Revision of the common bile duct in a combined PTCD/ERC approach - A case report.

INTRODUCTION AND IMPORTANCE: The endoscopic retrograde cholangiography (ERC) represents the standard treatment for choledocholithiasis. However, ERC in patients with previous gastrectomy and anastomosis is difficult due to altered access. CASE PRESENTATION: In our case, we report on a patient with previous gastrectomy and Y-Roux-anastomosis suffering from choledocholithiasis. Operative revision with simultaneous cholecystectomy failed. In a combined procedure of percutaneous transhepatic cholangiodrainage (PTCD) and endoscopic cholangiography the stone removal of the common bile duct was finally successful. CLINICAL DISCUSSION: There are some approaches for treatment of choledocholithiasis in pre-operated patients. However, prospective multi-center studies for complication and success rates are not available due to the rarity of such cases. CONCLUSION: Interdisciplinary procedures seem to be the safest and most promising way to succeed in the treatment of choledocholithiasis in challenging cases.

Castleman's disease mimicked melanoma metastasis in the mesentery - A case report.

INTRODUCTION: Castleman's disease (CD) is a rare and mainly asymptomatic cause of lymph node swelling. Often it is unicentric and located in the mediastinum. Due to rarity of the disease as well as a lack of symptoms, diagnosis proves to be challenging, especially when CD affects another region. PRESENTATION OF CASE: A 51-year old male underwent resection of a malignant melanoma. Further staging revealed an unclear abdominal mass located in the mesentery with close contact to small intestine. Under the assumption of metastasis, complete tumor removal including intestine resection and anastomosis was performed. Both, operation and postoperative phase proved uncomplicated. Surprisingly, however, histology revealed a benign lymphoproliferative disorder, CD. DISCUSSION: There are several differential diagnoses for abdominal soft tissue tumor, such as: gastrointestinal stromal tumor, sarcoma, lymphoma, or metastasis. In reference to the resected melanoma described above, metastasis was assumed with subsequent oncological resection. Both, the reliable detection of CD as well as the exclusion of malignant disease (e.g. lymphoma) can only be achieved through pathology, in that specific tests fail yet to exist. The etiology of CD remains barely understood and based upon few cases reported complete surgical resection is recommended. However, the common form is meant to be benign. CONCLUSION: The potential diagnosis of CD should be made more common to surgeons, especially in completely asymptomatic patients and non-superficial lesions, whereby close follow-up examination might be offered to patients.

[Therapy of pancreatic pseudocysts: endoscopy versus surgery]. / Therapie von Pankreaspseudozysten : Endoskopie vs. Chirurgie.

Pancreatic pseudocysts are frequent complications following acute and chronic pancreatitis as well as abdominal trauma. They originate from enzymatic and/or necrotizing processes within the organ involving the surrounding tissues through inflammatory processes following pancreatic ductal lesion(s). Pseudocysts require definitive treatment if they become symptomatic, progressive, larger than 5 cm after a period of more than 6 weeks and/or have complications. Cystic neoplasms must be excluded before treatment. Endoscopic interventions are commonly accepted first line approaches. Should these fail or not be feasible surgical procedures have been well established and show comparable results. In summary, pancreatic pseudocysts require a reliable diagnostic approach with a multidisciplinary professional management involving gastroenterologists and surgeons.

Laser-supported diaphanoscopy: a new technique in laparoscopic-endoscopic rendezvous procedures allowing better and more tissue-sparing tumor resection than wedge resection.

