Use of LigaSure vessel sealing system versus conventional axillary dissection in breast cancer patients: a retrospective comparative study.

BACKGROUND: In locally advanced breast cancer, axillary lymph node dissection remains a pivotal component of surgical therapy. Apart from this, it has been mostly replaced by sentinel node biopsy. Complications after axillary dissection include wound infection, neuropathy, lymphedema and-most frequently-seroma. In this retrospective multi-centre study, we compared the use of LigaSureTM with monopolar electrocautery regarding perioperative outcome. METHODS: A retrospective data analysis from female breast cancer patients who underwent axillary dissection at two breast centres in Austria that are using two different surgical techniques was performed for this study. We compared the rate of complications and re-operations, length of hospital stay, time to drain removal, total drain fluid, seroma formation after drain removal, number of seroma aspirations and total seroma fluid. RESULTS: Seventy one female patients with a median age of 63 (30-83) were included in this study. In 35 patients LigaSureTM and in 36 monopolar cautery was used for axillary dissection. There was no significant difference regarding intraoperative complications and rate of re-operations between the two groups (2.9 vs. 5.6%; p = 1 and 2.9 vs. 13.9%; p = 0.199). The time to drain removal and the length of hospital stay was similar in both groups. A significant difference in the occurence of postoperative wound infection could also not be shown. However, we found a significantly smaller total drain fluid in the LigaSureTM-group compared to the cautery-group (364.6 ml vs. 643.4 ml; p = 0.004). Seroma formation after drain removal was more frequent in the LigaSureTM-group (68.6 vs. 41.7%; p = 0.032) with a higher number of outpatient seroma aspirations (2.0 vs. 0.9; p = 0.005). CONCLUSION: LigaSureTM and monopolar cautery provide equivalent techniques in axillary lymph node dissection with comparable postoperative outcomes.

Cognitive impairment in relation to depression, anxiety and virological response in hepatitis C patients in Egypt.

OBJECTIVE: Cognitive impairment commonly occurs in hepatitis C virus (HCV) patients. The objective of this study was to estimate the prevalence and sociodemographic and clinical correlates of cognitive impairment in HCV patients before and after 12 weeks of interferon treatment in comparison with a control group. METHODS: Hundred and sixteen consecutive HCV patients were included in the study and divided into treated and untreated groups. All patients were assessed using sociodemographic and clinical questionnaire, Montreal Cognitive Assessment Scale (MOCA) and Hospital Anxiety and Depression Scale (HADS) before and after 12 weeks of treatment or observation. RESULTS: Thirty-eight percent of treated patients showed cognitive impairment at baseline, which increased to 69% after 12 weeks of interferon treatment. This cognitive impairment was reflected in the total MOCA score and in visuo-constructional skills, attention, concentration, working memory, language, and short-term memory, which was not shown by untreated group after 12 weeks of observation. Cognitive impairment was associated with low education, but not with depression, anxiety, or virological response. CONCLUSIONS: Cognitive impairment is common in HCV patients and increases significantly after interferon treatment. It is not related to depression or anxiety in HCV patients. Future research should focus on prevention, treatment and outcome of cognitive impairment in HCV patients, particularly those receiving interferon therapy.

Laparoscopic versus open appendectomy for complicated appendicitis in high risk patients.

INTRODUCTION: Laparoscopic appendectomy is widely used for the treatment of complicated appendicitis. Its use in patients with high operative risk is still on debate. The aim of the presented study was to investigate the benefits of laparoscopic appendectomy in patients with high peri- and postoperative risk factors. METHODS: We performed a retrospective analysis of all patients who underwent appendectomy in our center between 2006 and 2013. Patients were classified according to their preoperative risk (classification of the American Society of Anesthesia--ASA score). Only patients with ASA 3 and 4 were included and were divided into two groups--open appendectomy (OA group) and laparoscopic appendectomy (LA group). RESULTS: The operation time was slightly longer in the LA group (p = 0.05), but hospital stay was shorter (p = 0.05). Complications graded according to the Clavien Dindo classification were slightly more frequent in patients after LA, whereas severe complications occurred more frequently in patients after OA (p = 0.01). The postoperative WBC decreased steadily and significantly in patients after OA, whereas the decrease in patients after LA was delayed (p = 0.03). CRP slightly increased after OA and decreased thereafter, whereas it steadily decreased after LA (p = 0.05). CONCLUSION: Laparoscopic appendectomy can be recommended for patients with complicated appendicitis even with higher risk categories.

