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1.
Life (Basel) ; 14(7)2024 Jun 27.
Artículo en Inglés | MEDLINE | ID: mdl-39063574

RESUMEN

Anastomotic insufficiencies are severe complications of abdominal surgery, often leading to prolonged hospitalization, serious tissue inflammation, and even sepsis, along with the need for recurrent surgery. Current non-surgical treatments such as self-expanding metal stents (SEMSs) and endoscopic vacuum therapy (EVT) have limitations, including stent migration or perforation. This review evaluates the effectiveness of the VacStent GITM (Möller Medical GmbH, Fulda, Germany), a novel medical device combining SEMS and negative-pressure wound therapy in treating gastrointestinal leaks. Data were gathered from four prospective studies and compared with existing treatments. Studies on the VacStent GITM application demonstrate technical success and competitive closure rates in upper gastrointestinal leaks, with minimal complications reported. Comparative analyses with SEMS and EVT reveal promising and most importantly equally good outcomes while maintaining the possibility for sustained enteral nutrition and reducing the risk of stent migration. The VacStent GITM presents a promising alternative to current non-surgical treatments. Ongoing research aims to validate its efficacy in lower gastrointestinal leaks and comprehensively establish its role in leak management. Further investigation is necessary to confirm these findings and optimize treatment protocols. Future usages of the VacStent GITM in colonic anastomotic insufficiencies promise an effective approach and might be able to lower the rates of necessary implementations of a stoma.

2.
Langenbecks Arch Surg ; 409(1): 234, 2024 Jul 31.
Artículo en Inglés | MEDLINE | ID: mdl-39083099

RESUMEN

PURPOSE: Anastomotic leak (AL) represents the most relevant and devastating complication in colorectal surgery. Endoscopic vacuum therapy (EVT) using the VACStent is regarded as a significant improvement in the treatment of upper gastrointestinal wall defects. The innovative concept of the VACStent was transferred to the lower GI tract, gaining initial experience by investigating safety and efficacy in 12 patients undergoing colorectal resections. METHODS: The pilot study, as part of a German registry, began with 2 patients suffering from AL, who were treated with the VACStent after stoma placement. Subsequently, 6 patients with AL were treated with the VACStent omitting a stoma placement, with a focus on fecal passage and wound healing. Finally, the preemptive anastomotic coverage was investigated in 4 patients with high-risk anastomoses to avoid prophylactic stoma placement. RESULTS: In total 26 VACStents were placed without problems. The conditioning and drainage function were maintained, and no clogging problems of the sponge cylinder were observed. No relevant clinical VACStent-associated complications were observed; however, in 2 patients, a dislodgement of a VACStent occurred. The 6 patients with AL but without stoma had a median treatment with 3 VACStents per case with a laytime of 17 days, leading to complete wound healing in all cases. The 4 prophylactic VACStent applications were without complications. CONCLUSION: The clinical application of the VACStent in the lower GI tract shows that successful treatment of anastomotic colonic leaks and avoidance of creation of an anus praeter is possible. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov NCT04884334, date of registration 2021-05-04, retrospectively registered.


Asunto(s)
Fuga Anastomótica , Humanos , Proyectos Piloto , Fuga Anastomótica/prevención & control , Femenino , Masculino , Persona de Mediana Edad , Anciano , Estomas Quirúrgicos/efectos adversos , Terapia de Presión Negativa para Heridas , Resultado del Tratamiento , Anastomosis Quirúrgica/efectos adversos , Anciano de 80 o más Años , Adulto
3.
Front Surg ; 10: 1133083, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-37066006

RESUMEN

Introduction: Endoscopic treatment by vacuum therapy (EVT) or covered stents has emerged as an improved treatment option for upper gastrointestinal wall defects and is regarded as an improved treatment option for anastomotic leakage (AL) after esophagectomy. However, endoluminal EVT devices may lead to obstruction of the GI tract; and a high rate of migration and missing functional drainage has been shown for covered stents. The recently developed VACStent, a combination of a fully covered stent within a polyurethane sponge cylinder may overcome these issues allowing EVT while stent passage is still open. Initial clinical applications have demonstrated efficacy, practicability and safety in the treatment of esophageal leaks (AL). Methods: In this pilot study, 9 patients with high-risk anastomosis after neoadjuvant therapy undergoing hybrid esophagectomy received the VACStent in a preemptive setting for the assessment of the reduction of the AL rate, postoperative morbidity and mortality. Results: Technical success of the application of the VACStent® was achieved in all interventions. One patient experienced anastomotic leakage 10 days after esophagectomy and was successfully treated with two consecutive VACStents and a VAC Sponge. In summary, mortality in-hospital was 0% and anastomotic healing was uneventful without septic episodes. No severe device-related adverse events (SADE) nor significant local bleeding or erosion could be observed. Oral intake of liquids or food was documented in all patients. The device handling was regarded uncomplicated. Discussion: The preemptive application of the VACStent offers a promising new option for improved clinical treatment avoiding of critical situations in hybrid esophagectomy, which should be validated in a large clinical study.

