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Many cases of Clostridium perfringens sepsis prove to be fatal. We present a case of C. perfringens sepsis with a liver abscess as the focus of infection, which was successfully treated by an interdisciplinary intensive medical care management. The sepsis with this rare pathogen was favored by the presence of a bilioenteric anastomosis and immunosuppressive treatment of a pre-existing Crohn's disease. Antibiotic treatment with clindamycin and penicillin G was initiated and the abscess was drained. Hemodialysis with high cut-off filters was started because of acute kidney failure in the Acute Kidney Injury Network (AKIN) stage III, hemolysis and rhabdomyolysis. Therapeutic plasma exchange was performed due to sepsis and acute liver failure.Eine Clostridium-perfringens-Sepsis endet oft tödlich. Wir berichten über eine C.-perfringens-Sepsis mit einem Leberabszess als Fokus, die durch ein interdisziplinäres intensivmedizinisches Management erfolgreich behandelt wurde. Begünstigende Faktoren für die Sepsis mit diesem seltenen Keim waren eine vorliegende biliodigestive Anastomose und eine immunsuppressive Therapie bei Morbus Crohn. Es erfolgten eine antibiotische Therapie mit Clindamycin und Penicillin G, eine Abszessdrainage, eine Hämodialyse mit High-cut-off-Filter bei akutem Nierenversagen im Acute-Kidney-Injury-Network(AKIN)-Stadium III, Hämolyse und Rhabdomyolyse sowie ein Plasmaaustausch bei Sepsis und akutem Leberversagen.

The most frequent primary hepatic malignancies are hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (intrahepatic cholangiocellular adenocarcinoma [iCCA]). For HCC in cirrhosis, liver transplantation offers the advantage of a complete hepatectomy radically removing all tumorous tissue along with the surrounding cirrhotic parenchyma, which is otherwise associated with a very high risk of recurrence. For HCC in non-cirrhotic livers and iCCA, liver resection is the treatment of choice. Nowadays, even extended resections can be performed with low mortality in experienced centers. Surgical therapy is more and more embedded into multimodal treatment concepts and decision making should be interdisciplinary as for other gastrointestinal tumors.

In cancers of the upper and lower intestinal tract the risk of lymphatic metastases depends on the histological results, tumor grading, and depth of tumor infiltration (T-stage). Pretherapeutic staging is of particular importance for determining the surgical strategy (local excision vs. en bloc resection with regional lymphadenectomy) as well as for evaluating the necessity of neoadjuvant therapy. While the first part on "Lymphadenectomy in oncological visceral surgery" focused on hepatobiliary and pancreatic cancer, this second part contains an overview of anatomical conditions of lymphatic drainage of the esophagus, stomach, duodenum, small intestine, colon, rectum and anus. Based on this, the principles and techniques of lymphadenectomy for cancer in these organs and the requirements on systematic regional lymphadenectomy in the actual TNM classification (8th edition) are discussed.

Lymphadenectomy is an integral component of the oncological surgery of cancer of the gastrointestinal tract and the hepato-pancreato-biliary system. The lymph node dissection is mainly prognostic but may also offer therapeutic advantages in the treatment of most cancers. Moreover, lymphadenectomy enables an accurate TNM staging, which is essential for a further stratification of the individual treatment as well as the inclusion in clinical trials on adjuvant therapy. This article gives an overview of the anatomy of the lymphatic drainage system of visceral organs and summarizes the current role of a systematic lymphadenectomy in oncological surgery (Part 1: hepatobiliary tumors and pancreatic cancer).

Primary hepatobiliary malignancies are hepatocellular carcinoma, cholangiocarcinoma and the rare hepatocellular cholangiocarcinoma (mixed tumor). The indications for liver transplantation and the oncological prognosis differ considerably between these tumor entities. Treatment and decision making for these tumors are often complicated by an underlying chronic liver disease. The aim of this review is to delineate the indications for transplantation and bridging therapies for each cancer entity as well as to highlight some aspects pertinent to transplantation, such as the principles of organ allocation.

Laparoscopic surgery has become the standard for most visceral surgery procedures in many hospitals. Now, liver resections are also being increasingly carried out laparoscopically. The advantages of the laparoscopic technique have been demonstrated in numerous case series and in a recent randomized controlled trial.The aim of this review article is to present the available techniques for laparoscopic liver surgery (LLS).The technical variations reported in the literature as well as the own experience with LLS are reported.Optimal patient and trocar positions are crucial for successful LLS and they are chosen according to the planned type of liver surgery: the literature offers several options in particular for surgery of the cranial and dorsal liver segments. As for open liver surgery, a restrictive volume management and the application of the Pringle maneuver are helpful to reduce intraoperative blood loss in LLS. In addition, several dissection techniques have been adopted from open liver surgery. The Cavitron Ultrasound Surgical Aspirator (CUSA™) is particularly suitable for parenchymal dissection close to major vascular structures, since it guarantees a meticulous parenchymal dissection with minimal vascular injuries.The developments of minimally invasive surgery nowadays allow complex liver resections, which can mostly be performed comparable to open liver surgery. Hopefully, minimally invasive liver surgery will further develop in Germany in the near future, since it offers several advantages over open liver surgery.

