Intraoperative esophageal washout reduces free intraluminal tumor cells during resection of carcinomas of the esophagus and cardia.

OBJECTIVE: Intraluminally shed viable tumor cells might contribute to anastomotic recurrence in cancer of the esophagus and the cardia. The study aimed to establish a method of esophageal washout and, hence, to reduce intraluminal cancer cells before esophageal anastomosis. METHODS: Forty-eight consecutive patients with esophago-gastric resection for histologically proven cancer of the esophagus or the cardia were included in a prospective, interventional study. Before transection, the esophagus was clamped proximally to the tumor and rinsed with 1:10 diluted povidone-iodine-solution (10 × 30 ml) applied by a transorally inserted 24F-Foley catheter. The first, fifth and tenth portion of the lavage fluid were sent to cytological examination. RESULTS: Intraoperative frozen sections confirmed clear proximal resection margins of the esophagus. The cytological examination of the fluid recovered from the esophageal washout revealed malignant cells in 13/48 patients (27%). The presence of malignant cells was significantly less likely in patients with neoadjuvant treatment than in patients without neoadjuvant treatment: 2/23 (9%) vs. 11/25 (44%) (p = 0.009). Repetitive washout reduced the probability of detectable malignant cells from 13 to 8 (62%) patients after 5, and further to 4 patients (30%) after 10 washout maneuvers. CONCLUSIONS: Free malignant cells may be present in the esophageal lumen following intraoperative manipulation of cancers of the esophagus or cardia. Transoral washout of the esophagus is novel, feasible and enables reduction or even elimination of these tumor cells. The reliability of this procedure raises with increasing washout volume. Esophageal washout might be especially worthwhile in patients who do not receive neoadjuvant therapy.

Liver Cirrhosis/Severe Fibrosis Is a Risk Factor for Anastomotic Leakage after Colorectal Surgery.

Purpose. Liver cirrhosis associated with high perioperative morbidity/mortality. This retrospective study determines whether liver cirrhosis represents a risk factor for anastomotic leakage after colonic anastomosis or not. Methods. Based on a prospective database with all consecutive colorectal resections performed at the authors' institution from 07/2002 to 07/2012 (n = 2104) all colonic and rectal anastomoses were identified (n = 1875). A temporary loop ileostomy was constructed in 257 cases (13.7%) either due to Mannheimer Peritonitis-Index > 29 or rectal anastomosis below 6 cm from the anal verge. More than one-third of the patients (n = 691) had postoperative contrast enema, either at the occasion of another study or prior to closure of ileostomy. The presence of liver cirrhosis and the development of anastomotic leakage were assessed by chart review. Results. The overall anastomotic leakage rate was 2.7% (50/1875). In patients with cirrhosis/severe fibrosis, the anastomotic leakage rate was 12.5% (3/24), while it was only 2.5% (47/1851) in those without (p = 0.024). The difference remained statistically significant after correction for confounding factors by multivariate analysis. Conclusion. Patients with liver cirrhosis/severe fibrosis have an increased risk of leakage after colonic anastomosis.

Mandatory resection of strangulation marks in small bowel obstruction?

BACKGROUND: No evidence is available on how to treat intraoperatively detected band-shaped strangulation marks of the bowel wall originating from an adhesive band or hernia ring. The authors prefer to resect these hazardous strangulation marks to avoid secondary small bowel perforation. This retrospective study investigated the prevalence of intraoperatively unrecognized ulceration and transmural necrosis at the site of the strangulation marks. METHODS: From July 2003 to July 2011, a total of 31 of 461 patients with acute bowel obstruction underwent small bowel resection due to strangulation marks, exclusively. Seven patients had two strangulation marks, resulting in 38 strangulation marks to be analyzed. RESULTS: From 38 examined strangulation marks, 14 (36.8 %) exhibited deep ulceration or transmural necrosis. Four (10.5 %) necrotic lesions had already been recognized intraoperatively, while 7 (18.4 %) unsuspicious strangulation marks showed deep ulceration and 3 (7.9 %) showed transmural necrosis exclusively at final histopathologic examination. The number of strangulation marks that needed to be resected for prevention of one missed deep ulceration and/or transmural necrosis of the small bowel was 3.4. The presence of deep ulceration or transmural necrosis is associated with an obvious decrease in bowel diameter caudad to the strangulation mark. No anastomotic leak occurred. CONCLUSION: The severity of small bowel damage at the site of band-shaped strangulation marks may be underestimated by surgeons. The present series showed favorable results with a resection-per-principle policy for these strangulation marks. If an obvious decrease of bowel diameter aborally to the strangulation mark is present, resection or seromuscular invagination of the later is particularly recommended.

Prevalence and clinical implications of diverticulosis of the vermiform appendix.

OBJECTIVE: The epidemiology and the aetiology of inflammatory diseases of the vermiform appendix remain poorly understood. The prevalence of appendiceal diverticulosis and diverticulitis in patients undergoing appendectomy for suspected acute appendicitis was investigated. METHODS: A retrospective study was completed on patients who underwent appendectomy for suspected acute appendicitis. Pathology reports of all patients were screened for diverticula of the vermiform appendix. Patients with either diverticulitis of the vermiform appendix or normal appendicitis were compared. RESULTS: Out of two sets of consecutive patients (n = 1073), nine (0.8%) were identified with diverticulosis of the vermiform appendix. Two of these patients had diverticulitis of the vermiform appendix without appendicitis, three had diverticulitis with consecutive localized appendicitis, and four had proper acute appendicitis with a noninflamed diverticulum of the vermiform appendix. One patient had perforated appendicitis. Two patients had an obstructing neuroendocrine carcinoid which may have caused diverticular formation. CONCLUSIONS: Diverticula of the vermiform appendix are rare. If inflamed, they mimic acute appendicitis and are treated by appendectomy. If not inflamed, and diagnosed intraoperatively, incidental appendectomy is recommended.

