Complications in endoscopy of the lower gastrointestinal tract. Therapy and prognosis.

This is a report on 126 prospectively registered and controlled complications in 29,695 consecutive endoscopic procedures of the lower gastrointestinal tract. The overall complication rate is 0.4%. All endoscopic procedures were performed in our institution; no referrals "from other hospitals" are included. The therapy and prognosis of occurring complications are described. Especially after therapeutic endoscopy--above all, after polypectomy--the complication rate of 0.83% is not negligible. A serious aspect is the average interval of 30 h from endoscopically caused complication to the onset of symptoms. Bleeding could be managed conservatively in 76% of cases. Nevertheless perforation and transmural burn injuries required surgical intervention in 78% of cases. The authors conclude that in the case of transmural burn an attempt at "active conservative treatment" is justified if the patient is under close surgical control, if the symptoms improve, and if there is a possibility of immediate surgery.

Management of bile duct injuries and strictures following cholecystectomy.

During 7057 conventional cholecystectomies (1972-1991), 16 bile duct injuries occurred, amounting to a risk of 0.22%. A total of 1022 laparoscopic cholecystectomies were performed without such a complication since April 1990. In a retrospective study, 64 patients (16 of our patients and 48 referrals) with an injury or stricture due to conventional cholecystectomy were investigated. In 14 of our 16 patients the injury was recognized and immediately repaired with a good long-term result of 93%, including one successful repair of a subsequent stricture. Two cases of unrecognized injury were managed by nonoperative means. The group of 48 referred patients comprised 10 early postoperative complications (21%) and 38 strictures after an "uneventful" cholecystectomy. Of the 64 total patients, 10 (16%) underwent nonoperative treatment, and 54 required surgery. The mean follow-up period after surgery was 7.4 +/- 4.9 years. Most cases (93%) were repaired by bilioenteric anastomosis (i.e., foremost hepaticojejunostomy) with an 18% restricture rate. Including second and third repairs for restricture, a total of 60 operations (14 primary and 46 secondary reconstructions) were performed without hospital mortality. A good long-term result after stricture repair was achieved in 75% of the patients, whereas 17% had a poor outcome owing to restricture or death (10% had related mortality within 10 years). The other 8% had a moderate result due to recurrent cholangitis. Thus immediate repair of a bile duct injury offers the better chance of a favorable prognosis compared to secondary stricture repair.

[Multilocular angiosarcoma with involvement of the heart]. / Multilokuläres Angiosarkom mit Befall des Herzens.

A thyroid tumour, initially diagnosed as an anaplastic carcinoma of the thyroid, was removed in a 66-year-old woman. Further examination, other than ultrasonography of the abdomen (normal), were refused, 26 months later a painful swelling was noted in the right buttock: a fist-sized haematoma, without evidence of malignancy was removed at another hospital. Computed tomography revealed a cystic tumour in the left upper abdomen, about 8 x 11 cm, not clearly related to any organ. Echocardiography, performed because of atrial fibrillation, demonstrated a space-occupying lesion, 42 x 38 mm, in the left atrium with central necroses and originating broad-based from the interatrial septum and the aortic root. The retroperitoneal upper-abdominal tumour encircling the root of the aorta and a gluteal tumour in the area of the previous haematoma could not be completely removed. Histologically they and the previously removed (and again examined) thyroid tumour were angiosarcomas. Removal of the atrial tumour was not attempted. Six months later it had penetrated the entire atrial septum and grown into the right atrium. The patient had lost 25 kg and three months later died of respiratory failure. Autopsy was refused. The findings suggest a left-atrial angiosarcoma which may well have been the primary tumour site. In case of angiosarcomatous tumours echocardiography should be performed as a staging examination.

[Leiomyosarcoma of the vena cava. Case report and review of the literature]. / Das Leiomyosarkom der V. cava. Fallbeschreibung und Literaturübersicht.

The leiomyosarcoma of vascular origin is a very rare tumor which is rarely recovered before the disease has reached an advanced stage because of non-specific and late symptoms. This is a report of 3 cases with leiomyosarcoma of the vena cava and a review of the literature. A high local recurrence rate and high frequency of distant metastases are responsible for the bad long-term prognosis. Early hematogenous tumor spread is favored by intraluminal tumor growth. Only complete surgical resection--if necessary with vascular reconstruction--can improve the bad long-term prognosis.

[An unusual "tumor-like finding" between the head of the pancreas and the duodenal wall]. / Ungewöhnlicher "tumorartiger Befund" zwischen Pankreaskopf und Duodenalwand.

