Anal sphincter function after total mesorectal excision is comparable to that of healthy subjects: results of a matched pair analysis.

AIM: The aim of this paper was to compare healthy subjects and patients after total mesorectal excision concerning anal resting/squeeze pressure and surface-electromyography of the sphincter. METHODS: Forty patients (9 female/31 male) after total mesorectal excision due to low or middle rectal cancer were compared to a sex-, age- and BMI-matched group of healthy volunteers by means of anorectal pull-through manometry using a microtip-transducer system and by means of endoanal surface electromyography using a bipolar plug electrode. RESULTS: Resting pressure (59.2 ± 3.1 mmHg vs. 68.3 ± 4.3 mmHg; P=0.056) and squeeze pressure (127.3 ± 3.2 mmHg vs. 128.9 ± 4.6 mmHg; P=0.78) were comparable between patients after total mesorectal excision and healthy volunteers whereas surface electromyography amplitude (9.5 ± 0.4 µV vs. 13.9 ± 0.6 µV; P=0.01) was significant lower in patients after total mesorectal excision compared to healthy subjects. Correlation between squeeze and resting pressure as well as between squeeze pressure and surface electromyography were weaker in patients after total mesorectal excision compared to healthy controls. CONCLUSION: Objective measurable sphincter pressure after total mesorectal excision seems to be comparable to that of healthy subjects whereas surface-electromyography is significant higher in healthy subjects.

[Radiofrequency ablation for treatment of colorectal liver metastases: scientific evidence and clinical reality]. / Die Radiofrequenzablation in der Behandlung von kolorektalen Lebermetastasen: Was ist belegt?

Radiofrequency ablation (RFA) of colorectal liver metastases is frequently reported, but, however, lacks clear criteria for indication and reliable, convincing results with 5-year survival ranging from 17 to 48 %. RFA may be the appropriate treatment modality in approximately 3 to 5 % of all patients suffering from colorectal liver metastases. To date, RFA seems to be limited to no more than three metastases, each smaller than 3 cm. The main indication remains irresectability due to number, site, distribution and/or marginal liver function. Tumours in the vicinity of larger vessels (predominantly branches of portal or hepatic veins) are a case for controversy, since advances in hepatobiliary surgery enable a proportion of patients to undergo resections which would have been declared irresectable until most recently, and the oncological value of a thermoablation is questioned, as a certain amount of temperature is lost due to convective heat sinks. RFA is not a curative alternative to hepatic resection unless small tumours appear during open or laparoscopic procedures in a patient with elevated risk for early recurrence or postoperative morbidity following liver resection. The inclusion of RFA into a holistic system of oncological therapy is mandatory. Early RFA followed by systemic (regional?) chemotherapy can rather be recommended than chemo only, RFA only or first-line chemo with subsequent RFA.

[Minimal-invasive microwave coagulation therapy for liver tumours: laparoscopic and percutaneous access]. / Laparoskopische und perkutane Mikrowellenablation maligner Lebertumoren: Anwendbarkeit und Effizienz.