[Abdominal wall closure by incisional hernia and herniation after laparostoma]. / Bauchdeckenverschluss bei Narbenhernien und Herniationen nach Laparostoma.

As hernias and abdominal wall defects have a variety of etiologies each with its own complications and comorbidities in various constellations, efficient treatment requires patient-oriented management. There is no recommended standard treatment and the very different clinical pictures demand an individualized interdisciplinary approach. Particularly in the case of complicated hernias, the planning of the operation should focus on the problems posed by the individual patient. Treatment mainly depends on the etiology of the hernia, immediate or long-term complications and the efficiency of individual repair techniques. Abdominal wall repair for recurrent herniation requires direct closure of the fascia generally using the sublay technique with a lightweight mesh. It is still unclear whether persistent inflammation, mesh dislocation, fistula formation or other long-term complications are due to certain materials or to the surgical technique. With mesh infections it has been shown to be advantageous to remove a polytetrafluoroethylene (PTFE) mesh, while the combination of systemic and local treatment appears to suffice for a polypropylene or polyester mesh. Heavier meshes in the sublay position or plastic reconstruction with autologous tissue are indicated as substitutes for the abdominal wall for giant hernias, repeated recurrences and large abdominal wall defects. A laparostoma is increasingly more often created to treat septic intra-abdominal processes but is very often responsible for a complicated hernia. If primary repair of the abdominal wall is not an option, resorbable material or split skin is used for coverage under the auspices of a planned hernia repair.

Management of pancreatic trauma and its consequences--guidelines or individual therapy?

BACKGROUND/AIMS: Diagnosis of pancreatic trauma and its complications may be difficult due to non-specific signs and symptoms and treatment recommendations are not unequivocal. METHODOLOGY: Clinical data of a series of 47 patients with pancreatic trauma were analyzed; most of them were polytraumatized and treated by an interdisciplinary team. RESULTS: The most common causes were traffic accidents and sport injuries with 66% and 15%, respectively. Concomitant injuries were seen in 96% (nonpancreatic intra-abdominal injuries 85% including spleen 38% and liver 34%, extra-abdominal injuries 70%). Concomitant liver injuries were treated conservatively in 31% and operatively in 69% (including hepatic packing in 38%). Concomitant splenic injuries were usually very severe and could be managed conservatively in only 11%. All patients with pancreatic injuries grade III, IV or V (17%) according to the American Association of Surgical Trauma Classification required surgery, endoscopic treatment or interventional radiology. The most common posttraumatic complications were necrotizing pancreatitis (15%), pseudocyst formation (9%), abscesses (6%) and fistulas (4%). CONCLUSIONS: The status of the pancreatic duct is the crucial point for management of pancreatic trauma and should be assessed as early as possible. Treatment has to be tailored to the individual situation, especially in patients with severe concomitant injuries or prolonged course.

Treatment of patients with pyogenic liver abscess.

BACKGROUND: Pyogenic liver abscess (PLA) remains a serious disease with a mortality of 6-14%. METHODS: Clinical data of 76 patients with PLA were analyzed. Treatment options comprised antibiotics, percutaneous puncture/drainage, endoscopic papillotomy/stenting and/or surgery as indicated. RESULTS: Fifty-eight patients (76%) had single and 18 patients multiple PLA (right lobe: 65%; both lobes: 22%). The most frequent etiologies were: biliary (38%), hematogenous and posttraumatic (11%). Factors associated with the need for surgery included gallbladder empyema, biliary fistulas, malignancy, perforation, multicentricity, vascular complications and foreign bodies (e.g. infected ventriculo-peritoneal shunt, toothpick). CONCLUSIONS: Microbiological testing provides important information for treatment monitoring and modification. Complementary assessment of risk factors for a complicated course is crucial for timely identification of patients requiring additional treatment.