For virtual reality laparosopic simulation we developed a new, highly immersive simulation mode. The goal of the current pilot study was to investigate if kinetosis or other negative vegetative side effects can be caused by a total virtual training set-up (TVRL).In this study 20 participants with varying degrees of expertise in laparoscopy performed 3 tasks (i.e. ring exchange, fine dissection and cholecystectomy) in regular (VRL) and immersive mode (TVRL) with a head-mounted display (HMD) on a laparoscopic simulator. Aside from performance scores, the heart rate was recorded and the occurrence of vertigo was investigated.Surgical performance was independent of the VR mode (VRL or TVRL). Participants' heart rate was higher in TVRL without reaching statistical significance. Kinetosis occurred in two participants (10%) with a history of motion sickness.Laparoscopic training can take place in a total virtual environment with limited nagative vegetative side effects. Special attention should be paid to participants with a history of motion sickness. The development of TVRL enables new perspectives for surgical training.

Extended left hemihepatectomy (left trisectionectomy) with resection of liver segments 1, 2, 3, 4 a/b, 5 and 8 is a challenging procedure. In well-selected patients, the indication for this procedure may offer the chance of curative resection for primary or secondary liver tumours in complicated locations. Morbidity and mortality are increased compared to non-extended liver resections. This procedure requires precise imaging and accurate surgical planning in due consideration of the remaining liver volume and additional factors such as preliminary damage of the liver parenchyma caused by chemotherapy or fibrosis/cirrhosis. Left trisectionectomy is necessary in tumours affecting either the middle and left hepatic vein or the blood vessels of the liver hilum to the left and middle liver sector. The procedure necessitates the preservation of the right hepatic vein and the portal-venous and arterial branches supplying segments 6 and 7, as well as the bile ducts of these segments. This video article illustrates the surgical procedure of extended left hemihepatectomy performed due to an intrahepatic cholangiocellular carcinoma, which centrally surrounds the left and middle hepatic vein and potentially infiltrates the right hepatic vein. This condition requires the tangential resection and reconstruction of the right hepatic vein.

The main scope of the present article is to describe the different technical aspects and steps that were implemented towards a thorough earthquake risk estimation for the city of Khujand, the capital of Tajikistan’s northernmost province, Sughd. The development of the risk model involved both extensive fieldwork and computational work, including: soil amplification studies; defining ground shaking scenarios for earthquakes on local active faults that could cause damage, and for historical earthquakes that have caused damage to the city’s building stock; demarcation of the Khujand city area and its subdivision into geographical units; definition of building typology classes and generating corresponding vulnerability functions; collection of building inventory data as well as socio-economic information, and the computation of damage and loss scenarios. The earthquake risk model for the city of Khujand can be used as guidance for local authorities for future city planning and earthquake mitigation actions by helping to predict earthquake intensity in a given location, and the expected damage and socio-economic losses for any class of building. The procedure and many of the conclusions drawn can be applied in risk studies of other areas in Tajikistan and Central Asia.

In patients with primary or secondary malignant central liver tumours, the standard surgical procedure is extended left or right hemihepatectomy. Since extended resections are associated with increased morbidity and mortality and a loss of a large amount of functional liver parenchyma, central liver resection or mesohepatectomy (resection of segments 4a/4b, 5 and 8) with or without the resection of segment 1 is an alternative procedure, although technically demanding and not widely used so far. Resection margins are to the right of the falciform ligament and at the border between segments 5/6 and 7/8, which can be difficult to differentiate. Intraoperative sonography is highly recommended. The current video shows the technique of mesohepatectomy under exclusion of segment 1 in a case of a central colorectal liver metastasis.

Practical operative training in the discipline of visceral surgery is currently under discussion. Aside from surveys, data on this topic in Germany are sparse. The aim of the study was an objective collation of surgical residents' practical training in the operating room in our department.All surgical cases from 2015 were prospectively included. Procedures were stratified into resident and non-resident operations and complex cases with sub-steps which could potentially be performed by residents. We analyzed whether an operation or surgical sub-steps were performed by a resident. If this was not achieved, the reasons were analyzed. An anonymous online survey was conducted among employees in the surgery department regarding surgical training.Out of 2896 surgical cases 1141 (39.4 %) were classified as potential resident training operations, which were actually performed by a resident in 743 cases (65.1 %). The survey showed an underestimation of this proportion, where sub-steps were assisted in 30.3 % (n = 265) of 876 potential cases. This proportion significantly increased during the observation period (p 0.001); however, it was highly overestimated by residents as well as fellows and senior consultants. Often organizational reasons were responsible when resident operations or sub-steps were not performed by a trainee (13.1 % and 30.0 %, respectively).The monocentric analysis per se resulted in an improvement in practical surgical training. In the training environment, assisting with sub-steps provides a great potential. Multicenter studies are needed.