A 48-year-old woman complained of right-sided upper abdominal pain and recurrent vomiting, and had lost 10 kg in 4 months. Ultrasound and computed tomography showed a solid, space-occupying lesion in the head of the pancreas, not separable from the duodenum. Despite thorough investigation the nature of the lesion remained obscure. Operation revealed a divided pancreas with stenosis of the accessory duct at the papilla. Histological examination showed pseudosarcomatous myofibroblastic proliferation within the duodenal wall in the vicinity of a duodenal wall cyst which had been destroyed by inflammation. In cases of divided pancreas it is the accessory duct which drains the main bulk of the pancreas, while the main duct carries little or no secretion; the stenosis of the accessory duct in this patient had therefore led to low-grade pancreatitis involving the head of the pancreas.

[Tumor resections in the liver]. / Tumorresektionen in der Leber.

Over a 16-year period 54 patients presented with primary malignant liver tumours: 10 (18.5%) were considered inoperable, 44 underwent laparotomy. Nineteen (35%) turned out to be inoperable. A resection with curative intention was performed 25 times (47%) (11 right or extended right and 2 left hemihepatectomies, 12 mono- or bisegmentectomies). Hospital mortality was 8% (n = 2). The median survival time of those who died following resection was 22 months. Four patients have survived for more than 5 years, and three of them are still free of recurrence (5 year survival rate: 17% excl. hospital mortality).

[Iatrogenic damage of the bile ducts caused by cholecystectomy. Treatment and results]. / Iatrogene Schäden an den Gallenwegen infolge Cholecystektomie. Behandlung und Ergebnisse.

This report concerns 44 patients with iatrogenic injuries to the bile ducts treated at the Mannheim University Clinic from 1973 to 1987. Group A: 12 own patients with lesions of the common bile duct among 6020 operations for cholelithiasis, i.e. a risk of 0.19%. All 12 lesions were recognized during operation and immediately repaired with eventual success. Group B: 32 patients referred to us from another hospital after cholecystectomy alone or previous repair. 11 of these patients had progressive jaundice in the immediate postoperative period (1. to 9. week) due to unrecognized bile duct injury. The other 21 patients developed strictures after an uneventful postoperative course within time intervals varying from 3 months to 23 years. 72% of patients (Group B) had reconstructive surgery within two years after last operation in another hospital. We performed 47 reconstructive operations in 42 patients without hospital mortality including 5 second or third operations for recurrent stricture. Biliary-intestinal anastomosis (70%) as sutured mucosa-to-mucosa anastomosis was the most favoured method of reconstruction (30 Roux-Y hepaticojejunostomies and 3 choledochoduodenostomies). An end-to-end anastomosis was only performed in 3 cases of plain transection of the common duct. In management of high biliary strictures (type III and IV according to Bismuth's classification) preference would be given to Hepp-Couinaud's modification of hepaticojejunostomy using the left hepatic duct for a long side-to-side anastomosis. Overall morbidity amounted to 28% while the rate of relaparotomy for surgical complications was 13% (n = 6 without postoperative death). 10 patients died since reconstructive surgery, death being independent from bile duct injury in 5 cases. The injury related one-year-mortality was 4.5%. Overall stricture recurrence rate was 15% (18% for hepaticojejunostomy) with a mean follow-up of 72 months. Local infection was the most obvious cause of recurrence, thus a two stage procedure with postponement of reconstructive surgery must be recommended in case of subhepatic abscess or biliary fistula. Including second and third repairs, a good longterm result was achieved in over 80% of patients.

Protective effect of fibronectin in temporary liver ischemia: an experimental study.

Only 50% of rabbits survive 90 min hepatic ischemia in spite of decompression of the gut. The remainder die within 36 h after operation. A single application of fibronectin before hepatic ischemia delays death for only a few hours. However, three postischemic applications of fibronectin--immediately after operation and 5 h and 24 h later--are associated with a statistically significant rise in the survival rate. Analysis of the transaminases indicates that fibronectin obviously limits the extent of ischemic liver cell necrosis. Of major significance is the fact that fibronectin supplement enables the RES of the liver to improve its phagocytic capacity, as shown by the RES clearance test. The presented experimental model shows that the liver with its RES, located between the splanchnic and the systemic circulation, is of particular significance for the entire organism. Hepatic ischemia or shock, independent of the initial cause, leads to significant reduction of hepatic phagocytosis. The results indicate that substitution of opsonins supports the phagocytic capacity.

