Malignant triton tumor of the rectum - A case report and review of the literature.

INTRODUCTION: Malignant triton tumors (MTT) are rare but highly aggressive tumors that originate from the Schwann cells. These tumors can occur in any part of the body, mostly present late and carry poor prognosis. PRESENTATION OF CASE: We present a 24-year-old man with a rectal MTT causing non-specific abdominal pain and recurring ileus. The MRI showed a rectal mass near the urinary bladder with compression on the seminal vesical. A complete surgical resection of the tumor was performed. The immunohistological report confirmed a rectal MTT. Because of persistent ileus during the post-operative palliative chemotherapy, another tumor debulking was performed. The patient died 9 months after the diagnosis of MTT due to local recurrence under chemotherapy. DISCUSSION AND CONCLUSION: MTTs are uncommon tumors in young age with high morbidity and mortality because of local recurrence also after complete resection.

Feasibility and safety profile of posterior retroperitoneoscopic adrenalectomy in high-risk patients - A retrospective analysis.

OBJECTIVES: Posterior retroperitoneoscopic adrenalectomy (PRA) is used for removal of benign adrenal lesions. Though literature shows low complication rate in this procedure, there is no consensus about safety profile of PRA in high-risk patients. This study aimed to determine the feasibility and safety profile of PRA in high-risk patients. METHODS: This retrospective study recruited all patients who underwent PRA for benign adrenal lesions in the study center. Patients with an American Society of Anesthesiologists (ASA) score of ≥3, on anticoagulant therapy or a body mass index (BMI) over 30 were classified as high-risk patients. We analyzed patients' demographics, comorbidities, perioperative mean arterial pressure and operative time, postoperative complications and tumor characteristics. Mortality and morbidity rates and length of hospital stay of the high-risk and low-risk groups were compared. The chi-square and t tests were used to determine relationships between categorical variables between groups. RESULTS: Forty two PRA procedures were done on 21 men and 21 women; mean age of 50 years in low and 62 years in high risk groups. Twenty six (61.9%) patients had high-risk profile. We recorded 4 (9.5%) intra- and postoperative complications, while one (2.3%) PRA was converted to open due to intra-operative hemorrhage. Mean operative time of 86.45 and 108.19 min (p = 0.204), and postop hospital stay of 4.44 and 6.65 (p = 0.25) days were recorded for low and high risk groups, respectively. Intraoperative arterial pressure of ≥170 mmHg was noted for 6 low and 11 high risk patients (p = 885). CONCLUSION: Our results indicate that PRA for benign adrenal lesions is safe and feasible in patients with a high-risk profile without a risk of increased peri- and postoperative complications.

Comparison of conservative versus surgical therapy for acute appendicitis with abscess in five German hospitals.

INTRODUCTION: The aim of this study was to evaluate the effectiveness of initially conservative therapy compared to immediate appendectomy for acute appendicitis with abscess in terms of medical and economic outcomes. METHODS: Of all the patients treated for appendicitis from January 2009 to December 2017 in five German hospitals, 240 were included in the study. Fifty-three patients received conservative (CON) and 195 patients received surgical (SUR) therapy as initial treatment. RESULTS: Length of stay was similar (12.5 days in CON vs. 13.3 days in SUR, p = 0.530). Readmission rate was higher in the conservative group (54.7% vs. 6.2%, p < 0.001). The majority (53.7%) of the 41 operations in CON group were appendectomies (22 procedures), 1 (4.5%) of them was in the first hospital stay because of persisting symptoms, 21 (95.5%) after a recovery interval. Seven (33.3%) of the recovery appendectomies were performed due to persisting or recurrent symptoms and 14 (66.7%) due to the request of patient. Twenty-one patients (39.6%) in the CON group did not need surgery. The rates of complication-related operations per patient (0.04 versus 0.58, p < 0.001), conversions of surgical technique (1.9% vs. 34.9%, p = 0.0287), and extended resections (1.9% vs. 31.3%, p < 0.001) were higher in SUR group. Furthermore, morbidity, hospital costs, and loss in quality of life were significantly higher in the surgical group (17.0% vs. 66.2%, p < 0.001; € 5044 vs. € 8457, p < 0.001, and 4.3 days vs. 7.5 days, p < 0.001, CON vs. SUR). CONCLUSION: Initially, conservative treatment for acute appendicitis with abscess is preferable to immediate surgical treatment in reduction of morbidity, hospital costs, and loss in quality of life.

