Zusammenfassung Einführung Die Behandlung der Perforantenvarikose (PV) gehört zu den großen Herausforderungen in der Phlebologie – nicht nur aufgrund der Vergesellschaftung mit chronischen Ulzera crurium und der Rezidivrate. Endovenöse Verfahren der Perforantenablation (EPA) unterliegen technischen Schwierigkeiten. Wir berichten von einer ersten Serie der EPA mit einem neuartigen Radiowellensystem. Material, Patienten und Methoden Ausschließlich isolierte PV wurden in die Studie aufgenommen. Zur Diagnosestellung wurden dopplersonografische Untersuchungen (DU) durchgeführt. Die ultraschallgeführte EPA erfolgt unter sterilen Kautelen in der ambulanten Operationsabteilung. Postinterventionelle DU wurden nach einem Tag und 14 Tagen, 5 Wochen sowie 3, 6 und 12 Monaten terminiert. Im Falle einer Rekanalisierung wurde eine Schaumsklerosierung angestrebt. Ergebnisse Neun PV wurden behandelt. Der durchschnittliche Energieeintrag betrug 969J. Nach einem medianen Nachuntersuchungszeitraum von 257 Tagen betrug die primäre Verschlussrate 75%, die sekundäre nach Schaumsklerosierung 89%. Die minimale Komplikationsrate trug zu einer hohen Patientenakzeptanz bei. Schlussfolgerung Die EPA zur Behandlung der PV mit dem neuen Radiowellensystem hat sich als wirksam und verträglich bewährt. Weiteren Untersuchungen wird es vorbehalten sein, die endgültige Rolle der EPA in der Behandlung von PV zu definieren.

Background: Microwave ablation developed into an accepted treatment for benign thyroid nodules. Definition and risk factors for recurrence are under discussion. We assumed recurrence in case of a second procedure for the same reason or if clinical symptoms reappear after initial relief, and analyzed our prospectively collected data for risk factors and outcome. Methods: Indications included benign thyroid nodules (n=24), cystic nodules (n=9), autonomous functioning nodules (n=9), recurrent cancer (n=3) and Basedow’s disease (n=2). For microwave ablation, a CE certified generator was used. All procedures were conducted under ultrasound control and with general anesthesia or mild sedation. Followup included ultrasound, laboratory parameters and a standardized questionnaire. Results: A total of 47 patients were enrolled into the study. Among them were 19 cases with risk factors for recurrence which were defined as nodule size exceeding 4 cm with or without cystic appearance. Recurrence occurred in 9 cases leading to conventional hemithyreoidectomy (n=1), reablation (n=5) or sclerotherapy (n=1). The association of recurrence with the presence of a risk factor was statistically significant (p<0,001, Chi square test). In case of recurrence, statistically significant less energy was deployed in comparison to successful MCT (0,39 +/- 0,31 kJ/mL vs. 1,57 +/- 2,37 kJ/mL, p< 0,005, t-test). Conclusion: Recurrence is a common problem following microwave ablation of thyroid nodules. Nodules > 4 cm and cystic disease seem to predispose for treatment failure. Further studies are required to define recurrence and the best indications for microwave ablation of thyroid nodules.

BACKGROUND:Thermoablation is an attractive treatment of thyroid nodules for its minimal-invasiveness. It remains unclear whether results and morbidity meet the patients' expectations.OBJECTIVE:The aim of the presented study is to show data obtained after microwave thyroid ablation from a patients' perspective.METHODS:Indications and preoperative diagnosis were chosen according to international guidelines. Thermoablation was achieved using a CE certified microwave system. The procedures heeded the published recommendations of the European Federation of Societies for Ultrasound in Medicine and Biology. Follow-up included ultrasound, laboratory parameters and a standardized questionnaire.RESULTS:Thirty patients were enrolled into the study. All patients reported an improvement of complaints following the procedure. Scar formation occurred in 3 cases (10%) with 0.5 ± 1.3 mm length and 0.4 ± 1.0 mm width. No cosmetic, neurological, vocal or pharyngeal complication occurred. Energy required for non-functioning nodules (n= 15, 50%) was 2.56 ± 3.41 kJ/mL, for autonomous adenoma (n= 8, 27%) 0.96 kJ/mL (p< 0.05, t-test).CONCLUSION:The presented data summarize an initial experience in selected patients and resemble excellent patient reported outcome with minimal morbidity. These preliminary data indicate the majority of patients satisfied with the procedure. Further trials will be required to endorse these findings.

