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SummaryLaparoscopic cholecystectomy has become the standard procedure worldwide since the early 1990s for those patients whose gallbladder has to be removed as part of their underlying disease (NIH Consensus Statement 1992). The most common complication is iatrogenic bile duct injury, which has not improved significantly since the introduction of open laparoscopic cholecystectomy as compared with open cholecystectomy. The intraoperative injuries are mostly the result of a misinterpretation of anatomical structures due to severe inflammation or topographical variations. In order to minimize this risk, a number of improved operative techniques and behavioral measures have been formulated. Here, we present methodological and operative possibilities as well as techniques that in unclear situations can help to minimize the risk of intraoperative injuries of the biliary tract and the accompanying vascular system.

BACKGROUND/AIM The liver is a frequent site for metastases of colorectal cancer. Approximately 15% of patients have hepatic metastases at the time of diagnosis and another 50% develop them over the course of their disease. Only 10-25% of patients are candidates for liver resection. The aim of this study was to assess the benefit of preoperative computed tomography (CT)-guided wire marking of disappearing colorectal liver metastases (CRLMs) (radiological disappearance of metastases) before surgical resection. PATIENTS AND METHODS Between January 2011 and January 2014, 20 patients with potentially disappearing CRLMs were selected for CT-guided wire marking. Following treatment with neoadjuvant chemotherapy, disappearing CRLMs were marked via CT guidance. Afterwards, the marked sites were resected. RESULTS Complete histological response to neoadjuvant chemotherapy was only in 10 resected sites (18%), and 46 (82%) resected liver metastases showed metastatic tissue present. Both overall survival and the disease-free rates in patients after using our method were 55%. CONCLUSION This study demonstrated the usefulness of CT-guided wire marking to mark disappearing CRLMs in order to improve long-term effectiveness of surgical treatment.

Purpose A device that provides continuous, long-term, accurate seizure detection information to providers and patients could fundamentally alter epilepsy care. Subgaleal (SG) EEG is a promising modality that offers a minimally invasive, safe, and accurate means of long-term seizure monitoring. Methods Subgaleal EEG electrodes were placed, at or near the cranial vertex, simultaneously with intracranial EEG electrodes in 21 epilepsy patients undergoing intracranial EEG studies for up to 13 days. A total of 219, 10-minute single-channel SGEEG samples, including 138 interictal awake or sleep segments and 81 seizures (36 temporal lobe, 32 extra-temporal, and 13 simultaneous temporal/extra-emporal onsets) were reviewed by 3 expert readers blinded to the intracranial EEG results, then analyzed for accuracy and interrater reliability. Results Using a single-channel of SGEEG, reviewers accurately identified 98% of temporal and extratemporal onset, intracranial, EEG-verified seizures with a sensitivity of 98% and specificity of 99%. All focal to bilateral tonic--clonic seizures were correctly identified. Conclusions Single-channel SGEEG, placed at or near the vertex, reliably identifies focal and secondarily generalized seizures. These findings demonstrate that the SG space at the cranial vertex may be an appropriate site for long-term ambulatory seizure monitoring.

Die chirurgische Therapie von Tumorerkrankungen der Bauchspeicheldruse erfordert komplexe operative Interventionen. Diese weisen mittlerweile eine signifikant reduzierte Mortalitat (

Introduction Low skeletal muscle mass is a known predictor of morbidity and mortality in patients undergoing major pancreatic surgeries. We sought to combine low skeletal muscle mass with established risk predictors to improve their prognostic capacity for postoperative outcome and morbidity. Methods As established parameters to predict preoperative mortality risk for patients, the ASA classification and the Charlson Comorbidity Index (CCI) were used. The Hounsfield Units Average Calculation (HUAC) was measured to define low skeletal muscle mass in 424 patients undergoing pancreatic resections for malignancies. Patients in the lowest sex-adjusted quartile for HUAC were defined as having low skeletal muscle mass (muscle wasting). Multivariable Cox regression analysis was utilized to identify preoperative risk factors associated with postoperative morbidity. Results Median patient age was 63 years (19–87), 47.9% patients were male, and half the cohort had multiple comorbidities (Charlson Comorbidity Index [CCI]>6, 63.2%), 30-day mortality was 5.8% (n = 25). Median HUAC was 19.78 HU (IQR: 15.94–23.54) with 145 patients (34.2%) having low skeletal muscle mass. Preoperative frailty defined by low skeletal muscle mass was associated with an increased risk for postoperative complications (OR 1.55, CI 95% 0.98–2.45, p = 0.014), and a higher 30-day mortality (HR 5.17, CI 95% 1.57–16.69, p = 0.004). With an AUC of 0.85 HUAC showed the highest predictability for 30-day mortality (CI 95% 0.78–0.91, p = 0.0001). Patients with CCI ≥6 and low skeletal muscle mass defined by the HUAC had a 9.78 higher risk of dying in the immediate postoperative phase (HR 9.78, CI 95% 2.98–12.2, p = 0.0001). Conclusion Low skeletal muscle mass predicts postoperative mortality and complications best and it should be incorporated to conventional risk scores to identify high risk patients.

