Intermittent activity-induced hemobilia caused by liver hemangioma.

BACKGROUND: Intestinal bleeding of unknown origin can lead to a difficult workup. Abdominal colic, melena/hematemesis, and jaundice represent the pathognomonic triad for hemobilia, but clinical presentation and etiology of this entity are varying. Seldom all of these symptoms are present, and rarely does hemobilia cause melena or hematemesis. Often the correct diagnosis is missed. Patients frequently have a long history of complaints and inadequate therapy. CASE REPORT: We report on a patient who complained of repeated, severe epigastric pain and massive melena induced by exercise activity. After 2 years of complaints and an unnecessary operation, ultrasound detected a liver hemangioma. It was supposed that the hemangioma was causing hemobilia during strenuous physical activity. The patient underwent a partial liver resection to eliminate the hemangioma. All complaints resolved, and the patient remained asymptomatic postoperatively. CONCLUSIONS: Physicians should be aware of hemobilia as a rare cause of upper gastrointestinal bleeding, especially if esophagogastroduodenoscopy cannot demonstrate any bleeding source. Ultrasound is able to visualize many diseases leading to hemobilia and should be integrated into the early workup of unclear intestinal bleedings.

Vascular injuries within the hepatoduodenal ligament: recognition by laparoscopic color Doppler ultrasound.

BACKGROUND: Lesions of vascular structures are rare but serious complications of laparoscopic cholecystectomy. The purpose of this blind randomized animal study was to investigate the possibility of detecting different vascular lesions within the hepatoduodenal ligament using laparoscopic color Doppler ultrasound (LCDU). METHODS: Twenty-four lesions of the hepatic artery and portal vein were created laparoscopically in six farmer pigs using titanium clips. The following injuries were studied: (a) partial occlusion of the hepatic artery (eight cases), (b) complete occlusion of the hepatic artery (eight cases), (c) partial occlusion of the portal vein (eight cases). There were also eight cases without lesions of the vascular vessels. The order in which the injuries were created was randomly assigned. The study was performed in a blind fashion. Recognition of the injuries was attempted with LCDU. RESULTS: All injuries were recognized correctly by LCDU. There were no false positive results. The clips were reliably located. Using color Doppler imaging, partial occlusions of the hepatic artery and portal vein were visualized by changes of the blood flow from laminar to turbulent behind the clip. Complete occlusion of the hepatic artery was recognized as a complete cessation of the colored blood flow. CONCLUSION: LCDU is a very efficient tool for visualizing vascular structures and evaluating the bloodstream. Partial or complete vascular occlusion by clips that may occur as a result of difficult dissection during laparoscopic cholecystectomy can be visualized reliably using this technique.

Laparoscopic ultrasonography reliably visualizes bile-duct injuries - a blind randomized porcine study.

INTRODUCTION: Despite use of intraoperative cholangiography (IOC), only one-third or less of bile duct injuries that occur during laparoscopic cholecystectomy are detected at the primary operation. Therefore, there is a need to investigate other intraoperative diagnostic methods, especially laparoscopic ultrasound, for detecting bile-duct injuries. MATERIALS AND METHODS: Detection of different bile-duct injuries by laparoscopic intraoperative ultrasonography was evaluated in a blind, randomized animal study. Fifty bile-duct injuries were created using laparoscopic techniques in 23 pigs. The number of single lesions and the order in which the injuries were created was randomly assigned. The lesions created were: (1) partial occlusion by a clip, (2) complete occlusion by a clip, (3) partial laceration, (4) transection without clips, (5) transection between clips and (6) excision between clips. In addition, there were cases without lesions. Different types of clips were used. A screening of the injuries by laparoscopic ultrasound using a flexible probe was attempted. The study was performed in a blind fashion. RESULTS: Complete ultrasonographical imaging of the hepatic and common bile duct between its bifurcation and its insertion into the duodenum was accomplished in all 23 animals before surgery was performed. Eight cases without lesions were correctly recognized. In 48 of 49 cases, the injuries were detected (sensitivity 98%). In one instance, the injury was obvious without the use of ultrasound. Forty-four cases were correctly diagnosed and, in 12 cases, the injuries were equivocally differentiated (specificity of 100%, overall accuracy of 98.3%). There was only one false diagnosis. The different types of clips were also reliably differentiated. CONCLUSIONS: We conclude that laparoscopic ultrasonography can reliably visualize most relevant bile-duct injuries. A standard for doing the ultrasound examination is proposed. Direct and indirect ultrasound signs of bile-duct injuries are explained.

Prospective randomized comparison of laparoscopic ultrasonography using a flexible-tip ultrasound probe and intraoperative dynamic cholangiography during laparoscopic cholecystectomy.