Abstract Rationale: Microwave ablation (MWA) has been proven to be an efficient and safe method for local tumor control of liver tumors. Reported complications are rare, but include liver abscess, hematoma, pleural effusion, and occasional thermal injury of the adjacent colon. Intestinal perforation usually requires immediate surgical treatment to prevent generalized peritonitis and sepsis. Patient concerns and diagnosis: Herein, we describe a case of gastric perforation following percutaneous MWA for hepatocellular carcinoma as a bridging therapy prior to liver transplantation. Interventions: Due to the clinical condition of the patient, conservative treatment was considered sufficient. Nine months after MWA, successful liver transplantation followed. Intraoperative findings revealed a scar in the gastric wall with tight adhesions to the liver, requiring adhesiolysis and subsequent suturing. Postoperative recovery was uneventful. Outcome: At present, the patient is doing well. No further gastrointestinal events occurred. Lesson: To our knowledge, this is the first report of such a complication occurring after MWA. Moreover, in this case, the gastric perforation could be treated conservatively.

Background Perforating veins (PV) as the underlying factor for varicose veins belong to the more challenging treatments in phlebology since they are frequently associated with chronic ulcers and because of their recurrence rates. Endovenous treatment modalities are technically difficult to accomplish. We report herein initial results of endovenous perforator ablation (EPA) using a novel radiofrequency (RF) device. Materials, patients and methods Only isolated PV were accepted for treatment. Doppler ultrasound (DU) was exerted prior to indicating a procedure. After informed consent, the interventions were performed under aseptic conditions in an operation theatre using local anesthesia as day surgery under ultrasound control. Postinterventional follow-up encompassed DU after 1 day, two and 5 weeks as well as 3, 6 and 12 months. In case of recurrence, foam sclerosing was intended. Results Nine patients have been treated. The average energy deposition was 969 J. Median follow-up was 257 days. Primary occlusion rate was 75 %, secondary after foamsclerosing 89 %. One minor complication occurred. Patient reported outcome was excellent. Conclusions EPA using the novel RF device is effective and well tolerated. Further investigation is required to define the eventual role of RF in the treatment of PV.

Hepatocellular carcinoma (HCC) ranks among the most common primary cancers of the liver. The major risk factor for the formation of HCC is liver cirrhosis. The grade of cirrhosis as well as the extent of the tumor itself, can play an important role in the treatment options and patient prognosis. An operation aimed at an R0 resection is the treatment of choice for patients in an early stage of the disease and is associated with favorable long-term and recurrence-free survival. Liver transplantation offers an even better long-term survival rate after 5 years for selected patients with HCC meeting the Milan criteria as the underlying cirrhosis, the major risk factor for HCC recurrence, is simultaneously treated. Local tumor ablation is the least invasive curative surgical treatment, however, it is associated with an increased local recurrence rate; therefore, the early detection of tumors is of essential importance. As tumor-associated symptoms tend to arise only in advanced tumor stages, it is indispensable to identify patients with typical risk factors and to provide closely monitored screening examinations.

Das hepatozelluläre Karzinom (HCC) zählt zu den häufigsten primären Malignomen der Leber. Hauptrisikofaktor für die Entstehung eines HCC ist die Leberzirrhose, deren Ausprägung, neben der Tumorausdehnung selbst, erhebliche Bedeutung hinsichtlich möglicher Therapieoptionen und der Prognose haben kann. Die Operation mit dem Ziel der R0-Resektion ist bei Patienten im frühen Stadium der Erkrankung die Therapie der Wahl und mit einem hohen Langzeit- und rezidivfreien Überleben assoziiert. Bei selektionierten Patienten mit HCC innerhalb der Milan-Kriterien kann durch Transplantation aufgrund der simultanen Behandlung der Leberzirrhose als Trigger eines möglichen HCC-Rezidivs ein noch besseres Langzeitüberleben nach 5 Jahren erreicht werden. Die lokale Tumorablation ist das kurative Therapieverfahren mit der geringsten Invasivität, welches allerdings mit einer erhöhten Lokalrezidivrate einhergeht. Somit kommt der frühen Diagnosestellung eine essenzielle Bedeutung zu. Da Symptome oftmals erst bei fortgeschrittenen Befunden auftreten, ist es unverzichtbar, Patienten mit typischen Risikofaktoren zu identifizieren und ihnen engmaschige Früherkennungsuntersuchungen anzubieten.