Summary Incisional hernias (IHs) occur universally after orthotopic liver transplantation (OLT). This study aimed to investigate the effectiveness of porcine dermal collagen (PDC) as a closing aid in giant hernias after OLT in a prospective trial. If direct closure (DC) was not feasible due to the hernia size and abdominal wall constitution, a PDC mesh was implanted. All patients from the PDC and DC groups were followed prospectively for 24 months. IH recurrence rates served as the primary endpoint, and the development of infections and wound healing disorders served as the secondary endpoints. Recurrence rate was 21% (4/19) in DC patients and 12% (2/16) in PDC patients (P = 0.045). Implant site infections occurred in five of PDC and one of DC patients (P

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.

Liver metastases originating from various types of sarcoma are a rare reason for hepatic resection. So far, even multicentre studies do hardly provide statistically relevant sample sizes. Thus, review of available data can provide surgeons with useful information in similar cases. Therefore, this study can be regarded more as a contribution to this pool of data than as a stand-alone paper.The study includes 10 women and five men who underwent subtotal hepatic resection for solitary (n = 4) and multiple (n = 11) liver metastases originating from sarcoma. The median tumour diameter was 60 mm (range 20-200 mm).Morbidity was 33%. One patient died within 30 days after surgery. Resection was complete (R0) in 67%. Median overall survival was 33.6 months, 5-year survival 27%. The use of Pringle manoeuvre was significantly associated with poorer outcome (p = 0.014) and shorter period of recurrence-free survival (p = 0.012). Diameter of liver lesion over 50 mm showed significantly shorter recurrence-free survival (p = 0.042).Hepatic resection may be beneficial in patients with isolated sarcoma metastasis in the liver.

Increasing concern has been expressed worldwide on the problem of finding young doctors to enter a training programme in an operative speciality. A survey comprising 22 questions on working conditions and job satisfaction was placed on the homepage of the Austrian Society of Surgery; 667 questionnaires were completed. The question whether surgery is threatened by a trainee shortage was answered with “yes” by 68%. Only 37% were satisfied with their working conditions. The majority (61%) specified documentation as making up between 20% and 40% of their workload, 22.5% estimated an even higher percentage. Only 17.7% were satisfied with payment. A clear majority works 60 to 80 h per week or more. Only 32.5% stated that they can leave the hospital in the morning after weekend duty; for night duty during the week, this percentage decreased to just 4.2%. As for surgical training, 33.3% were satisfied. Regular assessments between the trainees and their department heads were confirmed by only 34%. A clear majority (96%) is in favour of rotations in other hospitals during residency for the sake of broader experience. Working hour restrictions are essential, but not enough: Substantial improvements in the professional profile and in training are required.

The superior diastolic blood pressure reduction (BP) of high‐dose combination therapy with trandolapril (Tr) and verapamil‐SR (Ve) compared with monotherapy has previously been reported. Guideline changes, placing greater emphasis on systolic BP, prompted a re‐evaluation of TV‐51 and an assessment of a subset of patients from the INternational VErapamil‐SR Trandolapril STudy (INVEST). The objective of this analysis was to determine if the short‐term antihypertensive effects of high‐dose Tr+Ve (Tr/Ve study) could be confirmed in a sample of higher‐risk INVEST patients with longer follow‐up. The Tr/Ve study was a double‐blind, randomized, parallel‐group, placebo‐controlled trial to evaluate the antihypertensive effects of trandolapril and verapamil‐SR alone or in combination in 631 patients randomized to placebo, 4 mg trandolapril, 240 mg verapamil‐SR or 4mg/240mg Tr+Ve combination for 6 weeks; 581 INVEST patients were selected for comparison with 24‐month BP data, 90% use of trandolapril and verapamil‐SR c...

BACKGROUND: Palliative gastroenteric bypass surgery, the mainstay in the treatment of gastric outlet obstruction, has several disadvantages, including significant morbidity and mortality rates, and is frequently associated with delayed gastric emptying. Endoscopic stenting is reported to be an efficient and less invasive procedure for the symptomatic treatment of malignant GI tract obstruction. This study compares the outcomes of gastroenteric bypass surgery and endoscopic stenting. METHODS: We retrospectively analyzed 22 patients who underwent palliative endoscopic stenting of malignant gastric outlet obstruction or malignant obstruction in the upper part of the jejunum and compared them with 17 patients treated with palliative gastric bypass surgery during the same period. RESULTS: Obstructive symptoms improved in all 22 patients (100%) after endoscopic stenting compared to 11 of 17 patients (64.5%) after palliative gastric bypass surgery. The stent patients had a shorter hospital stay (4 days vs. 13 days), tolerated oral nutrition earlier (1 day vs. 6 days), had lower costs for hospital treatment (€ 2143 vs. € 6617) and had no procedure-related mortality after stent implantation (0/22 vs. 3/17). The differences in hospital stay, in improvement of symptoms, in time until resumption of oral nutrition and in hospital charges were statistically significant (p < 0.05). CONCLUSIONS: Endoscopic stent implantation, as palliative treatment for malignant gastric outlet obstruction or malignant stenosis in the upper part of the jejunum, is a highly effective, extremely safe and cost-efficient method. It should be the first choice in the treatment of malignant obstruction in this part of the GI tract.