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.

[A new cholecystectomy with no visible scarring and low risk. A possible alternative to natural orifice transluminal endoscopic surgery]. / Suprasymphysäre laparoskopische Cholezystektomie ohne sichtbare Narben. Eine Alternative zu NOTES?

Laparoscopic cholecystectomy was established in the 1980s and is the gold standard for treating cholecystolithiasis and cholecystitis. Laparoscopy offers reduction of postoperative pain, smaller scars, and a lower complication rate, resulting in shorter hospitalisation and faster recovery. In recent years alternative approaches for cholecystectomy have been developed to meet requirements of aesthetic surgery (scarless surgery, natural orifice transluminal endoscopic surgery). Access to the abdominal cavity with these methods is transgastral, transcolonal via endoscopy, or transvaginal with potential fatal effects such as peritonitis. In this paper a new variation with minimal risks is presented. In contrast to conventional laparoscopy, no visible scars are left behind.

[Intrathoracic lesions in association with germ cell tumor of the testis]. / Bihiläre Lymphome bei nichtseminomatösem Keimzelltumor.

Intrathoracic enlarged lymph nodes in patients with malignant diseases always arouse suspicion of lymphatic metastases. Despite modern diagnostic investigation, surprising findings sometimes emerge. The present case of a young man with intrathoracic lesions in association with a germ-cell tumor of the testis turned out to have sarcoidosis mimicking testicular cancer relapse.

Pancreatic cancer: a generalized disease--prognostic impact of cancer cell dissemination.

BACKGROUND: Pancreatic ductal adenocarcinoma is the fifth leading cause of death among all malignancies, leading to approximately 40,000 deaths each year in Europe. The annual incidence rate for all types of pancreatic cancer is approximately nine new cases per 100,000 people, ranking it as the 11th among all cancers. Stage, grade and resection margin status are currently accepted as the most accurate pathologic variables predicting survival. All classification systems fail prognostically to distinguish between different stages. Even in patients with seemingly early tumours (T1, N0), the likelihood of relapse is high. This reflects the shortcomings of the pathologic staging to sufficiently discriminate patients with a high risk to develop tumour recurrence from those that carry a lower risk. RESULTS: On the other hand, none of the currently used systems includes or takes into consideration the role of disseminated tumour cells neither in the lymph nodes nor in the bone marrow. Occult residual tumour disease is suggested when either bone marrow or lymph nodes, from which tumour relapse may originate, are affected by micrometastatic lesions undetectable by conventional histopathology. For detection, antibodies against tumour-associated targets can be used to detect individual epithelial tumour cells both in lymph nodes and in bone marrow. The clinical significance of these immunohistochemical analyses is still controversial. Various monoclonal antibodies are still in use for micrometastatic detection, thus contributing to the incongruity of data and validity of results. These assays have been rarely used in patients with pancreatic carcinoma. CONCLUSION: The presence or absence of lymph-node metastases can predict the likelihood of survival for most, if not all, patients with pancreatic ductal adenocancer and the likelihood that metastases will develop at distant sites.

Pre-incisional epidural ropivacaine, sufentanil, clonidine, and (S)+-ketamine does not provide pre-emptive analgesia in patients undergoing major pancreatic surgery.

