Search

BACKGROUND: Even with standardization and increasing experience, laparoscopic cholecystectomy still entails the risk of injury to the bile ducts. The incidence of iatrogenic bile-duct injury is currently estimated at 0.3–0.9%. In spite of the downward trend compared to the historical course, the incidence of iatrogenic bile duct injuries is still higher and so continues to be a determining factor for morbidity with LCHE. METHODS AND RESULTS: Independent of the frequency, the nature of bile duct lesions has also changed. There are not only direct injuries, similar to the direct transection of the bile duct with open LCHE, but there are also long substance defects due to resection of the hepatic duct up to or beyond the bifurcation. In one-quarter of cases, neighboring vascular structures are also injured. With inadequate treatment, the life quality suffers due to functional long-term damage reflected in cholangitis or secondary biliary cirrhosis with portal hypertension up to loss of liver function. CONCLUSIONS: Corrective surgery requires suitable surgical expertise in hepatobiliary surgery as well as institutional resources that allow an individual treatment plan based on interdisciplinary cooperation among surgeon, interventional radiologist and gastroenterologist. The long-term prognosis will depend on early diagnosis and efficient therapeutic management.

BACKGROUND: Unlike colon surgery, gastric surgery developed only slowly. Standardized stomach surgery can be said to have begun in 1881 with Billroth's successful gastric resection. The Department of Surgery in Graz was involved in the development and then rapid dissemination of gastric surgery, with respect to both ulcer and cancer surgery. Since the introduction of the modern proton-pump inhibitors, surgery for gastric ulcers today is mainly limited to the treatment of complications. In spite of the worldwide decrease in the incidence of stomach cancer, it is still of great clinical importance in Austria. METHODS: The development of gastric surgery at the Department of Surgery in Graz is presented on the basis of the literature. RESULTS: Still today, the only curative option for stomach cancer is radical surgical removal with lymphadenectomy as indicated. In the period of January 1, 1994 to December 31, 2004, 341 patients with stomach cancer were treated at the Division of General Surgery in Graz; 265 of them could be operated and the average 5-year survival rate was 36% without regard to tumor stage. CONCLUSIONS: It may be said that more than one hundred years of development have led to the standardization and optimization of gastric surgery, and that the contributions of surgeons in Austria and in Graz were considerable.

BACKGROUND: The rare malignant tumors of the small intestine comprise a heterogeneous group. Adenocarcinomas are the most frequent, followed by neuroendocrine tumors, lymphomas, gastrointestinal stromal tumors (GIST) and leiomyosarcomas. Because of their rarity, individual institutions often have little experience with diagnostic and therapeutic management of this tumor group. METHODS: On the basis of the literature, incidence, classification, risk factors and symptoms of these tumors are presented. Furthermore, diagnostic algorithms for malignant small-intestinal tumors, as well as recent therapeutic modalities, are shown. RESULTS: Due to their unspecific symptoms, these tumors are usually diagnosed late. Along with endoscopy and contrast studies, capsule endoscopy has become an important tool in the diagnosis of these tumors. Good long-term survival can only be achieved with radical surgery including regional lymphadenectomy. With neuroendocrine tumors, tumor size and location will determine the surgical procedure. Therapy of small-intestinal lymphomas is multimodal. When there are multiple tumors, or lymph-node involvement has been shown preoperatively, as is usually the case, primary systemic treatment is preferred. Small-intestinal sarcomas are very rare and are treated surgically. For gastrointestinal stromal tumors involving the small intestine, STI-571 (Imatinib, Glivec®) has additionally become established as pharmacotherapy. CONCLUSIONS: Preoperative diagnosis is established in only 50 % of malignant small intestinal tumors. So in many cases, these tumors are diagnosed by laparotomy and following histological examination of the resected tumor. In most of these tumors radical surgery is the decisive treatment option. A promising new treatment modality with very good results was introduced for the therapy of gastrointestinal stromal tumors.