Due to their size or location liver tumors can infiltrate important vascular structures, which are essential for postoperative liver function.To present the technical possibilities and results of current concepts of vascular resection and reconstruction in liver surgery.A literature search of the Medline and Cochrane databases was performed regarding currently available studies on vascular resection and reconstruction in liver surgery.Portal vein resections are routinely performed by many institutions and can be performed as an end-to-end anastomosis or graft interposition. This is the basis of the en bloc resection concept, especially for Klatskin tumors. Reconstruction of the inferior vena cava as well as the hepatic arteries is technically feasible and is increasingly being reported in smaller series. In particular, the resection of tumors near the hepatic veins may require total vascular exclusion for complete interruption of liver perfusion, which enables resection in the non-perfused liver and by this reduced blood loss. Furthermore, in situ cooling, ante situm and ex situ resections increase both technical resectability and the ischemic tolerance of the liver to more than 60 min. The majority of vascular reconstructions can be performed without a significant increase in morbidity; however, vascular tumor infiltration is associated with impaired long-term survival.Based on the experience of transplantation surgery concepts for vascular reconstruction can be safely applied to liver surgery. These concepts contribute to increasing the resectability of liver tumors. Due to the often impaired prognosis of vascular tumor infiltration, the use of these concepts should be individually assessed by weighing the prognosis against the morbidity.

Modern chemotherapy regimen for colorectal cancer results in complete radiologic remission in a substantial number of cases. However, these "vanished liver metastases" (VLM) often contain vital tumor cells, which mandates the resection of such lesions. In these cases, intraoperative identification of VLM can be challenging, in particular in laparoscopic approaches. We describe the first laparoscopic computer-assisted 3D-navigated resection of a VLM.A 60-year-old patient with a synchronous liver metastasis (segment IVb) of sigmoid colon cancer (T4 N1 M1) was referred to our center for elective liver resection after laparoscopic sigmoid resection and systemic chemotherapy (FOLFIRI/Panitumumab). The metastasis was not visible anymore on preoperative CT or sonography. Thus, a 3 D reconstruction of the liver was performed. The size of the initial metastasis (before chemotherapy) was transferred into the current CT. A computer-assisted 3D-navigated laparoscopic resection of the metastasis was performed on these fused images. The metastasis was also not clearly visible upon intraoperative ultrasound. Histology of the resected specimen revealed a 0.5 cm metastasis with predominantly vital tumor cells (regression degree 4 of Rubbia-Brandt) and a sufficient resection margin of at least 7 mm. The postoperative course was uneventful.Computer-assisted 3D-navigation enabled a safe oncologic resection of a vanished liver metastasis after chemotherapy. This technique was particularly helpful due to the limited haptic feedback of laparoscopic surgery. Further studies are necessary to verify the clinical benefit of computer assisted 3D-navigated liver surgery.

Surgical residents need to train laparoscopic skills for minimally invasive procedures at an early stage. The aim of this study was the investigation and assessment of appendectomy carried out at a university medical center over the previous decade regarding the frequency of operations by residents in training and the type of surgical technique used (laparoscopic vs. open).A retrospective analysis of appendectomies carried out from 2005 to 2014 at the clinic for general, visceral and transplant surgery was performed. Operators were stratified into two groups (group 1: residents and group 2: fellows/attending surgeons). Surgery was classified as laparoscopic or open appendectomy.Out of 1,587 appendectomies analyzed 946 were performed laparoscopically (59.6 %). The percentage of laparoscopic appendectomies increased significantly over the decade analyzed (p 0.001) and reached 94.4 % in 2014. From 2005 until 2007 the rate of appendectomies by residents was 17.9 % (77 out of 430). Laparoscopic appendectomy was performed in 5.8 % and was only performed by fellows or attending surgeons. From 2008 to 2014 the rate of surgeries by residents significantly increased (p 0.001) and accounted for 57.6 % (range 19.4-66.9 %).Regardless of the surgical technique used, appendectomy is still a primary training operation for surgical residents. An early and focused training of minimally invasive visceral surgery in the new regulations for continuing medical education starts with laparoscopic appendectomy.

Transanal minimally invasive surgery (TAMIS) represents a promising technique for total mesorectal excision (TME) with respect to radicalness and preservation of function. There are only few publications in the literature describing results in patients with distal rectal cancer.Between May 2013 and March 2015, 24 selected patients with a rectal carcinoma 6 cm from the anal verge underwent a laparoscopically assisted TAMIS TME (Hybrid-TAMIS TME) procedure. This prospective observational study was conducted to examine the safety of the technique and the quality of TME surgery in distal rectal cancer and to assess the short-term postoperative outcome.The median age of patients (18 male and 6 female) at the time of surgery was 57 years (range 35-77 years) and 7 patients (29 %) had a body mass index (BMI) 30 kg/m(2). Specimen excision was carried out transanally in 19 patients. Pathological grading of TME specimens was good in 22 (92 %) and moderate in 2 cases. After neoadjuvant radiochemotherapy a complete pathological remission was identified in five patients. The median distal resection margin was 7 mm (range 2-30 mm), the median circumferential resection margin was 6 mm (range1 mm-30 mm) and in 2 patients the tumor was ≤ 1 mm from the positive circumferential margin. A colonic reservoir was created in 19 patients (79 %) and no 30-day mortalities occurred. Morbidity was 29 %, including 1 anastomotic leak, 2 hematomas and 1 neurogenic bladder.Hybrid-TAMIS TME for distal rectal cancer is safe and can provide a sphincter-preserving high-quality TME in difficult cases. Studies with long-term follow-up assessing oncological and functional results are mandatory.