BACKGROUND: The concept of pre-emptive analgesia remains controversial. This prospective, randomized, and double-blind study compared epidural administration of ropivacaine 2 mg ml(-1), sufentanil 0.5 microg ml(-1), clonidine 3 microg ml(-1), and S(+)-ketamine 0.25 mg ml(-1) (study solution) given before incision with the same combination started at the end of the operation. METHODS: After testing the stability of the solution using high performance liquid chromatography (HPLC) and examining 12 patients for possible side-effects in comparison with the epidural infusion of ropivacaine 2 mg ml(-1) and sufentanil 0.5 microg ml(-1), 30 patients undergoing major pancreatic surgery were recruited into the study. Before induction of anaesthesia, an epidural catheter was inserted (TH6-8). Patients in Group 1 received a bolus of 8 ml followed by a continuous infusion (8 ml h(-1)) of the study solution before induction of anaesthesia. In Group 2, patients received the same volume of saline before operation, the study solution was started at the end of surgery. After operation, the infusion was maintained for at least 96 h using a patient-controlled epidural analgesia (PCEA) pump in both groups. Patients were evaluated up to the seventh postoperative day for pain and side-effects. RESULTS: Visual analogue scale (VAS) values at rest were as follows: G1 vs G2: 24 h, 19 (sd 23) vs 6 (13); 48 h, 4 (10) vs 11 (21); and 72 h, 12 (22) vs 13 (21). VAS values during coughing and mobilization were also comparable. Total volume of epidural infusion was 904 (114) ml in G1 vs 892 (154) ml in G2. The incidence of side-effects (nausea, vomiting, and motor block) was low and not different between the groups. CONCLUSIONS: Pre-incisional epidural analgesic infusion did not provide pre-emptive analgesia compared with administration started at the end of surgery, but both groups had low pain scores.

Laparoscopic gastric tailoring for huge subcardial gastrointestinal stromal tumor.

BACKGROUND: A 67-year-old woman with a gastrointestinal stromal tumor (GIST) of the stomach presented to our outpatient clinic. Preoperative computed tomographic scans and endoscopic examination revealed a spherical submucosal tumor (7.7 x 6.1 x 6 cm) in the posterior wall of the stomach less than 1cm away from the cardia, on the small curvature side. METHODS: The tumor, which endosonographically had a volume of 282 cm(3), was completely resected by a full-thickness laparoscopic wedge excision without discontinuous gastric resection. The whole procedure was performed using 4 working ports (one 12-mm and three 5-mm ports) and 1 camera port (12 mm). Because the resection margins were tumor free on frozen sections and the distance between the resection margin and cardia was wide enough not to compromise food passage, there was no need for total gastrectomy or upper discontinuous gastric resection. The patient was discharged on the fourth postoperative day after an uneventful clinical course. RESULTS: Histological examination revealed a malignant gastrointestinal stroma tumor of the stomach. The patient was therefore enrolled for Imatinib adjuvant therapy. Careful and long-term follow-up of 21 months showed no signs of local or distant tumor recurrence. However, further follow-up is needed to monitor for signs of possible recurrence or distant metastases. CONCLUSION: The described technique prevented proximal gastric resection and a risk of anastomosis without compromising the food passage and radicality.

Immune-mediated activation of the endocannabinoid system in visceral adipose tissue in obesity.

The aim of the study was to investigate if the endocannabinoid system (ECS) is activated in visceral adipose tissue and if adipose tissue inflammation affects the ECS activation state. Therefore, expression of fatty acid amide hydrolase (FAAH), cannabinoid receptor 1 (Cb1), adiponectin, and tumor necrosis factor (TNF)-alpha was compared in visceral adipose tissue from 10 normal-weight (BMI 24.4+/-1.1 kg/m2) and 11 obese subjects (BMI 37.6+/-13.6 kg/m2) using quantitative RT-PCR, and gene expression changes were analyzed after in vitro stimulation of visceral adipose tissue with TNF-alpha. The data demonstrate that the ECS is activated in obese visceral adipose tissue as shown by decreased FAAH, Cb1, and adiponectin expression. Obesity-related ECS activation is accompanied by elevated expression of the pro-inflammatory cytokine TNF-alpha, which in turn stimulates ECS activation in vitro. Our data show a strong association between adipose tissue inflammation and ECS activation in obesity, and indicate that a pro-inflammatory state may directly activate the ECS.

