[Tracheal stents for esophagotracheal fistula in laryngectomy patients. Safe fixation to the tracheostoma]. / Trachealstents wegen ösophagotrachealer Fistel beim Laryngektomierten. Sichere Fixierung am Tracheostoma.

BACKGROUND: Postradiotherapy or malignant esophagotracheal fistulas still represent a dilemma. In the absence of surgical options attempts are made to close the fistula endoscopically by means of esophageal and/or tracheal stents. Tracheal stent placement in laryngectomy patients with terminal stomas is particularly problematic due to the risk of stent dislocation during cannula replacement PATIENTS AND METHODS: Six laryngectomy patients with high esophagotracheal fistulas were each fitted with a coated Ultraflex stent (Boston Scientific, Watertown/MA, US). Following skin undermining, the stents were fixed to the tracheostoma with interrupted sutures and the skin flaps attached to the stent with a second row of sutures. RESULTS: Fistulas could be completely closed in all patients and there were no cases of stent dislocation. Cannula replacement was unproblematic. CONCLUSIONS: Suture fixation of tracheal stents is a viable procedure even for patients with esophagotracheal fistulas and terminal tracheostomy following laryngectomy.

[Management of cholecysto- and choledocholithiasis--survey and analysis of 16 615 cholecystectomies and common bile duct explorations in bavaria]. / Aktuelle Therapie der Cholezysto- und Choledocholithiasis - Umfrageergebnisse mit Analyse von 16 615 Eingriffen in Bayern.

BACKGROUND AND METHODS: The aim of this study was the evaluation of the management of cholecysto- and choledocholithiasis and outcome of -laparoscopic as well as open cholecystectomy (CHE) and common bile duct (CBD) exploration in Bavaria, Germany. A written questionnaire -in-cluding 201 structured items was sent to all 180 hospitals and departments performing gen-eral or abdominal surgery in Bavaria. RESULTS: The response rate was 60 %. A total of 16 615 operations for gallstone disease including 16 051 cholecystectomies and 453 CBD explo-ra-tions with or without cholecystectomy were -reported. 88 % of all cholcystectomies started -laparoscopically, the conversion rate was 5.6 %. The Veres needle (69 %), 4 trocar techniques and electrosurgical hook knife were reported as standard procedures. A retrieval bag was used by 53 % of all surgeons. The overall complication rate for cholecystectomy was 5.46 % including 0.15 % -major bile duct injuries. Relaparoscopy was performed in 0.35 %, relaparotomy in 0.44 % and postoperative treatment by ERC in 1.45 %. The overall hospital mortality rate was 0.13 %. When choledocholithiasis was suspected, a two-stage management ("therapeutic splitting") with preoperative ERC was preferred (99 %). The conversion rate of simultaneous laparoscopic CHE+CBD exploration was 43 %. CONCLUSION: These results allow an estimation of the frequency and overall risks in surgical therapy for gallstones. At present, new techniques like combined laparoscopic and endoscopic proce-dures, microinstruments or N.O.T.E.S do not play a significant role in Germany.

Ursodeoxycholic acid reduces lipid peroxidation and mucin secretagogue activity in gallbladder bile of patients with cholesterol gallstones.

BACKGROUND: Recently it has been postulated that gallbladder mucin hypersecretion observed in the pathogenesis of cholesterol gallstone disease may be induced by biliary lipid peroxidation. Ursodeoxycholic acid treatment reduces mucin concentration and the formation of cholesterol crystals in the gallbladder bile of patients with cholesterol gallstones and this effect might be mediated by a decrease of biliary lipid peroxidation. MATERIAL AND METHODS: In a double-blind, placebo-controlled trial patients with symptomatic cholesterol gallstones received either ursodeoxycholic acid (750 mg daily) (n = 10) or placebo (n = 12) 10-12 days prior to cholecystectomy. As a marker for lipid peroxidation malondialdehyde was measured in bile together with mucin concentration. In addition, the mucin secretagogue activity of the individual bile samples was assessed in cultured dog gallbladder epithelial cells. RESULTS: Ursodeoxycholic acid therapy resulted in a significant reduction of lipid peroxidation in bile as determined by the biliary malondialdehyde concentration (1.36 +/- 0.28 vs. 2.05 +/- 0.38 micromol L(-1); P < 0.005) and the malondialdehyde (micromol L(-1))/total bile acid (mmol L(-1)) ratio (0.02 +/- 0.005 vs. 0.06 +/- 0.01; P < 0.001). Furthermore, a decrease in mucin concentrations (0.7 +/- 0.3 vs. 1.3 +/- 0.5 mg mL(-1); P < 0.005) and of the mucin secretagogue activity of gallbladder bile (0.9 +/- 0.2 vs. 2.2 +/- 0.3 times control; P < 0.001) was observed. CONCLUSIONS: The reduction of lipid peroxidation and mucin secretagogue activity of gallbladder bile induced by ursodeoxycholic acid treatment may contribute to the beneficial effects of this drug on gallbladder bile composition and symptoms in cholesterol gallstone patients.

