The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects.

AIM: Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects. METHODS: We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal. RESULTS: Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes. CONCLUSIONS: The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.

[Intrahepatic cholangiocarcinoma : Results after 84 resections]. / Das intrahepatische Cholangiokarzinom : Ergebnisse nach 84 Resektionen.

BACKGROUND: The incidence of intrahepatic cholangiocarcinoma (ICC) is increasing worldwide. Surgical resection is the only curative treatment option. AIM OF THE STUDY: This study analyzed the prognostic factors after resection of ICC. MATERIAL AND METHODS: A total of 84 patients were surgically treated under potentially curative intent. Perihilar and distal cholangiocarcinomas were excluded. The 5­year survival was analyzed with respect to tumor stage (TNM), number of lesions, complete surgical resection (R0), peritoneal carcinosis and postoperative complications. RESULTS: The 5­year survival was 27% and 77% of patients underwent R0 resections. In the univariate analysis a T stage >2, an N+ situation or an R+ resection as well as peritoneal and multilocular intrahepatic spread were associated with a poorer prognosis. Postoperative complications also negatively influenced survival. On multivariate analysis the absence of peritoneal spread, node-negative tumor stages, singular hepatic lesions and a low T stage as well as the absence of complications were associated with improved survival. DISCUSSION: The prognosis of ICC is poor even after successful surgical resection. Well-known tumor characteristics such as TNM are relevant prognostic factors. Surgical resection is accompanied by postoperative complications (most frequently biliary), which negatively influence survival. Adjuvant strategies are urgently needed to improve long-term survival even after complete surgical resection.

Is there any role for minimally invasive surgery in NET?

Neuroendocrine tumors (NET) represent the variability of almost benign lesions either secreting hormones occurring as a single lesion up to malignant lesions with metastatic potential. Treatment of NET is usually performed by surgical resection. Due to the rarity of NET, surgical treatment is mainly based on the experience and recommendations of experts and less on the basis of prospective randomized studies. In addition, the development and establishment of new surgical procedures is made more difficult by their rarity. The development of laparoscopic-assisted surgery has significantly improved the treatment of many diseases. Due to the well-known advantages of laparoscopic surgery, this method has also been increasingly used to treat NET. However, due to limited comparative data, the assumed superiority of laparoscopic surgery in the area NET remains often unclear or not yet proven. This review focuses on the present usage of laparoscopic techniques in the area of NET. Relating to the current literature, this review presents the evidence of various laparoscopic procedures for treatment of adrenal, pancreatic and intestine NET as well as extraadrenal pheochromocytoma and neuroendocrine liver metastases. Further, this review focuses on recent new developments of minimally invasive surgery in the area of NET. Here, robotic-assisted surgery and single-port surgery are promising approaches.

Interobserver variability in target volume delineation of hepatocellular carcinoma : An analysis of the working group "Stereotactic Radiotherapy" of the German Society for Radiation Oncology (DEGRO).

BACKGROUND: Definition of gross tumor volume (GTV) in hepatocellular carcinoma (HCC) requires dedicated imaging in multiple contrast medium phases. The aim of this study was to evaluate the interobserver agreement (IOA) in gross tumor delineation of HCC in a multicenter panel. METHODS: The analysis was performed within the "Stereotactic Radiotherapy" working group of the German Society for Radiation Oncology (DEGRO). The GTVs of three anonymized HCC cases were delineated by 16 physicians from nine centers using multiphasic CT scans. In the first case the tumor was well defined. The second patient had multifocal HCC (one conglomerate and one peripheral tumor) and was previously treated with transarterial chemoembolization (TACE). The peripheral lesion was adjacent to the previous TACE site. The last patient had an extensive HCC with a portal vein thrombosis (PVT) and an inhomogeneous liver parenchyma due to cirrhosis. The IOA was evaluated according to Landis and Koch. RESULTS: The IOA for the first case was excellent (kappa: 0.85); for the second case moderate (kappa: 0.48) for the peripheral tumor and substantial (kappa: 0.73) for the conglomerate. In the case of the peripheral tumor the inconsistency is most likely explained by the necrotic tumor cavity after TACE caudal to the viable tumor. In the last case the IOA was fair, with a kappa of 0.34, with significant heterogeneity concerning the borders of the tumor and the PVT. CONCLUSION: The IOA was very good among the cases were the tumor was well defined. In complex cases, where the tumor did not show the typical characteristics, or in cases with Lipiodol (Guerbet, Paris, France) deposits, IOA agreement was compromised.

