[Outpatient multimodal pain therapy : Results of a 1-week intensive outpatient multimodal group program for patients with chronic unspecific back pain - retrospective evaluation after 3 and 12 months]. / Ambulante multimodale Schmerztherapie : Ergebnisse eines 1­wöchigen ambulanten intensiven multimodalen Gruppenprogramms für Patienten mit chronischen unspezifischen Rückenschmerzen ­ retrospektive Evaluation nach 3 und 12 Monaten.

BACKGROUND: Interdisciplinary pain therapy is nowadays the state of the art for the treatment of chronic unspecific back pain. The aim of this article is to present the retrospective analysis of the data from a 1-week intensive outpatient multimodal interdisciplinary pain therapy group program for treatment of patients with chronic unspecific back pain. DESIGN AND METHODS: The questionnaire-based data from patients who attended the program were evaluated before as well as 3 and 12 months after finishing the program. The patients were questioned regarding parameters, such as pain severity, quality of life, pain-related disability, depression and pain acceptance. RESULTS: On average a significant improvement of all parameters after 3 and 12 months could be demonstrated (excluding the domains "social" and "environment" in the context of quality of life). DISCUSSION: Interestingly, the results showed a significant improvement of almost all evaluated parameters even after a period of 12 months (unfortunately only data for 41 patients were available). In our opinion this improvement is due to the special constellation of the presented program, which with 1 week is relatively short but very intensive with 34 h of treatment. In addition, the program is integrated into a long-term multimodal outpatient treatment, a concept in which the multimodal treatment is individually continued after the 1­week program. On the other hand, the results especially after 12 months have to be interpreted particularly in this context.

Neoadjuvant treatment with weekly high-dose 5-Fluorouracil as 24-hour infusion, folinic acid and oxaliplatin in patients with primary resectable liver metastases of colorectal cancer.

PURPOSE: To evaluate the efficacy and safety of neoadjuvant treatment comprising weekly high-dose 5-fluorouracil (5-FU) as a 24-hour infusion, folinic acid (FA) and biweekly oxaliplatin (L-OHP), followed by metastatic resection in patients with primarily resectable liver metastases of colorectal cancer (CRC). PATIENTS AND METHODS: 20 patients with primarily resectable liver metastases of CRC were enrolled in a prospective phase II study. On an outpatient basis, the patients received a treatment regimen comprising biweekly 85 mg/m(2) L-OHP in the form of a 2-hour intravenous infusion and 500 mg/m(2) FA as a 1- to 2-hour intravenous infusion, followed by 2,600 mg/m(2 ) 5-FU administered as a 24-hour intravenous infusion once weekly. A single treatment cycle comprised one infusion per week during a period of 6 weeks followed by a 2-week rest. Two cycles were administered, with a third being added when the treatment was well tolerated. Thereafter, curative resection of the liver metastases was attempted, and the patients were followed up. RESULTS: After neoadjuvant therapy, 2 of the original 20 patients showed complete remission (CR; 10%) and 18 patients partial remission (PR; 90%). As the main symptom of toxicity, diarrhea (CTC toxicity grade 3-4) was observed in 6 patients (30%), followed by vomiting in 3 patients (15%). The curative resectability rate was 80% (16 of 20). In 9 of 18 patients (50%) undergoing surgical intervention, mild postoperative complications, mainly wound healing disturbances (n = 5), occurred. No postoperative mortality was observed. Over a median follow-up of 23 months (12-38) 6 of 16 curatively resected patients developed distant metastases and 1 patient a local pelvic recurrence. The 2-year disease-free survival rate was 52% and the 2-year cancer-related survival rate 80%. CONCLUSION: The neoadjuvant treatment with weekly high-dose 5-FU in the form of a 24-hour infusion combined with FA and L-OHP is very effective and well tolerated. Surgical morbidity does not appear to be increased by the neoadjuvant treatment.

Clinical value of MRC in the follow-up of liver transplant patients with a choledochojejunostomy.