4.
Langenbecks Arch Surg ; 407(2): 655-662, 2022 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-34964915

RESUMEN

PURPOSE: Hysterectomy alters the anatomy of the posterior vaginal vault used as access for transvaginal/transumbilical hybrid NOTES cholecystectomy (NC), creating potential consequences for the feasibility and complication rate of the procedure. Therefore, the aim of our retrospective analysis of prospectively collected data was to analyze the postoperative course after NC in previously hysterectomized (PH) patients compared with patients who had not undergone hysterectomy (NH). METHODS: A total of 126 NH patients and 50 PH patients aged over 42 who had an NC from 12/2008 to 04/2021 were compared regarding age, body mass index (BMI), ASA classification, number of percutaneous trocars, need for intraoperative urinary bladder catheterization, length of procedure, conversion rate, and intraoperative and postoperative complication rate according to the Clavien/Dindo classification, Comprehensive Complication Index (CCI), mortality, and hospital length of stay. RESULTS: PH patients were older than NH patients (63.0 vs 51.5 years; P < 0.001) but did not differ significantly in ASA classification (P = 0.595) and BMI (26.8 vs 27.9 kg/m2; P = 0.480). They required more percutaneous trocars (P = 0.047) and longer procedure time (66.0 vs. 58.5 min; P = 0.039). Out of all 287 scheduled NC only one had to be "converted" to traditional laparoscopic cholecystectomy. Intraoperative and postoperative complication rates, Clavien/Dindo classification, CCI, need for intraoperative urinary bladder catheterization, and length of stay did not differ significantly. CONCLUSION: Our results indicate an increased degree of difficulty of NC in PH patients, although there is no major impact on intraoperative and postoperative complication rates. Urinary bladder perforation is a specific access-related complication in PH patients.


Asunto(s)
Colecistectomía Laparoscópica , Cirugía Endoscópica por Orificios Naturales , Anciano , Colecistectomía/efectos adversos , Colecistectomía/métodos , Colecistectomía Laparoscópica/efectos adversos , Colecistectomía Laparoscópica/métodos , Femenino , Humanos , Histerectomía/efectos adversos , Cirugía Endoscópica por Orificios Naturales/efectos adversos , Cirugía Endoscópica por Orificios Naturales/métodos , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Vagina/cirugía
5.
Clin Pract ; 11(3): 532-542, 2021 Aug 18.
Artículo en Inglés | MEDLINE | ID: mdl-34449573

RESUMEN

BACKGROUND: In patients with prostatic and breast cancer the application of peridural anesthesia (PDA) showed a beneficial effect on prognosis. This was explained by reduced requirements for general anesthetics and perioperative opioids as well as a lower perioperative stress level. The impact of PDA in patients with more aggressive types of cancer has not been completely elucidated. Here, we analyzed the prognostic influence of PDA on overall survival after surgery as primary in patients that underwent radical resection of pancreatic adenocarcinoma. METHODS: Records of 98 consecutive patients were reviewed. In 70 of these cases PDA was applied. Patient characteristics such as demographics, TNM stage, and operative data were retrospectively collected from medical records and analyzed. Survival data were analyzed by Cox's proportional hazard regression model. RESULTS: Overall, no significant prognostic influence of PDA on recurrence or overall survival (p = 0.762, Hazard Ratio [HR] 0.884, 95% confidence interval [CI] 0.398-1.961) was found. However, there was a trend towards a longer overall survival (p = 0.069, HR 0.394, 95% CI 0.144-1.078) associated with PDA in a subgroup of patients with better differentiation of pancreatic adenocarcinoma. CONCLUSION: The observation of longer survival associated with PDA in our subgroup of patients with better-differentiated pancreatic carcinomas is in line with previous reports on various other less aggressive tumor entities. Our results indicate that PDA might improve the oncological outcome of patients with pancreatic adenocarcinoma.

