[Acute squamous cell carcinoma of the gallbladder: a rare cause of acute cholecystitis]. / Primäres Plattenepithelkarzinom der Gallenblase als seltene Ursache für eine akute Cholezystitis.

HISTORY AND ADMISSION FINDINGS: A 54-year-old woman with signs of acute cholecystitis but no other relevant diseases was admitted into our hospital. INVESTIGATIONS: The abdominal ultrasonography showed an acute cholecystitis with possibly an abscess in the bed of the gallbladder (DD gall bladder cancer). Therefore a laparoscopy was performed which revealed a tumorous infiltrating the adjacent organs. A R1 resection was performed. DIAGNOSIS, TREATMENT AND COURSE: The histological examination revealed the rare finding of a squamous cell cancer of the gall bladder. On advice of our tumor board, chemotherapy with cisplatin and 5-flourouracil was initiated. Tumor-associated bile duct stenosis required endoscopic stent implantation. Despite the poor prognosis the disease remained stable 18 month later, with a Karnofsky index of 100 %. CONCLUSION: Squamous cell carcinoma of the gallbladder is rare and requires a good interdisciplinary management. In an individual setting it is possible to increase survival with interdisciplinary treatment and palliative chemotherapy.

Clip migration in clipped intestinal non-perforating anastomosis (CINPA).

INTRODUCTION: Our studies of clipped intestinal non-perforating anastomosis (CINPA) of the small bowel in a rat model have demonstrated that all clips migrated from the outside to the inside of the small bowel during the healing process. The aim of this study was to describe how the clips migrate. MATERIAL AND METHODS: In male Sprague Dawley rats small bowel anastomoses were performed with single, non-perforating metal clips. Bowel specimens were obtained from the anastomosed region for histological examination. RESULTS: On the day of surgery all clips were situated in the serous membrane. On the first postoperative day, an intramural migration could be observed. By days 6, 8, and 10 no clip was found in the peritoneum. All egested clips were found either in the distal lumen of the bowel or in the solid feces. H&E staining of the anastomoses studies indicated that the bowel wall everts immediately after being cut and becomes more and more inverted during the first few days after being anastomosed. CONCLUSION: Our studies showed that the observed dynamic movement of the bowel wall determines the movement of clip migration from the serosal to the mucosal side of the small bowel. In pediatric surgery the observed clip migration would be an important precondition for employing clipped intestinal non-perforating anastomosis (CINPA) routinely. However, further studies are necessary before the technique can be applied in daily practice.

[Rupture of a superior mesenteric artery aneurysm]. / Ruptur eines Aneurysmas der Arteria mesenterica superior.

HISTORY AND ADMISSION FINDINGS: A 54-year-old patient presented with acute abdominal pain that had started after having a bowel movement. INVESTIGATIONS AND DIAGNOSIS: Ultrasound examination revealed free intraabdominal fluid with no signs of organ rupture. CT-scan showed a peripherally located ruptured aneurysm of a branch of the superior mesenteric artery. TREATMENT AND COURSE: Intraoperatively the aneurysm was then ligated. A vascular reconstruction or bowel resection was not necessary. After an uneventful postoperative course, the patient could be discharged from the hospital on postoperative day four. Two weeks later the patient was readmitted, with fever and dyspnea. Transesophageal echocardiogram suggested the presence of bacterial growth on the aortic and mitral valves. Blood cultures and valvular vegetations grew Streptococcus viridans. The diagnosed infective endocarditis was caused by a tooth-infection, that had been recurrent for one year. After treatment of the tooth infection, the mitral and aortic valves were replaced without any complications. CONCLUSION: Because of the high mortality associated with rupture, it is important that visceral aneurysms are taken into consideration in the differential diagnosis of unexplained abdominal pain. It should also be kept in mind that the aneurysm could be due to an infective endocarditis. Therefore, echography should be carried out in each case, to avoid further complications and to give optimal treatment.

Multimodal perioperative rehabilitation for colonic surgery in the elderly.

BACKGROUND: Traditional perioperative care for colonic surgery in elderly patients is associated with increased morbidity and mortality compared to that of younger patients. Although multimodal perioperative rehabilitation has evolved as a valid concept to improve postoperative outcome, its use has not yet been established for colonic surgery in the elderly. METHODS: Data from 24 German hospitals performing multimodal perioperative rehabilitation as the standard perioperative care for elderly patients who have undergone elective colonic resection was assessed in a prospective multicenter study between April 2005 and April 2007. RESULTS: A total of 742 patients aged > or = 70 were examined. Overall compliance with the multimodal care protocol decreased with increasing age. Although laparoscopic colonic surgery was performed in 39.1% of the septuagenarians, the number decreased to 25.1% in the very old patients. The overall complication rate was 22.9% in the septuagenarians (18.1% surgical and 11.6% general complications) and increased in the very old patients to 38.4% (28.0% and 23.6%, respectively) The overall mortality rate was 1.0% and showed no age-specific variations. CONCLUSIONS: Although the overall morbidity did increase with age, it was still less when compared to that of historical groups with traditional care. Therefore, multimodal perioperative rehabilitation should be recommended for the elderly.