BACKGROUND: We investigated the clinical value of magnetic resonance cholangiography (MRC) in liver transplant patients receiving choledochojejunostomy (CDJ). METHODS: Twenty-five MRCs were performed in 23 initially asymptomatic patients 19 months (mean) after liver transplantation with biliary reconstruction via CDJ. The images were evaluated by consensus (two investigators) for bile duct strictures and dilatations. As a standard of reference, clinical follow-up (including laboratory analysis) was used in 20 cases and direct cholangiography or surgery in three cases. RESULTS: Fourteen pathologic findings were observed in 11 patients (anastomotic strictures in four, left or right bile duct strictures in three, and peripheral segmental dilatations with or without strictures in seven). Patients with pathologic MRC findings had significantly higher levels of alkaline phosphatase (p < 0.05) and more frequently had histories of cholangitis than did patients with normal MRC. Four of six patients with stenoses of the central bile ducts subsequently developed biliary complications requiring treatment (three confirmed by direct cholangiography). In patients with unremarkable bile ducts or only peripherally located changes on MRC, no bile duct complications or relevant changes in the cholestasis parameters occurred during follow-up (mean = 30 months). CONCLUSION: MRC can noninvasively detect pathologic biliary tract changes in liver transplant patients in the asymptomatic stage and provide information for planning invasive therapeutic procedures.

Surgical treatment of HELLP syndrome-associated liver rupture -- an update.

In some 2% of the cases of the HELLP syndrome, severe spontaneous bleeding into the liver accompanied by haemorrhagic liver cell necrosis and rupture of the organ occurs and represents one of the main cause of death. On the basis of our own experience with four cases, a review of the literature is presented with particular focus on a therapeutic concept based on appropriate surgery. Within a MEDLINE search covering the period 1990-1999, the case reports of this kind of liver complication in the literature were analysed in terms of clinical course and outcome.In addition to our own four patients, a total of 49 cases with rupture of the liver were found in the literature. Despite surgical interventions, HELLP syndrome-associated liver rupture carried a mortality of 39%. Most patients died of haemorrhagic shock and organ failure. In order to improve survival, patients with ruptured liver or hepatic failure should be transferred to a centre with the necessary experience in liver surgery including liver transplantation. An interdisciplinary approach is required, including the use of temporary packing of the liver to control the bleeding, and during the further course of the condition, possibly even liver transplantation, as in one of our own cases.

[Pseudoaneurysm of the hepatic artery--a rare complication after orthotopic liver transplantation]. / Pseudoaneurysma der A. hepatica--eine seltene Komplikation nach orthotoper Lebertransplantation.

INTRODUCTION: Pseudoaneurysm of the hepatic artery is a rare complication of liver transplantation, the most common cause of which--apart from technical surgical problems--is an infection. The most common symptoms are rupture and hemorrhage. METHOD: The present case report describes an asymptomatic pseudoaneurysm of the hepatic artery following liver transplantation, and its treatment. RESULTS: In this patient, an pseudoaneurysm involving an eroded branch of the hepatic artery was found. Surgical treatment consisted in the excision of the aneurysm and oversewing of the branch of the hepatic artery. CONCLUSION: The potential for rupture and hemorrhage makes surgical intervention mandatory even in asympotomatic patients with pseudoaneurysm of the hepatic artery. The surgical procedure depends on the local situation and the time elapsed since transplantation. Preservation or reconstruction of the arterial perfusion is essential.

[Resection of liver metastases--goal, timing and results]. / Resektion von Lebermetastasen--Ziel, Zeitpunkt und Ergebnisse.

If left to run their natural course, numerous malignant diseases will eventually produce liver metastases. Without treatment, afflicted patients have a life expectancy of only eight months. At the present time, the only therapeutic option that offers the patient with liver metastases from colorectal carcinoma the chance of a cure is resection of the metastases. Depending on the primary tumour, this also applies to some patients with carcinomas at sites other than the colorectum. A point of continuing controversy is the timing of such resection. While some authors recommend a test 'of time' ranging from several weeks to months, others call for resection of the metastases immediately after their detection. Solitary synchronous liver metastases involving only a single segment can be resected at the same time as surgical treatment of the primary when, in particular, the surgical access is readily possible and the risk of complications calculable. Most authors advocate surgery in two sessions. The location, number and size of the metastases, together with the presence of concomitant diseases, provide the basis for the decision to perform a resection. At the same time, however, the risk to the patient must be within justifiable limits. This applies in particular to non-colorectal, non-endocrine metastases. Following curative resection of colorectal hepatic metastases, 25-51% of the patients are still alive after 5 years. During the same period, some 51-76% of the patients develop a recurrence. From these data, the calculated resulting median survival for all patients undergoing resection is roughly 30 months. A tumour-free 5-year survival rate of up to 34% is achieved. In view of their different clinical course and prognosis, non-colorectal liver metastases should be classified into non-colorectal neuroendocrine (NCNE) and non-colorectal non-endocrine (NCNN) metastases. While the former group has a 5-year survival rate following curative resection of up to 62%, the figure for the latter group is only 15-35%.