6.
Endosc Int Open ; 9(6): E971-E976, 2021 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-34079885

RESUMEN

Background and study aims Endoscopic treatment has markedly improved the high morbidity and mortality in patients with upper gastrointestinal tract leakage. Most procedures employ either covered self-expanding metal stents (SEMS) or endoscopic vacuum therapy (EVT), both with good clinical success but also with concomitant significant shortcomings inherent in each technique. A newly developed device, the VACStent, combines the fully covered SEMS with a polyurethane sponge cylinder anchored on the outside. This allows endoluminal EVT while keeping the intestinal lumen patent. The benefit is prevention of stent migration because the suction force of the sponge-cylinder immobilizes the VACStent on the intestinal wall, while at the same time, the attached external vacuum pump suctions off any secretions and improves healing with negative-pressure wound treatment (NPWT). Patients and methods In this pilot study, the first patients to receive the VACStent were assessed. Outcomes included the applicability and stability of the VACStent system together with the clinical course. Results Three patients with different clinical courses were managed with the VACStent. The first patient suffered anastomotic leakage following subtotal esophagectomy and was successfully treated with two postoperative VACStents for 12 days. The second patient received a covered SEMS for 14 days for acute Boerhaave syndrome. Due to persistent leakage, management was converted to EVT. Seven days, later a VACStent was inserted to allow oral nutrition while the leak finally closed. In the third patient, a LINX Reflux Management System had to be removed for erosion, leaving the gastroesophageal junction (GEJ) with a full-thickness gap. After VACstent insertion, successful closure was achieved within 4 days. Conclusions These clinical cases demonstrate the applicability and efficacy of the VACstent in management of esophageal and anastomotic leakage. With its vacuum sponge, the stent fosters wound healing while the covered SEMS keeps the passage patent for nutrition.

7.
Langenbecks Arch Surg ; 397(7): 1099-107, 2012 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-22722636

RESUMEN

PURPOSE: The increasing detection of adrenal tumors and the availability of a more sophisticated biochemical work-up leading to rising numbers of sub-clinical Conn's and Cushing's syndromes coincide with a rising number of adrenalectomies worldwide. The aim of our study was to report a single institution's experience with adrenal surgery. METHODS: We report data of 528 adrenalectomies, operated at our institution before and after the onset of minimally invasive endoscopic surgery (1986-1994, 1995-2008). Gender, age, indication, imaging, surgical approach, operating time, histology, tumor size, hospital stay, and complications were analyzed retrospectively. RESULTS: A total of 478 patients underwent adrenal surgery during the time observed. The average number of yearly adrenalectomies increased from 14 to 21 (p = 0.001) after the onset of laparoscopic surgery. Imaging techniques showed a significant shift towards magnetic resonance imaging (p < 0.001) and preoperative assessment of tumor size was significantly correlated to malignancy: 10.8 % (11/102) and 42 % (21/50) of tumors measuring 4-6 cm and ≥6 cm, respectively, were malignant in the final histology report (p < 0.001). Patients operated by minimally invasive endoscopy were significantly younger (mean 49.4 years, p = 0.046), had significantly shorter operating times (mean 118 min, p < 0.001), had shorter hospital stays (mean 7.1 days, p < 0.001), and had less complications (6.9 %, p = 0.004) compared to patients resected through open procedures. CONCLUSION: Although adrenalectomy rates increased and minimally invasive endoscopic surgery reduced hospital stay and complications at our institution, the yearly number of procedures was still low with often high surgical complexity. We therefore believe that adrenal surgery remains a highly specialized procedure that should preferably be performed at endocrine surgery centers.


Asunto(s)
Neoplasias de las Glándulas Suprarrenales/cirugía , Glándulas Suprarrenales/cirugía , Adrenalectomía/métodos , Neoplasias de las Glándulas Suprarrenales/patología , Glándulas Suprarrenales/patología , Distribución de Chi-Cuadrado , Diagnóstico por Imagen , Femenino , Alemania/epidemiología , Humanos , Laparoscopía/métodos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Resultado del Tratamiento
8.
Artículo en Inglés | MEDLINE | ID: mdl-26504694

RESUMEN

OBJECTIVE: Rectovaginal fistulae (RVF) are a serious and debilitating problem for patients and a challenge for the treating surgeons. We present our experiences in the surgical treatment of these patients. METHODS: Study population consisted of 22 consecutive patients (range 26-70 years) with RVF treated in our department between 2003 and 2009. 13 RVF were observed after colorectal or gynaecological surgery, 3 occurred after radiotherapy, 2 due to tumour infiltration, 4 because of local inflammation (3x diverticultis, 1x ulcus simplex recti). The RVF was classified in all patients before treatment as either 'low' or 'high'. RESULTS: Local procedures (transvaginal excision, preanal repair) as initial treatment were performed in 9 patients with low fistula. In 13 cases with high fistula an abdominal approach was performed to close the fistula. A recurrence was observed in 8/22 cases (36%), which were treated by a gracilis flap (n=2), a bulbospongiosus composite (n=1), a second abdominal approach (n=4), and a re-local excision (n=1). Ultimatively, in 19 cases the defect healed but in 3 patients the RVF persisted. CONCLUSIONS: Most important predictor of healing/failure is etiology followed by localization and recurrence of the RVF. Local (preanal, transvaginal) procedures are suitable for low RVF, whereas abdominal surgery is necessary in high RVF. In recurrent RVF, muscle flaps are promising procedures.