Sedation with propofol for interventional endoscopy by trained nurses in high-risk octogenarians: a prospective, randomized, controlled study.

BACKGROUND AND STUDY AIMS: Sedation with the short-acting anesthetic agent propofol has shown several advantages, particularly in interventional endoscopy. So far, however, there are no valid data on the safety of nurse-administered propofol sedation (NAPS) during interventional endoscopy in elderly high-risk patients. PATIENTS AND METHODS: A total of 150 patients aged > 80 years with high comorbidity were randomized to receive midazolam plus meperidine (n = 75) or propofol alone (n = 76) for sedation during endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), or double-balloon endoscopy (DBE). Sedation was supervised by a trained nurse and a trained physician both of whom were not involved in the endoscopic procedure. Vital signs were continuously monitored as well as patient cooperation and tolerance. Mortality and morbidity at 30 days was analyzed. RESULTS: The overall cardiopulmonary complication rate was 16 % in the midazolam group and 23.7 % in the propofol group ( P > 0.05). The mean decline in oxygen saturation (initial vs. lowest O (2) saturation) and the mean decline of blood pressure (initial vs. lowest blood pressure) were significantly greater with propofol (7 % +/- 3 % vs. 4 % +/- 2 % [ P < 0.05] and 10 % +/- 2 % vs. 8 % +/- 2 %, respectively [ P < 0.05]). No procedure had to be interrupted due to serious adverse events. Patient cooperation was statistically significantly better in the propofol group (7 +/- 2 vs. 5 +/- 2 points). Patients sedated with propofol showed a significantly lower oxygen saturation rate during recovery time (8 % vs. 28 %; P < or = 0.01). CONCLUSION: NAPS during interventional endoscopy is as safe as midazolam/pethidine sedation even in high-risk patients aged > 80 years.

[Colonic perforation after extracorporeal shock wave lithotripsy]. / Kolonperforation nach extrakorporaler Stosswellenlithotripsie.

HISTORY AND CLINICAL FINDINGS: A 40-year-old man had undergone extracorporeal shock wave lithotripsy (ESWL) due to left sided urinary lithiasis. 20 hours later he presented with left lower quadrant abdominal pain. INVESTIGATIONS: Ultrasound examination revealed free intraabdominal air and free perisplenic fluid. An injury of the left kidney could be excluded. TREATMENT AND COURSE: Due to increasing abdominal pain a laparoscopy was performed, revealing a faecal peritonitis. Since no perforation could be detected laroscopically, a laparotomy was performed, demonstrating a perforation of the descending colon. The perforation was oversewn, a defunctioning colostomy was not performed. Postoperatively the patient had an uncomplicated hospital stay and was discharged home on postoperative day 8. CONCLUSION: ESWL is considered a safe method to treat urinary lithiasis with a low complication rate. Nevertheless serious potentially life-threatening pararenal complications can occur. Due to the increasing number of outpatient procedures, a careful clinical and ultrasound monitoring of the patient with early recognition and interdisciplinary management of complications is necessary after each ESWL therapy.

Thyroid surgery in Burkina Faso, West Africa: experience from a surgical help program.

BACKGROUND: Endemic goiter caused by iodine deficiency is still very common in sub-Saharan Africa and is a surgical challenge because of the often large size of the goiters. METHODS: A retrospective analysis was made of patients who underwent operation for thyroid diseases during a surgical help program in Leo/Burkina Faso during a 7-year period from 2001 to 2008. RESULTS: A total of 253 cases presented with goiters grade III (WHO classification) were operated on: 134 hemithyroidectomies, 108 hemithyroidectomies combined with subtotal contralateral resection, and 11 total thyroidectomies were performed. The recurrent laryngeal injury rate was 0.8%, and the re-exploration rate for bleeding was 1.2%. Median hospital stay was 3.1 days. Histological examinations showed Graves' disease in 6 cases, and multinodular goiter in 231 cases. Follicular cancer was found in 15 cases, and anaplastic carcinoma was found in 1 case. CONCLUSIONS: Thyroid surgery can be performed with low complication rates under basic surgical conditions. Because of the size and pathology of the goiters, total thyroidectomy is the method of choice. However, considering the risk of the development of hypothyroidism due to poor understanding or difficult access to medication, a limited resection, e.g., hemithyroidectomy, is the most optimal operative strategy.