Zusammenfassung Das hepatozelluläre Karzinom (HCC) zählt zu den häufigsten primären Malignomen der Leber. Hauptrisikofaktor für die Entstehung eines HCC ist die Leberzirrhose, deren Ausprägung, neben der Tumorausdehnung selbst, erhebliche Bedeutung hinsichtlich möglicher Therapieoptionen und der Prognose haben kann. Die Operation mit dem Ziel der R0-Resektion ist bei Patienten im frühen Stadium der Erkrankung die Therapie der Wahl und mit einem hohen Langzeit- und rezidivfreien Überleben assoziiert. Bei selektionierten Patienten mit HCC innerhalb der Milan-Kriterien kann durch Transplantation aufgrund der simultanen Behandlung der Leberzirrhose als Trigger eines möglichen HCC-Rezidivs ein noch besseres Langzeitüberleben nach 5 Jahren erreicht werden. Die lokale Tumorablation ist das kurative Therapieverfahren mit der geringsten Invasivität, welches allerdings mit einer erhöhten Lokalrezidivrate einhergeht. Somit kommt der frühen Diagnosestellung eine essenzielle Bedeutung zu. Da Symptome oftmals erst bei fortgeschrittenen Befunden auftreten, ist es unverzichtbar, Patienten mit typischen Risikofaktoren zu identifizieren und ihnen engmaschige Früherkennungsuntersuchungen anzubieten.

We present a case of early postoperative anastomotic leakage after abdomino-thoracic esophageal resection for cancer in a female, due to a necrotizing, transmural infection with Candida species (spp). The infection was treated successfully with redo surgery and systemic antimycotic therapy with caspofungin. The patient was disease-free at 49 month follow-up, but her long-term quality of life, as assessed by the EORTC questionnaire (QLQ C-30) was reduced. Aggressive surgical and medical therapy led to successful treatment of this rare complication.

Local ablation of malignant liver tumors is considered an established treatment modality with curative intention for irresectable disease. Recently, laparoscopic access has been suggested because of presumed advantages for diagnosis and effectiveness. In a recently published retrospective study, improved local tumor control as well as prolonged disease-free survival could be confirmed for laparoscopic in comparison to percutaneous microwave coagulation therapy (MCT) using multivariate analysis [1]. Occasionally, percutaneous needle placement and precise targeting of the tumor is difficult in laparoscopic MCT. The following article is meant to illustrate technical options, which are available for laparoscopic MCT.

Liver transplantation has been established as a first-line therapy for a number of indications. Conventional ultrasound and contrast-enhanced ultrasound (CEUS) are methods of choice during the postoperative period as a safe and fast tool to detect potential complications and to enable early intervention if necessary. CEUS increases diagnostic quality and is an appropriate procedure for the examination of vessels and possibly bile ducts. This article presents the state of the art of ultrasound application during the early period after liver transplantation. It addresses common vascular complications and describes the identification of postoperative abnormal findings using ultrasound and CEUS.

Local ablation of liver tumors matured during the recent years and is now proven to be an effective tool in the treatment of malignant liver lesions. Advances focus on the improvement of local tumor control by technical innovations, individual selection of imaging modalities, more accurate needle placement and the free choice of access to the liver. Considering data found in the current literature for conventional local ablative treatment strategies, virtually no single technology is able to demonstrate an unequivocal superiority. Hints at better performance of microwave compared to radiofrequency ablation regarding local tumor control, duration of the procedure and potentially achievable larger size of ablation areas favour the comparably more recent treatment modality; image fusion enables more patients to undergo ultrasound guided local ablation; magnetic resonance guidance may improve primary success rates in selected patients; navigation and robotics accelerate the needle placement and reduces deviation of needle positions; laparoscopic thermoablation results in larger ablation areas and therefore hypothetically better local tumor control under acceptable complication rates, but seems to be limited to patients with no, mild or moderate adhesions following earlier surgical procedures. Apart from that, most techniques appear technically feasible, albeit demanding. Which technology will in the long run become accepted, is subject to future work.