INTRODUCTION: Local ablative treatments play an important role in current surgical treatment strategies. Radiofrequency ablation (RFA) as one of the most popular examples suffers from partly inacceptable local tumour control. Microwave coagulation therapy (MCT) is a comparatively new type of ablation promising several improvements. This series is to the best of our knowledge the first within the central European area, which reports on the successful clinical implementation of MCT in a surgical department. PATIENTS AND MATERIALS: A novel 915 MHz system (MedWaves™, AveCure Inc., SanDiego, CA/U. S. A.) was used to treat 47 patients with 80 tumour nodules in 51 treatment sessions. Average tumour size was 2.6 ± 0.9 cm. Indications were hepatocellular carcinoma in 29 patients and metastases in 14 as well as 4 cholangiocellular carcinomas. The approach was laparoscopic (20) or percutaneous (31). High-risk conditions defined by unfavourable tumour localisation like invisibility in native transabdominal ultrasound, superficial tumour site or risk of heat sink phenomena were found in 28 cases (53 %). RESULTS: Local recurrence rate was 17 % on a per-patient and 12 % on a per-tumour basis (n = 9). One patient died because of incurable upper gastrointestinal bleeding during the postoperative hospital stay. No MCT-associated complication occurred. Median follow-up period was 20 months. Local tumour recurrence was significantly different on comparing laparoscopic to percutaneous MCT (p = 0.032, χ2 test), as was global recurrence (p = 0.011, χ2 test). In a univariate logistic Cox regression, tumour size, access and high-risk localisation were significant prognostic factors for local tumour recurrence, however, in a multivariate reiteration, only the chosen access to MCT (p = 0.012) and tumour size (p = 0.044) remain significant. CONCLUSION: MCT seems to be a useful tool, easy to implement in a surgical environment and may eventually prove to be superior to other local ablative treatment modalities. Even unfavourable tumour localisations could be treated safely and efficiently using MCT without increased risk of local tumour recurrence.

Conservative treatment of gastric perforation after microwave ablation of a hepatocellular carcinoma: Case report.

RATIONALE: Microwave ablation (MWA) has been proven to be an efficient and safe method for local tumor control of liver tumors. Reported complications are rare, but include liver abscess, hematoma, pleural effusion, and occasional thermal injury of the adjacent colon. Intestinal perforation usually requires immediate surgical treatment to prevent generalized peritonitis and sepsis. PATIENT CONCERNS AND DIAGNOSIS: Herein, we describe a case of gastric perforation following percutaneous MWA for hepatocellular carcinoma as a bridging therapy prior to liver transplantation. INTERVENTIONS: Due to the clinical condition of the patient, conservative treatment was considered sufficient. Nine months after MWA, successful liver transplantation followed. Intraoperative findings revealed a scar in the gastric wall with tight adhesions to the liver, requiring adhesiolysis and subsequent suturing. Postoperative recovery was uneventful. OUTCOME: At present, the patient is doing well. No further gastrointestinal events occurred. LESSON: To our knowledge, this is the first report of such a complication occurring after MWA. Moreover, in this case, the gastric perforation could be treated conservatively.

Feasibility of hepatic radiofrequency ablation in patients with bilioenteric anastomoses.

BACKGROUND/AIMS: Radiofrequency ablation (RFA) in the liver is contraindicated in the presence of bilioenteric anastomoses, because it predisposes to occasionally devastating infectious complications. The purpose of this single-center experience is to demonstrate the technical feasibility of such procedures. METHODOLOGY: Patients with bilioenteric anastomoses were offered ultrasound-guided RFA, if an interdisciplinary tumor board endorsed this decision, or an intraoperative opportunity to achieve a tumor-free situation emerged. All procedures were carried out under general anesthesia in a surgical operation theatre. RFA was performed percutaneously (n=3) and open surgically (n=3) with two different types of monopolar devices. All patients received antibiotic prophylaxis with various different agents. RESULTS: Six patients with seven tumor nodules were treated. The average age of the patients was 59 +/- 7 years. Mean size of the tumors was 20 +/- 7 mm. Median follow up was 15 months. No infectious complication including intrahepatic abscess occurred. No local recurrence was detected. CONCLUSIONS: The presented data indicates the feasibility of RFA in patients with bilioenteric anastomoses, and infectious problems, namely intrahepatic abscess formation, do not inevitably occur. The role of antimicrobial prophylaxis remains unclear. The importance of ensuring an unobstructed and uninhibited biliary flow distally in the bilioenteric track is stressed.

Advances in image guided conventional and minimal invasive liver surgery.