[Gossypiboma - the retained surgical towel]. / Gossypibom - Das vergessene Bauchtuch.

HISTORY AND CLINICAL FINDINGS: A 48-year-old woman with a history of five previous laparotomies had symptoms of nonspecific abdominal pain and recurrent postoperative paralytic ileus six months after her last operation. Because of her as yet undiagnosed abdominal pain admission to a psychosomatic hospital was suggested. INVESTIGATIONS: MRI was performed because of increasing abdominal pain. It revealed an intraabdominal large surgical towel retained in the abdomen (gossypiboma: gossypium [Latin]:cotton; boma [Swahili]: place of concealment). TREATMENT AND COURSE: The surgical towel, accidentally left behind at one of the previous intraabdominal operation) was removed through a previous appendectomy scar. An abscess was additionally found at the operation. Three days later, a second laparotomy became necessary because of multiple intraabdominal interenteric abscesses. A segmental resection had to be performed for a chronic small-bowel stricture. Postoperatively, a subcutaneous wound infection developed. The patient was discharged home on 12th postoperative day. CONCLUSION: Retained surgical towel (gossypiboma) is a rare but well known complication of surgery. It presents a diagnostic problem if there are no symptoms for a long time. To make the correct diagnosis it is important to simply to consider the possibility of gossypiboma after a complicated or unsatisfactory postoperative course.

[Splenic rupture after colonoscopy]. / Die Milzruptur nach Koloskopie.

HISTORY AND CLINICAL FINDINGS: A 57-year-old woman was admitted with nonspecific pain in the left upper quadrant of the abdomen, radiating to her left shoulder, starting eight hours after a prophylactic colonoscopy. Her past surgical history consisted of a pylorus-preserving partial duodenopancreatectomy for chronic pancreatitis. INVESTIGATIONS: After a colon perforation had been excluded ultrasound and computed tomography revealed a covered splenic rupture. TREATMENT AND COURSE: Because the patient was hemodynamically stable she was observed in the intensive care unit with hemodynamic monitoring. When the patient became hemodynamically unstable an ultrasound revealed an increase of the perisplenic fluid. She immediately had an exploratory laparotomy and the spleen wrapped in a Vicryl net. Postoperatively the patient had an uncomplicated hospital stay and was discharged on postoperative day 7. CONCLUSION: Splenic rupture is a known but rare complication of colonoscopy. Early recognition and interdisciplinary management will assure successful management of this potentially life-threatening injury.

[Iatrogenic colon perforation: experiences with early laparoscopy]. / Iatrogene Kolonperforation : Erfahrungen mit der umgehenden laparoskopischen Therapie.

BACKGROUND: Perforation during colonoscopy is a rare but severe complication. PATIENTS AND METHODS: Retrospective analysis was done of 15 patients operated on for perforation from colonoscopy between January 2000 and December 2006. RESULTS: Three perforations occurred during diagnostics and 12 during interventional colonoscopy. Two perforations occurred as transmural thermal injury to the colon wall. Peritonitis was found in four cases and correlated significantly with mean time between perforation and operation. Twelve perforations were sutured laparoscopically and three by laparotomy. Hospital stay was significantly shorter after laparoscopic treatment than by laparotomy. One patient had a postoperative wound infection, and mortality was 0%. CONCLUSION: Early laparoscopic suturing is a safe and effective method in the treatment of perforation from colonoscopy.

"Fast-track" rehabilitation for elective colonic surgery in Germany--prospective observational data from a multi-centre quality assurance programme.

BACKGROUND: The results of "Fast-track" colonic surgery in an unselected population outside of specialised units has been unknown yet. MATERIALS AND METHODS: Data from 24 German hospitals performing "Fast-track" rehabilitation as the standard peri-operative care for patients undergoing elective colonic resection were collected in a prospective multi-centre study conducted between April 2005 and September 2006 to evaluate local and general morbidity. RESULTS: One thousand and forty-seven patients undergoing elective "fast-track" colonic resection were included. Compliance to essential parts of "fast-track" rehabilitation was high (epidural analgesia 86,6%, early oral feeding and mobilisation on the day of surgery 85.5 and 85.4%). Surgical morbidity was observed in 148 patients (14.1%) and general morbidity in 95 patients (9.1%), while mortality was 0.8%. Predefined discharge criteria were met within 5 (1-83) days after surgery, but because of economical restraints in the German DRG system, patients were discharged only after 8 (3-83) days. Re-admission rate was 3.9%. CONCLUSION: "Fast-track" rehabilitation for elective colonic resection was safe and feasible in German hospitals of all sizes and yielded a low general morbidity and re-admission rate. Post-operative recovery was enhanced, but discharge from hospital was delayed because of economical reasons.