[The surgical technique of laparoscopic right hemihepatectomy. Technical aspects and results]. / Chirurgische Technik der laparoskopischen Hemihepatektomie rechts. Machbarkeit und Ergebnisse.

INTRODUCTION: This study compared the technical aspects and results for two different techniques of total laparoscopic anatomical right hemihepatectomy. PATIENTS AND METHODS: From September 2010 to February 2013 a total of 16 patients underwent total laparoscopic right hemihepatectomy at the University Hospital of Freiburg. Of the patients 8 received an intraglissonian approach (IGA) and the other 8 patients an extraglissonian approach (EGA). In the patients of the IGA group, vascular inflow control of the right liver was accomplished by dissection and dividing the right hepatic artery, the right portal vein and the right bile duct separately before parenchymal dissection. In contrast, vascular control for patients in the EGA group was performed by enclosure and transsection of the whole right pedicle using a vascular linear stapler. RESULTS: Indications for right hemihepatectomy were benign tumors in 2 and malignancies in 14 cases. The average maximum tumor diameter was 5.5 cm (range 1.5-10.0 cm). Adequate tumor-free surgical margins (R0) were confirmed in all patients with malignancies. The perioperative mortality rate was 0 %, surgical complications according to Clavien's classification were grade I (n = 1 trocar site superficial wound infection), grade II (n = 2 cholangitis) and grade IIIb (n = 1 wound dehiscence after conversion to open procedure). The median operating time was 366 min (range 265-422 min) and 313 min (range 247-417 min) in the IGA and EGA groups, respectively. Conversion from laparoscopic to open minimal access procedure was necessary in three patients in the IGA group and two patients in the EGA group. Mean intraoperative blood loss was 644 ml (200-1000 ml) and 518 ml (200-1500 ml) in the IGA and EGA groups, respectively. Transfusion of two units of packed red blood cells was necessary for one patient in group EGA. No patient in either group needed a Pringle maneuver. Mean postoperative hospital stay was 11 days (range 7-23 days) and 13 days (range 7-31 days) in the IGA and EGA groups, respectively. CONCLUSIONS: Total laparoscopic anatomical right hemihepatectomy is a feasible procedure. The extraglissonian technique can provide shorter operating times by correctly facilitating vascular control of the right liver.

[Timing of resection in patients with colorectal carcinoma and synchronous liver metastases]. / Zeitlicher Ablauf von Leber- und Darmresektion bei Patienten mit kolorektalem Karzinom und synchronen Lebermetastasen.

Timing of surgical therapy in patients with synchronous colorectal liver metastases is becoming more complex. The standard therapy for most of the patients remains resection of the colorectal cancer first followed 6 weeks later by liver resection. Simultaneous colon and liver resection is safe and advisable in cases of minor liver resections and right-sided colon tumours. Major liver resections in combination with resection of the colorectal cancer carry the risk of increased postoperative morbidity and mortality. They should be considered for selected patients only. A pre-requisite is, in addition, special expertise of the operating surgeon in colorectal as well as in hepatobiliary surgery. If the synchronous liver metastases are near to essential anatomic structures, the liver resection should be performed before the bowel resection. The same holds if the metastases are technically resectable, but the future liver remnant seems to be too small. Using well known techniques, the future liver remnant should be increased and the liver metastases resected before treatment of the colonic primary tumour. The risk for local complications is very low when leaving the colorectal tumour in situ during treatment of liver metastases. When synchronous liver metastases are technically not resectable or carry a high risk of an R1 resection, patients should be treated first with systemic neo-adjuvant chemotherapy. If sufficient down-sizing of the metastases can be achieved, liver resection should be performed before bowel resection. A close cooperation between the oncologist and the hepatobiliary surgeon is most important, since the window for curative surgery is rather limited in these patients. In patients with resectable synchronous liver metastases, the advantage of a neoadjuvant chemotherapy has not been proven yet.

[Hepatic resection for hepatocellular carcinoma--results and analysis of the current literature]. / Leberresektion beim Hepatozellulären Karzinom - Eigene Ergebnisse und Literaturübersicht.