9.
Ann Surg ; 255(1): 79-85, 2012 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-22156926

RESUMEN

OBJECTIVE: This study was designed to evaluate the clinical outcome of patients undergoing portal vein embolization (PVE) and autologous CD133 bone marrow-derived stem cell (CD133+ BMSC) application before extended right hepatectomy. BACKGROUND: We have previously shown that portal venous infusion of CD133+ BMSCs substantially increases hepatic proliferation, when compared with PVE alone. METHODS: : Among 40 consecutive patients with a median follow-up of 28 months (7.4-57.2) scheduled for extended right hepatectomy, we compared a preconditioned group with PVE and CD133+ BMSC cotreatment (PVE+SC group, n = 11) and a group pretreated only with PVE (PVE group, n = 11). Functional and overall outcomes after extended right hepatectomy were evaluated. Patients without presurgical treatment served as controls (n = 18). RESULTS: In preconditioned patients, mean hepatic growth of segments II/III 14 days after PVE in the PVE+SC group was significantly higher (138.66 mL ± 66.29) when compared with that of PVE group patients (62.95 mL ± 40.03; P = 0.004). There were no significant differences among all 3 groups regarding general and oncological characteristics and functional parameters on postoperative day (POD) 7. Lack of hepatic preconditioning, extrahepatic extension of resection, and postoperative complications were of negative prognostic value, using univariate analysis (P < 0.05). In multivariate analysis, freedom from postoperative major complications (P = 0.012), coagulation status on POD 7 (international normalized ratio < 1.4; P = 0.027), and presurgical expansion of the future liver remnant volume (P = 0.048) were positively associated with overall survival. Post hoc analysis revealed a better survival for the PVE+SC group (P = 0.028) compared with the PVE group (P = 0.094) and compared with controls. CONCLUSION: Promising data from this survival analysis suggest that PVE, together with CD133+ BMSC pretreatment, could positively impact overall outcomes after extended right hepatectomy.


Asunto(s)
Antígenos CD , Trasplante de Médula Ósea , Embolización Terapéutica , Glicoproteínas , Hepatectomía/métodos , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Regeneración Hepática/fisiología , Péptidos , Vena Porta , Antígeno AC133 , Anciano , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Pruebas de Función Hepática , Neoplasias Hepáticas/mortalidad , Masculino , Persona de Mediana Edad , Tomografía Computarizada Multidetector , Estadificación de Neoplasias , Complicaciones Posoperatorias/mortalidad , Cuidados Preoperatorios , Estudios Retrospectivos , Análisis de Supervivencia , Acondicionamiento Pretrasplante
10.
Strahlenther Onkol ; 187(10): 656-64, 2011 Oct.
Artículo en Alemán | MEDLINE | ID: mdl-21858416

RESUMEN

BACKGROUND: Hemangiosarcomas of the breast represent a rare disease of the breast mainly occurring as secondary neoplasias with a latency of 5-10 years after primary treatment of breast cancer and are associated with an unfavourable prognosis. Radiation therapy, which is integrated within the concept of breast conserving therapy ranks as the main risk factor. PATIENTS AND METHODS: In this report we describe the clinical course of 4 patients including their molecular genetic pattern and give a summary of the actual literature. RESULTS: Hemangiosarcomas occur as a secondary neoplasm with a latency of 5-10 years after primary treatment of breast cancer and have an unfavorable prognosis. A genetic predisposition is assumed, but we could not find a significant role of tumor suppressor genes BRCA1, BRCA2 or p53 in our patients. CONCLUSION: Due to limited data available for these tumors, recommendations for therapy include radical tumor resection achieving wide free margins and inconsistent regimens of chemo- and/or immunetherapy modalities. In the majority these are based on systemic therapy regimens for other cutaneous sarcomas, such as Kaposi's sarcoma. Efforts should be taken for a nation-wide systematic registration of all cases of post-irradiation hemangiosarcomas.


Asunto(s)
Neoplasias de la Mama/genética , Neoplasias de la Mama/radioterapia , Neoplasias de la Mama/cirugía , Genes Supresores , Hemangiosarcoma/diagnóstico , Hemangiosarcoma/genética , Mastectomía Segmentaria , Neoplasias Inducidas por Radiación/diagnóstico , Neoplasias Inducidas por Radiación/genética , Neoplasias Primarias Secundarias/diagnóstico , Neoplasias Primarias Secundarias/genética , Patología Molecular , Adulto , Anciano , Proteína BRCA2/genética , Neoplasias de la Mama/diagnóstico , Quimioterapia Adyuvante , Terapia Combinada , Análisis Mutacional de ADN , Diagnóstico Diferencial , Resultado Fatal , Femenino , Humanos , Persona de Mediana Edad , Recurrencia Local de Neoplasia/diagnóstico , Recurrencia Local de Neoplasia/genética , Radioterapia Adyuvante/efectos adversos , Colgajos Quirúrgicos , Proteína p53 Supresora de Tumor/genética , Ubiquitina-Proteína Ligasas/genética
11.
Prostaglandins Other Lipid Mediat ; 94(1-2): 25-33, 2011 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-21167292