BACKGROUND: Though recent developments in operative and non-operative therapy have added considerably to the therapeutic spectrum for primary hepatoma, there is a need for exact evaluation of their success and guidelines for their application. METHODS: Current therapeutic options for primary hepatoma are rated on the basis of recent publications and results of consensus conferences. RESULTS: According to the Milan criteria only a few patients with hepatocellular carcinoma are eligible for liver transplantation. Early detection of these tumours by surveillance of cirrhotic patients is essential for the success of the transplantation concept. Resection rates for hepatocellular and intrahepatic or hilar cholangiocellular carcinoma amount to about 10–20 %; there is wide consensus that R0-resection is a crucial prognostic factor. For the majority of patients neither transplantation nor resection is an option. For this very delicate patient group, a variety of therapeutic procedures are warranted with effects difficult to compare given the bias of patient selection and the great inter-patient and inter-institutional variability. Especially for procedures with promising results such as radiofrequency ablation, further studies are needed if clinical decisions are to be based on a high level of evidence. CONCLUSIONS: Primary hepatoma should be treated in specialised centres by a team that is truly dedicated to the very special problems of these patients and that holds regular interdisciplinary conferences to optimise the multimodal approach to this disease. Guidelines are helpful for treatment management but must be individually modified and tailored to the specific situation of every single patient.

INTRODUCTION: Polycystic liver disease (PLD) is a rare affliction frequently observed in association with polycystic kidney disease. Only symptomatic patients require treatment, which can be conservative or surgical, i.e. laparoscopic or conventional. We report the results of our experience in the surgical management of polycystic liver disease. METHODS: Between 1994 and 2003, 19 patients (16 female, 3 male) were referred to our center for the management of PLD. Their median age was 50 years (range, 33–72). All were symptomatic and their cysts had a median diameter of 11 cm (range, 5–22). RESULTS: Laparoscopic management was undertaken in eight patients, with one conversion to open technique because of bleeding from a superficial hepatic vein. An open procedure was performed in 11 patients: one left hemihepatectomy, deroofing in two patients, segment resection 2/3 plus deroofing in six patients, and segment resection 5/6 plus deroofing in two patients. Four patients had complications: one case of biliary leakage was managed conservatively; two patients had pneumothorax caused by the cava catheter inserted for anesthesia, and one patient’s abdominal drain tore off and had to be removed by relaparotomy on the fourth postoperative day. Median follow-up of all patients was 49 months (range, 7–98). In one patient there was symptomatic recurrence with hepatomegaly and compression of the inferior vena cava 84 months after the first operation. CONCLUSIONS: Careful selection of patients and meticulous surgical technique are recommended in the management of PLD. The treatment of choice for symptomatic Gigot or Morino type 1 PLD is laparoscopic surgery, and for advanced-stage PLD, combined hepatic resection and cyst fenestration.

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: Hepatocellular carcinoma (HCC) is one of the most common malignancies. Tumor recurrence is, however, frequent and may be due to undetectable tumor cells. Reverse transcriptase polymerase chain reaction (RT-PCR) has been used to detect those tumor cells in peripheral blood but has several disadvantages. METHODS: Peripheral blood from 47 patients (group A, 19 patients with newly diagnosed HCC; group B, 20 control patients with non-HCC liver lesions; Group C, 8 HCC aftercare patients) was tested for the presence of circulating HCC cells by demonstration of alpha-fetoprotein mRNA by the RT-PCR technique. RESULTS: Six patients with newly diagnosed HCC tested positive for circulating HCC cells. No patient in the control group or the aftercare group was positive for alpha-fetoprotein mRNA. CONCLUSIONS: The specificity (100%) of alpha-fetoprotein mRNA as a marker for HCC cells in circulating blood was satisfactory but the sensitivity (31.6%) was disappointing. Our experience is that this method of detecting circulating HCC cells did not provide any clinically relevant information and that we should focus our interest on methods like the isolation by size of epithelial tumor cells for the detection of circulating tumor cells in the future.