Quality control of endoscopic ultrasound in preoperative staging of esophageal cancer.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasonography (EUS) is generally established as the most sensitive diagnostic tool for the assessment of locoregional tumor stage in esophageal carcinoma. It therefore has a crucial impact on the decision whether patients should undergo surgery as primary treatment or should receive neoadjuvant therapy. This study retrospectively evaluates the accuracy of EUS in tumor and nodal staging of prospectively evaluated patients with esophageal carcinoma in relation to tumor type, tumor grading, tumor site, and the influence of dilation. PATIENTS AND METHODS: All 214 patients included in the study underwent surgery without neoadjuvant therapy and had tumor-free resection margins with no evidence of distant metastasis. EUS investigations were done at our Department of Interdisciplinary Endoscopy. EUS results were compared with the pathological findings. RESULTS: EUS correctly identified T status in 141 patients (65.9 %). The sensitivity and specificity in relation to T status were 68.1 % and 98.2 % respectively for T1, 40.9 % and 83.4 % for T2, 84.3 % and 64.6 % for T3, and 14.3 % and 98.8 % for T4. The overall diagnostic accuracy of EUS in relation to N status was 64.5 % (n = 138); sensitivity and specificity for the diagnosis of N1 were 93.8 % and 20 %, respectively. Sixty-eight (80 %) of 85 pN0-staged tumors were overstaged as uN1. Dilation had a significant influence on the accuracy of EUS staging in advanced tumors ( P = 0.02), whereas tumor grading impacted on EUS staging in early tumors ( P = 0.01). Tumor site and tumor type did not show any influence. CONCLUSIONS: Endosonographic staging of esophageal carcinoma is still unsatisfactory. An improvement in staging accuracy may be achieved by adding fine-needle aspiration biopsy (FNA) to EUS, because FNA improves N-stage accuracy, but it has no bearing on T-stage accuracy.

TNF-alpha alters visfatin and adiponectin levels in human fat.

Adiponectin and visfatin are newly discovered adipokines that are strongly expressed in human visceral adipose tissue. To identify new regulatory mechanisms in fat, the effect of TNF-alpha (TNF) on adiponectin, on its two receptors, and on visfatin was investigated by incubating human visceral adipose tissue from patients without diabetes mellitus with TNF for 24, 48 and 72 hours. The mRNA expression of visfatin, adiponectin, and its two receptors, as well as the protein expression of adiponectin were determined. A decrease of adiponectin mRNA expression of 97% after incubation with TNF (5.75 nmol/l) for 24 hours, a decrease of 91% after 48 hours, and a decrease of 96% after 72 hours were measured. The reduction of protein expression was measured to be 42% after 24 hours, 28% after 48 hours, and 39% after 72 hours of incubation with TNF (5.75 nmol/l). The mRNA level of adiponectin receptor 1 (AdipoR1) was elevated about 72% after 48 hours of incubation and 67% after 72 hours of incubation, whereas the mRNA expression of adiponectin receptor 2 (AdipoR2) was not altered significantly. The visfatin mRNA level was found to be highly increased by 255% after 24 hours and 335% after 48 hours and 341% after 72 hours of incubation with TNF (5.75 nmol/l). Our results support the concept of visceral adipose tissue as an endocrine organ. We demonstrate that TNF has regulatory functions on adiponectin, AdipoR1 and on visfatin in human visceral adipose tissue. TNF levels are elevated in states of obesity and insulin resistance. Due to this fact TNF could be the reason that there is a decrease in the level of adiponectin, whereas there is an increase in the level of visfatin in states of obesity and insulin resistance.

[Arterio-venous aneurysm of splenic vessels--a rare differential diagnosis for cardio-circulatory symptoms]. / Arteriovenöses Aneurysma der Milzgefässe--Eine seltene Differentialdiagnose bei kardio-zirkulatorischen Symptomen.

Patients with arterio-venous fistula of the splenic hilum seek medical assistance because of abdominal discomfort and symptoms of portal hypertension. We report on a 43 year old female who was diagnosed with an arterio-venous aneurysm after suffering from dyspnoea, tachycardia and extrasystolies for several years. After uncomplicated distal splenopancreatectomy the patient was discharged free of symptoms.