Impact of surgery on survival in palliative patients with metastatic colorectal cancer after first line treatment with weekly 24-hour infusion of high-dose 5-fluorouracil and folinic acid.

BACKGROUND: In palliative first-line treatment of colorectal cancer, the secondary resection of distant metastases after downstaging has constantly gained in importance. The objective of this prospective study was to examine the tumor response rate, the toxicity, the median survival time and the prognostic impact of metastatic resection after downstaging of consecutively enrolled patients with primary nonresectable colorectal cancer treated with once weekly 24-hour (24-h) infusion of high-dose 5-fluorouracil (5-FU) and folinic acid. PATIENTS AND METHODS: Between January 1995 and July 1997, 53 consecutive patients with primary nonresectable metastases were recruited for a prospective phase II study. The patients received in out-patient care 500 mg/m2 folinic acid in the form of a 1-2-hour infusion followed by 2600 mg/m2 5-FU administered as a 24-h infusion once weekly. One treatment cycle comprised six weekly infusions followed by a two week rest. Three cycles were administered, and in the event of complete remission (CR) or partial remission (PR) and good tolerability, a fourth cycle was undertaken. Thereafter, the possibility of performing a curative metastatic resection was investigated. RESULTS: Of the 53 patients treated, 7 showed a CR (13%), 15 patients a PR (28%), 26 patients stable disease (SD) (49%), and 5 patients progressive disease (PD) (10%). As the main symptom of toxicity, diarrhea (CTC grade 3 + 4) was observed in 11 patients (21%), followed by leucocytopenia (CTC grade 3 + 4) in 2 patients (4%), and the hand-foot syndrome in 1 patient (2%). The median survival time was 17 months with a median follow-up of 41 months (range: 28-59 months). In 9 patients (17%), a secondary metastatic resection was considered; in 6 patients (11%) curative resection was performed, and 4 patients (8%) showed no evidence of disease for at least three years. CONCLUSION: In this phase II study, we have been able to show prospectively that, after downstaging by palliative treatment using a weekly 24-h infusion of high-dose 5-FU and folinic acid, secondary curative metastatic resection was technically feasible in 11% of the patients. For some of these patients, long-term survival is therefore possible. Secondary metastatic resection should be carried out in close interdisciplinary cooperation, and should be further investigated in prospective phase III studies.

Description of an intraperitoneal tumour xenograft survival model in the pig.

AIMS: Experimental animal studies are necessary if the results of minimally invasive oncological surgery are to be improved. In particular the influence of surgical technique on tumour implantation needs further assessment. Small animals such as rodents are inappropriate for such laparoscopic surgical studies. There is a requirement for another animal tumour model with animals greater in size. METHODS: Accordingly we developed an intraperitoneal tumour xenograft survival model using the domesticated pig. After creating a 12 mmHg pneumoperitoneum, 10(7)human HeLa cells were injected into the peritoneal cavity of nine non-syngeneic animals to induce tumour xenograft. Resection of the sigmoid colon using four trocars and a transanal double-stapling technique was performed. The mean operating time was 69 min. No signs of post-operative pain symptoms were observed, and all the animals survived the procedure and gained weight. After 4 weeks, the animals were sacrified and all incision sites and anastomoses were excised. RESULTS: Immunohistochemical staining with antihuman pancytokeratin antibodies confirmed tumour implants in 25 out of 36 port-sites (63.8%). No peritoneal carcinosis nor tumour implants at anastomosis sites were observed. CONCLUSION: This intraperitoneal xenograft tumour model in the pig can be applied in survival studies to check the quality of surgical techniques and its influence on tumour implantation following laparoscopy for cancer.

Feasibility of therapeutic pneumoperitoneum in a large animal model using a microvaporisator.