Liver transplantation is the treatment of choice for acute hepatic failure or endstage liver disease. Long-time outcome following liver transplantation has been increased as a result of improvements in surgical technique, perioperative management, organ procurement and immunuosuppression. Differences in liver disease, access and allocation to liver transplantation as outcome due to gender have been reported. This review highlights the important differences in the field of liver transplantation.

Benign tumors of the esophagogastric junction are rare and mostly found incidentally during endoscopic or radiological procedures which are often performed for unrelated reasons. Epithelial lesions must be distinguished from subepithelial findings, where the latter are far more common and mostly represent benign leiomyomas, especially in the esophagus. Some benign tumors, such as small gastrointestinal stromal tumors, have malignant potential and must therefore be distinguished from completely benign lesions. Epithelial tumors can be diagnosed by standard endoscopic biopsies, whereas tissue acquisition of subepithelial lesions is more challenging. For this purpose endosonography is a valuable tool even before tissue acquisition or resection is performed. Endosonography can identify the gastrointestinal wall layer from which the lesion arises and gives additional information by identification of characteristic echographic features. Endoscopic resection techniques are used to remove those tumors that originate from the mucosa or submucosa. Some authors have even described resection of tumors originating from the deep muscle layer, but these techniques have a significant risk of perforation. Several surgical techniques are available for complete resection ranging from laparoscopic enucleation to combined endoscopic laparoscopic (rendezvous) techniques and abdominothoracic approaches. The current diagnostic and therapeutic challenges regarding benign tumors of the esophagogastric junction are outlined in this review article.

Liver cirrhosis develops as a terminal complication of chronic liver disease. The clinical course is determined by the underlying etiology and the accompanying risk factors, which are influenced by the geographic and cultural background.A total of 236 patients (159 men, 77 women, median age 57 [22-81] years) were included for retrospective analysis between July 2012 and February 2014 using standardized questionnaires during an outpatient visit at a hepatology clinic.The most common etiologies of liver cirrhosis were related to alcohol consumption (52 %), chronic hepatitis C (28 %) or hepatitis B (14 %) infection and NASH (nonalcoholic steatohepatitis, 6 %). At the time of presentation 55 % patients had compensated cirrhosis corresponding to Child-Turcotte-Pugh (CTP) stage A, while 45 % were in a decompensated stage (30 % CTP B and 15 % CTP C). Subgroups were analyzed for the incidence of complications and the emergence of infections. Most frequently esophageal varices (60 %) and ascites (49 %) were observed, followed by pleural effusion (14 %), hepatic encephalopathy (25 %) or hepatorenal syndrome (18 %). 16 % of patients exhibited infection based on clinical criteria. An infective agent was isolated in 38 % of all cases with infection and of those 50 % were gram positive bacteria. In multivariate analysis only the presence of ascites was an independent risk factor for infection.Despite improved medical therapies for viral hepatitis, these were the most frequent causes of liver cirrhosis, closely followed by alcoholic cirrhosis. The observed complications included bacterial infection and complication related to portal hypertension.

Approximately 50 % of patients with colorectal cancer (CRC) develop liver metastases, with the liver being the only site of metastasis in the majority of patients. Liver resection is the standard treatment of CRC liver metastases as it achieves a 5-year survival of 36-51 %. The primary goal in the treatment of non-resectable liver metastases is to achieve resectability by preoperative chemotherapy as even secondary liver resection after down-sizing is associated with improved overall survival. Furthermore, resectability can be increased by two-stage surgical procedures; however, the assessment of resectability varies widely even among experts in the field. In cases of suspected non-resectability patients should therefore be liberally admitted for a second opinion to centers of liver surgery. Perioperative chemotherapy in primarily resectable cases has only demonstrated an improvement in recurrence-free survival in subgroup analyses. Moreover, modern potent chemotherapy regimens increase the surgical morbidity depending on the duration of treatment: the lower the histological response of the metastases and the more treatment cycles are applied, the higher is the parenchymal damage with related surgical morbidity. Therefore, perioperative chemotherapy of resectable liver metastases should be viewed with caution and should not be considered the standard of care.

The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence- and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.