Nerve irritation after laparoscopic hernia repair.

BACKGROUND: Between October 1992 and May 1996, 893 hernia repairs were performed at the Surgical Clinic in Mannheim: 448 (50%) using laparoscopy (TAPP-method) and 445 (50%) using the conventional anterior approach (Shouldice). MATERIALS AND METHODS: For this study, 723 (81%) of these repairs were followed up in a prospective trial of postoperative nerve irritations. RESULTS: The rate of nerve entrapment in the laparoscopic group was 4.2% (n = 19), and in the group that underwent conventional surgery 1.8% (n = 8). The genitofemoral nerve was affected with particularly high frequency (2%), and the ilioinguinal nerve and lateral cutaneous nerve of the thigh (LCNT) each was affected in 1.1% of the cases. CONCLUSIONS: Reduction in the number of clips used and careful attention to the anatomic nerve course during preparation and placement of mesh led to a significant reduction in the occurrence of nerve irritations. In the last 100 patients who underwent laparoscopic hernia repair, only one nerve lesion was seen.

Resection of pancreatic cancer--surgical achievements.

INTRODUCTION: Looking back at the initially dismal record for pancreatic cancer surgery - Whipple himself felt that a 30-35% mortality was justifiable (!) - significant progress has been made. PROGRESS: The operative mortality has fallen below 5% and the serious complications of pancretic resections such as leaks and haemorrhage have been reduced to some 10% and we are better equipped to deal with these if they occur. The 5-year-survival of patients in whom pancreatic cancer was amenable to an R0-resection has risen to 30%. These are the surgical achievements using the standard Kausch-Whipple technique alone. There has been no improvement in these results, either by increasing radicality (regional pancreatectomy) or by reducing it (pylorus-preserving pancreatoduodenectomy). The same can be said of all other modalities of oncological treatment that have been tried so far: adjuvant radiochemotherapy, regional chemotherapy, hormonal or genetic manipulations. PERSPECTIVE: This does not mean that we should reduce efforts at improving early detection of the disease and unravelling its complex molecular biology. On the contrary, the results of surgery alone in spite of all improvements seem to have reached a plateau that gives little cause for complacency.

[Vascular surgery within the scope of visceral surgery-oncologic interventions]. / Gefässchirurgie im Rahmen visceralchirurgisch-onkologischer Eingriffe.

The surgeon dealing with oncological operations within the abdominal cavity will be frequently confronted with vascular problems. These include surgically relevant vascular anomalies, arteriosclerotic changes, tumor infiltration of vessels and iatrogenic vascular lesions. The diagnosis, indications and, above all, the vascular surgical techniques applied during oncological procedures on the pancreas and liver are described in this review.

Hemorrhage after pancreatoduodenectomy.

OBJECTIVE: The authors reviewed the hemorrhagic complications of patients who underwent pancreatoduodenectomies between 1972 and 1996. SUMMARY BACKGROUND DATA: Although recent studies have demonstrated a reduction in the mortality of pancreatic resection, morbidity is still high. Bleeding is a close second to anastomotic dehiscence in the list of dangerous postoperative complications. METHODS: The medical records from a prospective data bank of 559 patients who underwent pancreatic resection at the Surgical Clinic of Mannheim (Heidelberg University) were analyzed in regard to postoperative hemorrhagic complications. Differences were evaluated with the Fisher exact test. RESULTS: The overall mortality rate was 2.7%. Postoperative bleeding occurred in 42 patients (7.5%), with 6 episodes ending fatally (14.3%). Erosive bleeding after pancreatic leak was noted in 11 patients (26.2%), 4 of whom died. Gastrointestinal hemorrhage occurred in 22 patients, and operative field hemorrhage was present in 20 cases. Relaparotomy was necessary in 29 patients. An angiography with interventional embolization for recurrent bleeding was performed in three patients. Seven hemorrhages (4.6%) occurred after pancreatectomy for chronic pancreatitis and 35 episodes of bleeding (8.6%) were encountered after pancreatectomy for malignant disease. Obstructive jaundice was present in 359 patients (63.9%). In this group of patients, 32 (8.9%) postoperative hemorrhages occurred. Preoperative biliary drainage did not influence the type and mortality rate of postoperative hemorrhage in jaundiced patients. CONCLUSION: The prevention of these bleeding complications depends in the first place on meticulous hemostatic technique. Preoperative biliary drainage does not lower postoperative bleeding complications in jaundiced patients. Continuous, close observation of the patient in the postoperative period, so as to detect complications in time, and expeditious hemostasis are paramount.