BACKGROUND: Hepatocellular carcinoma (HCC) is the fifth-leading cause of cancer death world-wide. Although less frequent in Western Europe, its incidence is increasing in this region. Causes involved in the pathogenesis of HCC are, besides viral hepatitis, metabolic and nutritional factors (alcohol, diabetes, obesity). The therapeutic management depends strongly on the initial extent of disease and includes hepatic resection, liver transplantation and local ablation. In this context, we present our results on liver resection for HCC and a discussion of the current literature about (potentially curative) treatment for HCC. PATIENTS: From 1999 until 2008 93 patients [83 % male, median age 64 (range: 39-94) years] underwent hepatic resection for HCC. Postoperative follow-up was available in 85 patients [median follow-up: 1.2 (0.25-8) years]. RESULTS: In contrast to data, especially from Asia, a viral hepatitis as the origin of HCC was found in only 28 % of the patients in our series. Half of the patients had proven liver cirrhosis. The median number of intrahepatic tumours was one (1-11), median size of the largest tumour was 55 mm (5-250 mm). 58 % of the HCC were removed by atypical or segmental resection, 42 % of the patients underwent hemihepatectomy or extended -hemihepatectomy. Tumor-free resection margins were -achieved in 95 %. Total postoperative morbidity was 61 %. A reoperation for complications was -necessary in 10 %. Hospital mortality was 8.6 % in the entire study period but decreased from 14.9 % in 1999-2004 to 2.2 % in 2005 to 2008 (p = 0.03). Actuarial survival was 81 % after 1 year, 58 % after 3 years and 26 % after 5 years. The T-stage could be identified tendentially as a prognostic factor influencing survival. CONCLUSION: With the proper selection of patients, liver resection for HCC may be performed with a curative intention (i. e., free resection margins) in over 90 %. Although it decreased during the study period peri-operative mortality was higher than after resection of other hepatic tumours. Long-term survival in our series was comparable to reports from other European centres.

Evaluation of preservation solutions by ESR-spectroscopy: superior effects of University of Wisconsin over Histidine-Tryptophan-Ketoglutarate in reducing renal reactive oxygen species.

Despite the causative role of oxidative stress in renal ischemia-reperfusion (I-R) injury effects of preservation solutions on reactive oxygen species (ROS) release have not been sufficiently evaluated. We compared the effects of most common solutions in kidney transplantation, University of Wisconsin (UW) and Histidine-Tryptophan-Ketoglutarate (HTK). ROS formation in isolated perfused rat kidney was detected by electron spin resonance spectroscopy using spin label 1-hydroxy-3-methoxycarbonyl-2,2,5,5-tetramethyl-pyrrolidine. Donor kidneys from Lewis rats were pretreated with saline (controls), in therapeutic groups, kidneys underwent 18 h of cold storage (CS) preserved by HTK or UW solution. Experimental protocol included a stabilization period followed by additional I-R. Kidneys preserved by HTK produced highest ROS values in the control period after CS, whereas levels in UW and control group did not vary significantly. A peak release induced by additional I-R was also significantly highest in HTK kidneys, and UW did not differ from controls. During reperfusion, levels in HTK exceeded control and UW values. Renal vascular resistance, caspase-3-activity, and tissue hydration were enhanced in HTK compared with UW group, whereas ATP concentration was less reduced in UW-preserved tissue. These data show the greater antioxidative potential of UW solution, which also attenuated organ impairment after CS in the early reperfusion period.

Glucagon expression shift in a syngeneic single-donor intrahepatic rat islet transplantation model.

In the native rat pancreas glucagon is expressed by alpha cells in the outer layer of the spheroid islet, producing a circular immunohistochemical staining pattern. We asked whether this pattern would remain unchanged after short-term and long-term intrahepatic islet transplantation. Islets of inbred Lewis rats were isolated with liberase, purified by discontinuous density gradients, handpicked, and cultured for 24 hours. After rats were rendered diabetic with streptozotocin, islets were implanted intraportally. Transplanted animals were sacrificed at 1 to 2 days (n = 5) or 100 days (n = 6). Islet clusters were detected by hematoxylen-and-eosin staining. Serial slides were stained for glucagon and insulin with the alkaline phosphatase and alkaline phosphate method at 1 to 2 days after transplantation islets with strong insulin expression were found within the portal vein branches. However, glucagon staining showed an incomplete circular staining pattern. After 100 days insulin expression remained strong, whereas only few glucagon-expressing cells were detected. Intrapancreatic islets showed inversion of the ratio of insulin- to glucagon-positive cells in favor of the glucagon-expressing cells that now composed the major part of the islet. Streptozotocin had selectively damaged beta cells in the recipient. In transplanted islets glucagon expression faded over time, possibly due to a functional involution process or to stress/inflammatory mechanisms during the isolation, transplantation, and the posttransplantation periods.

[Soft-tissue tumors: primary excision or wait and see?]. / Lipom, Atherom, Fibrom. Wann muss ein Weichteiltumor raus?