Technological developments, advances in perioperative medicine and ongoing scientific research have led to reduced rates of mortality and morbidity in patients undergoing major liver surgery. Under these conditions, the frontier of resectability is constantly in movement towards more complex cases with extended tumor spread and potentially minimized remnant liver volume. A promising technique to support oncological correct and safe liver surgery is the introduction of preoperative computer based planning models and intraoperative navigation systems. Whereas three-dimensional (3D) liver models are commercially available and have been clinically implemented, the use of navigation systems is currently under evaluation by different groups using a variety of techniques. This manuscript is meant to give the reader an overview on current developments, difficulties and future aspects of image guided liver surgery.

Hepatic artery calcification in a liver transplant recipient.

The abdominal aorta and the renal, mesenteric, and splenic arteries are frequently affected with arterial wall calcification upon increasing age; the hepatic artery is far less often found to be calcified. We report the case of a liver transplant recipient who presented with a calcified hepatic artery in the liver graft 13 years after transplantation for primary sclerosing cholangitis. Although the etiology of hepatic artery calcification was unknown, underlying causes for calcification may include chronic hemodialysis for renal insufficiency and subsequent secondary hyperparathyroidism, as well as a calcified aneurysms. However, it remained unclear whether hepatic artery calcification had to be considered an epiphenomenon or an original pathology of the liver. It thus seems unlikely that hepatic artery calcification as a single finding is to be considered a serious pathologic entity, even for a liver graft.

[Early stage liver cancer : Hepatocellular carcinoma]. / Frühkarzinom der Leber : Hepatozelluläres Karzinom.

Hepatocellular carcinoma (HCC) ranks among the most common primary cancers of the liver. The major risk factor for the formation of HCC is liver cirrhosis. The grade of cirrhosis as well as the extent of the tumor itself, can play an important role in the treatment options and patient prognosis. An operation aimed at an R0 resection is the treatment of choice for patients in an early stage of the disease and is associated with favorable long-term and recurrence-free survival. Liver transplantation offers an even better long-term survival rate after 5 years for selected patients with HCC meeting the Milan criteria as the underlying cirrhosis, the major risk factor for HCC recurrence, is simultaneously treated. Local tumor ablation is the least invasive curative surgical treatment, however, it is associated with an increased local recurrence rate; therefore, the early detection of tumors is of essential importance. As tumor-associated symptoms tend to arise only in advanced tumor stages, it is indispensable to identify patients with typical risk factors and to provide closely monitored screening examinations.

[The diagnosis and imaging of the a. hepatica after orthoptic liver transplantation--a comparison of frequency-modulated and amplitude-modulated color Doppler sonography]. / Diagnostik und Darstellung der A. hepatica nach orthotoper Lebertransplantation--Vergleich von frequenzmodulierter und amplitudenmodulierter Farb-Doppler-Sonographie.

PURPOSE: We examined whether amplitude-modulated color Doppler (power Doppler) sonography provides a better anatomic imaging of the vascular course of the hepatic artery after liver transplantation. PATIENTS AND METHODS: 82 patients were examined with Doppler sonography after liver transplantation. The distal section of the hepatic artery was imaged both with frequency-modulated color Doppler (color Doppler) and power Doppler and a Doppler spectrum derived from each mode for determination of the flow velocity. RESULTS: Native imaging of the hepatic artery was possible in 78/82 patients, in 2/82 patients only after administration of Levovist, and in 2/82 patients it could not be seen. In these two patients the diagnosis of hepatic artery occlusion was confirmed by angiography. The anatomic course was demonstrated more longitudinally by power Doppler than by color Doppler (p < 0.001; chi 2 test) which made the angle correction easier. A disadvantage of power Doppler was the lack of image contrast to the portal veins; thus evaluation of the vascular course in this section was better possible with color Doppler by means of a specifically generated aliasing in the flow of the hepatic artery (p < 0.001; chi 2 test). Determination of the flow velocity showed no significant differences between color and power Doppler supported duplex sonography. CONCLUSIONS: The combined use of color Doppler and power Doppler improves visualization of the hepatic artery after liver transplantation. The lack of visualization of the vessel after administration of Levovist is diagnostic for occlusion of the vessel.