BACKGROUND: Locating gastrointestinal stromal tumors (GIST) during laparoscopic surgery continues sometimes to be difficult and inaccurate. In addition, the methods used for tumor mapping often do not lead to precise location of tumors. Also, they are too expensive or too complex for an easy surgical approach. Furthermore, the standard wedge resection often sacrifices too much healthy tissue. METHODS: The current study introduces an innovative tissue-sparing method using laser-supported diaphanoscopy (Endolight) for exact location of GIST during laparoscopic surgery. The instrument was developed by the authors' group. This study retrospectively evaluated two groups of patients experiencing GIST. The first group of 10 patients was treated by standard wedge resection. The second group of 10 patients was treated by Endolight-guided laparoscopic resection during a laparoscopic-endoscopic rendezvous procedure. RESULTS: After precise location of GIST using Endolight, all patients could be successfully resected. The largest resection margins using Endolight (9.8±3.8 mm) were significantly smaller than the largest resection margins using wedge resection (stapler) without Endolight (21.5±9.1 mm; p<0.0001). The average surgery time for the group treated by standard wedge resection was 65 min (range, 28-108 min). The surgery time required for the group treated by Endolight-guided resections ranged from 48 to 189 min (average, 123 min). The number of marks used for Endolight resections ranged from four to seven depending on the location and size of the tumor. CONCLUSION: The reported technique allows the precise location of GIST, leading to exact and tissue-sparing transmural laparoscopic resection of these tumors compared with standard wedge-resection. Laser-supported diaphanoscopy using the newly developed innovative device offers new perspectives and a highly effective technique for resecting GIST that combines an endoscopic with a laparoscopic approach.

Laser-supported diaphanoscopy: an innovative technique for locating gastric stromal tumors in gastroscopic-laparoscopic rendezvous: a case series.

Development of an innovative method of endoscopic laser-supported diaphanoscopy, for precise demonstration of the location of gastrointestinal stromal tumors (GISTs) at laparoscopy is described. The equipment consists of a light transmission cable with an anchoring system for the gastric mucosa, a connecting system for the light source, and the laser light source itself. During surgery, transillumination by laser is used to show the shape of the tumor. The resection margins are then marked by electric coagulation. Ten patients have been successfully treated using this technique in laparoscopic-endoscopic rendezvous procedures. Average time of surgery was 123 minutes. The time for marking the shape of the tumor averaged 16 minutes. Depending on tumor location and size, 4-7 marks were used, and resection margins were 4-15 mm. This new and effective technique facilitates precise locating of gastric GISTs leading to exact and tissue-sparing transmural laparoscopic resections.

[Gastric schwannoma: a "typical" clinical course?]. / Abdominelles Schwannom : Ein "klassischer" Fallbericht?

Intra-abdominal schwannoma is a rare tumor entity. Although often detected incidentally, its diagnosis and surgical planning are difficult-as with all intramural intra-abdominal tumors. Puncturing is often not satisfying due to the inhomogeneous proliferation rates of different regions of the tumor. We describe the procedure using the example of a gastric schwannoma that was found incidentally. The leading symptom was perforation of a peptic stomach ulcer.

[Atypical vascular supply from the coeliac trunk. Recurrent bleeding from a duodenal ulcer]. / Atypische Gefässversorgung aus dem Truncus coeliacus. Rezidivblutung aus einem Ulcus duodeni.

Hemorrhagic duodenal ulcers should primarily be controlled by endoscopy. In cases of recurrent bleeding or if bleeding cannot be controlled endoscopically, open surgery is the gold standard. Rarely, atypical origin of arteries or additional atypical arteries may lead to further unexpected hemorrhagic recurrences and angiography with surgical intervention is the treatment of choice. In this article a rare case of an atypical visceral artery connecting the coeliac trunk and the gastroduodenal artery leading to recurrent bleeding from a duodenal ulcer is presented.

How do gynecologists feel about transvaginal NOTES surgery?

BACKGROUND: Natural-orifice transluminal endoscopic surgery (NOTES) is regarded as safer and less invasive than laparoscopic surgery. However, there has been no documentation of the opinions of surgically active, experienced gynecologists about the indications, contraindications, risks, and complications of transvaginal access. METHODS: A two-page questionnaire was distributed to the heads of the gynecological departments at 181 university and major teaching hospitals across Germany, Austria, and Switzerland. Fifty-two questionnaires (28.7 %) were returned and evaluated. The questionnaire contained ten questions, four of which were yes/no questions and another five of which allowed between four and seven answers. The questionnaire contained one additional open question. RESULTS: Of the respondents, 69.2 % classified transvaginal access for extrapelvic abdominal surgery as ethical; the remaining 30.8 % described it as experimental. Only 28.8 % would recommend NOTES to their patients if NOTES presented the same surgical risks as the laparoscopic approach. When asked about NOTES-associated complications, 73.1 % mentioned the risk of infection, 61.5 % visceral lesions, 44.2 % infertility, and 34.6 % adhesions. In terms of long-term problems, gynecologists are concerned about dyspareunia and infertility. Adopting their patients' point of view, 17.3 % voted the lack of scarring compared to laparoscopy as important and 57.6 % as unimportant. CONCLUSIONS: While transvaginal NOTES is argued to be a promising access for scarless surgery, gynecologists mention postoperative infection, visceral lesions, infertility, and adhesions as conceivable complications. Since long-term experience has not yet been achieved, potential problems such as dyspareunia, infertility, and the spread of pre-existing endometriosis remain definitely conceivable complications.