Effects of isovolaemic haemodilution on oxygenation of liver and skeletal muscle.

BACKGROUND AND OBJECTIVE: Hydroxyethyl starch is frequently used for volume substitution during surgical procedures and for isovolaemic haemodilution. Haemodilution has also been shown to improve tissue oxygen tension in skeletal muscle: However, effects of this volume substitute on tissue oxygen tension of the liver during haemodilution remains unknown. METHODS: Fourteen foxhounds were anaesthetized with fentanyl/midazolam and mechanically ventilated with 30% oxygen. Following splenectomy animals were randomly assigned to a control group without haemodilution but fluid substitution with Ringer's lactate (Group C) or underwent isovolaemic haemodilution to a haematocrit of 25% with hydroxyethyl starch 70/0.5 (Group H). Haemodynamic parameters and oxygen transport during 100 min following isovolaemic haemodilution were measured. Liver oxygen tension was recorded using a flexible polarographic electrode tonometer, whereas in the muscle a polarographic needle probe was used. RESULTS: Animal characteristics and baseline haematocrit were similar in both groups. At baseline the tissue oxygen tension of liver and skeletal muscle were not different between groups. Haemodilution with hydroxyethyl starch 70/0.5 provided augmentation of mean liver tissue oxygen tension (baseline: 46 +/- 13 mmHg; 20 min: 60.3 +/- 12 mmHg; 60 min: 60 +/- 16 mmHg; 100 min: 63 +/- 16 mmHg; P < 0.05 vs. baseline), while oxygen tensions in Group C remained unchanged (baseline: 48 +/- 16 mmHg; 20 min: 52 +/- 19 mmHg; 60 min: 49 +/- 12 mmHg; 100 min: 52 +/- 16 mmHg) and no differences could be detected between groups. Oxygen tension in skeletal muscle changed as follows: Group H - baseline: 24 +/- 32 mmHg; 20 min: 32 +/- 3 mmHg; 60 min: 33 +/- 7 mmHg; 100 min: 33 +/- 11 mmHg. Group C - baseline: 22 +/- 6 mmHg; 20 min: 21 +/- 3 mmHg; 60 min: 24 +/- 4 mmHg; 100 min: 18 +/- 4 mmHg (P < 0.05 vs. baseline, p < 0.05 vs. Group C). CONCLUSION: In this animal model, isovolaemic haemodilution with hydroxyethyl starch 70/0.5 increased tissue oxygen tension in liver and skeletal muscle in comparison with baseline values. However, when compared between groups haemodilution only resulted in an increase of tissue oxygen tension in the muscle but not in the liver.

Klatskin tumors and Klatskin mimicking lesions of the biliary tree.

AIM: We report on the preoperative capability of imaging modalities and clinical assessment to differentiate between Klatskin tumors and Klatskin mimicking lesions of the biliary tree. Adenocarcinomas of the hepatic ducts (Klatskin tumors) mimic benign fibrosing cholangitis. Extensive resections carry a substantial risk but offer the only chance for cure in patients with a Klatskin tumor. METHODS: Thirty-three consecutive patients who underwent resection for suspicion of a malignant tumor of the hepatic hilum were reviewed. All patients underwent preoperative ultrasonography, computed tomography, ERCP and angiography. The patients were divided into a group of true Klatskin tumors and a group of benign Klatskin mimicking lesions. RESULTS: Twenty-seven of the resected specimens were malignant tumors, and six lesions showed only fibrosing cholangitis. Preoperative clinical presentation and imaging modalities were very similar between Klatskin tumors and fibrosing cholangitis. CONCLUSIONS: Management of obstruction of the liver hilum is dictated by the suspicion of malignancy. Complete removal of the tumor remains the therapeutic aim but clinical presentation and imaging modalities cannot help to differentiate between Klatskin tumors and Klatskin mimicking lesions prior to surgery.

Ambulatory long-term pH monitoring in pigs.