[Effect of different infusion regimens on the hormonal and metabolic reaction before, during and after cholecystectomy]. / Der Einfluss unterschiedlicher Infusionsregime auf die hormonelle und metabolische Reaktion vor, während und nach Cholezystektomie.

18 metabolically healthy female patients with cholelithiasis, who had to undergo cholecystectomy, were divided into 3 groups and studied for a 4-day period. Group I, n = 6, received beginning on the operationday 0,19 g/kg BW X h of a polyol-mixture-solution (Sorbitol/Xylitol 1:1) and 0,86 g 1-crystalline amino acids (AA)/kg BW X day. Group II, n = 6, received beginning 24 h preoperatively only 1,14 g 1-crystalline AA/kg BW X day. Group III, n = 6, received beginning 24 h preoperatively 0,07 g Xylitol/kg BW X h, 0,03 g Glucose/kg BW X h and 1,14 g 1-crystalline AA/kg BW X day. In this study we could demonstrate that the pre-, intra- and postoperative hormonal and metabolic response is strongly influenced by different infusion regimens. Only by the simultaneous infusion of carbohydrate together with AA during the preoperative period a significant drop of triiodothyronine can be avoided. The rise of insulin and cortisol in the early postoperative period is augmented by the infusion of carbohydrates together with AA. There was no difference in growth hormone response to surgery between group I-III. All 3 groups showed a continuous fall of cholesterol during the study period.

[Comparison of xylose and glucose as energy sources in hypocaloric, postoperative parenteral nutrition]. / Vergleich von Xylit und Glukose als Energieträger im Rahmen der hypokalorischen postoperativen parenteralen Ernährungstherapie.

After a 5 day preoperative preparing period 24 metabolically healthy patients, who had to undergo gastric resection, were fed postoperatively by hypocaloric total parenteral nutrition for a 5 day period. Group I (n = 13) received 0,11 g Xylitol/kg BW X h; Group II (n = 11) received 0,11 g Glucose/kg BW X h; Both groups received 1,71 g L-crystalline amino acids/kg BW X day. During the whole postoperative period group II had significantly higher serum Glucose and Insulin levels. Due to the high postoperative Insulin concentration in group II. Free Fatty Acids, Acetate, beta-Hydroxybutyrate and Branched Chained Amino Acids were significantly lower. The augmented release of Muscle Amino Acids and the covering of a part of the energy expenditure by increased Fatty Acid oxidation in group I led to a higher postoperative synthesis rate of visceral proteins. From postoperative day 3 on Transferrin and from postoperative day 6 on Albumin and Total Protein were significantly higher in group I. This study could demonstrate, that due to its special role in the intermediary metabolism during the postoperative period Xylitol leads to a significantly higher regeneration rate of visceral proteins compared to Glucose during total parenteral nutrition.

[Possible surgical treatment of liver metastases (author's transl)]. / Möglichkeiten der chirurgischen Therapie bei Lebermetastasen.

Resection of liver metastases was performed in 31 patients from 1973 to 1980. There were 25 atypical partial resections and 6 anatomical hemihepatectomies. In agreement with some large collective there was a relatively favourable prognosis after resection of solitary metastases or of those restricted to a lobe or segment when the primary tumour was colorectal. Surprisingly favourable individual results were also obtained with en-bloc resection of malignant gastric tumour in which the liver had been infiltrated locally. Other oncological methods of treatment are inferior to surgical intervention and should only be used for inoperable liver metastases in the course of controlled clinical studies. Regular postoperative control with exhaustive application of all diagnostic possibilities for discovering metastases are justified in view of the therapeutic consequences only with respect to primary tumours in the colorectal region.

[Treatment of solitary pyogenic liver abscess (author's transl)]. / Die Therapie des solitären pyogenen Leberabszesses.

A solitary pyogenic liver abscess usually requires open surgical drainage. Digital exploration of the cavity is important for eliminating any loculations and avoiding complications after the drainage procedure. Chronic liver abscesses which are enclosed by a fibrous capsule and thus may simulate a neoplastic tumor are best treated by atypical liver resection close to the abscess or by a procedure similar to pericystectomy. Early radical operation is indicated for a complicated liver abscess whenever two drainage procedures have failed and the patient's condition is deteriorating. In such a case the development of sepsis and (or) multiple abscesses caused by an internal fistula to the bile duct system are a potential and increasing danger. Anatomical liver resection, though the most radical operation, carries a comparatively low risk as its mortality rate is less than 10%. The prognosis of solitary abscess has improved during the last decade due to an earlier diagnosis and adequate surgical drainage in combination with antibiotics. Anaerobic liver abscesses have the best prognosis.