Für die Planung der therapeutischen Strategie der akuten Divertikulitis des Kolon sigmoideum ist das Wissen um den Spontanverlauf der Erkrankung, die Möglichkeit der Herausbildung von Komplikationen und das Vorgehen in der Notfallsituation von entscheidender Bedeutung. Ausgehend von anamnestischen Daten, dem klinischen Untersuchungsbefund und der bildgebenden Diagnostik ist eine exakte Klassifikation der akuten Divertikulitis nach Hansen und Stock möglich. Nach dieser Einteilung wird die unkomplizierte Divertikulitis von der komplizierten Divertikulitis mit den entsprechenden Subtypen und der chronisch rezidivierenden Divertikulitis unterschieden. Im Stadium I, der unkomplizierten Divertikulitis ist ein konservatives Therapiekonzept zu favorisieren. Die komplizierte Divertikulitis (Stadium II) sollte prinzipiell operiert werden. Der Operationszeitpunkt ist dabei vom Ausprägungsgrad der Komplikationen abhängig. Liegt eine phlegmonöse Entzündung mit Peridivertikulitis vor, empfiehlt sich die frühelektive Resektion. Ist eine gedeckte Perforation nachweisbar oder findet sich eine abszedierte Divertikulitis, empfiehlt sich ebenfalls eine frühelektive Resektion, gegebenenfalls nach vorheriger interventioneller Drainage. Die freie Perforation ist eine Notfallsituation und sollte sofort operiert werden. Die Verfahrenswahl sollte sich unter anderem nach der Expertise des OP-Teams, dem ASA-Score des Patienten, dem Ausmaβ der Perforation sowie dem Ausbildungsgrad der Peritonitis richten. Die chronisch rezidivierte Divertikulitis stellt beim Vorliegen sekundärer Komplikationen wie Stenosen oder Fisteln ebenfalls eine Indikation zur elektiven Sigmaresektion dar.
Endoscopic and Endosonographic Diagnostics The diagnostic workup of patients with esophageal cancer is often difficult. Early neoplastic lesions that are often very subtle are hard to detect. Besides a high level of experience there are new technical developments such as chromoendoscopy, virtual chromoendoscopy (NBI and CVC) and autofluorescence that can facilitate the detection of early neoplastic lesions. For staging, endosonography is the diagnostic tool with the highest accuracy regarding local and nodal staging; however, correct differentiation between mucosal and submucosal carcinomas is often problematic.
The association between hospital volume and outcome has been investigated in several studies and meta-analyses. For specific oncological operations and cardiovascular procedures adequate evidence for an association between volume and outcome is available. Not clear is whether interventions using volume-based referral produce better results. In a first step, hypothetical studies investigating the potential benefit of volume-based interventions are considered. In a second step volume-based interventions that have been implemented are evaluated. In some of the hypothetical scenarios major effects on mortality are postulated for specific procedures and cutoff points, if patients are directed to hospitals with high volume. Other studies, investigating the potential benefit, are questioning the feasibility of such interventions and describe limited effects on mortality. Two volume-based interventions have been really implemented: the Leapfrog-model in the USA and the national regulation on minimum hospital volume in Germany. For the Leapfrog-model only hypothetical data are available. The introduction of the national regulation on minimum hospital volume in Germany was evaluated in a research project. A clear-cut trend was observed towards fulfilling the minimum volume regulation, however, a considerable proportion of hospitals did not pass the cut-off values of the regulation, due to allowed exceptions from the regulation and no stringent adherence to the rule. Evaluation of the effect of the minimum volume regulation on outcome was only possible for total knee replacement and was performed with a national database on the quality of inpatient care in Germany. A positive effect, at least partly attributable to the minimum volume regulation, was only found for the outcome criterion postoperative wound infection. Only with adequate quasi-experimental studies, which have to be performed, it can be decided whether volume-based interventions will lead to better results.