RESUMEN

Cytochrome P450 epoxygenases (CYP450) have been recently shown to promote malignant progression. Here we investigated the mRNA and protein expression and potential clinical relevance of CYP2C9 in esophageal cancer. Highest expression was detected in esophageal adenocarcinoma (EAC; n=78) and adjacent esophageal mucosa (NEM; n=79). Levels of CYP2C9 in EAC and NEM were significantly higher compared to esophageal squamous cell carcinoma (ESCC; n=105). Early tumor stages and well-differentiated tumors showed a significantly higher CYP2C9 expression compared to progressed tumors. Moreover, CYP2C9 expression was correlated to high Ki-67 labeling indices in EAC and Ki-67 positive tumor cells in EAC and ESCC. Selective inhibition of CYP2C9 decreased tumor cell proliferation (KYSE30, PT1590 and OE19) in vitro, which was abolished by 11,12-epoxyeicosatrienoic acid (11,12-EET). Cell-cycle analysis using FACS revealed that inhibition of CYP2C9 leads to a G0/G1 phase cell-cycle arrest. CYP2C9 seems to be relevant for early esophageal cancer development by promoting tumor cell proliferation. Pharmacological inhibition of CYP2C9 might contribute to a more efficient therapy in CYP2C9 highly expressing esophageal cancers.


Asunto(s)
Hidrocarburo de Aril Hidroxilasas/metabolismo , Carcinoma de Células Escamosas/enzimología , Carcinoma de Células Escamosas/patología , Proliferación Celular , Neoplasias Esofágicas/enzimología , Neoplasias Esofágicas/patología , Ácido 8,11,14-Eicosatrienoico/análogos & derivados , Ácido 8,11,14-Eicosatrienoico/farmacología , Hidrocarburo de Aril Hidroxilasas/genética , Línea Celular Tumoral , Citocromo P-450 CYP2C9 , Progresión de la Enfermedad , Fase G1 , Humanos , Inmunohistoquímica , Fase de Descanso del Ciclo Celular
12.
Arab J Urol ; 9(2): 93-9, 2011 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-26579275

RESUMEN

OBJECTIVE: Despite many efforts to prevent ureteric stenosis in a transplanted kidney, this complication occurs in 3-5% of renal transplant recipients. Balloon dilatation (BD) is a possible minimally invasive approach for treatment, but reports to date refer only to the antegrade approach; we analysed our experience with retrograde BD (RBD) and reviewed previous reports. PATIENTS AND METHODS: From October 2008 to February 2011, eight patients after renal transplantation (RTX) underwent RBD for transplant ureteric stenosis at our hospital. We retrospectively analysed the outcome and reviewed previous reports. RESULTS: The eight recipients (five men and three women; median age 55 years, range 38-69) were treated with one or two RBDs for transplant ureteric stenosis. There were no complications. The median (range) time after RTX was 4.5 (2.5-11) months. Long-term success was only achieved in one recipient, while five patients were re-operated on (three with a new implant, two by replacement of transplanted ureter with ileum) after a median (range) of 2.8 (0.7-7.0) months after unsuccessful RBD(s). For two recipients the success remained unclear (one graft loss due to other reasons, one result pending). When the first RBD was unsuccessful there was no improvement with a second. CONCLUSION: RBD is technically feasible, but our findings and the review of previous reports on antegrade ureteric dilatation suggest that the success rate is low when the ureter is dilated at ⩾10 weeks after RTX. From our results we cannot recommend RBD for transplant ureteric stenosis at ⩾10 weeks after RTX, while previous reports show favourable results of antegrade BD in the initial 3 months after RTX.