BACKGROUND: The pancreas is a rare site for renal cell carcinoma (RCC) metastases, which tend to develop many years after the primary tumor has been diagnosed and treated. An incidence of 1–3% has been reported. METHODS: We report a 52-year-old patient whose metastases to the pancreas were discovered by chance 8 years after tumor nephrectomy. RESULTS: After a pancreas left resection and splenectomy, histology demonstrated a renal cell carcinoma. CONCLUSIONS: Careful long-term follow-up is essential due to late development (8 years) of these metastases, and when they occur, radical surgery is of great importance for the prognosis.

BACKGROUND: The preoperative planning of liver resections is commonly based on two-dimensional imaging techniques such as sonography, computed tomography (CT), and magnetic resonance imaging. The operability of liver tumors depends on the three-dimensional relation of the parenchyma to be resected to the intrahepatic vascular structures which define the autonomously functioning liver segments. Our aim was to establish a liver surgery planning system (LSPS) for major liver resections by augmented-reality (AR) techniques for the accurate evaluation of operability. METHODS: The system provides methods for the processing and preparation of the input CT data, three-dimensional visualization, and resection planning. The output consists of quantitative indices (e.g., volume of liver tumors or segments) and an elaborated plan for the surgical procedure including information like the number of liver segments subject to resection and their spatial arrangement or the volume of the remaining or the removed liver tissue. Basically, the LSPS comprises two main components, a medical image analysis and an AR system. The medical image analysis part is responsible for the segmentation of the liver, the vascular structures, and the tumors and for liver segment approximation. The AR system is utilized for visualization and various kinds of user interaction. RESULTS: Experiments with anonymized CT data sets demonstrated the ability of surgeons to deal with different tasks in resection planning after a brief introduction. This led also to a high acceptance by colleagues who wanted to get information for their surgical strategy as quickly as possible. CONCLUSIONS: Quantitative measurements are of major importance for the planning of liver resections, for which precise measurements of distances and volumes are required. On the basis of the patient's CT dataset, the LSPS supports an effective way to find the optimal surgical strategy for each patient. The flexible design of this system allows the addition of functionality via plug-ins. Furthermore, an expansion of the developed core system for intraoperative applications is possible and provides the advantage of having one platform for planning and support during surgery.

BACKGROUND: Liver cysts occur with a prevalence of 4–7% in the population. We present our experience in the management of these cysts. METHODS: Between 1994 and 2003, 42 patients (33 women, 9 men) were referred for surgery of dysontogenetic liver cysts. There were 19 patients with polycystic liver disease (PLD), 18 with simple cysts, 4 with Caroli disease, and one with a malignant cyst. All patients were symptomatic. Results: Laparoscopic management was undertaken in 21 patients with simple cysts (n = 13) and PLD Gigot type 1 (n = 8). In the other patients, open procedure was chosen due to the extent of the disease. Caroli disease was monolobar, and segment resection 2/3 and left hemihepatectomy were performed. The patient with malignancy underwent right hemihepatectomy. CONCLUSIONS: Treatment of choice for patients with symptomatic simple cysts and PLD Gigot type 1 is laparoscopic deroofing and fenestration. In advanced-stage PLD, we recommend combined hepatic resection and cyst fenestration techniques, often as a bridging to transplantation. In monolobar and symptomatic Caroli disease, surgical resection represents the best treatment.

