Preservation of the superior rectal artery: influence of surgical technique on anastomotic healing and postoperative morbidity in laparoscopic sigmoidectomy for diverticular disease.

PURPOSE: To evaluate the impact of superior rectal artery (SRA) sparing technique on anastomotic leakage in laparoscopic sigmoidectomy for diverticular disease. MATERIAL AND METHODS: A retrospective multicenter analysis of all patients undergoing laparoscopic sigmoid resection for diverticular disease between 2002 and 2015 was conducted. Data were recorded in three hospitals: University Hospital Regensburg, Marienhospital Gelsenkirchen, and Städtisches Klinikum München Bogenhausen. The SRA was resected between 2002 and 2005. Since 2005, the artery was preserved in most cases. RESULTS: Two hundred sixty-seven patients were included. One hundred sixty patients presented with complicated diverticulitis (60%). The SRA was resected in 102 patients (group 1) and preserved in 157 patients (group 2, no data in eight cases). Anastomotic leakage occurred in 7% of patients in group 1 and 1.9% of patients in group 2 (p = 0.053). Duration of surgery was significantly shorter (157 vs. 183 min, p < 0.001) in group 2 patients. Length of hospital stay was without significant difference (group 1 8.2 days; group 2 8.3 days; p = 0.83). The conversion rate was higher in group 2 patients; however, the difference was not statistically significant (9 vs. 3%, p = 0.07). There was no significant difference between both groups regarding intraoperative complications and overall complication rate. The length of the resected specimen (19 vs. 21 cm, p = 0.001) was significantly shorter in group 2 patients. CONCLUSION: Preservation of the SRA seems to be associated with favorable outcome in patients undergoing laparoscopic sigmoid resection for diverticular disease.

[Pit-picking surgery for pilonidal disease]. / Pit-picking-Operation bei Patienten mit Sinus pilonidalis.

BACKGROUND: The pit-picking method was first described by J. Bascom in 1980, however, this minimally invasive technique is used only by a minority of surgeons yet. PATIENTS AND METHODS: Surgery was performed under local anesthesia. All primary pits in the midline were removed by excising a border of skin of <1 mm and a 1 cm long incision was made parallel to one side of the cleft to open the chronic abscess cavity. No specific postoperative wound care was given. RESULTS: Pit-picking surgery was carried out 157 times in a total of 153 patients (126 males) between June 2007 and November 2010. Follow-up information was available in 123 cases and 21 patients (17%) developed disease recurrence after a mean follow-up time of 7.1 months. By multivariate analysis, a body mass index (BMI) >25 kg/m(2) (p=0.019) and duration of the disease of ≥6 months (p=0.017) were statistically significantly associated with disease recurrence after pit-picking surgery. The recurrence occurred more often in male than in female patients (20% versus 4.5%, p=0.12) CONCLUSION: Patients with pilonidal disease can be successfully treated by the pit-picking procedure in more than 80% of selected cases. Female patients and non-overweight male patients with short-term disease benefit most from this treatment method.

Percutaneous transluminal angioplasty as first-line treatment of transplant renal artery stenosis.

BACKGROUND: Transplant renal artery stenosis (TRAS) is a frequent complication after renal transplantation, however long-term follow-up data after interventional treatment are rare. PATIENTS: In our transplant center 11 of 264 consecutive renal transplant recipients (4.17%) were diagnosed with TRAS. In addition, TRAS occurred in 2 renal transplant recipients that had been transplanted at other centers but who had their follow-up examinations in our center. Either a rise of the serum creatinine level and/or worsened systemic hypertension or routine examination with color Doppler sonography were indications for further diagnostic workup. METHODS: Direct angiography of the transplant renal artery was performed followed by percutaneous transluminal angioplasty (PTA) after the diagnosis of TRAS was confirmed in all of these patients. RESULTS: The immediate success rate for PTA was 92.3% (12/13). Only 1 patient with a severe kinking of the transplant renal artery had to undergo surgery to restore renal function. No complications occurred after the interventions. Thereafter the patients were monitored for a mean observation period of 33.15 months. Serum creatinine levels were significantly lower after the intervention, and estimated glomerular filtration rate (eGFR) increased accordingly. With regard to blood pressure there was only a trend for lower blood pressure levels and less antihypertensive use, whereas the dose of the prescribed drugs decreased significantly with time after interventional treatment of TRAS. In addition, a long-lasting rise of the hemoglobin levels could also be demonstrated. CONCLUSION: In summary, the beneficial effect of PTA of TRAS on renal function is long-lasting. Therefore, PTA, usually combined with stent placement, should be first-line treatment in TRAS in all patients. Surgical revascularization is only warranted, if PTA fails.