[Zenker's diverticulum treated by transoral diverticulostomy: technique and results]. / Die Technik der transoralen Divertikulostomie bei Zenker-Divertikeln - Langzeitresultate und Literaturvergleich.

AIM OF THE STUDY: The surgical technique of transoral diverticulostomy by a modified Endo-GIAtrade mark Stapler (Multifire Endo GIA, Tyco Healthcare) is described. Experiences of this procedure in 31 patients are analysed and compared with different endoscopic and conventional surgical therapies of Zenker's diverticula, which are reported in the literature. METHOD: From January 1996 to December 2005, 31 transoral diverticulostomies were performed. All patients were included porspectively into the study. The median follow-up time after diverticulostomy was 54 months. Manometry, pH-study of the esophagus, endoscopy and swallow radiography were performed before and after surgery. All patients completed the Gastrointestinal quality of live index (GQLI) and the Grosshadern dysphagia score (GHDS). RESULTS: Subjective comfort of the patients as measured by the Smiley Index, the GQLI and the GHDS was increased significantly (p < 0.001) after therapy. Manometry showed that the upper esophageal sphincter functioned normally before and after intervention. A gastrografin swallow excluded leakage at the stapler suture-line in all cases. A conversion to a conventional cricomyotomy with resection of the diverticulum had to be performed once due to a dissection of the esophagus that occurred during insertion of the spreader. In one patient a bleeding out of the suture line was successfully treated with a metal clip. A prothesis broke due to the insertion of the spreader. Two patients developed relapses during the follow-up period of 54 months. CONCLUSION: Compared to standard procedure the endoscopic minimal-invasive therapy proved to be safer. The operation time and the postoperative stay are shorter.

Lipid peroxidation and mucin secretagogue activity in bile of gallstone patients.

BACKGROUND: Chronic inflammation of the gallbladder wall and mucin hypersecretion are considered to be important factors in the pathogenesis of cholesterol gallstone disease. The aim of the study was to compare mucin concentration and mucin secretagogue activity with lipid peroxidation in gallbladder bile of patients with cholesterol or pigment stones. MATERIAL AND METHODS: We studied mucin concentration and, as a marker of lipid peroxidation, malondialdehyde concentration in 11 rapid (1 to 3 days) and eight non-nucleating (> 21 days) gallbladder biles of patients with cholesterol or pigment stones. Furthermore, the mucin secretagogue activity of rapid and non-nucleating gallbladder biles, as well as 1-5 micromol L(-1) malondialdehyde on cultured gallbladder epithelial cells, was determined. RESULTS: Our data show an increased malondialdehyde (7.2 +/- 1.8 vs. 3.8 +/- 0.5 micromol L(-1), P = 0.01) and mucin concentration (0.9 +/- 0.09 vs. 0.41 +/- 0.03 mg mL(-1), P = 0.01) and an increased mucin secretagogue activity (2.0 +/- 0.5 vs. 1.1 +/- 0.3 mucin secretion/control, P = 0.04) and cholesterol saturation index (1.2 +/- 0.1 vs. 08 +/- 0.1, P = 0.04) in rapid as compared to non-nucleating gallbladder biles. Malondialdehyde stimulated mucin secretion of cultured gallbladder epithelial cells in a concentration dependent manner. CONCLUSIONS: Our results support a promoting effect of gallbladder mucin hypersecretion by lipid peroxidation leading to rapid formation of cholesterol crystals in gallbladder bile. These findings suggest that besides hypersecretion of cholesterol in bile, chronic inflammation of the gallbladder wall is implicated in the pathogenesis of cholesterol gallstone disease.

Laparoscopic colonoscopic rendezvous procedures for the treatment of polyps and early stage carcinomas of the colon.

BACKGROUND AND AIMS: Endoscopic treatment of large or colonoscopically inaccessible polyps or early stage tumors in the colon holds the risk of incomplete resection and colonic perforation. The combination of colonoscopy and laparoscopy offers a minimally invasive treatment modality for the complete resection of polyps with low risk. Aim of this study was to assess the feasibility and outcome of patients operated on by laparoendoscopic rendezvous procedures at the colon. MATERIALS AND METHODS: The medical records of 38 patients (21 male, 17 female, median age 66 years [range 39-90]) undergoing rendezvous surgery at the colon were reviewed prospectively. Follow-up data were obtained by clinical examination and personal communication via telephone or questionnaire. The median follow up was 54 months. RESULTS: From January 1998 until April 2007, 38 patients were treated with rendezvous procedures in our hospital. In 30 cases, a colonoscopically assisted laparoscopic procedure was performed and in eight patients a laparoscopically controlled colonoscopic procedure. A benign lesion was confirmed histologically in 31 patients. In five cases, histopathologic diagnosis revealed a malignancy necessitating colonic surgery. A coprolith extraction and a suture of the sigma were performed in one case each. Complications occurred in two patients. One patient developed an anastomosis insufficiency that necessitated a revision. One patient developed pneumonia postoperatively. A conversion to laparotomy had to be performed in two cases. CONCLUSION: Rendezvous procedures offer a safe, minimal-invasive therapeutic approach allowing the resection of benign sessile or colonoscopically inaccessible localized polyps and of early stage colon cancer.