13.
J Med Case Rep ; 4: 402, 2010 Dec 10.
Artículo en Inglés | MEDLINE | ID: mdl-21143956

RESUMEN

INTRODUCTION: The standard operation for carcinoma of the pancreatic head is a partial pancreaticoduodenectomy. Unusual histological findings may occasionally occur in the surgical specimen. We present three unusual histologic diagnoses after pancreaticoduodenectomy. CASE PRESENTATIONS: In the first case, an 86-year-old Caucasian woman was admitted with abdominal pain and nausea. Preoperative evaluation showed a 3 cm cystic lesion in the head of the pancreas. Pathology revealed a benign multicystic mesothelioma. In the second case, a 45-year-old Caucasian man complained of nausea, vomiting and general malaise for several months. Endoscopic retrograde cholangiopancreatographic examination and a computed tomography scan showed a stenosis of the distal bile duct secondary to a mass in the head of the pancreas and duodenum. Histology showed an adenomyoma of the ampulla. In the third case, a 59-year-old Caucasian man presented with chronic alcoholic pancreatitis. A computed tomography scan revealed a 3.5 cm lesion in the head of the pancreas with cystic and solid components. Pathology showed an undifferentiated carcinoma, sarcomatoid variant. CONCLUSION: Partial pancreaticoduodenectomy is usually performed for ductal adenocarcinomas, neuroendocrine tumors or chronic pancreatitis. Compared to the majority of the above diagnoses, the three cases in our study are very rare. Benign multicystic mesothelioma is a very rare tumor that originates from the peritoneum. Although it demonstrates a benign clinical behaviour, it frequently recurs after resection. Adenomyoma of the bile duct or ampullary region is a very unusual, benign, localized lesion characterized by adenomyomatous hyperplasia. Undifferentiated carcinoma, sarcomatoid variant, is an aggressive tumor and is characterized by spindle cells. As the lesions were suspicious for carcinoma, partial pancreaticoduodenectomy was justified in all three patients. The histologic diagnosis after partial pancreaticoduodenectomy may differ from the preoperative and intraoperative findings. These cases demonstrate that a definitive diagnosis may only be obtained by a pathologic examination of the surgical specimen.

14.
J Clin Oncol ; 28(35): 5210-8, 2010 Dec 10.
Artículo en Inglés | MEDLINE | ID: mdl-21060024

RESUMEN

PURPOSE: Patients with locally advanced gastric cancer benefit from combined pre- and postoperative chemotherapy, although fewer than 50% could receive postoperative chemotherapy. We examined the value of purely preoperative chemotherapy in a phase III trial with strict preoperative staging and surgical resection guidelines. PATIENTS AND METHODS: Patients with locally advanced adenocarcinoma of the stomach or esophagogastric junction (AEG II and III) were randomly assigned to preoperative chemotherapy followed by surgery or to surgery alone. To detect with 80% power an improvement in median survival from 17 months with surgery alone to 24 months with neoadjuvant, 282 events were required. RESULTS: This trial was stopped for poor accrual after 144 patients were randomly assigned (72:72); 52.8% patients had tumors located in the proximal third of the stomach, including AEG type II and III. The International Union Against Cancer R0 resection rate was 81.9% after neoadjuvant chemotherapy as compared with 66.7% with surgery alone (P = .036). The surgery-only group had more lymph node metastases than the neoadjuvant group (76.5% v 61.4%; P = .018). Postoperative complications were more frequent in the neoadjuvant arm (27.1% v 16.2%; P = .09). After a median follow-up of 4.4 years and 67 deaths, a survival benefit could not be shown (hazard ratio, 0.84; 95% CI, 0.52 to 1.35; P = .466). CONCLUSION: This trial showed a significantly increased R0 resection rate but failed to demonstrate a survival benefit. Possible explanations are low statistical power, a high rate of proximal gastric cancer including AEG and/or a better outcome than expected after radical surgery alone due to the high quality of surgery with resections of regional lymph nodes outside the perigastic area (celiac trunc, hepatic ligament, lymph node at a. lienalis; D2).


Asunto(s)
Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/cirugía , Terapia Neoadyuvante/métodos , Neoplasias Gástricas/tratamiento farmacológico , Neoplasias Gástricas/cirugía , Adenocarcinoma/patología , Adulto , Anciano , Antineoplásicos/uso terapéutico , Cardias/patología , Cardias/cirugía , Terapia Combinada , Procedimientos Quirúrgicos del Sistema Digestivo , Supervivencia sin Enfermedad , Unión Esofagogástrica/efectos de los fármacos , Unión Esofagogástrica/patología , Unión Esofagogástrica/cirugía , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Gástricas/patología
15.
Dig Surg ; 27(4): 272-8, 2010.
Artículo en Inglés | MEDLINE | ID: mdl-20664203

RESUMEN

BACKGROUND/AIMS: Vacuum-assisted closure (VAC) leads to a high fascial closure rate in open abdomen within the first week of treatment. However, little data exist on the role of long-term VAC treatment in patients with peritonitis, where fascial closure cannot be accomplished within the first days. METHODS: We reviewed the medical records of 49 patients with open abdomen for more than 7 days due to secondary peritonitis, who underwent a VAC-treatment. Nonparametric analysis was performed using chi(2) test or Fisher's exact test. RESULTS: Fascial closure could be accomplished in only 11 patients (22%), whereas complications occurred in 43 patients (88%). Re-explorations after starting VAC were associated with the occurrence of enterocutaneous fistula (p < 0.001) and were also of prognostic value regarding the rate of fascial closure (p = 0.033). CONCLUSIONS: If fascial closure cannot be accomplished within the first days, patients show a dramatically lower fascial closure and an increased complication rate with VAC. Further studies are needed to evaluate whether this subgroup really benefits from VAC.