BACKGROUND: Evaluation of the impact of parenchymal liver transection by Ultracision® harmonic scalpel compared to ligation on operation course and outcome of elective liver surgery. METHODS: Our retrospective study included 64 consecutive patients. Liver resection was performed either by CUSA® (Cavitron ultrasonic surgical aspirator) and ligation (group L, n = 34) or by CUSA® and Ultracision® (group UC, n = 30). RESULTS: On the basis of comparable groups of patients and types of resections, we found in group UC a highly significant reduction in operation time and duration of drainage, a significant reduction in the length of hospital stay and a tendency towards less intraoperative blood substitution compared to the standard technique. Resection time, postoperative blood substitution, biliary fistula rate, complications, reinterventions and mortality showed no significant difference. CONCLUSIONS: The dissection of the liver by CUSA® and Ultracision® proved to be a safe technique with remarkable advantages compared to the conventional technique with CUSA® and ligation.

BACKGROUND: Our previous investigations demonstrated that there is an enormous increase in free catecholamines during prolonged intraoperative occlusion of blood flow to the liver (Pringle maneuver), with tachycardias indicating impending postoperative liver failure. As stress-induced changes in catecholamine levels also have clear metabolic consequences, we investigated changes in catecholamines and their metabolites before, during, and after surgery, looking for simple risk parameters that could serve as early onset predictors of postoperative liver failure. METHODS: We examined 26 patients with primary and secondary liver tumors. Their average age was 54 years (range, 27–79). Twenty-one patients had segmental liver resections, 3 had hemihepatectomies, and 2 hydatid cysts were treated by pericystectomy. Blood samples were taken 2 days before and during all phases of surgery and the following parameters were determined: free plasma epinephrine, total serum calcium and magnesium, serum triglycerides, and serum cholesterol. Catecholamine plasma values were determined by high-performance liquid chromatography. The patients were subdivided into 2 groups: one including those with postoperative liver failure; and the other, those without liver failure. Statistical analysis was performed with Clinical Stress Assessment Software. RESULTS: In patients with liver failure (LF), perioperative catecholamine increase was about threefold higher when compared to the increase observed in non-liver failure patients (nLF). However, there were no preoperative differences in catecholamine levels among the groups. Unlike the results for the catecholamines, there were significant preoperative differences in cholesterol, triglycerides, and total magnesium values, which were all lower in the LF group. Perioperative fall in cholesterol correlated significantly with decreased calcium levels, an electrolyte well known to be discharged from the blood stream into tissues with increasing catecholamine effect. Such an increase could also be shown by perioperative positive correlations between glutamic oxalacetic transaminase and epinephrine. CONCLUSIONS: Estimation of the risk of postoperative liver failure is of great importance for the surgeon and the patient. Disproportionately large increases in catecholamines in the LF group point towards a relative increase in surgical stress in persons who already are metabolically maladapted. Such metabolic exhaustion is well documented by preoperative "pseudonormal", i.e., relatively low cholesterol and triglyceride levels, that are usually not to be expected in middle-aged patients. Along with low magnesium concentrations, such parameters can be used as preoperative predictors for postoperative liver failure.

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: Most of the studies on intraoperative ultrasonography (IOUS) during partial hepatectomy date from a time when preoperative imaging was not as good as it is today. These studies thus reflected not only the benefits of IOUS but also the weaknesses of the then prevailing imaging techniques. Constant improvements in preoperative imaging demand continuous reevaluation of IOUS. METHODS: This prospective study included 160 patients who underwent magnetic resonance imaging (MRI) at a single institution using a standardized liver protocol. The results were compared to IOUS and to definitive histological work-up. RESULTS: In 19 out of 160 patients (11.9%), 21 additional malignant lesions were found intraoperatively (10 visible, 3 palpable and 8 [5%] detected by IOUS only; mean size, 1.4 cm; ratio of the number of lesions in the left lobe to that in the right lobe, 14 : 7), causing a change in surgical strategy in 17 patients (10.6%). The average total number of lesions in those patients was 3.4. Twelve pseudolesions (without intraoperative confirmation) were described on MRI (7 as benign, 5 as malignant; mean size, 1.5 cm; ratio of the number of pseudolesions in the left lobe to that in the right lobe, 2 : 10). CONCLUSIONS: Even under stringent conditions with preoperative MRI performed at a single institution and so without the usual variability of extramural imaging techniques and with precise discrimination of new intraoperative findings obtained by visual inspection and palpation from those actually provided exclusively by ultrasonography, IOUS still remains an indispensable surgical tool for lesion detection, anatomical resolution, and guidance of resection.