Resection of the esophagus is an invasive 2-cavitiy procedure which requires special anesthesiological expertise during perioperative care. Furthermore, in surgery new minimally invasive techniques are continually being established which place special challenges on the treatment team because the anesthesiologist is decisively involved in the course of surgery.The aim of this article is to present the development of surgical treatment options for esophageal cancer starting from classical open resection up to the minimally invasive technique of esophagectomy (MIE). Previous experience with MIE on a cohort of patients is presented and the special anesthesiological characteristics of this innovative technique are illustrated.In the department for general, visceral and transplantation surgery of the University Medical Center of Mainz, minimally invasive abdominothoracic esophageal resection has been carried out since 2010. High thoracic anastomization was performed using the EEA™-OrVil™ system operated by the anesthesiologist. Currently 17 highly selected patients have been surgically treated using this technique.Esophagogastric anastomosis with the EEA™-OrVil™ system was feasible in all patients. Transoral introduction of the gastric probe with the connecting sheath and the angled anvil led to minor dislocation of the double lumen tube in only one patient and could immediately be corrected. Further intraoperative complications did not occur. Four of the 17 patients developed pneumonia which could be controlled by intravenous antibiotics. None of the patients had to be reintubated. One patient developed gastric tube necrosis and died 51 days postoperatively due to massive intracerebral hemorrhage. There were no complications of anastomoses following OrVil™ anastomization. In all patients an R0 resection could be achieved.Minimally invasive esophagectomy with transoral anastomization appears to be an enrichment of the minimally invasive spectrum as interdisciplinary cooperation leads to reduced operation time and a more efficient process of anastomization. This also results in decreased one-lung ventilation time which is directly correlated to postoperative pulmonary complications. In particular, the interdisciplinary character of this technique and the necessity for targeted communication proved to be of assistance also in other situations.

The use of three-dimensional imaging in laparoscopy is a growing issue and has led to 3D systems in laparoscopic simulation. Studies on box trainers have shown differing results concerning the benefit of 3D imaging. There are currently no studies analysing 3D imaging in virtual reality laparoscopy (VRL).Five surgical fellows, 10 surgical residents and 29 undergraduate medical students performed abstract and procedural tasks on a VRL simulator using conventional 2D and 3D imaging in a randomised order.No significant differences between the two imaging systems were shown for students or medical professionals. Participants who preferred three-dimensional imaging showed significantly better results in 2D as wells as in 3D imaging.First results on three-dimensional imaging on box trainers showed different results. Some studies resulted in an advantage of 3D imaging for laparoscopic novices. This study did not confirm the superiority of 3D imaging over conventional 2D imaging in a VRL simulator.In the present study on 3D imaging on a VRL simulator there was no significant advantage for 3D imaging compared to conventional 2D imaging.

Die interdisziplinare Leitlinie der Qualitat S3 zur Diagnose und Therapie des hepatozellularen Karzinoms (HCC) ist ein evidenz- und konsensbasiertes Instrument, um die Diagnostik und Therapie des HCC zu verbessern, da die Diagnostik und Therapie des HCC ein auserst diffiziles Vorgehen erfordert. Es ist die Aufgabe der Leitlinie, dem Patienten (mit Verdacht auf HCC oder nachgewiesenem HCC) angemessene, wissenschaftlich begrundete und aktuelle Verfahren in der Diagnostik, Therapie und Rehabilitation anzubieten. Dies gilt sowohl fur die lokal begrenzte oder lokal fortgeschrittene Erkrankung als auch bei Vorliegen eines Rezidivs oder von Fernmetastasen. Die Leitlinie soll neben dem Beitrag fur eine angemessene Gesundheitsversorgung auch die Basis fur eine individuell zugeschnittene, qualitativ hochwertige Therapie bieten. Mit den erklarenden Hintergrundtexten ist es auch nicht spezialisierten, mitbehandelnden Kollegen moglich, den Patienten uber das Vorgehen der Spezialisten, Nebenwirkungen und Ergebnisse gut zu beraten. Mittel- und langfristig sollen so die Morbiditat und Mortalitat von Patienten mit HCC gesenkt und die Lebensqualitat erhoht werden.

Primary intestinal lymphangiectasia (PIL) is a protein-losing, exsudative gastroenteropathy causing lymphatic obstruction. Diagnosis depends on clinical examination and histological findings. Conservative treatment modalities include a low-fat diet and enteral nutritional therapy in order to reduce enteric protein loss and to improve fat metabolism. Other treatment options consist of administration of antiplasmin or octreotide to lower lymph flow and secretion. We report on a 58-year-old patient who underwent exploratory laparotomy due to a worsening physical status, recurrent chylaskos and leg oedema under conservative dietary therapy. Intraoperative findings showed a typical PIL of the jejunum about 20 cm distal to the Treitz's ligament. Histological examinations confirmed this diagnosis. One year after segmental small bowel resection (105 cm) with end-to-end anastomosis the patient is healthy, free of symptoms, has gained weight and his serum protein level has increased. Intraabdominal ascites and leg oedema have not reoccurred since.

The prognosis for patients with advanced esophageal cancer is poor. Proper risk assessment and knowledge of tumor biology may facilitate early diagnosis of adenocarcinomas and squamous cell cancer of the esophagus. New endoscopic techniques are available (e.g., (virtual) chromoendoscopy, autofluorescence, and endomicroscopy) for the early detection of cancer. Endoscopic therapy with complete resection of mucosal cancers offers long-term survival.En bloc resection combined with the removal of locoregional lymph nodes is the surgical option of choice for locally advanced cancer. In this respect, minimally invasive surgery offers the patient numerous advantages. Multimodal therapy results in better outcome for defined cancer stages and includes surgery, chemotherapy and chemoradiation. Multimodal treatment should always be individualized and requires cooperation of all subspecialties (tumor board conference). New chemotherapeutic strategies may offer improved survival but may also include new side effects. Patients with inoperable esophageal cancer also benefit from multimodal treatment.