Surgery for early gastric cancer: a European one-center experience.

Between 1972 and 1995 a total of 251 patients with early gastric cancer underwent resection in our department of surgery. At the time of the operation 10.8% of the patients were proved to have lymph node involvement, and two already had distant metastases. A subtotal gastric resection was performed in 59.8% of cases (n = 150), a total gastrectomy in 33.8% (n = 85), and either a proximal or an atypical resection in 6.4% (n = 16). Since 1985 subtotal distal resection and total gastrectomy were accompanied by a systematic lymphadenectomy of compartments I and II. The overall postoperative morbidity was 18.3%, and the hospital mortality, 4.9%; it was only 1.6% within the last decade. Concerning these short-term results there were no statistically significant differences between the different surgical procedures. The cumulative overall 5-year-survival rate was 82.6%. There was no statistically significant influence of either the different surgical procedures or the histologic types according to the Japanese classification of early gastric cancer.

Ultrafast magnetic resonance imaging improves the staging of pancreatic tumors.

OBJECTIVE: This prospective study was undertaken to evaluate the accuracy of a noninvasive "all-in-one" staging method in predicting surgical resectability in patients with pancreatic or periampullary tumors. SUMMARY BACKGROUND DATA: Despite progress in imaging techniques, accurate staging and correct prediction of resectability remains one of the chief problems in the management of pancreatic tumors. Staging algorithms designed to separate operable from inoperable patients to save the latter an unnecessary laparotomy are becoming increasingly complex, expensive, time-consuming, invasive, and not without risks for the patient. METHODS: Between August 1996 and February 1997, 58 consecutive patients referred for operation of a pancreatic or periampullary tumor were examined clinically and by 5 staging methods: 1) percutaneous ultrasonography (US); 2) ultrafast magnetic resonance imaging (UMRI); 3) dual-phase helical computed tomography (CT); 4) selective visceral angiography; and 5) endoscopic cholangiopancreatography (ERCP). The assessment of resectability by each procedure was verified by surgical exploration and histologic examination. RESULTS: The study comprised 40 male and 18 female patients with a median age of 63 years. Thirty-five lesions were located in the pancreatic head (60%), 11 in the body (19%), and 1 in the tail of the gland (2%); there were 9 tumors of the ampulla (16%) and 2 of the distal common duct (3%). All five staging methods were completed in 36 patients. For reasons ranging from metallic implants to contrast medium allergy or because investigations already had been performed elsewhere, US was completed in 57 (98%), UMRI in 54 (93%), CT in 49 (84%), angiography in 48 (83%), and ERCP in 49 (84%) of these 58 patients. Signs of unresectability found were vascular involvement in 22 (38%), extrapancreatic tumor spread in 16 (26%), liver metastases in 10 (17%), lymph node involvement in 6 (10%), and peritoneal nodules in only 2 patients (3%). These findings were collated with those of surgical exploration in 47 patients (81 %) and percutaneous biopsy in 5 (9%); such invasive verification was deemed unnecessary and therefore unethical in 6 clearly inoperable patients (10%). In assessing the four main signs of unresectability (extrapancreatic tumor spread, liver metastases, lymph node involvement, and vascular invasion), the overall accuracy of UMRI was 95.7%, 93.5%, 80.4%, as compared to 85.1%, 87.2%, 76.6% for US and 74.4%, 87.2%, 69.2% for CT. In assessing vascular invasion, the sensitivity, specificity, and overall accuracy of angiography were 42.9%, 100%, and 68.8%, respectively. There were 3 complications (12.5%) after 24 resections, 5 in 17 palliative procedures, and none after 6 explorations only. The hospital stay was 14 days after resection, 13 after palliative bypass, and 6 after exploration alone. There was no operative or hospital mortality in these 58 cases. CONCLUSIONS: Although it is by no means 100% accurate, UMRI is equal or even superior to all other staging methods. It probably will replace most of these, because it provides an "all-in-one" investigation avoiding endoscopy, vascular cannulation, allergic reactions, and x-radiation. But because even UMRI is not perfect, the final verdict on resectability of a tumor still will depend on surgical exploration in some cases.