[Surgical treatment of hepatic tumors-liver resection and transplantation]. / Chirurgische Therapie bei Lebertumoren ­ Leberresektion und -transplantation.

The most frequent primary hepatic malignancies are hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (intrahepatic cholangiocellular adenocarcinoma [iCCA]). For HCC in cirrhosis, liver transplantation offers the advantage of a complete hepatectomy radically removing all tumorous tissue along with the surrounding cirrhotic parenchyma, which is otherwise associated with a very high risk of recurrence. For HCC in non-cirrhotic livers and iCCA, liver resection is the treatment of choice. Nowadays, even extended resections can be performed with low mortality in experienced centers. Surgical therapy is more and more embedded into multimodal treatment concepts and decision making should be interdisciplinary as for other gastrointestinal tumors.

[Lymphadenectomy in oncological visceral surgery-Part 1 : Hepatobiliary tumors and pancreatic cancer]. / Lymphadenektomie in der onkologischen Viszeralchirurgie ­ Teil 1 : Hepatobiliäre Tumoren und Pankreaskarzinom.

Lymphadenectomy is an integral component of the oncological surgery of cancer of the gastrointestinal tract and the hepato-pancreato-biliary system. The lymph node dissection is mainly prognostic but may also offer therapeutic advantages in the treatment of most cancers. Moreover, lymphadenectomy enables an accurate TNM staging, which is essential for a further stratification of the individual treatment as well as the inclusion in clinical trials on adjuvant therapy. This article gives an overview of the anatomy of the lymphatic drainage system of visceral organs and summarizes the current role of a systematic lymphadenectomy in oncological surgery (Part 1: hepatobiliary tumors and pancreatic cancer).

[Extended Left Hemihepatectomy with Reconstruction of The Right Liver Vein in a Patient with an Intrahepatic Cholangiocellular Carcinoma]. / Erweiterte Hemihepatektomie links mit Rekonstruktion der rechten Lebervene bei intrahepatischem cholangiozellulärem Karzinom.

Extended left hemihepatectomy (left trisectionectomy) with resection of liver segments 1, 2, 3, 4 a/b, 5 and 8 is a challenging procedure. In well-selected patients, the indication for this procedure may offer the chance of curative resection for primary or secondary liver tumours in complicated locations. Morbidity and mortality are increased compared to non-extended liver resections. This procedure requires precise imaging and accurate surgical planning in due consideration of the remaining liver volume and additional factors such as preliminary damage of the liver parenchyma caused by chemotherapy or fibrosis/cirrhosis. Left trisectionectomy is necessary in tumours affecting either the middle and left hepatic vein or the blood vessels of the liver hilum to the left and middle liver sector. The procedure necessitates the preservation of the right hepatic vein and the portal-venous and arterial branches supplying segments 6 and 7, as well as the bile ducts of these segments. This video article illustrates the surgical procedure of extended left hemihepatectomy performed due to an intrahepatic cholangiocellular carcinoma, which centrally surrounds the left and middle hepatic vein and potentially infiltrates the right hepatic vein. This condition requires the tangential resection and reconstruction of the right hepatic vein.

[Technique of Mesohepatectomy]. / Technik der Mesohepatektomie.

In patients with primary or secondary malignant central liver tumours, the standard surgical procedure is extended left or right hemihepatectomy. Since extended resections are associated with increased morbidity and mortality and a loss of a large amount of functional liver parenchyma, central liver resection or mesohepatectomy (resection of segments 4a/4b, 5 and 8) with or without the resection of segment 1 is an alternative procedure, although technically demanding and not widely used so far. Resection margins are to the right of the falciform ligament and at the border between segments 5/6 and 7/8, which can be difficult to differentiate. Intraoperative sonography is highly recommended. The current video shows the technique of mesohepatectomy under exclusion of segment 1 in a case of a central colorectal liver metastasis.

[Transparent operative training in visceral surgery : Analysis at a German university medical center]. / Transparente operative Weiterbildung in der Viszeralchirurgie : Analyse an einer deutschen Universitätsklinik.

BACKGROUND: Practical operative training in the discipline of visceral surgery is currently under discussion. Aside from surveys, data on this topic in Germany are sparse. The aim of the study was an objective collation of surgical residents' practical training in the operating room in our department. METHODS: All surgical cases from 2015 were prospectively included. Procedures were stratified into resident and non-resident operations and complex cases with sub-steps which could potentially be performed by residents. We analyzed whether an operation or surgical sub-steps were performed by a resident. If this was not achieved, the reasons were analyzed. An anonymous online survey was conducted among employees in the surgery department regarding surgical training. RESULTS: Out of 2896 surgical cases 1141 (39.4 %) were classified as potential resident training operations, which were actually performed by a resident in 743 cases (65.1 %). The survey showed an underestimation of this proportion, where sub-steps were assisted in 30.3 % (n = 265) of 876 potential cases. This proportion significantly increased during the observation period (p < 0.001); however, it was highly overestimated by residents as well as fellows and senior consultants. Often organizational reasons were responsible when resident operations or sub-steps were not performed by a trainee (13.1 % and 30.0 %, respectively). CONCLUSION: The monocentric analysis per se resulted in an improvement in practical surgical training. In the training environment, assisting with sub-steps provides a great potential. Multicenter studies are needed.

[Appendectomy in surgical residency. What has changed over the past 10 years?]. / Weiterbildungseingriff Appendektomie. Was hat sich in 10 Jahren geändert?