A 35-year-old Kenian lady with advanced immunodeficiency due to HIV infection started on an antiretroviral therapy. Five months later, a severe colitis was diagnosed, however, no causal pathogen could be found. In order to avoid imminent perforation, a hemicolectomy became necessary, and immediately the symptoms and inflammation markers normalized rapidly. M. tuberculosis could be proven in culture in a draining abdominal lymph node. We assume that the severe inflammation was caused by an immune restoration inflammatory syndrome (IRIS). Essentials in diagnosis, pathogenesis and therapy of IRIS are discussed.

A 38-year-old man was referred to a gastroenterologist because of thoracic pain and dysphagia of uncertain cause.Endoscopy revealed a centrally depressed, coarse submucosal tumor, 1.0 cm in diameter, in the anterior wall of the esophagus at about 35 cm from the teeth. Button-hole biopsy revealed histologically and immunohistochemically a granular cell tumor (Abrikossoff's tumor), positive for S-100 protein. CT-staging was unremarkable, except for a thickening of the distal esophageal wall.Minimally invasive submucosal resection was undertaken using the videoscopic/endoscopic rendezvous technique. Histological examination confirmed complete resection of the tumor. The clinical course was uneventful and endoscopy 6 and 12 weeks after the operation showed complete resection of the tumor.An exact preoperative diagnosis beyond a mere description of site and morphology, but also providing the histopathological data creates favorable conditions for planning and performing a minimally invasive resection. Submucosal resection with the videoscopic/endoscopic in rendezvous technique offers the possibility of complete resection, which can often not be achieved in a submucosal tumor by only endoscopic resection.

Esophageal involvement in the context of opportunistic infections in human immunodeficiency virus (HIV) positive patients is a frequent phenomenon. However, worldwide esophageal achalasia has been described only twice in HIV-infected patients.We report the case of a 44-year-old Caucasian patient with HIV and Hepatitis C virus (HIV/HCV) coinfection who, within 2.5 years, displayed a progressive symptomatology with dysphagia, retrosternal pain, regurgitation as well as a considerable loss of weight before achalasia was finally diagnosed. Treatment was performed primarily surgically by means of laparoscopic Heller myotomy with an anterior 180° semifundoplication according to Dor.Histopathology of the specimens taken from the lower esophageal sphincter high-pressure zone proved alterations with abundant connective tissue and only scarce parts of the smooth muscular system without inflammatory infiltrations. In addition, the ganglia cells of the myenteric plexus as well as the interstitial cells of Cajal were significantly reduced. Interestingly, specific gene sequences of the hepatitis C virus could be detected in the esophageal tissue specimen. In contrast, analysis of specific HIV-gene sequences in the same tissue revealed a negative result.The possible but previously unknown relationship between esophageal achalasia and coinfection with HIV and HCV, also described as neurotropic viruses, will be discussed.

A 74-year-old woman was admitted with a history of recurring dyspnea for several months. During radiological examination of the chest computed tomography demonstrated a giant paraesophageal hernia containing transverse colon with a significant amount of paracolic fat tissue. Physical examination was unremarkable.Routine blood tests and abdominal ultrasound were within the normal range. Endoscopy showed a normal upper and lower gastrointestinal tract and barium swallow was normal without any esophageal motor dysfunction. The esophagogastric junction and gastric fundus were below the diaphragm.Laparoscopy revealed the colonic herniation and mediastinal adhesiolysis, complete resection of the hernia sac and reposition of the intrathoracic migrated transverse colon were undertaken. Hiatal repair was performed by anterior and posterior hiatoplasty and construction of an anterior 180˚ semifundoplication with fundopexy.Patients with giant paraesophageal hernias often present with nonspecific cardiac and respiratory symptoms and the condition is often misdiagnosed. If it is demonstrated, a possible abdominal involvement should be looked for. Minimally invasive surgery is feasible and efficacious in this condition and in addition to being better tolerated by the patient provides a far better visualization of the intrathoracic parts of a type IV hiatal hernia to the surgeon.

Approximately one third of patients with colorectal cancer (CRC) present with metastases confined to the liver only. In 15 % of these patients the metastases are primarily resectable. After resection of colorectal liver metastases the 5-year survival rate is 25 - 40 %. The EORTC trial of Nordlinger et al. has examined the role of perioperative/neoadjuvant chemotherapy of resectable liver metastases and found in the subgroup of resected patients a significant improvement in disease-free survival through chemotherapy. The results were not significant in the intent-to-treat population. Possible arguments pro neoadjuvant therapy of resectable liver metastases are the early eradication of disseminated tumour cells, the identification of a worse prognosis tumour biology in the individual patient and the higher dose density which can be achieved preoperatively versus postoperatively. Arguments against preoperative chemotherapy are the chemotherapy-induced hepatotoxicity and related increase in perioperative morbidity, the risk of achieving a complete remission of lesions which then cannot be detected intraoperatively and the uncertain optimal duration of chemotherapy. Especially surgical oncologists in Germany do not consider the neoadjuvant treatment of resectable liver metastases as a standard of care. In summary, because of the lack of level 1 evidence, patients with resectable liver metastases of colorectal cancer should be discussed within interdisciplinary tumour boards together with surgeons, gastroenterologists and medical oncologists. Potentially, overall survival data of the EORTC trial which is expected for late 2010 could change the level of evidence.