Liver transplantation for hilar cholangiocarcinoma: a German survey.

BACKGROUND: The present study reports a German survey addressing outcomes in nonselected historical series of liver transplantation (OLT) for hilar cholangiocarcinoma (HL). PATIENTS AND METHODS: We sent to all 25 German transplant centers performing OLT a survey that addressed (1) the number of OLTs for HL and the period during which they were performed; (2) the incidence of HL diagnosed prior to OLT/rate of incidental HL (for example, in primary sclerosing cholangitis); (3) tumor stages according to Union Internationale Centre le Cancer; (4) patient survival; and (5) tumor recurrence rate. RESULTS: Eighty percent of centers responded, reporting 47 patients who were transplanted for HL. Tumors were classified as pT2 (25%), pT3 (73%), or pT4 (2%). HL was diagnosed incidentally in 10% of cases. A primary diagnosis of PSC was observed in 16% of patients. Overall median survival was 35.5 months. When in-hospital mortality (n = 12) was excluded, the median survival was 45.4 months, corresponding to 3- and 5-year survival rates of 42% and 31%, versus 31% and 22% when in-hospital mortality was included. HL recurred in 34% of cases. Three- and 5-year survivals for the 15 patients transplanted since 1998 was 57% and 48%, respectively. Median survival ranged from 20 to 42 months based on the time period (P = .014). CONCLUSIONS: The acceptable overall survival, the improved results after careful patient selection since 1998, and the encouraging outcomes from recent studies all suggest that OLT may be a potential treatment for selected cases of HL. Prospective multicenter randomized studies with strict selection criteria and multimodal treatments seem necessary.

[Surgical therapy of benign liver tumors]. / Chirurgische Therapie der benignen Lebertumoren.

Benign liver tumors are being detected more frequently due to the widespread use of ultrasound and complementary methods and due to improvements in diagnostic accuracy. In the case of a reliable diagnosis of asymptomatic hemangioma or focal nodular hyperplasia surgery is not indicated. Hepatic adenoma of considerable size should be resected primarily based on the risk of rupture. Improvements in diagnostic imaging as well as the optimization of surgical procedures with extremely low complication rates permit an individualized management strategy founded on evidence-based algorithms. In the case of an equivocal diagnosis, we advocate low-risk tumor resection instead of tumor biopsy due to the inherent complication rates of hemorrhage or tumor-cell dissemination and possible misleading histology.

["Fast-Track" for laparoscopic-assisted rectum resection--what can be achieved? First results of a feasibility study]. / "Fast-Track" bei laparoskopisch assistierter Rektumresektion--was kann erreicht werden? Erste Ergebnisse einer Machbarkeitsstudie.

AIM: "Fast-track" multimodal rehabilitation is increasingly entering the perioperative management strategies in colon surgery aiming at minimized perioperative morbidity and accelerated recovery. So far little is known about the complementary effects of minimally invasive surgery along with "fast-track" rehabilitation in the treatment of rectal cancer. The aim of this pilot study was to investigate the influence of "fast-track" perioperative management on morbidity, recovery and length of hospital stay in laparoscopically-assisted rectum resections and to compare those data to earlier results. METHODS: An interdiciplinary "fast-track" multimodal rehabilitation strategy with avoidance of mechanical bowel cleansing, with a restrictive intravenous intra- and postoperative fluid regimen, forced mobilisation, and early enteral nutrition was introduced into clinical practice and applied in 16 laparoscopically-assisted rectum resections. Data were collected in the course af a prospective analysis. The mean patient age was 62 (42-79) years. RESULTS: Mean time of surgery was 245 (SD 46) min, and the mean intraoperative infusion rate was 11.2 (SD 2.6) ml/kg/BW. On day 2, 14 of the 16 patients tolerated solid food and 12 patients had had bowel movements. All patients returned to their initial body weight by day 4. The median postoperative hospital stay was 7.5 days (6-20), 12 patients were discharged between day 6 and 8. Two patients were readmitted for intestinal atony, one patient developed an anastomotic leakage. CONCLUSIONS: "Fast-track" rehabilitation is feasible in rectum surgery and seems to complement the beneficial effects of minimally invasive surgery without increasing the complication rate.

[Consensus-recommendations for sirolimus in liver transplantation]. / Konsensusempfehlung zum Einsatz von Sirolimus in der Lebertransplantation.