BACKGROUND: Surgical residents need to train laparoscopic skills for minimally invasive procedures at an early stage. The aim of this study was the investigation and assessment of appendectomy carried out at a university medical center over the previous decade regarding the frequency of operations by residents in training and the type of surgical technique used (laparoscopic vs. open). METHODS: A retrospective analysis of appendectomies carried out from 2005 to 2014 at the clinic for general, visceral and transplant surgery was performed. Operators were stratified into two groups (group 1: residents and group 2: fellows/attending surgeons). Surgery was classified as laparoscopic or open appendectomy. RESULTS: Out of 1,587 appendectomies analyzed 946 were performed laparoscopically (59.6 %). The percentage of laparoscopic appendectomies increased significantly over the decade analyzed (p < 0.001) and reached 94.4 % in 2014. From 2005 until 2007 the rate of appendectomies by residents was 17.9 % (77 out of 430). Laparoscopic appendectomy was performed in 5.8 % and was only performed by fellows or attending surgeons. From 2008 to 2014 the rate of surgeries by residents significantly increased (p < 0.001) and accounted for 57.6 % (range 19.4-66.9 %). CONCLUSION: Regardless of the surgical technique used, appendectomy is still a primary training operation for surgical residents. An early and focused training of minimally invasive visceral surgery in the new regulations for continuing medical education starts with laparoscopic appendectomy.

In vivo quantification of metastatic tumor cell adhesion in the pulmonary microvasculature.

In vivo and ex vivo fluorescence video microscopy used to be a well-established method in life science with a variety of applications, such as in inflammation or cancer research. In this book chapter, we describe a model of in vivo fluorescence microscopy of the rat's lung with the exclusive advantage of qualitative and quantitative in vivo analysis of cell adhesion within the complex microenvironment of the ventilated and perfused lung. Observation can include real-time, time-lapse, or fast-motion analysis. In our laboratory, we have used the model for qualitative and quantitative real-time analyses of metastatic colon cancer cell adhesion within the rat's pulmonary microcirculation. Using some modifications in another series, we have also applied the model to analyze thrombocyte and leucocyte adhesion within the pulmonary capillaries in experimental sepsis. For interventional studies, injected cells or animals may be pretreated with various reagents or drugs for further analysis of adhesion molecules involved in tumor cell-endothelial cell interactions.

Diagnostic accuracy in remote expert consultation using standard video-conference technology.

An international multicenter study (Germany, Sweden, and Switzerland) was performed to investigate the feasibility and diagnostic reliability of standard video-conferencing (VC) technology for remote expert consultation in radiology. Three high-spatial-resolution films (hand-bone, mammography, chest) and two low-spatial-resolution image sets (liver CT and MRI) were studied (total 446 images taken from different examinations). The images were recorded by a video camera, transmitted via public broadband networks, and displayed on a video monitor. The resolution of the recorded images varied from 2.4 lp/mm to 4.8 lp/mm at maximum zoom. After 3-4 months, the images were reexamined using conventional light-box reading. Diagnostic reliability was evaluated by receiver operating characteristics (ROC) analysis. With video conferencing, there was a noticeable loss of diagnostic accuracy for the high-spatial-resolution films, whereas for liver CT and liver MRI images VC reading seemed to be satisfactory (average area value difference < 0.02).

Chemical synthesis of a gene for human cystatin C and its expression in E. coli.

A DNA containing the coding sequence for the human cysteine proteinase inhibitor protein cystatin C has been obtained by enzymatic ligation of chemically synthesized deoxyoligonucleotides, using the Khorana ligation method. The 375 bp synthetic gene carries signals for the translation initiation and termination and was expressed in E. coli as a beta-galactosidase fusion protein as well as a secreted protein under the control of the E. coli alkaline phosphatase signal sequence. The secreted hybrid protein was shown to have similar biological properties as the authentic protein isolated from human plasma.

[Upper Austria model study to assess the prevalence and incidence of congenital abnormalities]. / Modellstudie Oberösterreich Zur Ermittlung der Häufigkeit und Inzidenz angeborener Fehlbildungen.

Among the 15.998 live births recorded in Upper Austria in the year 1985, a representative malformation rate of 1.79, respectively a representative incidence of 17.94 in 1000 live births is reported. The incidences of characteristic malformations and of single malformations combined in malformation groups are determined. An instrument of investigation, especially developed for and successfully used in this examination in form of an illustrated questionnaire is introduced.

Biamnial alpha fetoprotein concentration in twins, one with multiple malformations.

In the 18th week of pregnancy in a 22 year old patient, twins were diagnosed by ultrasound. It was found that one twin had an abnormal skull outline and an echo-free area covered by a thin membrane in the region of the abdomen. The second embryo showed no sign of malformation. Amniocentesis was performed and the AFP in both samples of amniotic fluid were in the pathological range. Our own observations with indirect immunofluorescence confirmed that one twin with defects leading to abnormally high AFP levels can cause pathological AFP levels in the amniotic sac of a healthy twin.

One thousand consecutive midtrimester amniocenteses.

One thousand women underwent amniocentesis as part of a prenatal investigation and were observed throughout gestation and delivery. Amniocenteses and chromosome determinations were performed at a center with great experience in these techniques. Under these conditions, the risks attached to amniocentesis are minimal, and the chromosome determinations are reliable. In this study, 21 women chose to terminate their pregnancy because the fetus was expected to have a serious abnormality. In all the cases in which the diagnosis could be investigated after legal termination, the cytogenetic diagnosis proved correct.