BACKGROUND: pH monitoring has been established as the "gold standard" in the diagnosis of gastroesophageal reflux. Evaluation of experimental antireflux therapy should therefore also include this technique, but a suitable technique in an experimental model did not exist so far. The aim of our study was to establish a reliable method for the evaluation of an experimental reflux model in pigs. METHODS: A total of 33 German Landrace pigs with an average body weight of 56 (50.2-67.2) kg were included. pH monitoring was performed before and after open cardiomyotomy in each animal. All manipulations were performed under general anesthesia. After manometric localization of the gastroesophageal high-pressure zone, a standard pH probe was inserted into the pharynx through a small needle-punctured canal on the side of the animal's snout and placed under endoscopic guidance with the proximal sensor 3 cm above the lower esophageal sphincter (LES) and the distal sensor in the stomach for reference. The harness to carry the pH recorder on the animal's back consisted of a modified belly strap that enabled the animal to move around without limitation. For analysis the same threshold levels were defined as in humans. Gastroesophageal reflux was induced by cardiomyotomy. RESULTS: The placement of the standard pH probe was possible in all cases. Inserting the probe on the side of the snout left the animals free to nuzzle, which complies with the normal habits of pigs, without breaking the probes and without being compromised in their natural behavior. Repeated punctures for multiple measurements were easily feasible. We performed up to three examinations in each individual animal. Recording was performed for 48 h. A mean number of 67.3 (+/-9.7) acidic refluxes were registered. The mean number of long acidic refluxes was 3.2 (+/-0.75). For an average total time of 75.5 (+/-14.3) min the pH was below 4 accounting for a fraction time pH below 4 of 3.5% (+/-0.68%). Following cardiomyotomy the number of acidic refluxes increased significantly to 166.1 (+/-21.8) and the number of long refluxes to 17.74 (+/-3.35). The total time of pH below 4 increased to 371.3 (+/-62) min so that the fraction time pH below 4 was 14.5% ( p = 0.0006). CONCLUSION: pH monitoring should be mandatory in any investigation of antireflux therapy. Our method is easy and secure to perform. It is suitable for other gastrointestinal investigations (Bilitec, long-term manometry) that could be carried out using the same technique. The described data represent the basis for other investigations of experimental antireflux therapy.

Chronic pancreatitis: etiology, pathogenesis, diagnosis, and treatment.

BACKGROUND AND AIMS: This review discusses current concepts regarding the etiology, pathogenesis, diagnosis, and treatment of chronic pancreatitis. RESULTS: Treatment of patients suffering from complications of chronic pancreatitis remains a major challenge. Continuous alcohol consumption, a disease with enormous personal and social impact, is still the leading factor in the development of chronic pancreatitis. The most distressing symptom for the patient is pain, which in many instances has already led to a considerable analgesic abuse before a specialist is even consulted. The development of an enlargement of the pancreatic head, the "pacemaker of the disease," parallels pain and potential organ complications such as common bile duct stenosis or portal hypertension. What triggers pancreatic head enlargement is still not known; in particular it is unclear what triggers growth factors to step into action. Pain is most likely due to a combination of hypertension in the organ and parenchymal alterations. Current therapeutic concepts therefore aim at alleviating pain and at management of organ complications while preserving functional tissue to best prevent exocrine and endocrine dysfunction. The ideal procedure thus seems today to be the "customized" pancreatic head resection with additional optional drainage of the pancreatic body and tail.

Intractable hiccup: an odd complication after laparoscopic fundoplication for gastroesophageal reflux disease.

Intractable hiccup can be an unbearable circumstance and its treatment is often frustrating. More than 100 causes for hiccup have been described in the literature; the most common cause is gastroesophageal reflux disease (GERD). We report a case of a 31-year-old patient who suffered from intractable hiccup starting 3 weeks after laparoscopic Nissen fundoplication for GERD, a potential surgical complication that has not been described. After frustrating medical treatment, the patient underwent computed tomography and nerve stimulator-guided blockade of vagal and phrenic nerves on each side separately. Hiccup ceased only after blockade of the right phrenic nerve with 4 ml/h l% ropivacaine and relapsed soon after discontinuation. He underwent thoracoscopic right phrenicectomy, which rendered him symptom free for well over 2 months, at the time of this writing.