Treatment of recurrent hepatocellular carcinoma confined to the liver with repeated resection and radiofrequency ablation: a single center experience.

BACKGROUND: Recurrence of hepatocellular carcinoma (HCC) after surgical treatment is a common problem. It can be treated by radiofrequency ablation (RFA) or repeated hepatic resection (HR). This report compares both in a retrospective, single-institution database. PATIENTS AND METHODS: A prospectively collected database was retrospectively analyzed. RFA was performed under ultrasound control using two different monopolar devices. All kinds of access were used: open surgical (n=10), percutaneous (n=13) and laparoscopic (n=4). HR was performed using an ultrasound aspiration device. Indication for a particular treatment was allocated on a case-by-case basis; the final decision was often made intraoperatively. RESULTS: Survival after RFA (median 40 months) was similar compared to that after HR (48 months, p=0.641, logRank-test). Tumor-free survival was markedly impaired after RFA (15 vs. 29 months). This difference was however not significant (p=0.07, logRank-test). Both groups were different regarding occurrence of cirrhosis, maximal tumor size, time after initial diagnosis and duration of the procedure. CONCLUSION: In this non-randomized retrospective trial, survival and disease-free survival was not significantly different when compared between patients treated by RFA and HR. There was however a tendency towards a longer tumor-free survival in the resected patients.

Recurrent intrahepatic cholangiocarcinoma: single-center experience using repeated hepatectomy and radiofrequency ablation.

BACKGROUND: Intrahepatic cholangiocarcinoma (IHC) is a rare liver malignancy with a rising incidence worldwide. Since no standard treatment has been established so far, the aim of this study was to assess the safety and efficacy of repeated liver resection and/or radiofrequency ablation (RFA) in selected cases with recurrent IHC. PATIENTS AND METHODS: The outcome of 13 patients who had been treated at least once for recurrent IHC by repeated liver resection and/or RFA was retrospectively analyzed. A total of 12 repeated liver resections and 8 radiofrequency ablations were performed in these patients between 2002 and 2008. RESULTS: After a median follow-up period of 28 months after primary liver resection (12-69 months), seven patients (54%) are still alive and three of these patients (23% of the entire cohort) are regarded as disease-free. The median survival for all patients was 51 months (12-69 months). One- and three-year survival after primary surgery was 92 and 52%, respectively, with an overall complication rate of 7.6%. CONCLUSION: According to the present data, repeated liver resection and radiofrequency ablation are feasible in select patients with recurrent IHC. Both procedures can be regarded as safe and might lead to a prolongation of patient survival.

Results of liver resection in combination with radiofrequency ablation for hepatic malignancies.

INTRODUCTION: Liver tumors should be surgically treated whenever possible. In the case of bilobar disease or coexisting liver cirrhosis, surgical options are limited. Radiofrequency ablation (RFA) has been successfully used for irresectable liver tumors. The combination of hepatic resection and RFA extends the feasibility of open surgical procedures in patients with liver metastases and hepatocellular carcinoma (HCC). PATIENTS AND METHODS: RFA was performed with two different monopolar devices using ultrasound guidance. Intraoperative use of RFA for the treatment of liver metastases or HCC was limited to otherwise irresectable tumors during open surgical procedures including hepatic resections. Irresectability was considered if bilobar disease was treated, the functional hepatic reserve was impaired or appraised marginal for allowing further resection. RESULTS: Ten patients with both liver metastases and HCC, and two patients with cholangiocellular carcinoma were treated. Complete initial tumor clearance was achieved in all patients. Two patients of the metastases group and five patients of the HCC group suffered from local recurrence after a median of 12 months (1-26) (local recurrence rate 32%). Five patients of the metastases group and six patients of the HCC group developed recurrent tumors in different areas of the ablation site after a median time of 4 months (2-18) (distant intrahepatic recurrence in 55%). Survival at 31 months was 36%. CONCLUSION: RFA extends the scope of surgery in some candidates with intraoperatively found irresectability.