Background: Hemobilia is defined as hemorrhage into the biliary tract. With frequent use of invasive hepatobiliary procedures in current gastroenterology practice and promptly advancing imaging and endoscopic techniques, this disease process is increasingly being diagnosed. Clinically, this condition often presents as a classic triad of biliary colic, jaundice and upper gastrointestinal bleed (manifesting as hematemesis or melena). Case Report: A 35-year-old white woman with recent liver biopsy presented to the emergency department with 1 week's history of right upper quadrant abdominal pain, nausea, vomiting, and multiple episodes of bleeding per rectum. X-ray abdomen and CT scan were unremarkable. Esophagogastroduodenoscopy was performed which showed ongoing blood flow through the ampulla of Vater. Diagnosis of hemobilia was made. Angiographic embolization of the segmental hepatic artery was done with resolution of bleeding. Conclusion: To conclude, hemobilia is a rare cause of upper gastrointestinal bleed. Trauma, predominantly iatrogenic and occasionally accidental, is the most common cause for this disease entity. Bleeding in these cases manifests predominantly as hematemesis or melena. In rare cases, as in our patient, bleeding may present as hematochezia. Diagnosis is predominantly made on upper gastrointestinal endoscopy. Angiographic embolization remains the cornerstone of management.
Brunner’s gland hyperplasia is usually asymptomatic and found as an incidental finding after biopsy during upper gastrointestinal endoscopy. Symptomatic patients mostly present with either upper gastrointestinal bleed manifesting as melena or anemia, or with subacute intestinal obstruction manifesting as intractable nausea and vomiting. Gastric outlet obstruction secondary to Brunner’s gland hyperplasia has been rarely reported. Conservative management with naso-gastric suction provides temporary improvement in symptoms. Most patients have near complete resolution of symptoms after resection of the culprit lesion.
In this review, the current standard of surgical treatment in colorectal liver metastases is described. Traditional factors associated with resectability of liver metastasis concentrated on the tumor number, tumor size, and extrahepatic disease, i.e. on the lesions that have to be removed. Now resectability is defined by the function of the residual liver, i.e. by what will remain after resection. The future liver remnant should be at least 25% in patients with normal liver, 40% in patients who have received intensive chemotherapy or in case of fatty liver, liver fibrosis or diabetes, and 50-60% in patients with cirrhosis. At least 2 adjacent liver segments need to be spared. R0 resection of both intra- and extrahepatic disease must be feasible. The number of patients with resectable disease has increased due to the concept of portal vein embolization prior to resection inducing contralateral lobar hypertrophy, two-stage hepatectomy and preoperative chemotherapy which permits complete resection in 15-30% of cases with initially non-resectable disease. Combining hepatic resection with radiofrequency ablation can also expand the number of patients that may be otherwise untreatable. These findings have to be implemented in a larger scale in the future. So far only 8% of all liver metastases are treated surgically.
Image-supported treatment for local tumor ablation has been established as valuable amendment in oncologic therapy concepts. For the treatment of liver metastases, interventional radiology offers local as well as locoregionary procedures. Whereas local treatment is applied using image-supported interstitial techniques, the vascular access is best suited to allow for locoregionary distribution of antitumor drugs. In the present article, the following currently used interstitial ablation techniques were assessed based on the literature available thus far: radiofrequency, laser-induced thermotherapy, and CT-guided brachytherapy. With respect to locoregionary vascular techniques, the following procedures were assessed: intraarterial chemotherapy via minimally invasively implanted port systems, transarterial chemoembolization, and radioembolization. The article focuses on the therapy of liver metastases of colorectal carcinomas which are currently best documented with respect to minimal invasive interventions.
Background: Since the first orthotopic liver transplantation (oLTx) in 1963, liver transplantation has been established as the standard therapy for progressive liver diseases. Ever since, survival rates have continuously improved. Side effects of immunosuppressive therapy play more and more a key role. Particularly the incidence of arterial hypertonia (AH), post-transplant diabetes mellitus (PTDM) and renal insufficiency (RI) are relevant problems which limit quality of life and prognosis of patients and cause high costs. Patients and Methods: In a retrospective analysis, data of 248 oLTx of the Transplant Center Bonn from 01/1992 to 01/2005 were evaluated. Results: As a function of the according immunosuppressive therapy, a significantly higher postoperative incidence of AH (pre-25% vs. postoperative 50%; cyclosporin A (CyA) 47% vs. tacrolimus (FK) 46%) and NI (pre-29% vs. postoperative 67%; CyA 65% vs. FK 57%) was observed. PTDM showed a high postoperative incidence around 50%, but no significant difference between the two immunosuppressive treatments (CyA 45% vs. FK 51%). Conclusions: Postoperative NI and further complications after oLTx are frequently caused by calcineurin inhibitor (CNI)-based immunosuppressive therapy. By modification of immunosuppressive therapy regimes, e. g. by use of mycophenol acid in combination with CyA or FK and corticosteroids, many of the CNI side effects could be avoided or minimized. The use of mammalian target of rapamycin (mTOR) inhibitors and monoclonal antibodies targeting IL-2 receptors represent further therapeutic alternatives.