AIM:The aim of this paper was to compare healthy subjects and patients after total mesorectal excision concerning anal resting/squeeze pressure and surface-electromyography of the sphincter.METHODS:Forty patients (9 female/31 male) after total mesorectal excision due to low or middle rectal cancer were compared to a sex-, age- and BMI-matched group of healthy volunteers by means of anorectal pull-through manometry using a microtip-transducer system and by means of endoanal surface electromyography using a bipolar plug electrode.RESULTS:Resting pressure (59.2 ± 3.1 mmHg vs. 68.3 ± 4.3 mmHg; P=0.056) and squeeze pressure (127.3 ± 3.2 mmHg vs. 128.9 ± 4.6 mmHg; P=0.78) were comparable between patients after total mesorectal excision and healthy volunteers whereas surface electromyography amplitude (9.5 ± 0.4 µV vs. 13.9 ± 0.6 µV; P=0.01) was significant lower in patients after total mesorectal excision compared to healthy subjects. Correlation between squeeze and resting pressure as well as between squeeze pressure and surface electromyography were weaker in patients after total mesorectal excision compared to healthy controls.CONCLUSION:Objective measurable sphincter pressure after total mesorectal excision seems to be comparable to that of healthy subjects whereas surface-electromyography is significant higher in healthy subjects.

OBJECTIVE:This investigation uses the comprehensive complication index (CCI) to compare complications after natural orifice transluminal endoscopic surgery (NOTES) procedures.BACKGROUND:NOTES procedures are developed to miniaturize surgical trauma. NOTES publications inconsistently report complications. The CCI improves reporting of complications.METHODS:The CCI is calculated using complication data from a single center, double blind, randomized controlled trial comparing transvaginal [transvaginal cholecystectomy (TVC), N = 41] and conventional laparoscopic cholecystectomy (CLC, N = 51). Complications are assessed using the classification of surgical complications (CSC). Two different scenarios are applied to the CSC for definition of complications with an emphasis on minor complications. CSC data are fed into the free online CCI-calculator. The CCIs from complication data from other NOTES reports are calculated accordingly and compared to our results.RESULTS:The CCI allows easy indexing of complications with or without a CSC table. For scenario I, the mean CCI of CLC versus TVC is 3.3 (± 6.3; SD) versus 3.5 (± 6.4; n.s.) and for scenario II it is 7.6 (± 6.4) versus 6.5 (± 7.0; n.s.). The difference of the mean between the two scenarios is highly significant (p < 0.000). The mean CCIs of both groups and scenarios are below the CCI of 8.7 for a grade I CSC complication. Similar calculation of CCIs from other NOTES publications yields mean CCIs below 8.7 for the surgical procedures reported.CONCLUSION:The CCI results in a single, easily comparable complication index for surgical procedures whereas the CSC yields tabular results. A significant difference in interpretation occurs with variation in definition of complications. Average CCIs below a value of 10 describe low complication rates. Authors need to describe their definition of complications if using the CSC and the CCI. More emphasis should be given to reporting of minor complications. The use of the CCI for NOTES procedures will enable international comparison.