Maligne Magenausgangsstenosen sind durch Tumorobstruktion bedingt und beeintrachtigen die orale Nahrungsaufnahme des Patienten und damit auch dessen Lebensqualitat. Durch die endoskopische Implantation von selbstexpandierbaren Metallstents (SEMS) ist es moglich, Stenosen im Gastrointestinaltrakt zu beseitigen, die Passage wieder herzustellen und aufrecht zu erhalten. Sieben Patienten (Alter 50–90 Jahre) sind zwischen Oktober 2001 und April 2003 wegen einer malignen Magenausgangsstenose oder malignen Stenose im Bereich des proximalen Jejunums durch die Implantation von SEMS behandelt worden. Vier Patienten hatten eine maligne Magenausgangsstenose im Bereich des proximalen Duodenums oder Antrum ventriculi, zwei Patienten hatten eine Tumorstenose im Bereich der abfuhrenden Jejunumschlinge nach subtotaler Billroth II Operation wegen eines Magenkarzinoms und ein Patient hatte eine Tumorbstruktion des Jejunums durch ein Tumorrezidiv nach Gastrektomie 20 cm distal der Osophagojejunostomie. Bei allen sieben Patienten konnte die Obstruktionsymptomatik mittels endoskopischer Platzierung von SEMS beseitigt werden, sodass alle Patienten ab dem zweiten Tag oral ernahrt werden konnten. Es kam bei der Stentimplantation zu keinen schwerwiegenden Komplikationen und die Mortalitatsrate des Eingriffes lag bei null Prozent. Die Stentimplantation zur Therapie von malignen Magenausgangsstenosen ist ein risikoarmes, Ressourcen schonendes und fur den Patienten wenig belastendes Verfahren, das sich hervorragend zur Palliation bei Patienten mit malignen Magenausgangsstenosen eignet.

Laparoscopic appendectomy is widely used for the treatment of complicated appendicitis. Its use in patients with high operative risk is still on debate. The aim of the presented study was to investigate the benefits of laparoscopic appendectomy in patients with high peri- and postoperative risk factors. We performed a retrospective analysis of all patients who underwent appendectomy in our center between 2006 and 2013. Patients were classified according to their preoperative risk (classification of the American Society of Anesthesia—ASA score). Only patients with ASA 3 and 4 were included and were divided into two groups—open appendectomy (OA group) and laparoscopic appendectomy (LA group). The operation time was slightly longer in the LA group (p = 0.05), but hospital stay was shorter (p = 0.05). Complications graded according to the Clavien Dindo classification were slightly more frequent in patients after LA, whereas severe complications occurred more frequently in patients after OA (p = 0.01). The postoperative WBC decreased steadily and significantly in patients after OA, whereas the decrease in patients after LA was delayed (p = 0.03). CRP slightly increased after OA and decreased thereafter, whereas it steadily decreased after LA (p = 0.05). Laparoscopic appendectomy can be recommended for patients with complicated appendicitis even with higher risk categories.

Grundlagen: Die Weiterentwicklung der Leberchirurgie und der Intensivmedizin in den letzten beiden Jahrzehnten fuhrte zu einer Ausweitung der Indikationsstellung und der Grose der Eingriffe, brachte aber auch die Notwendigkeit einer kritischen Risiko- und Komplikationsanalyse mit sich.

Grundlagen:Longo’s Technik der Stapler-Mukosektomie in der Behandlung 3- bis 4-gradiger prolabierender Hamorrhoidalknoten findet auch in Osterreich breite Anwendung. Nach anfanglicher Euphorie bezuglich des neuen nahezu schmerzlosen Verfahrens werden nach und nach Berichte uber schwerwiegende Komplikationen bekannt. Die Ursache fur postoperativ uber Wochen bis Monate bestehende funktionelle Probleme wie Dranginkontinenz, verbunden mit brennenden Schmerzen im Bereich des Rektums trotz korrekt ausgefuhrter Longo-Technik, ist bis heute noch unbekannt.

Analfissuren werden haufig chirurgisch mit einer lateralen Sphinkterotomie behandelt, wobei jedoch die Gefahr einer postoperativen Inkontinenz besteht. Dies ist besonders ein Problem bei jungeren Frauen, die noch mehrere Geburten vor sich haben, die eine weitere Belastung fur die Sphinktermuskulatur darstellen. Stickstoffmonoxid-(NO-)Freisetzer wie Glyceryltrinitrate (GTN) konnten in kleineren Studien wirksam zur reversiblen chemischen Sphinkterotomie eingesetzt werden. NO ist ein wichtiger Neurotransmitter, der die Relaxation des inneren Schliesmuskels bewirkt. Die klinische Wirksamkeit der lokalen NO-Therapie wurde in unserer prospektiv randomisierten Studie untersucht.