BACKGROUND: The wide application of peritoneal dialysis that has developed during the past two decades is above all due to the introduction of continuous ambulatory peritoneal dialysis (CAPD). With CAPD, adequate clearance of urine components via the peritoneum as a semipermeable membrane can be achieved with a method that is usually well accepted by patients and which they themselves can manage. METHODS: On the basis of the literature and the authors’ experience, indications and contraindications for CAPD, pre- and postoperative management, surgical technique for catheter implantation, possible complications and their avoidance and treatment, are presented and discussed. RESULTS: The frequency of occurrence of one or more complications in peritoneal-dialysis patients such as exit-site or tunnel infections, peritonitis, leakage or catheter dislocation is given in the literature as 56–70 %. During the study period of July 1, 2000, to June 30, 2003, there were 50 patients in the peritoneal dialysis program (48 CAPD, 2 automated peritoneal dialysis, APD) of the Division of Nephrology at the University Hospital in Graz. Of them, 58 % (29 patients) were new to the program (all catheters implanted at the Division of General Surgery, University Surgical Clinic Graz). In the study period, there were 26 cases of peritonitis with a peritonitis rate of 33.5 months, and in two cases, the catheter had to be removed. All exit site infections could be controlled with antibiotics. A tunnel infection was diagnosed in 3 patients and in one case the catheter had to be replaced. One patient experienced postoperative leakage. In 4 cases, postoperative tunnel canal bleeding stopped spontaneously. Transfer to the hemodialysis program was due in two cases to peritonitis that could not be managed conservatively, in two cases to loss of ultrafiltration, in one case to massive abdominal adhesions and in two cases to lack of compliance. CONCLUSIONS: Today, CAPD is a common and patient-friendly alternative to hemodialysis. The outcome of catheter implantation depends mainly on the experience and care of the surgeon, as well as perioperative management. Further factors in the total catheter survival time are the quality of postoperative catheter care and fast response when infections occur. The prerequisite for trouble-free CAPD and efficient management of complications is close cooperation between surgeon and nephrologist with active inclusion of the patient in the decision-making process.

Grundlagen: In etwa einem Drittel aller Polytraumatisierten kommt es zur Verletzung intraabdomineller Organe. Die Lebensgefahr fur diese Verletzten hangt wesentlich vom Verletzungsgrad der beteiligten Viszeralorgane ab.

Grundlagen: Die intraoperative Schnell-(Gefrier)schnittdiagnostik stellt ein Standarduntersuchungsverfahren der modernen interdisziplinaren Onkologie dar. Die Leistungsfahigkeit hangt dabei wesentlich von der Indikationsstellung und der Art der vorliegenden Mammalasionen ab. Es ist daher von praktischem Interesse, nicht nur die diagnostischen Moglichkeiten, sondern auch die Grenzen dieser Untersuchungsmethode zu analysieren. Methodik: die Verlaslichkeit der intraoperativen Schnell(Gefrier)schnittdiagnostik wurde anhand 5479 konsekutiver Falle retrospektiv analysiert. Die Gefrierschnittdiagnosen wurden intraoperativ auf dem Originaleinsendeformular von den Pathologen handschriftlich festgehalten. Die Ubereinstimmung dieser intraoperativen Diagnosen mit dem spateren definitiven Pathologiebefund wurde uberpruft. Ergebnisse: Bei entsprechender Erfahrung des Pathologen ist die intraoperative Schnell(Gefrier)schnittdiagnostik ein hochverlasliches Diagnoseverfahren. Auf der Basis dieser Vorbedingungen konnte eine definitive, operationstaktisch relevante Diagnose in 93,7% der 5479 konsekutiven Falle gestellt werden. Trotzdem mus dabei berucksichtigt werden, das vor allem intraduktale, sklerosierende und papillare Lasionen im intraoperativen Gefrierschnitt vielfach nicht ausreichend sicher erkannt werden konnen. Sowohl die falsch-positiven (0,07 aller Falle) und ein hoher Prozentsatz der falsch-negativen Diagnosen (0,8% aller Falle) als auch die Majoritat der Falle, in denen die Paraffinschnitthistologie abgewartet werden muste, fanden sich in der Gruppe der obengenannten Lasionen. Insgesamt wurde in 5,2% aller Falle keine definitive intraoperative Diagnose gestellt. In 0,2% der Falle konnte aufgrund sparlichen schlecht erhaltenen Gewebes uberhaupt keine Diagnose gestellt werden. Schlusfolgerungen: Die intraoperative Schnell(Gefrier)schnittdiagnostik stellt einen integralen Bestandteil der interdisziplinaren Zusammenarbeit im Rahmen moderner Behandlungskonzepte, insbesondere von Mammalasionen dar. Die Verlaslichkeit der Methode ist heute allgemein hoch. Allerdings ist es praktisch sowohl fur den Chirurgen als den Pathologen wichtig, die Grenzen dieser Methode zu kennen, um diagnostische Fehler zu vermeiden und Falle ohne definitive intraoperative Diagnose zu verstehen. Speziell sklerosierende, papillare und intraduktale Lasionen inklusive der meisten Subtypen des DCIS stellen derartige diagnostische Probleme dar, in denen haufig die Paraffinschnittdiagnose abgewartet werden mus. Daruber hinaus wird der standige klinische Fortschritt mit Diagnose immer fruherer und kleinerer maligner und pramaligner Mammalasionen fur den Pathologen zukunftig den Schwierigkeitsgrad in der intraoperativen Gefrierschnittdiagnostik erhohen und damit zu einem Ansteigen der Falle ohne definitive intraoperative Diagnose fuhren.