Sirolimus is an m-TOR inhibitor without renal side effects and potentially protects against the development of malignancy. Due to a higher incidence of complications in two trials and an official warning in the drug information, the use of Sirolimus in liver transplantation is limited. The participants of this consensus meeting had to analyse and evaluate the literature with respect to the potential role of Sirolimus in liver transplantation. This consensus statement follows the scheme normally employed for the presentation of guidelines including the grading of evidence (1a-5) and the extent of recommendation (A-C). Moreover, the consensus included the experience of the authors with respect to the handling of Sirolimus after liver transplantation.

Acute pneumatosis cystoides intestinalis following allogeneic transplantation -- the surgeon's dilemma.

Pneumatosis cystoides intestinalis (PCI) is still a poorly understood phenomenon, currently considered to result from primary mucosal insult from varying causes. We report a case of severe PCI in a patient with chronic GVHD after bone marrow transplantation (BMT) performed to treat secondary AML. Post BMT, the patient suffered acute intestinal and cutaneous GVHD, eventually developing intestinal and biopsy-proven cutaneous chronic GVHD, which necessitated continuous steroid therapy. Chronic pancreatitis associated with GVHD was diagnosed by explorative surgery in February 2000 on the basis of increasing epigastric discomfort, tumour marker (CA 125) increase and the CT finding of a suspicious mass in the pancreas. Readmission occurred in April 2000 for rapid onset of inferior abdominal pain with distinct peritoneal signs. Relaparotomy, deemed necessary on the grounds of both clinical and radiological findings, revealed marked PCI of the ascending and transverse colon and attached mesentery in an otherwise intact gastrointestinal tract. Post-operative reconvalescence was uneventful, with no clinical or radiological recurrence of PCI in the following 10 months. In the context of a review of the relevant literature, this case report illustrates the complex underlying pathophysiology, and difficulty in making a differential diagnosis and treating PCI.

Renal transplantation in a patient with end stage renal disease due to cholesterol embolism.

BACKGROUND: Renal failure due to cholesterol emboli is mostly irreversible. Therefore chronic renal replacement therapy is necessary. However, to the best of our knowledge no published experience exists with renal transplantation in patients with end-stage renal disease (ESRD) due to cholesterol embolization (CE). METHODS: Renal transplantation was performed in a 64-year-old man who suffered from ESRD due to CE after coronary angiography. Because our patient presented with a typical profile of cardiovascular risk factors effective long-term control of these risk factors before and after transplantation was a mandatory prerequisite before considering transplantation. RESULTS: After one rejection episode serum creatinine values have been stable and no major complications have occurred during a follow-up of 18 months. No signs of recurrent cholesterol emboli into the donated kidney were seen in renal biopsies performed due to graft rejection. CONCLUSION: Cholesterol embolization is an uncommon reason for ESRD and mainly occurs after invasive vascular procedures in patients with hyperlipidemia, arterial hypertension, and smoking. Because ESRD due to CE often is irreversible, chronic renal replacement therapy may be necessary. As demonstrated in our report, renal transplantation should be considered. However, in this setting effective long-term control of the underlying risk factors before and after renal transplantation has to be ensured.

[Differential diagnosis and therapy of acute abdomen in sickle cell crisis. A rare case in visceral surgery]. / Differentialdiagnose und Therapie des akuten Abdomens bei der Sichelzellkrise. Der seltene Fall in der Viszeralchirurgie.

Surgical therapy of the acute abdomen often allows only limited time for differential diagnosis to confirm the indication for surgery. Under consideration of clinical aspects and case history both common and rare causes of an acute abdomen should be investigated without undue loss of time. Differential diagnostic considerations and eventual therapy are presented in the following case of a 25-year-old Afro-american who developed multiorgan failure after an initial course of lower-back pain. In addition to the clinical setting of an acute abdomen the patient presented with acute respiratory failure and laboratory signs of severe hemolysis in combination with newly detected splenomegaly. The indication for splenectomy was made following CT-proven complete splenic infarction due to repeated acute squestration. Histologic examination of the spleen together with hemoglobin electrophoresis confirmed the clinical assumption of unusually late primary manifestation of a sickle cell crisis. In the underlying case, the hemoglobinopathy was in fact the less common form of combined sickle-cell-beta-thalassemia. A ten-day course of intensive care therapy was necessary to treat ongoing multiorgan failure due to persistent sickle cell crisis. Current diagnostic and therapeutic procedures in connection with sickle cell crisis as a rare cause of an acute abdomen with the necessity for surgical intervention are presented.