The aim of our study was to assess the influence of intraoperative hypoxic stress -unavoidably brought about by so called Pringle maneuver - on free and conjugated catecholamines during major hepatic resection. Judging from earlier results of fatigue-experiments in rats we also wanted to check the relationship between of poor general preoperative condition and conspicuously low triglyceride serum concentrations. The study included 26 patients with primary and secondary liver tumors. The mean age was 54 years (range 27-79). Twenty-one patients had segmental liver resections, 3 had hemihepatectomies and 2 hydatid cysts were treated by cystectomy. Blood samples were taken 2 days before and throughout surgery. Catecholamine plasma values were determined by high performance liquid chromatography. Statistical comparisons were made by t-test, ANOVA and chi square test. Free plasma catecholamines increased significantly during prolonged intraoperative ischemia (Pringle time 50-125 minutes). Patients with elevated intraoperative catecholamines had a significant correlation to postoperative episodes of tachycardia, and prolonged hospital stay. On the other hand, we could also see postoperative tachycardias in patients with short Pringle times (18-49 minutes) but with decreased preoperative serum triglycerides as an indicator of chronic stress and reduced general condition. Intraoperative hypoxic stress is associated with increased catecholamine values. Elevated catecholamines may well cause postoperative sinus-tachycardias (mean 20 hours) and are strongly related to postoperative liver failure and prolonged hospital stay.

The incidence of hydatid disease of the liver caused byEchinococcus granulosus in Austria, a nonendemic region in central Europe, is documented over a 10-year period. Since 1984, 28 patients (24 women, 4 men) with hydatid disease of the liver have undergone surgery in our department. A definitive diagnosis was established by combining serological tests (an enzyme-linked immunosorbent assay withEchinococcus multilocularis antigen and an indirect hemagglutination assay withEchinococcus granulosus antigen) and abdominal imaging (computed tomography scan and ultrasonography). Twenty-four patients (85.7%) had uncomplicated echinococcosis; in most of them (16) total closed pericystectomy was done. Four patients (14.3%) had complicated echinococcosis, suffering from intrabiliary rupture and spontaneous perforation into the peritoneal cavity, and in two of these patients (7.1%) pyogenic transformation, one with abscess perforation, occurred. Postoperative complications were significantly more common in patients with complicated echinococcosis and included two bile leaks (necessitating prolonged tube drainage), pleural effusion, atelectasis, and wound infection. One recurrence of hydatid infection due to previous spontaneous perforation required reoperation 4 years after the primary event. The low recurrence rate of uncomplicated echinococcosis (0%) over a mean period of 5.6 years and of 3.6% when peritoneal echinococcosis was included may be the result of the radical surgical technique employed.

PURPOSE: Nitric oxide is an important neurotransmitter mediating internal anal sphincter relaxation. Patients suffering from fissure-in-ano were treated with topical nitroglycerine. The clinical evidence for therapeutic adequacy was examined in a prospective, randomized study. METHODS: The study included 35 patients with acute and chronic anal fissures. In Group A, including 20 patients with the clinical diagnosis of acute (12 patients) and chronic (8 patients) anal fissures, treatment consisted of topical nitroglycerine. Group B, consisting of 15 patients (10 acute and 5 chronic fissures), received topical anesthetic gel during therapy. Manometry was performed before and on days 14 and 28 in the course of topical application of either 0.2 percent glyceryl trinitrate ointment or anesthetic gel (lignocaine). Anal pressures were documented by recording the maximum resting and squeeze pressures. RESULTS: In 60 percent of cases treated with topical nitroglycerine (Group A, 11 acute (91.6 percent) and 1 chronic (12.5 percent)), anal fissure healed within 14 days, in contrast to Group B in which no healing was observed. The healing rate after one month was 80 percent (11 acute (91.6 percent); 5 chronic (62.5 percent)) in Group A and was significantly superior to Group B (healing rate, 40 percent: 5 acute (50 percent); 1 chronic (20 percent)). DISCUSSION: Previously increased maximum resting pressures decreased from a mean value of 110 to 87 cm H 2 O. This represents a mean reduction of 20 percent (P =0.0022). We also noted a significant decrease in squeeze pressures (from 177.8 to 157.9 cm H 2 O (11 percent)). However, anal pressures did not decrease significantly in the four chronic fissure patients from Group A, whose fissures only healed after 28 days. Similarly to these Group A chronic fissure patients, no significant anal pressure reduction was observed in any Group B patients. Except for mild headache (20 percent), no side effects of treatment were reported. CONCLUSIONS: Topical application of nitroglycerine represents a new, easily handled, and effective alternative in the treatment of anal fissures. All of our patients reported a dramatic reduction in acute anal pain. However, it should be noted that a lack of sphincter tone reduction is a likely reason for the great tendency of chronic anal fissures to recur.

Background: Hepatocellular carcinoma (HCC) is one of the most common malignancies. The treatment of choice for HCC is liver resection and in certain cases liver transplantation. Tumour recurrence is, however, frequent and may be explained by the existence of undetectable tumour cells. The reverse transcriptase polymerase chain reaction (RT-PCR) can detect even small numbers of tumour cells in peripheral blood. Methods: Peripheral blood from 47 patients (group A: 19 patients with newly diagnosed HCC; group B: 20 control patients with non-HCC liver lesions; group C: eight HCC aftercare patients) was tested for the presence of circulating HCC cells by demonstration of α-fetoprotein (AFP) mRNA with RT-PCR technique. Results: Six patients with newly diagnosed HCC tested positive for circulating HCC cells. No patient in the control group or in the aftercare group was positive for AFP mRNA. Conclusions: The specificity (100%) of AFP mRNA as a marker for HCC cells in circulating blood was satisfactory, but the sensitivity (31.6%) was disappointing. This method of detecting circulating HCC cells did not provide any clinically relevant information that was not available from routine imaging or laboratory tests.