Pancreatitis-associated protein (PAP) in patients with pancreatic cancer.

BACKGROUND: Pancreatitis-associated protein (PAP) is known as a marker for pancreatitis and cystic fibrosis. The aim of our study was to evaluate PAP in patients with pancreatic cancer, to assess its correlation to the extent of the disease and to compare it to CA19-9. PATIENTS AND METHODS: This prospective study comprised 75 individuals. Thirty had pancreatic cancer, 30 were healthy controls and 15 had benign lesions of the pancreas. PAP was determined by enzyme-linked immunosorbent assay. Statistical analysis was by Wilcoxon test and Spearman correlation coefficients. RESULTS: As compared to healthy individuals and using a cut-off of 18 micrograms/l corresponding to a sensitivity of 90%, the specificity of PAP for pancreatic cancer was 82.8%. PAP elevation in cancer patients could not be explained by concomitant pancreatitis (p = 0.649). PAP did not show correlation to tumour size (p = 0.14), T-stages (p = 0.706) or tumour grading (p = 0.105), but was significantly correlated to the overall extent of the disease according to the UICC stages (p = 0.002). No correlation between PAP and CA19-9 was seen. Jaundice was not found to influence PAP values (p = 0.4). CONCLUSION: Elevation of PAP in patients with pancreatic cancer is not merely explainable by concomitant pancreatitis, but seems to be due to increased PAP production by the cancer cells and is also correlated to tumour load as expressed by the UICC stages.

Liver ischemia, catecholamines and preoperative condition influencing postoperative tachycardia in liver surgery.

The aim of our study was to assess the influence of intraoperative hypoxic stress -unavoidably brought about by so called Pringle maneuver - on free and conjugated catecholamines during major hepatic resection. Judging from earlier results of fatigue-experiments in rats we also wanted to check the relationship between of poor general preoperative condition and conspicuously low triglyceride serum concentrations. The study included 26 patients with primary and secondary liver tumors. The mean age was 54 years (range 27-79). Twenty-one patients had segmental liver resections, 3 had hemihepatectomies and 2 hydatid cysts were treated by cystectomy. Blood samples were taken 2 days before and throughout surgery. Catecholamine plasma values were determined by high performance liquid chromatography. Statistical comparisons were made by t-test, ANOVA and chi square test. Free plasma catecholamines increased significantly during prolonged intraoperative ischemia (Pringle time 50-125 minutes). Patients with elevated intraoperative catecholamines had a significant correlation to postoperative episodes of tachycardia, and prolonged hospital stay. On the other hand, we could also see postoperative tachycardias in patients with short Pringle times (18-49 minutes) but with decreased preoperative serum triglycerides as an indicator of chronic stress and reduced general condition. Intraoperative hypoxic stress is associated with increased catecholamine values. Elevated catecholamines may well cause postoperative sinus-tachycardias (mean 20 hours) and are strongly related to postoperative liver failure and prolonged hospital stay.

Bronchogenic cyst appearing as a hepatic mass.

Because bronchogenic cysts may be found in or near any organ derived from the embryonic foregut, they sometimes pose considerable diagnostic difficulties. We describe the plain chest X-ray, computed tomographic, and angiographic findings in a patient with elevated CA 19-9 and upper quadrant abdominal pain due to a cystic tumor appearing as a hepatic mass. Surgery and histology showed a bronchogenic cyst located in the lower lobe of the right lung.

Normothermic liver ischemia and antioxidant treatment during hepatic resections.

