1) sham-operated animals (sham group, n=7); (2) 1 hr ischemia followed by 1 hr reperfusion (control group, n=7); (3) administration of 50 microg/kg octreotide intravenously 15 min before ischemia (octreotide group, n=7). At the end of reperfusion, intravital fluorescence microscopy was performed assessing the functional capillary density (FCD), leukocyte-endothelium interaction (LEI), and the microvascular permeability. Finally serum amylase and lipase were measured. RESULTS: The application of octreotide significantly reduced the ischemia-reperfusion-induced reduction of FCD (318.4+/-44.1 cm/cm vs. 257.4+/-11.7 cm/cm, P<0.001). The increase of LEI due to ischemia-reperfusion (466.9+/-52.2 cells/mm) was reduced in the octreotide group (264.4+/-55.1, P=0.001). Permeability was significantly lower in the octreotide group (0.56+/-0.57x10 cm/sec vs. 2.2.1+/-0.54x10 cm/sec, P<0.001). The level of serum lipase was reduced significantly after octreotide therapy (72.4+/-53.4 U/L vs. 136.7+/-66.5 U/L, P=0.026). CONCLUSION: Octreotide significantly attenuated pancreatic dysfunction caused by ischemia-reperfusion when given before ischemia. Furthermore, we could prove for the first time a beneficial role of octreotide on preservation of the microvascular barrier for macromolecules.

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.

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.

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.

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.

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

UNLABELLED: 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.