Colorectal cancer is one of the three most frequent malignancies in humans. Survival is mainly determined by local recurrence, lymphatic and hematogenous dissemination. Primary liver resection for metastases is possible in ~20-25% of patients with hepatic metastases and results in a 50% recurrence rate within 23 months. The five-year survival without treatment in patients with UICC stage IV is only 5%, the mean survival 6-9 months. As a result of promising developments in chemotherapy and targeted therapies in the last decade, the mean survival rate has significantly improved to over more than two years. Furthermore, the use of polychemotherapy in combination with anti-angiogenic and anti-proliferative biologicals has resulted in a significant increase of secondary resectability of liver metastases. Despite of a R0-resection (i.e. resection with clear margins) of liver metastases, only 30% of patients remain free of recurrence in the long-term. Prognostic scores are used for optimal patient selection, e.g. the Fong-Score. Resection is often limited by a high number of recurrences: intrahepatic micrometastases and disseminated tumor cells (DTC) are suspected as the cause of their development. In this connection the load of disseminated tumor cells correlates significantly with the survival and recurrence rate after resection. These micrometastases are targets in current adjuvant treatment studies (e.g. MT 201) by using anti-EpCam antibodies. The detection of DTC can supplement the previously used scores and represents the indication for an adjuvant antibody-based treatment (e.g. anti-EpCam) in the context of clinical trials.

Squamous cell carcinomas of the oesophagus are a completely different entity from adenocarcinomas in regard to their aetiopathology, tumour biology, co-morbidity, operative risk, and prognosis. For superficial squamous cell carcinomas, the risk of a relevant lymph node metastatisation already exists from the mucosal infiltration level m3 onward, and thus oncological resection is indicated. Neoadjuvant radiochemotherapy is the international standard for locally advanced squamous cell carcinoma. The early-response should be determined. Non-responders must be identified early, and a salvage operation with a justifiable operative risk should be carried out. Due to its high complete response rate, definitive radiochemotherapy is an option especially for squamous cell carcinomas of the upper third of the oesophagus and for patients with a high operative risk, even though local tumour control is significantly better after surgical therapy. Due to the success of definitive radiochemotherapy, the question is being asked increasingly, whether surgical resection after neoadjuvant radiochemotherapy will still be necessary in the future or whether radiochemotherapy alone can attain similar results for relapse-free survival and total survival. Surgical therapy should always be carried out in a specialised high volume centre with low morbidity and mortality. Future research will focus on predictors of the histopathological response, in order to possibly more accurately avoid surgical morbidity in patients with complete pathological responses after multimodal therapy.

The surgeon is the key "prognosis factor" for colorectal cancer. For this reason quality criteria were recently established (including minimum numbers) in order to treat patients who are entitled to the best quality of care and to improve the prognosis. The aim of this study was to critically discuss the existing demands on the surgeon based on the current literature and our own results and to formulate evidence-based quality criteria for surgical clinics. After reviewing the current literature criteria were compiled, discussed and finally presented in a summarized form. These are based on current developments on the diagnostic and therapy of large intestine and colorectal carcinoma. New developments of the German Cancer Society for planning of organ centers are incorporated. The quintessence of our study is that the number of cases alone is not decisive for the success of therapy. Important are the application of the correct surgical-oncology operation procedure, adherence to standards and the training of surgeons. Following the S3 guidelines stage-oriented therapy should additionally be carried out in a structured sequence. This includes an interdisciplinary decision making on the diagnostic and therapy strategy (tumor board). The organization structure of the hospital (teams, tumor board, emergency care with intensive care unit, emergency diagnostic and options for interventional measures) can be more important than the hospital case numbers alone. These demands which have been evaluated from published data and own results are designed to raise the therapy of colorectal cancer to the best possible level of quality and to effect a further improvement in the prognosis.

Minimally invasive surgery has influenced the treatment of achalasia more than that of any other gastrointestinal disorder. Laparoscopic Heller myotomy has thus evolved to the first-line therapy in patients with achalasia and led to a significant change in the treatment algorithm of this disorder. The aim of this article is to present technical aspects and pitfalls of Heller myotomy with combined antirefluxplasty. After injection of 0.9% NaCl into the muscularis and submucosa of the distal esophagus and proximal fundus, whereby the submucosal layer can be easily separated from the mucosa, myotomy of the longitudinal and circular musculature is performed up to 6-7 cm proximally to the esophagogastric junction and completed distally by 1.5-2 cm onto the fundus. We prefer the 180 degrees anterior semifundoplication according to Dor as antirefluxplasty, which is sutured in a two-rowed manner into the two sites of the myotomy. The pitfalls are incomplete myotomy, especially at its distal, fundic site, with consecutive persistence or recurrence of symptoms, as well as occult mucosal perforations, which can be detected by intraoperative endoscopy.