Background and aims: Post-operative hyperbilirubinaemia in patientsundergoing liver resections is associated with high morbidity and mortality.Apart from different known factors responsible for the development of post-operative jaundice, little is known about the role of hepatobiliary transportsystems in the pathogenesis of post-operative jaundice in humans after liverresection. Methods: Two liver tissue samples were taken from 14 patientsundergoing liver resection before and after Pringle manoeuvre. Patients wereretrospectively divided into two groups according to post-operative bilirubinserum levels. The two groups were analysed comparing the results of hepa-tobiliary transporter [Na-taurocholate cotransporter (NTCP); multidrugresistance gene/phospholipid export pump(MDR3); bile salt export pump(BSEP); canalicular bile salt export pump (MRP2)], heat shock protein 70(HSP70) expression as well as the results of routinely taken post-operativeliver chemistry tests. Results: Patients with low post-operative bilirubin hadlower levels of NTCP, MDR3 and BSEP mRNA compared to those with highbilirubin after Pringle manoeuvre. HSP70 levels were significantly higherafter ischaemia–reperfusion (IR) injury in both groups resulting in 4.5-foldmedian increase. Baseline median mRNA expression of all four transportersprior to Pringle manoeuvre tended to be lower in the low bilirubin groupwhereas expression of HSP70 was higher in the low bilirubin group com-pared to the high bilirubin group. Discussion: Higher mRNA levels ofHSP70 in the low bilirubin group could indicate a possible protective effectof high HSP70 levels against IR injury. Although the exact role of hepatobil-iary transport systems in the development of post-operative hyper bilirubin-emia is not yet completely understood, this study provides new insights intothe molecular aspects of post-operative jaundice after liver surgery.Liver resections for colorectal metastasis can nowa-days be performed safely with low mortality andmorbidity rates in specialized high-volume liver cen-tres. However, up to 75% of patients undergoingabdominal surgery develop abnormal liver chemistrytests post-operatively (1,2). Various factors may beresponsible for the development of post-operativejaundice including intra-operative blood loss withconsecutive blood transfusions, post-operative haema-toma, parenteral nutrition, anaesthetic agents andmedications (e.g. antibiotics, analgetics), sepsis andoxidative stress (3–6).Particularly, intermittent occlusion of blood hepaticinflow to control bleeding during liver surgery (Pringlemanoeuvre) results in an ischaemic reperfusion (IR)injury and hyperbilirubinaemia and elevations of liverenzymes are common (7,8). Severe post-operativejaundice, however, is rare in patients without preexist

Background The outcome of liver resections depends on complete removal of all detectable foci. Our aim was to determine the value of preoperative routine magnetic resonance imaging (MRI) for complete detection of hepatic lesions. Methods We compared 271 lesions seen on MRI in 182 patients to intraoperative findings (including intraoperative ultrasonography) and histology. Results The overall rate of lesions was 7% each for segments 2 and 3, as compared to 14–17% each for segments 5, 6, 7, and 8. Twenty-three additional lesions were found intraoperatively, two thirds of them in the left lobe (mean size: 1.4 cm; mean total number of lesions in those patients: 2.2). In segments 2 and 3, the relative frequency for intraoperative diagnosis of additional lesions was 17% and 20%, respectively. On the other hand, most of the 15 MRI lesions not verified intra- or postoperatively had been described in the right hepatic lobe (maximum: segment 6). Conclusion MRI provided reliable preoperative lesion detection. Special attention should be paid to segments 2 and 3, which showed a lower total number of lesions but an elevated relative frequency of intraoperatively detected additional foci.

Background: Pyogenic liver abscess (PLA) remains a serious disease with a mortality of 6–14%. Methods: Clinical data of 76 patients with PLA were analyzed. Treatment options comprised antibiotics, percutaneous puncture/drainage, endoscopic papillotomy/stenting and/or surgery as indicated. Results: Fifty-eight patients (76%) had single and 18 patients multiple PLA (right lobe: 65%; both lobes: 22%). The most frequent etiologies were: biliary (38%), hematogenous and posttraumatic (11%). Factors associated with the need for surgery included gallbladder empyema, biliary fistulas, malignancy, perforation, multicentricity, vascular complications and foreign bodies (e.g. infected ventriculo-peritoneal shunt, toothpick). Conclusions: Microbiological testing provides important information for treatment monitoring and modification. Complementary assessment of risk factors for a complicated course is crucial for timely identification of patients requiring additional treatment.