Asunto(s)
Pared Abdominal/cirugía , Fístula Cutánea/cirugía , Terapia de Presión Negativa para Heridas/métodos , Peritonitis/complicaciones , Trasplante de Piel/métodos , Cavidad Abdominal/cirugía , Pared Abdominal/patología , Anciano , Vendajes , Fístula Cutánea/etiología , Femenino , Estudios de Seguimiento , Hernia Ventral/etiología , Hernia Ventral/cirugía , Humanos , Fístula Intestinal/etiología , Fístula Intestinal/cirugía , Cuidados a Largo Plazo , Masculino , Persona de Mediana Edad , Selección de Paciente , Peritonitis/cirugía , Estudios Retrospectivos , Medición de Riesgo , Mallas Quirúrgicas , Cicatrización de Heridas/fisiología
16.
Platelets ; 21(5): 348-59, 2010.
Artículo en Inglés | MEDLINE | ID: mdl-20569187

RESUMEN

Platelets have been implicated in the pathogenesis of liver damage after orthotopic liver transplantation (OLT). Early graft dysfunction is frequently caused by reperfusion injury subsequent to cold ischemia (IRI). Therefore, we investigated activation of the pivotal haemostatic cells, platelets and monocytes, from patients with elevated markers of IRI and from patients with uneventful course (control-group), respectively during the first week after OLT. Flow cytometry analysis of citrate anticoagulated blood samples revealed that platelets from IRI patients became significantly activated within 48 h after OLT in vivo, with increased surface presentation of P-selectin, CD40L, thrombospondin-1 and tissue-factor. Platelet activation in IRI patients on post-transplant day 2 was accompanied by significantly enhanced tissue-factor expression on peripheral blood monocytes, significant elevated levels of C-reactive protein and hepatocellular damage. Towards post-transplant day 4, levels of platelet-derived microparticles rose significantly in IRI patients if contrasted to control patients. Thus, activated cellular haemostasis is involved in the early inflammatory response of hepatocellular damage subsequent to reperfusion of the transplanted liver. Targeting distinct activation patterns of platelets and monocytes in an early phase of hepatic grafting may counteract the extent of IRI via inhibition of micro-thrombus formation and inflammation without exacerbating the existing bleeding risk.


Asunto(s)
Hepatopatías/sangre , Trasplante de Hígado/fisiología , Monocitos/metabolismo , Activación Plaquetaria/fisiología , Daño por Reperfusión/sangre , Tromboplastina/biosíntesis , Adulto , Plaquetas/fisiología , Estudios de Casos y Controles , Femenino , Humanos , Inflamación/sangre , Inflamación/patología , Hígado/irrigación sanguínea , Hígado/patología , Hepatopatías/inmunología , Hepatopatías/patología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Daño por Reperfusión/inmunología
17.
Eur J Endocrinol ; 162(2): 391-8, 2010 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-20097833

RESUMEN

OBJECTIVE: EpCAM (CD326) is overexpressed in progenitor cells of endocrine pancreatic islands of Langerhans during fetal development and was suggested to act as a morphoregulatory molecule in pancreatic island ontogeny. We tested whether EpCAM overexpression is reactivated in insulinomas, endocrine tumors arising in the pancreas. DESIGN/METHOD: We used monoclonal anti-EpCAM antibody Ber-Ep4 for immunohistochemistry on formalin-fixed and paraffin-embedded tumor material. We analyzed 53 insulinomas: 40 benign (disease stage

Asunto(s)
Antígenos de Neoplasias/genética , Moléculas de Adhesión Celular/genética , Insulinoma/genética , Insulinoma/mortalidad , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/mortalidad , Anciano , Antígenos de Neoplasias/metabolismo , Moléculas de Adhesión Celular/metabolismo , Molécula de Adhesión Celular Epitelial , Femenino , Estudios de Seguimiento , Regulación Neoplásica de la Expresión Génica , Humanos , Hiperinsulinismo/genética , Hiperinsulinismo/mortalidad , Inmunohistoquímica , Insulinoma/secundario , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Neoplasias/genética , Neoplasias/mortalidad , Neoplasias/patología , Páncreas/metabolismo , Páncreas/patología , Neoplasias Pancreáticas/patología , Pronóstico , ARN Mensajero/metabolismo , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Factores de Riesgo
18.
Langenbecks Arch Surg ; 395(3): 227-34, 2010 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-19998042