Neuroendocrine malignancies encompass a variety of tumors that differ considerably in origin, hormonal activity, and biological behavior. Because of their rarity most therapeutic recommendations have been based on limited evidence from small retrospective series observing miscellaneous patient cohorts. Only in recent years proposals for TNM and histological grading systems have been elaborated that allow further stratification of patients suffering from these tumors. Especially patients with well and moderately differentiated neuroendocrine malignancies benefit from resection of liver metastases, improving the 5-year survival rate from50% to 80%. Orthotopic liver transplantation can likewise improve survival in carefully selected patients. New developments in imaging modalities, intensive care treatment, and in liver surgery itself have broadened the selection of potentially resectable tumors.

Development of a megaesophagus with a sigmoid-shaped distal part in patients with achalasia--even in the course of successful myotomy with reduction of the resting pressure of the lower esophageal sphincter--is often the expression of an irreversible progression of the disease. Management of patients with end-stage achalasia and aperistaltic, dilated "burned-out" esophagus--with or without peptic stenosis--is a therapeutic challenge for gastroenterologists and surgeons. We report on a 37-year-old female patient with decompensated dolichomegaesophagus following multiple endoscopic and operative interventions at the lower and upper esophageal sphincters presenting with severe dysphagia and weight loss. Esophageal resection with gastric tube pull-up was indicated and performed as a two-stage procedure with ischaemic preconditioning of the esophageal substitute, with the intention of a microcirculatory improvement of the gastric fundus for the anastomosis, which was thought to be potentially compromised due to the previous interventions. The postoperative course was uneventful with dysphagia completely relieved and quality of life markedly improved. The concept of ischaemic preconditioning of the gastric tube offers, in particular, patients with esophageal resection for benign motility disorders, such as end-stage achalasia after multiple surgical procedures at the cardia and gastric fundus, a safe and practicable alternative to one-stage esophageal resection and reconstruction.

In this review, standards of diagnosis and treatment of colorectal liver metastases are described on the basis of a workshop discussion. Algorithms of care for patients with synchronous / metachronous colorectal liver metastases or locoregional recurrent tumour are presented. Surgical resection is the procedure of choice in the curative treatment of liver metastases. The decision about the resection of liver metastases should consider the following parameters: 1. General operability of the patient (comorbidity); 2. Achievability of an R 0 situation: i. if necessary, in combination with ablative methods, ii. if necessary, neoadjuvant chemotherapy, iii. the ability to eradicate extrahepatic tumour manifestations; 3. Sufficient volume of the liver remaining after resection ("future liver remnant = FLR): i. if necessary, in combination with portal vein embolisation or two-stage hepatectomy; 4. The feasibility to preserve two contiguous hepatic segments with adequate vascular inflow and outflow as well as biliary drainage; 5. Tumour biological aspects ("prognostic variables"); 6. Experience of the surgeon and centre! Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases provided a complete resection of both intra- and extrahepatic disease is feasible. Even in bilobar colorectal metastases and 5 or more tumours in the liver, a complete tumour resection has been described. The type of resection (hepatic wedge resection or anatomic resection) does not influence the recurrence rate. Preoperative volumetry is indicated when major hepatic resection is planned. The FLR should be 25 % in patients with normal liver, 40 % in patients who have received intensive chemotherapy or in cases of fatty liver, liver fibrosis or diabetes, and 50-60 % in patients with cirrhosis. In patients with initially unresectable colorectal liver metastases, preoperative chemotherapy enables complete resection in 15-30 % of the cases, whereas the value of neoadjuvant chemotherapy in patients with resectable liver metastases has not been sufficiently supported. In situ ablative procedures (radiofrequency ablation = RFA and laser-induced interstitial thermotherapy = LITT) are local therapy options in selected patients who are not candidates for resection (central recurrent liver metastases, bilobar multiple metastases and high-risk resection or restricted patient operability). Patients with tumours larger than 3 cm have a high local recurrence rate after percutaneous RFA and are not optimal candidates for this procedure. The physician's experience influences the results significantly, both after hepatectomy and after in situ ablation. Therefore, patients with colorectal liver metastases should be treated in centres with experience in liver surgery.

Recent developments in image-based computer assistance provide an improved visualisation of the intrahepatic vascular branching system in a virtual three-dimensional model of the liver, allowing a quantitative assessment of any vascular territory. The advantages of computer-assisted resection planning refer to a better preoperative assessment of functional resectability in areas at risk for either devascularisation or impaired drainage. In selected cases, this information may have a considerable influence on operative planning, especially with regard to the extent of resection or the need for vascular reconstruction. Due to the great anatomical variability of the intrahepatic branching patterns of the right liver lobe, this seems to be particularly important in extended left hepatectomies or in repeat hepatectomy when intrahepatic vascular anatomy may be altered. The development of navigation techniques to ensure the accurate application of the preoperative planned resection line is under investigation but not available yet.

Hepatic surgery has grown considerably in importance during the last two decades. Major roles in this development have been played by improvements in imaging diagnostics and intensive care and particularly advancements in general hepatic surgical techniques. We present the terminology of functional and segmental anatomy of the liver on which current hepatic surgery is based, along with operative strategies for standard, nonconventional, and repeat resections. Intraoperative complications are also discussed.