Liver cysts occur with a prevalence of 4%–7% in the general population. Laparoscopic surgery is effective for solitary cysts and in selected patients with polycystic liver disease (PLD). We present our experience in the laparoscopic management of dysontogenetic cysts. Between 1994 and 2002, 36 patients were referred to our centre for the management of dysontogenetic cystic liver disease. Management was laparoscopic in 16 cases. Indications were solitary giant cysts (n=9) and PLD (n=7). Laparoscopic procedures were completed in 15 patients. Mean operating time was 90 min. There were no deaths. In one case there was an intraoperative complication: bleeding from a superficial hepatic vein necessitated conversion to an open procedure. There were two postoperative complications: one patient with biliary leakage, which was managed conservatively, and one patient with a pneumothorax caused by the cava catheter installed for anaesthesia. Median follow-up was 36 months. There was no symptomatic recurrence. Laparoscopy can be recommended as the procedure of choice for symptomatic solitary giant cysts and PLD Gigot type I.

Because bronchogenic cysts may be found in or near any organ derived from the embryonic foregut, they sometimes pose considerable diagnostic difficulties. We describe the plain chest X-ray, computed tomographic, and angiographic findings in a patient with elevated CA 19-9 and upper quadrant abdominal pain due to a cystic tumor appearing as a hepatic mass. Surgery and histology showed a bronchogenic cyst located in the lower lobe of the right lung.

The purpose of our study was to evaluate the clinical impact of reperfusion injury after normothermic ischemia during major liver resections and the effect of an intraoperative antioxidant infusion. This prospective randomized study comprised 50 patients; half of them (treatment group) were given an antioxidant infusion containing tocopherol and ascorbate immediately prior to reperfusion onset. Venous blood samples for the determination of MDA-TBARS (malondialdehyde-thiobarbituric acid reactive substances) by a HPLC-based test as a marker of lipid peroxidation were taken prior to ischemia, 30 min after reperfusion onset and at the end of the operation. In the control group there was a significant increase of MDA-TBARS (p = 0.001) at 30 min after reperfusion onset. At the end of the operation the values had returned to the initial level. The treatment group showed only a marginal increase (p-value for the difference between the two groups: 0.007). After exclusion of the patients with histologically proven advanced cirrhosis the increase in the control group (p0.001) and the difference between the increase in the two groups (p = 0.001) became more significant. Prothrombin time was also significantly better in the treatment group (p = 0.003). Postoperative complications such as prolonged liver failure, bleeding disorders and infections were seen more often in the control group. In our study MDA-TBARS was increased after liver ischemia, but in patients with advanced cirrhosis the effect was smaller or even absent. This increase and possible clinical consequences of reperfusion injury could be reduced by intraoperative administration of an antioxidant infusion.

PURPOSE Perianal endometriosis is an infrequent form of extragenital endometriosis and is usually situated in episiotomy scars. METHODS: We report a rare case involving the external anal sphincter in a 24 year-old female. The precise anatomical location of the endometriotic lesion was confirmed using preoperative and intraoperative anal endosonography. CONCLUSION: We believe this procedure to be essential when history, digital examination, and proctoscopy are not conclusive in the differential diagnosis of perianal pain or mass. Although hormonal suppression often is the therapy of choice in extrapelvic endometriosis, we think surgical excision, respecting the anatomical fiber architecture of the anal sphincter, is the best treatment for perianal endometriosis. Surgical excision is required for histological diagnosis, which is imperative in view of the albeit rare development of malignancy in extragenital endometriosis.

We report the case of a 76-year-old woman with biliary cystadenocarcinoma perforating the left biliary tree and exhibiting intra-tumoral gas bubbles resulting from invasion of the duodenum. The clinical history included subfebrile temperatures of 3 months duration, and pains associated with an abdominal mass in the right upper quadrant. Blood tests showed leucocytosis, and radiological studies revealed the features of a partially calcified septated tumor with nodular components combined with multiple gas-fluid levels, mimicking an infected hydatid cyst. Intraoperative ultrasonography, cholangiography and frozen section histology were necessary to prove the malignant nature of this cystic tumor. Provided that complete resection with strict adherence to oncological precepts is possible, the prognosis of cystadenocarcinoma is better than in hepatocellular or cholangiocellular carcinoma.

Biliary cystadenocarcinoma is a rare, usually intrahepatic neoplasm. A case is described in which an intrahepatic cystadenocarcinoma invaded the duodenum. This resulted in intratumoral gas.

Bei einer 45jahrigen Patientin wurde wegen einer Metastase nach einem Kolonkarzinom an der Leber eine Segmentresektion in Einflusokklusion durchgefuhrt. Kurz nach dem Pringle-Manover trat eine massive spontane Blutung aus dem linken Oberbauch auf. Als Ursache zeigte sich eine spontane Ruptur der Milz.