Acute upper gastrointestinal hemorrhage: is a radiological interventional approach an alternative to emergency surgery?

The aim of our study was to discuss the option of endovascular treatment compared to surgery for patients with endoscopically unmanageable nonvariceal hemorrhage of the upper gastrointestinal tract. From 2000 to 2006, 23 patients (male, 15 male; female, 8; mean age, 69 years) who failed endoscopic therapy for upper gastrointestinal hemorrhage were retrospectively evaluated. Twelve patients were operated on (SG), whereas 11 patients had an endovascular intervention (IG). Technical and primary clinical success rates and complications rates were calculated. Clinical parameters and comorbidities were related to outcome. The surgical group suffered less frequently from pre-existing pulmonary diseases (SG, 17%; IG, 55%; p = 0.05) and had a higher incidence of shock requiring catecholamines (p < 0.01) or plasma expander therapy (p < 0.01). There was no significant difference in the incidence of recurrent bleeding episodes (SG, 17%; IG, 27%; p = 0.35) and mortality rates (SG, 17%; IG, 27%, p = 0.35). Deaths in the IG were due to recurrent bleeding. In patients with unsuccessful endoscopic control of nonvariceal bleeding of the upper GI tract, surgery remains a very effective treatment. However, in patients with a high surgical risk due to unknown bleeding sources and/or severe pre-existing diseases/comorbidities, endovascular therapy offers an excellent treatment option. These patients should then be operated on as early as possible to minimize the risk of recurrent bleeding episodes, which are associated with high morbidity and mortality.

Endoscopic transanal vacuum-assisted rectal drainage (ETVARD): an optimized therapy for major leaks from extraperitoneal rectal anastomoses.

BACKGROUND AND STUDY AIMS: A major leak from a rectal anastomosis is an important surgical complication. Endoscopic transanal vacuum-assisted rectal drainage (ETVARD) is a new method for treating nonseptic major anastomotic leaks after extraperitoneal rectal anastomoses. PATIENTS AND METHODS: Between January 2002 and March 2007 a total of 17 patients (mean age 61.2 years) who developed anastomotic leakage after resection of the rectum or rectosigmoid colon were prospectively evaluated. Their treatment began with endoscopic debridement of the leak/cavity; nylon sponges were then endoscopically fitted into the cavity. Continuous suction was applied via suction tubes inserted into the sponges. Repeat endoscopies and sponge exchanges, including further debridement were essential. RESULTS: In 16/17 patients ETVARD was successful, relieving patients quickly from infectious symptoms and other complaints; one patient eventually required a Hartmann's procedure. Cavity sizes varied from 2 cm x 2 cm to 10 cm x 13 cm. The mean duration of drainage was 21.4 days, with a mean of 5.4 sponge exchanges and 10.7 endoscopies, and a mean total time to closure of the cavity of 53.1 days. The total time to closure of the cavity was directly dependent on the size of the cavity ( P< 0.015). Fifteen patients received additional intramural fibrin glue injections. In eight patients ETVARD was continued on an outpatient basis. There was no advantage demonstrated for patients with diverting loop ileostomies. Patients with anastomoses that were 6 cm or less from the anocutaneous line had considerably longer healing times. The healing time depended significantly on age ( P< 0.036). Follow-up endoscopies have shown only minor anastomotic changes in two patients. CONCLUSIONS: ETVARD is a well-tolerated and effective therapeutic option for the treatment of major leaks after extraperitoneal rectal anastomoses. In most cases ETVARD obviates the need for additional surgery, in particular diverting loop ileostomy.