BACKGROUND: We performed a prospective randomized comparison of laparoscopic intraoperative ultrasonography (LIOU) and dynamic intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). METHODS: LIOU and IOC were attempted in 518 consecutive patients scheduled for laparoscopic cholecystectomy. The order in which the diagnostic procedures were performed was randomly assigned. RESULTS: LIOU failed in two patients (0.4%), and there were 41 (7.9%) failed IOC. The common bile duct (CBD) was visualized reliably with both methods. Our patients showed sensitivities of 83.3% and 100% and specificities of 100% and 98.9%, with an overall accuracy of 99.2% and 98.9% for LIOU as compared to IOC for identifying unsuspected common bile duct stones. The time necessary for the examination was significantly shorter in LIOU than in IOC (7 versus 16 min). CONCLUSION: LIOU performed by experienced surgeons is a good and effective method to assess the CBD, including the neighboring structures of hepatoduodenal ligament. Using powerful, flexible-tip ultrasound probes, CBD exploration can be done in a longitudinal fashion, which is necessary for good anatomical clarity. A lack of adverse effects, shorter examination times, and lower costs are some of the advantages of this method. The most important advantage is the possibility of unlimited repetition, especially if there is difficulty identifying anatomic structures. In addition, there are some indications that LIOU has the potential to recognize major iatrogenic bile duct injuries.

[Online infection recording within the scope of total quality management]. / Online-Infektionserfassung im Rahmen des Total Quality Management.

The continuous and exact recording of infections is a condition sine qua non for total quality management. Therefore, at the Diakoniekrankenhaus Rotenburg (Wümme) a program which offers the possibility of online recording of data was integrated into the hospital intranet. The recording is done with network clients. The recording of data is supported by a series of plausibility controls. The advantage consists in immediate evaluation of up to date and extensive statistics of infections. By integration into the existing system, relevant influences and consequences such as the prolongation of hospitalisation, use of material, and frequency of reoperation can by recognized and immediately considered with high validity.

Laparoscopic transabdominal preperitoneal hernioplasty: results of 1000 consecutive cases.

From October 1992 until September 1995, 859 patients with 1000 inguinal hernias underwent a transabdominal preperitoneal mesh repair (TAPP) in the First Department of Surgery of the Diakonie-Hospital Rotenburg/Wümme, Germany. One hundred and seventeen of these repairs were for recurrences after previous open hernia surgery. There were 76 (7.6%) peri- and postoperative complications, but most of them were minor without necessity for surgical intervention. There were no implant infections or any adverse reaction of the mesh. During the postoperative follow-up period, which ranged from 2-36 months, 11 early recurrences were observed after TAPP, but none were in the recurrent hernia group. Our results support other studies and randomized trials reported in the literature and demonstrate that TAPP is an effective and safe operative procedure especially for the repair of recurrent groin hernias.

[Laparoscopic cholecystectomy--benefit or risk?]. / Laparoskopische Cholezystektomie--Nutzen oder Risiko?

A comparing observation between 600 patients with laparoscopic cholecystectomy and 921 conventionally operated patients reveals that while achieving the same standard of results, the laparoscopic cholecystectomy does not lead to an increased rate of complications. With the operating time slightly prolonged, there is quick freedom from pain, short hospitalization and a short period of convalescence. Thus the laparoscopic cholecystectomy appears to meet the standard of conventional cholecystectomy despite higher demands regarding personnel and materials. It is not only characterized by being better accepted by the patient, but also seems to represent an adequate therapy for symptomatic cholelithiasis from the economic point of view.

Effect of pacing on small intestinal motor activity and hormonal response in dogs.

In seven beagle dogs with a Thiry-Vella loop, the effect of pacing on small intestinal motor activity was examined by means of extraluminal strain gauge force transducers. Recordings were obtained from the loop and from the remaining small intestine. Our study showed that pacing of the loop results in a significant reduction of the motility of the loop in the overnight fasted state (up to 39%), during loop feeding (up to 55%), and oral feeding (up to 39%); a similar reduction of the motility of the remaining small intestine (up to 43%); and a significant postprandial increase of insulin (9.0 microU/ml) and decrease of glucagon (94 pg/ml). The motility reduction of the loop and of the remaining small intestine as well as the anabolically improved pancreatic endocrine function (shown by an increase of the insulin-glucagon ratio) suggests that this form of pacing could be of benefit for motility disorders with decreased transit time.

[Intestino-esophageal reflux following gastrectomy. Mechanism of action and effectiveness of esophago-jejunoplication]. / Intestino-oesophagealer Reflux nach Gastrektomie. Wirkungsmechanismus und Effektivität der Oesophago-Jejunoplicatio.

The influence of the type of reconstruction after gastrectomy upon the postoperative reflux was analyzed in 30 patients. The refluxed material could be directly gained by the long-term reflux aspiration test and, thus, the quality including bile acids could be evaluated. After esophago-jejunoplication and Roux en Y-derivation 5 out of 7 patients were asymptomatic; only one patient suffered from mild esophagitis. Total bile acid concentration was near to the test systems sensitivity. The result in 11 patients after esophago-jejunostomy without Y-en Roux, but with a preserved lower esophageal sphincter (LES) are similar to the former group, whereas in all cases of 12 patients in whom the LES was resected, severe reflux esophagitis and excessively elevated bile acid concentrations were present. These results confirm that a jejunoplication supports the antireflux effect of preserved parts of the LES. If--for oncologic reasons--the LES has to be resected, free intestinal-esophageal reflux is following. In these cases a Roux en Y-derivation is required.