Soft tissue tumors are relatively commonly seen lesions in the doctor's office. An initial differentiation between malignant and benign tumors is usually possible on the basis of the case history and a careful physical examination. In adults, primary excision under local anesthesia is the treatment of choice in many cases, while in children and in the case of large tumors suspected of being malignant, a histological diagnosis must always be obtained. A number of procedures are available for biopsy taking. If the definitive histological work-up confirms malignancy, or if the findings are uncertain, the diagnostic investigation should be extended to include such imaging procedures as CT scanning or MRI.

Organ procurement in experimental pancreas transplantation with minimal microcirculatory impairment.

BACKGROUND: Ischemia-reperfusion injury has been shown to deteriorate microcirculation in experimental pancreas transplantation. However, minor concern was taken on the impact of organ procurement in this condition. We examined the impact of a standardized technique of organ procurement on microcirculation and apoptosis in experimental pancreas transplantation. METHODS: Male Lewis rats were divided into three groups: sham-operated animals without dissection of the pancreas served as controls (n = 5); animals undergoing nearly total process of organ procurement with the pancreas pedunculated on the aorta and the hepatoduodenal ligament (n = 7), and animals receiving pancreaticoduodenal transplantation. Pancreatic grafts were preserved for 6 h in cold University of Wisconsin solution (n = 7). At 1 and 2 h reperfusion and in time-matched controls, microcirculation was assessed by means of intravital fluorescence microscopy. Tissue samples were obtained after 2 h measurement and DNA breaks of acinar cells were detected by in situ nick end-labeling (TUNEL assay). The apoptotic index (apoptotic cells per high- power fields; hpf) was quantified by microscopic counting of at least 50 hpf. RESULTS: Assessment of functional capillary density (FCD) in animals undergoing subtotal process of organ procurement revealed a slight non-significant decrease at 1 and 2 h compared with controls. In addition, leukocyte sticking to postcapillary venules (LAV) as well as the apoptotic index were found slightly increased after organ procurement compared with controls (p > 0.05). However, after pancreas transplantation the apoptotic index and the LAV were significantly increased and the FCD significantly decreased compared with both groups of non-transplanted animals (p < 0.01). CONCLUSIONS: Our validated technique of organ procurement does not negatively impact microcirculation and apoptosis in experimental pancreas transplantation.

Apoptosis is caused by prolonged organ preservation and blocked by apoptosis inhibitor in experimental rat pancreatic grafts.

UNLABELLED: Apoptosis is a major mode of cell death after ischemia/reperfusion injury in several organs. The aims of this study were to evaluate apoptosis induction after different conditions of pancreas preservation and to investigate the impact of a caspase inhibitor on apoptosis induction in pancreatic grafts. METHODS: Inbred male Lewis rats served as donors and recipients. Apoptosis was detected using an in situ cell death detection kit and an apoptotic DNA ladder kit (Roche, Germany). An apoptotic index (AI) was defined as the number of apoptotic cells per field (400x) under a light microscope. The five groups included: group 1 (n = 5), normal pancreata; group 2 (n = 7), pancreata stored in University of Wisconsin (UW) solution (4 degrees C) for 6 hours (hr); group 3 (n = 7), pancreata preserved in UW solution (4 degrees C) for 18 hr; group 4 (n = 7), pancreata preserved in 0.9% saline (4 degrees C) for 6 hours; and group 5 (n = 5), pancreata preserved in 0.9% saline (4 degrees C) for 6 hours with Z-Asp-2,6-dichlorobenzoyloxymethylketone (caspase inhibitor) treatment. The pancreatic grafts in all experimental groups underwent a 2-hr period of reperfusion after transplantation. RESULTS: The results in this study showed that the AI was not significantly increased among pancreatic grafts in group 2 compared to group 1 (P >.05). However, AI in group 3 was significantly higher than that in group 2 (P <.05). The highest AI was observed in group 4. Interestingly, AI in group 5 was significantly lower than that in group 4 (P <.01), and not significantly different from group 1 (P >.05). Apoptotic DNA ladders were detected in the pancreatic grafts in group 2, 3, and 4, but not in group 1 and 5. CONCLUSIONS: Prolonged preservation of pancreata in cold UW solution induces a dramatic increase in apoptotic cell death among the pancreatic grafts following Tx. This observation may well be an important mechanism of graft damage. A caspase inhibitor might be useful to inhibit apoptosis induction in pancreatic grafts.

Heterotopic pancreatitis with obstruction of the major duodenal papill--a rare trigger of obstructive orthotopic pancreatitis.