Transoral diverticulostomy with a modified Endo-Gia stapler: results after 4 years of experience.

BACKGROUND: The incidence of Zenker's diverticulum is low (2/100,000). Standard surgical treatment is cricopharyngeal myotomy with diverticulectomy. Various minimally invasive surgical approaches pursued recently have treated Zenker's diverticulum adequately. The functional minimally invasive therapy is performed alternatively using an Endo-Gia stapler inserted transorally to perform an esophageal diverticulostomia, or using thermal coagulation applied by a carbon dioxide (CO2) or argon plasma laser. The key to a successful procedure is adequate exposure of the diverticulum by insertion of a pharynx spreader before the surgery. METHODS: Since 1996, 31 patients who underwent minimally invasive diverticulostomies performed in our clinic have been included prospectively in the current study. All the patients were examined endoscopically before and after surgery. Furthermore, the intraesophageal and intragastric pressure was examined by transesophageal manometry, and the pH in the esophagus and stomach was determined by pH-metry. A barium swallow was performed to exclude leakage at the stapler suture line as proof of sufficient anastomoses. Manometry showed that the upper esophageal sphincter functioned normally before and after surgery. The results were compared with those of patients undergoing conventional procedures. RESULTS: The median follow-up period after resection of the diverticulum was 46 months. Both the Gastrointestinal Quality-of-Life Index (GQLI) (p < 0.001) and the modified dysphagia score (GHDS) increased significantly, indicating that the operations were successful. The minimally invasive procedure is faster than cricopharyngeal myotomy and significantly safer. It is better tolerated by patients, and they are discharged earlier. CONCLUSION: Transoral esophagodiverticulosomy has become the standard procedure for Zenker's diverticulum in the authors' department. The endoscopic minimally invasive approach proved to be safer than standard surgical procedures. It offers a significantly shorter operation time and postoperative hospital stay (p < 0.001).

[Role of vacuum therapy in the management of the septic abdomen]. / Einsatzmöglichkeiten der Vakuumtherapie zur Therapie des septischen Abdomens.

Progress in intensive care medicine contributed substantially in lowering the mortality rate of patients suffering from diffuse secondary peritonitis. In the medical care of patients presenting a septic abdomen the persisting septic focus is one of the greatest problems. This is associated with other problems like temporary closure of the abdomen, complications due to re-laparotomies, healing of the abdominal wall after soft tissue infection, loss of abdominal wall musculature, or persisting enteral fistulas. The vacuum therapy is used with increasing frequency for the treatment of septic complications in different areas of the body. The excellent drainage characteristics of the vacuum therapy appear to be a therapeutic option for the control of surgically untreatable septic processes in the abdominal cavity. More and more experience is gathered with the successful treatment of enterocutaneous fistulas, small intestine and pancreatic fistulas as well as anastomotic leakage after rectal surgery. There exist hardly any evidence-based recommendations for the application of vacuum therapy for treatment of the septic abdomen. But the good results of temporary closure of open abdomen of trauma patients by the vacuum therapy arises hope that the results can be transferred to the treatment modalities of persisting peritonitis. Additionally, these patients could profit from the drainage characteristics of the vacuum therapy.

Development of a cost-effective system for digital off-line analysis of transrectal ultrasound.

BACKGROUND: Transrectal ultrasound (TRUS) is the most sensitive and accurate technique for preoperative staging and follow-up of rectal cancer. One of the most relevant problems of this technique is that the assessment of TRUS is possible only during real-time examination. Furthermore, interpretation of the ultrasound findings is difficult and requires long experience. We show the development of a new, cost-effective software solution for off-line examination and documentation of transrectal ultrasound. METHODS: The ultrasound device is connected to a frame-grabber card in a standard PC. Video capturing is done using a freeware software solution and various video codecs. The whole examination course is recorded. The examiner only has to concentrate on producing an artifact-free realization of the examination. RESULTS: The software solution offers a flexible review of each individual "frame" of the investigation on the personal computer, very similar to CT and MRI scans. Infiltration depth and lymph node status can be assessed at any time, independently of the investigation and the investigator. The picture quality is excellent even if a lossy codec is used. It is not necessary to do definitive assessment of the TRUS during the examination. CONCLUSIONS: This new technique gives a cost-effective possibility for high-quality off-line staging, re-examination, re-evaluation, and documentation of rectal cancer. TRUS becomes an examiner-independent objective examination technique for staging and follow-up of rectal cancer.