BACKGROUND: Multimodal therapy is used increasingly in advanced gastrointestinal tumors. Potential benefits of using an intraoperative adjuvant therapy during laparoscopy for cancer have been documented in animal studies. The aim of this study was to develop a device that could deliver such an intraoperative drug therapy. METHODS: We developed a micropump suitable for minimally invasive surgery procedures that allowed microdroplets of therapeutic substance to be distributed into the pneumoperitoneum (CO2), creating a "therapeutic pneumoperitoneum." A closed-loop control system regulates drug delivery according to the gas flow. In vitro, the micropump is able to aerosolize various aqueous and ethanol solutions, including cytostatic and bacteriostatic drugs and adhesion-modulating agents. The size of the microdroplets has been optimized to prevent visual artifacts. RESULTS: The micropump was tested in an animal model (pig). The system was inserted into a 5-mm trocar. After insufflation of a 12-mm CO2 pneumoperitoneum, laparoscopic sigmoid colon resections could be performed with no special difficulties. No fog developed, and no system-related complication was observed. At autopsy, the active principle was distributed to all exposed peritoneal surfaces. CONCLUSIONS: As opposed to conventional peritoneal washing, therapeutic pneumoperitoneum reaches the entire peritoneal surface, allowing an optimal drug distribution. Drug diffusion into the tissues is enhanced by the intraperitoneal pressure. Precise determination of the instantaneous and total drug quantity is possible. Therefore, this drug delivery system has several advantages over conventional irrigation. Its potential domains of application are locoregional cancer therapy, prevention of port-site recurrences, immunomodulation, analgesia, peritonitis, and prevention of postoperative adhesions.

[Undifferentiated, embryonal sarcoma as a rare cause of spontaneous liver rupture in adults]. / Undifferenziertes, embryonales Sarkom als seltene Ursache einer Leberruptur beim Erwachsenen.

INTRODUCTION: Undifferentiated, embryonal sarcoma is a rare malignant tumour of the liver, the incidence of which is highest in children between 6 and 10 years of age (14.1 %). Among the primary tumours of the liver in childhood it ranks in third place after hepatocellular carcinoma and focal nodular hyperplasia. Embryonal sarcoma is much rarer in adults. To our knowledge, only 18 cases have been published in the last 50 years. METHODS AND RESULTS: We now present the case of a 29-year-old woman with spontaneous rupture of the liver caused by an undifferentiated sarcoma. CONCLUSION: This case report illustrates the possibility of an embryonal sarcoma being the reason for spontaneous rupture of the liver. The management of this case comprised primary tamponade, interventional embolisation of the feeding artery, and secondary resection under stable conditions.

Laparoscopic colorectal anastomosis: risk of postoperative leakage. Results of a multicenter study. Laparoscopic Colorectal Surgery Study Group (LCSSG).

BACKGROUND: We report on a prospective observational multicenter study of more than 1,000 consecutive patients undergoing laparoscopic colorectal procedures. The aim of the current study was to investigate the safety of laparoscopic colorectal surgery as reflected by the anastomotic insufficiency rates in the various sections of the bowel, and to compare these rates with those of open colorectal surgery. METHODS: The study was begun on August 1, 1995. Twenty-four centers in Germany, Austria, and Switzerland participated in this prospective multicenter study. All patients undergoing laparoscopic colorectal surgery were included in the study. No selection criteria were applied, which means that every operation begun as a laparoscopic procedure was included. Data on patient demographics, surgical indications, surgical course, and patient outcome were recorded prospectively in a computer database. All data were rendered anonymous. RESULTS: Between August 1995 and February 1998, the 24 participating centers treated 1,143 patients (male/female ratio, 1:1.36; mean age, 60.7 years). In all, 626 operations were performed for benign indications and 517 for cancer. Most procedures involved the sigmoid colon and rectum (80.9%). An anastomosis was performed in 83% of the operations. Most of the anastomoses were laparoscopically assisted using the stapling technique. We observed an overall leakage rate of 4.25% (colon 2.9%; rectum 12.7%), and surgical reintervention was required in 1% of the cases. The rate of conversion to open surgery was 5.6%. Intraoperative complications occurred in 5.9%, and reoperation was necessary in 4.1% of the cases. The overall morbidity rate was 22.3%, and the 30-day mortality rate was 1.57%. CONCLUSIONS: The feasibility and safety of the laparoscopic colorectal approach is demonstrated clearly. The current study shows that the laparoscopic or laparoscopically assisted approach to colorectal surgery is not associated with a higher risk of anastomotic leaks. Morbidity and mortality rates with this method approximate those seen with conventional colorectal surgery.

[Laparoscopic splenectomy]. / Laparoskopische Splenektomie.

To date more than 400 laparoscopic splenectomies have been reported in the literature. The main indications for the procedure are benign haematological diseases, in particular idiopathic thrombocytopenic purpura. Laparoscopic splenectomy to treat malignant illnesses is rare and is usually restricted to small or only moderately enlarged spleens. Technically, the lateral abdominal approach with the patient in a right decubitus position has the advantage over the anterior approach in the supine patient of permitting better access to the organ. Under the force of gravity the stomach and intestines drop out of the operating field, and the splenic ligaments are placed under tension. This facilitates dissection with the harmonic scalpel and safe divisioning of the hilar vessels using the linear stapler. The individual steps of the procedure are described in detail.