Implantation of a stent graft in the right pulmonary artery enables radical resection of a central endothelial sarcoma of the left pulmonary artery.

In a patient with a huge endothelial sarcoma of the left pulmonary artery, we report successful implantation of a stent graft in the right pulmonary artery, including the pulmonary arterial trunk. This preoperative measure enabled a safe and radical left-sided pneumonectomy, including the tumor and the central parts of the left pulmonary artery. No major blood loss occurred, and neither use of a heart-lung machine nor cardiopulmonary bypass was necessary.

Pretherapeutic MRI for decision-making regarding selective neoadjuvant radiochemotherapy for rectal carcinoma: interim analysis of a multicentric prospective observational study.

PURPOSE: To study the accuracy of different cutoffs for an involved circumferential resection margin (CRM) compared with T and N categories measured by MRI as basis for selective application of neoadjuvant radiochemotherapy (nRCT) in rectal carcinoma. MATERIALS AND METHODS: In a prospective multicenter observational study involving 153 primarily operated patients, the preoperative results of MRI with pathohistological findings of resected specimens were compared. RESULTS: For a cutoff of ≤1 mm for involvement of the CRM, the accuracy of preoperative MRI was 90.9% (139/153). The negative predictive value was 98.5% (134/136). The four participating departments did not differ significantly. For a cutoff of >2 mm and >5 mm, the rates of false-positive findings increased significantly from 5% to 12% and 35% with a decrease in accuracy to 82% and 62%, respectively. In contrast, the accuracy in predicting T (69.3%) and N categories (61.4%) was much lower. CONCLUSION: The indication for nRCT should be based on the determination of the minimal distance of the tumor from mesorectal fascia with a cutoff point of >1 mm as measured by MRI.

C-reactive protein is superior to bilirubin for anticipation of perforation in acute appendicitis.

OBJECTIVE: Very recently it has been shown that hyperbilirubinemia is a specific predictor of perforation in acute appendicitis. We compared the diagnostic importance of bilirubin, C-reactive protein (CRP), leukocyte count and age as markers of perforation in acute appendicitis. MATERIAL AND METHODS: A two-center retrospective cohort study was completed. Patients with acute appendicitis (n = 725) were divided into two groups, group A with perforation (n = 155) and group B without (n = 570). RESULTS: In group A an elevated CRP (> 5 mg/l) was measured in 98% of cases versus 72.5% in group B. Hyperbilirubinemia (> 20 micromol/l) was measured in 38% of cases in group A versus 22.3% in group B. Leukocytosis (> 10 x 10(9)/l) was measured in 85% of cases in group A versus 79.3% in group B. Analysis of qualitative and quantitative data showed every marker to be significantly correlated with perforation except elevated white cell blood count. However CRP showed the strongest correlation. The logistic regression model showed CRP to be by far the most significant marker of perforation. CONCLUSIONS: Our results confirm hyperbilirubinemia to be a statistically significant marker of perforation in acute appendicitis. However, CRP is superior to bilirubin for anticipation of perforation in acute appendicitis.

Incidence, management, and outcome of incidental gallbladder carcinoma: analysis of the database of the Swiss association of laparoscopic and thoracoscopic surgery.

BACKGROUND: Little is known about the long-term survival of patients with incidental gallbladder carcinoma (IGBC). The role of radical resection for this disease is discussed controversially in the literature. We present the long-term survival and the results of re-resection versus simple cholecystectomy of the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS) from 1994 to 2004. METHODS: Eighty-nine patients with histologically confirmed carcinoma of the gallbladder were identified out of 30,960 patients undergoing laparoscopic cholecystectomy. Sixty-nine patients were included in our study. Long-term survival by different T-stage and comparison of patients with extended resection versus simple cholecystectomy were calculated using the log-rank test. The time-to-event data are demonstrated by Kaplan-Meier curves. RESULTS: The overall incidence of IGBC in patients who underwent laparoscopic cholecystectomy was 0.28% (89 of 30,960). Fifty patients underwent simple cholecystectomy [n = 2: carcinoma in situ (CIS); n = 2: pT1a; n = 10: pT1b; n = 23: pT2; n = 8: pT3; n = 5: pT4], whereas extended resection was performed in 19 cases (n = 2: pT1b; n = 11: pT2; n = 6: pT3). The comparison of simple cholecystectomy versus extended re-resection of the gallbladder bed and regional lymph node resections showed a significant benefit in overall survival for the pT2 and pT3 group (p < 0.05). The pT1b group showed no significant benefit in overall survival (p = 0.34). CONCLUSION: IGBC has a low incidence (0.28%). We present a large study of patients with IGBC, comparing the overall survival by different histological findings. We observed a significant benefit for the group with pT2 and pT3. Therefore we recommend extended resection of the gallbladder bed and the regional lymph nodes for patient with incidental histologically confirmed pT2 and pT3 carcinoma of the gallbladder after performance of laparoscopic cholecystectomy. For patients with pT1b stage no recommendations can be given based on this study.