Iatrogene Gallenwegskomplikationen nach laparoskopischen Cholezystektomien oder endoskopischen Interventionen sind mit einer erheblichen Morbidität und Mortalität für den Patienten vergesellschaftet. Ein frühzeitiges Erkennen der Komplikationen, für deren Einteilung verschiedenste Klassifikationssysteme zur Verfügung stehen, ist mit einer deutlichen Prognoseverbesserung assoziiert. Das Management solcher Komplikationen richtet sich nach Schwere, Typ und Lokalisation der Verletzung sowie nach dem Zeitpunkt der Erstdiagnose. Ihre Behandlung sollte immer an einem Zentrum mit hoher Kompetenz in hepatobiliärer Chirurgie, Endoskopie und interventioneller Radiologie vorgenommen werden. Neben endoskopischen Verfahren und perkutanen transhepatischen Interventionen nimmt die chirurgische Rekonstruktion des Galleabflusses einen wichtigen Stellenwert in der Therapie dieser Patienten ein. Die meisten Patienten sind auf eine langfristige Nachsorge angewiesen und die besten Ergebnisse werden bei interdisziplinärer Zusammenarbeit zwischen Chirurgie, Endoskopie und interventioneller Radiologie erzielt.
Die vorliegende Arbeit setzt sich das Ziel, den aktuellen Stand der chirurgischen Behandlung von Lebermetastasen kolorektaler Karzinome zu beschreiben. Richtete sich die Aussage zur Resektabilität von Lebermetastasen früher nach deren Anzahl, Gröβe und dem extrahepatischen Tumornachweis – also nach dem Ausmaβ dessen, was entfernt werden sollte –, ist die Definition heute darauf ausgerichtet, nach der Funktion dessen zu fragen, was nach der Resektion verbleibt, d.h. nach dem adäquaten funktionellen Restgewebe. Mindestanforderungen an die Restgröße der Leber sind 25% des gesunden Lebergewebes bei Patienten mit normaler Leber, 40% bei Zustand nach Zytostatika, Fettleber, Fibrose und Diabetes und 50–60% bei Zirrhose. Mindestens 2 benachbarte Lebersegmente müssen erhalten werden. Angestrebt werden muss des Weiteren die R0-Resektion sowohl von intra-als auch von extrahepatischem Tumorgewebe. Durch die Entwicklung neuer Möglichkeiten hat die Zahl resektabler Lebermetastasen in den letzten Jahren deutlich zugenommen. Dazu zählen die portalvenöse Embolisation vor Resektion zur Vergrößerung der funktionellen Leberreserve, die zweizeitige Leberresektion, die neoadjuvante Chemotherapie zur präoperativen Tumorreduktion sowie die Kombination der Resektion mit lokaldestruierenden Verfahren wie der Radiofrequenzablation. Diese Erkenntnisse müssen flächendeckend umgesetzt werden. Zurzeit werden nur zirka 8% aller Lebermetastasen chirurgisch angegangen.
The minimum caseload of pancreas and esophagus surgery required at present only has a minor impact on specialist training in visceral surgery yet. Distributional effects will however lead to a decreasing number of hospitals which undertake pancreas and esophagus surgery. As a result, the number of training jobs available will decrease, and consequently it will no longer be possible in the future to complete a specialist training at just one institution. These prospects necessitate a reorientation and further assessments. The current training curriculum with its defined number of required surgical procedures can therefore not provide for an adequate advanced training in visceral surgery. The challenge of today's surgery require better trained 'general' visceral surgeons and only a small number of more qualified 'special' visceral surgeons.