RESUMEN

PURPOSE: Hepatic resection is established as a safe procedure for colorectal, neuroendocrine, and sarcoma liver metastases. The present study evaluates whether liver resection is an option for patients with non-colorectal, non-neuroendocrine, and non-sarcoma metastases of the liver. METHODS: According to data from our prospective clinical tumor registry, we reviewed the medical records of 44 consecutive patients with non-colorectal, non-neuroendocrine, and non-sarcoma liver metastases, who underwent hepatic resection from January 2000 to December 2008. Univariate Kaplan-Meier analysis and a stepwise multivariable Cox regression model were applied. RESULTS: Following hepatic resection, mean overall survival was 21 months, and 5-year survival was 20%. Following hepatic resection, gender, histology, and chemotherapy were of prognostic value in our patient cohort in univariate analysis (p < 0.05). Multivariate survival analysis confirmed chemotherapy (p = 0.002) as an independent prognostic variable. Following initial resection of the primary tumor, synchrone occurrence of metastases, histology, localization of primary, perioperative complications, interval between initial resection of the primary tumor and resection of the metastases, and metastases in follow-up after hepatic resection were of prognostic value in univariate analysis (p < 0.05). Histology (p = 0.017) and interval between resection of the primary and resection of the metastases (p = 0.030) were confirmed as independent prognostic variables in multivariate survival analysis. CONCLUSIONS: Hepatic resection seems to be a safe and promising additive for a selective group of patients with non-colorectal, non-neuroendocrine, and non-sarcoma metastases of the liver.


Asunto(s)
Neoplasias Hepáticas/cirugía , Adulto , Anciano , Femenino , Hepatectomía , Humanos , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/secundario , Masculino , Persona de Mediana Edad , Cuidados Paliativos , Pronóstico , Modelos de Riesgos Proporcionales , Sistema de Registros , Análisis de Supervivencia
19.
Hepatobiliary Pancreat Dis Int ; 8(6): 650-2, 2009 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-20007086

RESUMEN

BACKGROUND: Obstructive jaundice caused by an intraductal hepatocellular carcinoma is a rare initial symptom. We report a rare case of an extrahepatic icteric type hepatocellular carcinoma. METHODS: A 75-year-old patient was admitted to our hospital because of obstructive jaundice 3 months after resection of multilocular hepatocellular carcinoma. A postoperative bile leakage was treated by placement of a decompressing stent in the common bile duct. Endoscopic retrograde choledochoscopy showed extended blood clots filling the bile duct system and computed tomography revealed a local swelling in the common extrahepatic bile duct. The level of alpha-fetoprotein (AFP) was only slightly elevated but that of CA19-9 was dramatically increased. Cholangiography showed an intraductal filling defect typical of a cholangiocellular carcinoma. RESULTS: Bile duct brushing cytology showed no cholangiocellular carcinoma but hepatocellular carcinoma cells in the extrahepatic bile duct. An extrahepatic bile duct resection was performed. Histological examination confirmed the diagnosis of extrahepatic intraductal growth of hepatocellular carcinoma. CONCLUSION: Ectopic hepatocellular carcinoma is a rare but important differentially diagnosed of extrahepatic bile duct filling defect.


Asunto(s)
Neoplasias de los Conductos Biliares/complicaciones , Conductos Biliares Extrahepáticos/patología , Carcinoma Hepatocelular/complicaciones , Colestasis Extrahepática/etiología , Ictericia Obstructiva/etiología , Neoplasias Hepáticas/complicaciones , Anciano , Neoplasias de los Conductos Biliares/diagnóstico por imagen , Neoplasias de los Conductos Biliares/patología , Neoplasias de los Conductos Biliares/cirugía , Conductos Biliares Extrahepáticos/diagnóstico por imagen , Conductos Biliares Extrahepáticos/cirugía , Biomarcadores de Tumor/sangre , Biopsia , Antígeno CA-19-9/sangre , Carcinoma Hepatocelular/diagnóstico por imagen , Carcinoma Hepatocelular/patología , Carcinoma Hepatocelular/cirugía , Colangiopancreatografia Retrógrada Endoscópica , Colestasis Extrahepática/diagnóstico por imagen , Colestasis Extrahepática/patología , Colestasis Extrahepática/cirugía , Humanos , Ictericia Obstructiva/diagnóstico por imagen , Ictericia Obstructiva/patología , Ictericia Obstructiva/cirugía , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/cirugía , Masculino , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , alfa-Fetoproteínas/análisis
20.
Case Rep Med ; 2009: 676392, 2009.
Artículo en Inglés | MEDLINE | ID: mdl-19718250

RESUMEN

Fistulae between an ileal pouch and the vagina are an uncommon complication of ileal pouch-anal anastomosis following proctocolectomy and mucosectomy in patients with familial adenomatous polyposis coli. Several reports describe the successful use of muscle flaps to close recurrent pouch-vaginal-fistulae (PVF). However, series only contain small numbers and an optimal management has not yet been determined. We report the case of a 26-year old woman with a third recurrence of a PVF after proctocolectomy for treatment of familial adenomatous polyposis in October 2005. Because local approaches failed, definitive closure of the fistula was achieved by interposition of a gracilis muscle flap between the pouch-anal anastomosis and the vagina. The postoperative course was uneventful; the patient was discharged 7 days after surgery and remained free of recurrence and symptomatic complaints for 22 months now. The gracilis muscle flap proved to be an effective method in the treatment of recurrent PVF.

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