Grundlagen Bei Patientinnen mit Brustkrebs konnen sich im Fruhstadium lokale Rezidive und/oder Fernmetastasen bilden. Das Hauptziel klinischer Studien ist verlasliche Prognosekriterien zu finden, um Patientengruppen, die von einer adjuvanten Therapie zur Verhinderung eines Fortschreitens der malignen Grundkrankheit profitieren, selektieren zu konnen.

Grundlagen: Eine exakte Tumorklassifikation ist sowohl fur die Wahl des Behandlungsverfahrens im Rahmen einer modernen multimodalen Therapie von Karzinomen des Analkanals als auch fur die Schatzung der Prognose und der Analyse von Therapieergebnissen wesentlich. Voraussetzung dafur ist eine exakte Unterscheidung der Karzinome des Analkanals von solchen des Rektums einerseits und Karzinomen des Analrandes andererseits.

Grundlagen: Eine kleine Patientengruppe mit Rektumkarzinom ist bei Diagnosestellung fur einen kurativen Eingriff nicht geeignet, benotigt aber eine symptomatische, palliative Therapie.

Grundlagen: In den letzten Jahren werden zunehmend Einflusse des Mondes auf Naturvorgange diskutiert, wonach insbesondere das menschliche Verhalten, Krankheitsinzidenzen und die Reaktion auf operative Eingriffe mit den Mondphasen variieren sollen. Hinsichtlich postoperativer Komplikationen wird in Laienpublikationen behauptet, das generell bei zunehmendem Mond und insbesondere bei Vollmond vermehrt mit Komplikationen gerechnet werden muste.

Background: Until recently intraductal carcinomas (DCIS) were thought to be a single entity of disease. In order to examine this theory we examined DCIS with respect to several morphological parameters. Methods: 88 DCIS were investigated by steroid hormone receptors, p53 and cellular proliferation determined by MIB1. DCIS were classified according to the new suggestion by EORTC. This classification is based mainly on nuclear pleomorphism and architectural pattern. Results: All prognostic factors showed direct or inverse correlation, respectively, with subclassification of DCIS. There existed a significant correlation between steroid hormone receptor positivity and low proliferative activity in low grade DCIS subgroup compared to high grade DCIS. In contrast p53 expression was high in high grade DCIS and showed only little positivity in low grade DCIS. Conclusions: It is concluded that DCIS classification based on nuclear pleomorphism may become an important prognosticator in the future.

Breast cancers either in situ or invasive are typically not multicentric. However, about 60% of invasive tumors are multifocal in distribution. Residual poorly differentiated DCIS is most likely the source of local recurrence after breast-saving approach. Meticulous assessment of the extent of tumor multifocality by state-of-the-art mammography is essential in guiding the optimum treatment choice. In addition, MRI of the breast is apparently a promising imaging technique in this respect. The histologic evaluation of the surgical margins is a critical part of the assessment of any patient being considered for breast-saving therapy.