The purpose of our study was to evaluate the clinical impact of reperfusion injury after normothermic ischemia during major liver resections and the effect of an intraoperative antioxidant infusion. This prospective randomized study comprised 50 patients; half of them (treatment group) were given an antioxidant infusion containing tocopherol and ascorbate immediately prior to reperfusion onset. Venous blood samples for the determination of MDA-TBARS (malondialdehyde-thiobarbituric acid reactive substances) by a HPLC-based test as a marker of lipid peroxidation were taken prior to ischemia, 30 min after reperfusion onset and at the end of the operation. In the control group there was a significant increase of MDA-TBARS (p = 0.001) at 30 min after reperfusion onset. At the end of the operation the values had returned to the initial level. The treatment group showed only a marginal increase (p-value for the difference between the two groups: 0.007). After exclusion of the patients with histologically proven advanced cirrhosis the increase in the control group (p < 0.001) and the difference between the increase in the two groups (p = 0.001) became more significant. Prothrombin time was also significantly better in the treatment group (p = 0.003). Postoperative complications such as prolonged liver failure, bleeding disorders and infections were seen more often in the control group. In our study MDA-TBARS was increased after liver ischemia, but in patients with advanced cirrhosis the effect was smaller or even absent. This increase and possible clinical consequences of reperfusion injury could be reduced by intraoperative administration of an antioxidant infusion.

TUM2-PK (pyruvate kinase type tumor M2), CA19-9 and CEA in patients with benign, malignant and metastasizing pancreatic lesions.

The diagnostic value of the tumor marker pyruvate kinase type tumor M2 was evaluated in patients with benign, malignant and metastasizing pancreatic lesions and compared to the reference markers CA19-9 and CEA. This prospective study comprised 166 individuals; 66 patients had various pancreatic pathologies (38 histologically proven pancreatic cancer, 28 benign pancreatic lesions such as pseudotumorous pancreatitis, pseudocysts or pancreatic (cyst)adenoma) and 100 healthy blood donors served as controls. With a cut-off value of 28 U/ml (corresponding to a specificity of 90%) the sensitivity of TUM2-PK for pancreatic cancer (as related to the control group) was 79% (CA19-9: 65%, CEA: 22%). There was a good correlation between the TUM2-PK levels and tumor metastasis (p < 0.001 for no versus distant metastasis, p = n.s. for CA19-9 and CEA). However, TUM2-PK was also elevated in 64.3% of the patients with benign pancreatic pathologies. In our study TUM2-PK had good diagnostic qualities for pancreatic cancer and also showed better correlation to metastasis than CA 19-9 and CEA.

Primary biliary cystadenocarcinoma perforating the duodenum and left intrahepatic biliary tree--mimicking a hydatid cyst.

We report the case of a 76-year-old woman with biliary cystadenocarcinoma perforating the left biliary tree and exhibiting intra-tumoral gas bubbles resulting from invasion of the duodenum. The clinical history included subfebrile temperatures of 3 months duration, and pains associated with an abdominal mass in the right upper quadrant. Blood tests showed leucocytosis, and radiological studies revealed the features of a partially calcified septated tumor with nodular components combined with multiple gas-fluid levels, mimicking an infected hydatid cyst. Intraoperative ultrasonography, cholangiography and frozen section histology were necessary to prove the malignant nature of this cystic tumor. Provided that complete resection with strict adherence to oncological precepts is possible, the prognosis of cystadenocarcinoma is better than in hepatocellular or cholangiocellular carcinoma.

Antioxidant treatment during liver resection for alleviation of ischemia-reperfusion injury.