BACKGROUND: Heterotopic pancreas appears in 0.5 to 13% of autopsies. The most frequent locations are stomach, duodenum or upper jejunum. Pancreatitis in heterotopic pancreas is rarely described, and clinical symptoms caused by this heterotopic inflammation are uncommon. METHOD: We report a case of heterotopic pancreatitis localized in the major duodenal papilla causing biliary obstruction and mimicking a pancreatic head tumor. Clinically and radiologically, malignancy was suspected. Preoperative biopsies showed only fibrosis. A pylorus preserving resection of the pancreatic head was performed followed by an uneventful postoperative course. RESULT: Macroscopically, in the periampullary region on the pancreatic side a thickened duodenal wall with multiple lobules and cysts was found, compressing the common bile duct. Microscopic examination showed heterotopic pancreas with inflammatory lesions surrounding the ampulla. In the orthotopic pancreas a diffuse chronic pancreatitis with marked inflammation, fibrosis and atrophy of exocrine tissue was found. CONCLUSION: In our case it was impossible to differentiate between chronic pancreatitis and pancreas carcinoma preoperatively. Radiological findings and endoscopic biopsies were not sufficient to distinguish heterotopic pancreatitis from other tumors of the pancreatic head. Clear diagnosis could only be made by complete histological examinations after pancreatic head resection, being the treatment of choice for pancreatic head tumors of unclear dignity. The differential diagnosis of heterotopic pancreatitis as trigger of unclear enlargement of the pancreatic head is very seldom.

Significance of total vascular exclusion for hepatic cryotherapy: an experimental study.

BACKGROUND: In the liver, efficacy of cryosurgical ablation of tumors located near the retrohepatic vena cava is impaired by the heat-sink effect. This could be overcome by total vascular exclusion (TVE) of the liver. In this study, the effect of TVE on cryosurgical ablation of liver tissue close to the retrohepatic vena cava was investigated with regard to the extent of the cryolesion and complications arising from necrosis of the caval wall. METHODS: Of a total of 28 pigs, 14 underwent cryotherapy with TVE compared to 14 without TVE, both involving the vena cava. 7 animals in each group were subjected to one freeze cycle and 7 in each group to two freeze cycles. Temperatures in the cryolesion were monitored and cryolesions were documented sonographically. Laboratory parameters were determined pre- and postoperatively. Follow-up was 14 days. Morphology, extent of the cryolesion, damage to the vena cava and complications were assessed after autopsy. RESULTS: With TVE, freezing rates were increased and cryolesions were significantly larger than without TVE. Transmural necroses of the vena cava with complete necrosis of the intima occurred significantly more frequently after TVE. Macro- and microscopically, the damage to the caval wall was considerably more marked after cryotherapy under TVE but in all cases the continuity of the vessel wall remained intact. There were no ruptures, thrombosis, or strictures of the vena cava. CONCLUSIONS: The combination of cryotherapy and TVE increases the effectiveness of cryoablation in the liver involving the retrohepatic vena cava without any severe vascular complications occurring in the pig.

Hepatic cryotherapy involving the vena cava. Experimental study in a pig liver model.

Liver tumors located near the retrohepatic vena cava are often considered nonresectable. For these patients cryoablation could be a therapeutic option. In this study the safety and efficacy of hepatic cryosurgery involving the retrohepatic vena cava were investigated. Cryolesions involving the vena cava were created in 26 pigs. Follow-up was 24 h and 14 days. The extent of the cryolesion, damage to the vena cava and complications were assessed after autopsy. The cyronecrosis extended into the wall of the vena cava in 81% of the animals. All animals had an uneventful recovery without any complications such as ruptures of the vessel, thrombosis or pulmonary embolism. Microscopically elastic and collagenous fibers of the cava wall remained intact. The continuity of the vessel wall was conserved. In conclusion, the safety and efficacy of cryosurgical treatment involving the retrohepatic vena cava were shown in a pig model.

Embryonic lymphangiogenesis.

About 8-9 decades ago the development of embryonic lymphatics was studied intensively. Since then our knowledge has not considerably increased in this field, and it is still unknown whether lymphatics are derived by sprouting from veins, de novo from lymphangioblasts, or by both mechanisms. However, very recent studies have shown that the vascular endothelial growth factor-C (VEGF-C) is a highly specific lymphangiogenic growth factor. This raises new questions and perspectives. Here we will review the literature on embryonic lymphangiogenesis and lymphangiogenic growth factors. We also present a description of the pattern of the lymphatics of avian embryos with emphasis on lymph hearts. The avian embryo is highly suited for studies on lymphatics, because these can be demonstrated by injection methods, serial sectioning and in situ hybridization with VEGF-receptor-2 and -3 probes. The greatest advantage resides in the fact that the lymphatics of the chorioallantoic membrane are easily accessible for experimental studies.