[Motility disorders of the esophagus in progressive systemic scleroderma. Pathophysiology, diagnosis and therapy]. / Motilitätsstörungen des Oesophagus bei progressiver systemischer Sklerodermie. Pathophysiologie, Diagnostik, Therapie.

Gastrointestinal manifestations of collagen diseases are frequent. In progressive systemic sclerosis esophageal involvement is found in 60% of cases and is thus the main gastrointestinal complication. Atrophy of the smooth muscle and fibrotic degeneration of the distal esophagus result in progressive motility disorders which may cause severe reflux esophagitis with typical consequences, such as stenosis and strictures. Manometry and cinematography are basic diagnostic procedures. Esophagoscopy and long-term pH-monitoring are most useful for evaluating the degree of esophageal involvement. The severity of sclerodermatous motility disorders should be classified according to a modification of the Garrett scale, which is particularly recommended for determining the further prognosis and therapeutic approach. Esophageal involvement of grades I and II should be treated conservatively, whereas grade III is a clear indication for surgical therapy. The original Nissen type of fundoplication or distal gastric resection with Roux-en-Y anastonosis are the methods of choice.

[Treatment guidelines in intestinal burns]. / Behandlungsrichtlinien bei der intestinalen Verätzung.

Intestinal burns due to ingestion of acids or alkaline materials still put the physician in a difficult position because until now it is not possible to correlate the amount of ingested material to the extent of damage that can be expected. Furthermore, there are no objective criteria to determine the depth of the burn. Diagnosis is based on endoscopy. Mild, moderate and severe damage can be differentiated endoscopically. Mild and moderate burns are not operated upon primarily. Surgery is indicated with moderate burns whenever complications occur during intensive care treatment, and generally with severe corrosive burns. Operative management depends on intraoperative findings.

Computer-aided oesophageal manometry: prospects and problems.

We describe a method in which computer-aided analysis has been applied to oesophageal manometry, and address some of the major problems which were encountered. The elimination of pressure artefacts caused by respiration and normal cardiac function is necessary in order to define accurately the parameters required from the analysis. The most promising method of solving this signal/noise problem is to include a fast Fourier transform in the analytical program.

[Stomach cancer--the current situation from the surgical viewpoint]. / Magenkarzinom--Bestandsaufnahme aus chirurgischer Sicht.

From July 1st 1982 to December 31st 1986, 359 patients with a histologically confirmed gastric carcinoma were operated on. At the beginning of therapy, 44.3% were in the pathological anatomical stages I and II, 55.7% in stages III and IV (UICC 1987). 307 patients could be resected (resection rate 85.5%). The proportion of R0 resections (no residual tumor) was 61.9%, R1 resections (microscopically demonstrable tumor residues) 23.1% and R2 resections (macroscopical tumor residues) 15%. Overall, a curative resection could be carried out in 61.9% of the cases and a palliative resection in 38.1% of the cases. In 21.5%, a subtotal gastric resection, in 48.2% a total gastrectomy and in 30.3% an extended total gastrectomy was necessary in addition. The lethality was 3.0% for subtotal resection, 5.4% for the simple total gastrectomy and 9.6% for the extended total gastrectomy. The prognosis corresponds to the tumor stage at the beginning of therapy (three year actuarial survival: stage I 76%, stage II and III 26%, stage IV 7%).

[Esophagitis--hiatal hernia--indications and choice of procedure: alternative technics]. / Oesophagitis--Hiatushernie--Indikation und Verfahrenswahl: Alternative Techniken.

At present the clinical and experimental results allow only for Angelchik's silicone-antirefluxprosthesis as an alternative to Nissen-Rossetti fundoplication technique. Until now, there is no reproducible clinical evidence for the efficiency of hernia-repair alone as well as for measures with the aim of anatomical reconstruction of the gastric entrance region; on the other hand, these methods show rates of recurrence of reflux up to 66%. Thus, the latter operative techniques should meanwhile be considered obsolete.

[Esophageal carcinoma: transthoracic esophagectomy with regional lymphadenectomy and reconstruction with deferred priority]. / Osophaguskarzinom: transthorakale Osophagektomie mit regionaler Lymphadenektomie und Rekonstruktion mit aufgeschobener Dringlichkeit.

In a retrospective analysis the risks were assessed of transthoracic oesophagectomy with mediastinectomy and regional lymphadenectomy followed 48-72 hours later by an abdomino-cervical operation with supra-pancreatic lymphadenectomy, retrosternal gastric interposition and cervical oesophageal stump anastomosis. Results in this group of 37 patients were compared with those in a group of 42 patients who had undergone a transmediastinal oesophagectomy (without thoracotomy) and immediate reconstruction. The 30-day death rate was 8.1% in the former (group I) and 7.1% in the latter (group II), total hospital death rate 10.8% and 11.9%, respectively. The complication rate was similar in the two groups, as was the recorded operative stress. The results indicate that the risk of an oncologically indicated oesophagectomy with regional lymphadenectomy is no greater than that of a palliative transmediastinal oesophagectomy.