[Thoracoscopic truncal vagotomy]. / Thorakoskopische trunkuläre Vagotomie.

Abdominal re-operation in patients with recurrent peptic ulcer disease is associated with a high morbidity rate and a mortality rate of 5%. As an alternative procedure, therefore, transthoracic truncal vagotomy was early recommended as a less invasive intervention, and good results can be achieved with it. With the development of minimal invasive surgery, this procedure can now be performed via thoracoscopy and patient stress thus reduced even further. Via a left-sided thoracoscopy, the parietal pleura is incised and a 3-5 cm long segment of the distal oesophagus mobilised and dissected free. Both the posterior and anterior trunks of the vagus nerves are identified and, after applying clips, transected. In order to achieve complete vagotomy, further fine branches have to be searched out and, if found, also divided.

[Percutaneous laparoscopic gastrostomy]. / Perkutane laparoskopische Gastrostomie (PLG).

Percutaneous endoscopic gastrostomy (PEG) has now largely replaced the conventional operative procedure of gastrostomy. However, in patients with endoscopically non-passable pharyngo-oesophageal tumours or facial injuries rendering the stomach inaccessible to endoscopy, this technique has so far been unavailable. In this group of patients it is nevertheless possible to apply minimally invasive percutaneous gastrostomy using laparoscopy (PLG). The employment of a purse-string suture clamp facilitates the performance of the procedure and makes it reliable.

[Laparoscopic fenestration of non-parasitic liver cysts]. / Laparoskopische Fenestrierung von nicht-parasitären Leberzysten.

Cysts of the liver may be parasitic or non-parasitic, the non-parasitic cysts being further subdivided into neoplastic, inflammatory, post-traumatic and congenital. Symptomatic congenital solitary cysts represent a good indication for laparoscopic treatment. During the therapeutic procedure, the roof of the cyst is fenestrated or removed such that at least one-third of the circumference of the cyst is removed, which is best done using a harmonic scalpel. In order to prevent a recurrence, it is recommended that a portion of the greater omentum be placed in the floor of the cyst, thus filling the cystic cavity.

[Laparoscopic operation of a Morgagni hernia]. / Laparoskopische Operation einer Morgagni-Hernie.

Morgagni hernias are the least common form of diaphragmatic hernias. Although they are congenital, most of them are not diagnosed until later in life. The indication for surgery is based on the patient's symptoms or on the radiological evidence of incarcerated tissue, and until quite recently involved a laparotomy or thoracotomy. Laparoscopy not only permits the suspected diagnosis to be confirmed--which is otherwise often difficult--but also makes it possible to close the hernia site by suturing. For improved security, the hernia site is augmented by fixing in place a non-absorbable mesh. The operative technique employed is described.

Impact of arterialization on hepatic oxygen supply, tissue energy phosphates, and outcome after liver transplantation in the rat.

The importance of arterial reconstruction in experimental orthotopic rat liver transplantation is widely acknowledged in the literature. Non-rearterialization of the graft leads to impaired microcirculation and, in chronic models, to severe hepatobiliary damage, together with bile duct proliferation and fibrosis in such livers. The aim of the current study was to investigate the impact of rearterialization on hepatic oxygen tension (pO2), hepatic tissue content of adenine nucleotides, early graft function, and postoperative outcome. Orthotopic liver transplantation was performed in 27 male inbred rats. Ten rats underwent rearterialization and while 17 did not. A group of sham-operated animals (n = 6) served as controls. After reperfusion, liver grafts without arterial reconstruction showed significantly reduced levels of oxygen tension (mean +/- SD, 3.79 +/- 2.20 vs. 10.03 +/- 2.84 mmHg; P < 0.05) and a clear shift toward lower pO2 values in the pO2 histograms, as compared with arterialized grafts. Without arterialization, the level of liver ATP was 65% of that in sham animals, compared with 84% in arterialized livers. Without arterialization, bile secretion was reduced (0.42 +/- 0.04 vs. 0.71 +/- 0.06 mg/min x g liver; (P < 0.001), and the postoperative course of serum alanine transaminase, bilirubin, and alkaline phosphatase revealed severe hepatobiliary damage. These findings allow us to conclude that graft rearterialization is essential to ensure both an adequate oxygen supply and maintenance of tissue ATP. Arterialization may thus be a necessary part of liver transplantation models in this animal species, and should be considered when designing studies on the biochemical, microcirculatory, and histopathological status of the graft.