INTRODUCTION:Irreversible electroporation (IRE) is considered superior to thermoablations for tumors in the vicinity of larger vessels and the liver hilum. We report on an initial clinical experience of IRE.MATERIALS AND METHODS:Indications included focal liver lesions <3 cm, irresectability due to contraindications and expected complications and/or irradicality following radiofrequency ablation (RFA). Ultrasound was chosen for guidance and needle placement.RESULTS:IRE was intended to perform in 14 patients with 1 procedure aborted due to technical failure. Among the 13 successfully treated were 7 percutaneous, 4 laparoscopic, and 2 open surgical procedures. The average age was 63 ± 10 years. Twelve solitary nodules and one bifocal disease were treated with an average size of 1.5 cm ± 0.5 cm. Median follow-up was 6 months. Three incomplete ablations account for 21% (3/14), 2 of them occurring in 2 metastases larger than 2 cm percutaneously treated with 5 needles instead of 4 used for smaller tumor sizes.CONCLUSION:IRE was introduced without difficulties into clinical practice. As a main obstacle emerged in visualization of the needles, computed tomography may offer advantages in the guidance of percutaneous IRE of liver metastases larger than 2 cm. Local failure occurred in 21%.

Radiofrequency ablation (RFA) of colorectal liver metastases is frequently reported, but, however, lacks clear criteria for indication and reliable, convincing results with 5-year survival ranging from 17 to 48 %. RFA may be the appropriate treatment modality in approximately 3 to 5 % of all patients suffering from colorectal liver metastases. To date, RFA seems to be limited to no more than three metastases, each smaller than 3 cm. The main indication remains irresectability due to number, site, distribution and/or marginal liver function. Tumours in the vicinity of larger vessels (predominantly branches of portal or hepatic veins) are a case for controversy, since advances in hepatobiliary surgery enable a proportion of patients to undergo resections which would have been declared irresectable until most recently, and the oncological value of a thermoablation is questioned, as a certain amount of temperature is lost due to convective heat sinks. RFA is not a curative alternative to hepatic resection unless small tumours appear during open or laparoscopic procedures in a patient with elevated risk for early recurrence or postoperative morbidity following liver resection. The inclusion of RFA into a holistic system of oncological therapy is mandatory. Early RFA followed by systemic (regional?) chemotherapy can rather be recommended than chemo only, RFA only or first-line chemo with subsequent RFA.

Hintergrund: Lokal-ablative Behandlungsformen spielen eine wichtige Rolle in den modernen chirurgischen Therapiealgorithmen. Trotz großer Fortschritte leiden besonders Thermoablationen unter zum Teil inakzeptablen Lokalrezidivraten. Die Mikrowellenablation (MWA) ist eine vergleichsweise neuere Methode, die theroretisch einige Vorteile gegenüber anderen Methoden aufweist. Der vorliegende Bericht beschreibt die erste klinische Serie von Patienten, die im deutschsprachigen Raum mit MWA in einer chirurgischen Klinik behandelt wurden. Material und Methode: Eine retrospektive Analyse der prospektiv erfassten Daten einer konsekutiven Fallserie eines einzelnen Zentrums wurde vorgenommen. Als MWA-Applikator kam das 915-MHz-System MedWaves™ der Fa. AveCure Inc., San Diego, Kalif./USA, zur Anwendung. Die Indikationen zur Therapie folgten denselben Kriterien wie zu jeder Thermoablation und wurden jeweils in einer interdisziplinären Tumorkonferenz bestätigt. Ergebnisse: 51 Interventionen an 47 Patienten wurden zur Behandlung von 80 Tumoren vorgenommen. 31 Ablationen wurden perkutan, 20 laparoskopisch vorgenommen. Unter den Indikationen waren mehrheitlich hepatozelluläre Karzinome (HCC) und 14 Metastasen sowie 4 Rezidive eines cholangiozellulären Karzinoms. Die HCC-Diagnosen fanden sich alle in Zirrhose. Nach einem Nachuntersuchungszeitraum von 20 Monaten (Median) lag die Lokalrezidivrate bei 12 % pro Tumor (17 % pro Pat.). In einer univariaten logistischen Regressionsanalyse waren Tumorgröße, Zugangsweg und Risikolokalisation, multivariat dagegen nurmehr die Tumorgröße (p = 0,044) und der Zugangsweg (p = 0,012) signifikante Risikofaktoren für das Auftreten eines Lokalrezidivs. Schlussfolgerung: Nach steiler Lernkurve war die MWA rasch zu implementieren und mit großem Erfolg in den chirurgischen Alltag einzuführen. Auch ungünstige Tumorlokalisationen können ohne gesteigerte Lokalrezidivraten sicher behandelt werden.