BACKGROUND/AIMS: Many experimental studies on ischemia-reperfusion injury in animals suggest a preventive effect of antioxidants, but the clinical significance of these findings is still unclear. The aim of our study was to evaluate the effect of antioxidant treatment with vitamins on liver function parameters during liver resection. METHODOLOGY: Our prospective randomized study comprised 58 patients undergoing major liver surgery, including the Pringle maneuver. In the treatment group 32 patients received a multivitamin infusion (Omnibionta) which included 10 mg of alpha-tocopherol acetate, 2 mg of DL-alpha-tocopherol and 1 g of ascorbate. The control group consisted of 26 patients. Various parameters associated with liver function, such as transaminases, lactate, ammonia, bilirubin, cholinesterase and clotting parameters were measured preoperatively, at the beginning of liver ischemia, 15, 30 and 60 minutes after reperfusion onset and every 12 hours after the operation. RESULTS: The Mann-Whitney-Wilcoxon-Test showed statistically significant differences in the postischemic changes between the treatment group and the control group for the Quick test (prothrombin time): p = 0.01. The transaminases were also markedly better in the treatment group (splitting-up slightly more delayed than with the Quick test). A smaller effect was seen with cholinesterase. Lactate, however, increased intraoperatively with a strong correlation to the duration of ischemia and returned quickly to baseline values without any remarkable influence of the antioxidant treatment. CONCLUSION: In our study, antioxidant treatment with a multivitamin infusion showed a positive effect on postischemic liver function parameters.

Local nitroglycerin for treatment of anal fissures: an alternative to lateral sphincterotomy?

PURPOSE: Nitric oxide is an important neurotransmitter mediating internal anal sphincter relaxation. Patients suffering from fissure-in-ano were treated with topical nitroglycerine. The clinical evidence for therapeutic adequacy was examined in a prospective, randomized study. METHODS: The study included 35 patients with acute and chronic anal fissures. In Group A, including 20 patients with the clinical diagnosis of acute (12 patients) and chronic (8 patients) anal fissures, treatment consisted of topical nitroglycerine. Group B, consisting of 15 patients (10 acute and 5 chronic fissures), received topical anesthetic gel during therapy. Manometry was performed before and on days 14 and 28 in the course of topical application of either 0.2 percent glyceryl trinitrate ointment or anesthetic gel (lignocaine). Anal pressures were documented by recording the maximum resting and squeeze pressures. RESULTS: In 60 percent of cases treated with topical nitroglycerine (Group A, 11 acute (91.6 percent) and 1 chronic (12.5 percent)), anal fissure healed within 14 days, in contrast to Group B in which no healing was observed. The healing rate after one month was 80 percent (11 acute (91.6 percent); 5 chronic (62.5 percent)) in Group A and was significantly superior to Group B (healing rate, 40 percent: 5 acute (50 percent); 1 chronic (20 percent)). DISCUSSION: Previously increased maximum resting pressures decreased from a mean value of 110 to 87 cm H2O. This represents a mean reduction of 20 percent (P = 0.0022). We also noted a significant decrease in squeeze pressures (from 177.8 to 157.9 cm H2O (11 percent)). However, anal pressures did not decrease significantly in the four chronic fissure patients from Group A, whose fissures only healed after 28 days. Similarly to these Group A chronic fissure patients, no significant anal pressure reduction was observed in any Group B patients. Except for mild headache (20 percent), no side effects of treatment were reported. CONCLUSIONS: Topical application of nitroglycerine represents a new, easily handled, and effective alternative in the treatment of anal fissures. All of our patients reported a dramatic reduction in acute anal pain. However, it should be noted that a lack of sphincter tone reduction is a likely reason for the great tendency of chronic anal fissures to recur.

Intrahepatic hematoma with secondary Salmonella infection via biliary fistula.

Usually liver hematoma after blunt trauma is treated conservatively as long as clinically possible, in order to avoid infection via drainage. We report a patient who developed a huge liver abscess after a minor blunt trauma caused by a piece of wood that hit his hepatic region during work with a circular saw. Neither conservative treatment nor percutaneous drainage was successful and intraoperatively a biliary fistula was identified as the route of infection by salmonella. Cholecystectomy (here meaning removal of the salmonella reservoir) and consequent drainage of the gall flow via T-drain were the crucial therapeutic steps and the fistula finally closed after three months. Therapeutic possibilities in the management of blunt liver trauma, and biliary and septic complications are discussed.