[The ultrasound centre as a medically and economically relevant alternative--a report of the Regensburg experience]. / Das Ultraschallzentrum als ökonomisch und medizinisch sinnvolle Alternative--ein Erfahrungsbericht über das Regensburger Modell.

In most medical centres, ultrasonography is performed independently by several departments. In october 1997, the University hospital of Regensburg founded an ultrasound centre, integrating surgical and medical departments as well as the institutes for radiology and nuclear medicine. The aims of this centre were the concentration of organization, machines, financial resources, manpower and know-how, standardized training and quality, and strengthening of interdisciplinary cooperation in clinic, medical education and research. Booking, standardized reports and a joint archiving of reports are assisted by a collective computer system. Most examinations in the centre are performed by three all-day present gastroenterology, surgery and radiology residents who are supported by licensed sonographers of the other departments. Training is standardized, and the certification for ultrasound examinations is acquired after a test with theoretical and practical parts. The integration of various departments in the ultra-sound on-call service has led to significant savings. The pool of ultrasound machines is used jointly, department-specific resources for new machines have been put together. We are convinced that this way of a close interdisciplinary cooperation will result in improvements in quality, utilization of financial resources and clinical research.

Late onset primary oxalosis type I: an uncommon presentation of a rare disease.

A 46-year-old woman developed rapidly worsening renal insufficiency. Extensive calcification of the kidneys was found. The patient also suffered from ischaemic neuropathy, myopathy and arthritis. In a muscle biopsy multiple calcium oxalate crystals could be demonstrated surrounded by inflammatory infiltrates. Levels of oxalate in serum were markedly elevated. Diagnosis of primary hyperoxaluria type I was made by measuring alanine/glyoxylate aminotransferase activity in a liver biopsy. The patient underwent kidney transplantation twice, but each of the transplants failed after a very short time owing to hyperacute rejection and rupture of the organ, respectively. Eventually, combined liver/kidney transplantation was successfully performed. Two years after the transplantation, both organs work with good function. This case of primary hyperoxaluria type I is remarkable for the late onset of symptoms and the extensive involvement of other organ systems in addition to the kidneys. This case presentation confirms previous reports discouraging isolated kidney transplantation for patients with primary hyperoxaluria. Only combined liver/kidney transplantation can correct the metabolic defect and may give these patients superior long-term benefit.

[Arterial complications after liver transplantation]. / Arterielle Komplikationen nach Lebertransplantation.

Disturbances of the arterial perfusion of the graft following liver transplantation (LTx) are mainly of technical origin and contribute considerably to the postoperative morbidity and lethality. Aim of this retrospective survey was to determine the incidence and the consequences of hepatic artery thrombosis (HAT) and stenosis (HAS) in 203 patients (pts.) who underwent 246 liver transplantations. HAT was identified in 22 pts. by clinical, laboratory and sonographic and/or angiographic means. In 4 pts. HAT was asymptomatic and was detected during routine examination. Two pts. underwent immediate retransplantation, of which only one survived. Primary revascularization was performed in 16 pts., but was successfully only in 5 pts. Six pts. eventually underwent retransplantation with only one survivor. Biliary complications after HAT were observed in 10 pts. (45%), presenting in 8 pts. as biliary leak, in 2 pts. as bile duct stenosis. In the 12 patients with HAT who died the leading causes of death were sepsis (n = 3) and multiple organ failure (n = 3). HAS was observed in 11 pts., of which one was asymptomatic. Ten pts. underwent surgical revision. Redo of the arterial anastomosis was the most common procedure. Four pts. survived long term. Biliary tract complications were seen in 3 pts. (leak 1, stenosis 2). Three pts. died secondary to HAS from sepsis. These results confirm the life threatening character of any arterial complication after LTx. Because other reasons are rarely detected, the majority is attributable to technical faults. In order to avoid arterial complications extraordinary care has to be taken in the surgical handling of the arterial supply of the graft during harvesting, back table work and transplantation.

Influence of blood transfusions on tumor recurrence and survival rate in colorectal carcinoma.

Determinants for homologous blood transfusion and its influence on postoperative and long-term results were evaluated in 439 curatively resected colorectal cancer patients. The rate of transfusion was significantly higher in rectal cancer, large tumors, advanced pT stage and extended resection but not in tumor stenosis, lower graded tumors, advanced Dukes stage or less experienced surgeons. Transfused patients showed significantly more postoperative complications, higher recurrence rates as well as less favorable long-term survival. Homologous blood transfusions are negatively correlated to survival rates.