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Open access

Guenter Weiss, Hans Lippert and Frank Meyer

Successful Management of Non-Occlusive Mesenteric Ischemia (Nomi) - Case Report

Patients with non-occlusive mesenteric ischemia (NOMI) are still confronted with high mortality. The diagnostic is challenging and difficult because of the unspecific symptomatology. The aim of this systematic scientific report on an extraordinary and uncommon single clinical case and its successful course was to demonstrate the great potential of a partially novel non-surgical approach including its periinterventional management.

A 73-year old female is precisely described, who developed an acute abdomen during the postoperative course after cardiosurgical intervention. Only explorative laparotomy clarified the correct diagnosis - NOMI. Despite general intensive care, patient developed multi-organ failure after this second intervention. Using consequently an image-guided minimally invasive radiological approach comprising the introduction of a catheter into the superior mesenteric artery (Seldinger's technique) and the continuous application of vasodilating medication such as alprostadil (prostaglandin) through this catheter enabled us to improve mesenteric perfusion effectively and to overcome multiorgan failure.

In conclusion, specific risk factors may help to focus on the suspicion of NOMI. Diagnostic of choice is the arterial mesentericography, which allows specifically to exclude vascular occlusion including the consequence of a prompt surgical approach. Simultaneously, using the setting of the mesenteric angiography catheter can be placed for initiation of regional vasodilating treatment in case of NOMI. Only this approach may avoid fatal outcome.

Open access

Frank Eder, Frank Meyer, Christof Huth, Zuhir Halloul and Hans Lippert

Penetrating Abdomino-Thoracic Injuries: Report of Four Impressive, Spectacular and Representative Cases as Well as Their Challenging Surgical Management

Gunshot wounds are rare events in European countries, but stab and impalement injuries occur more frequently and are often spectacular.

The aim of the study was to describe several types of penetrating abdomino-thoracic injuries as well as the appropriate surgical interventions, including complex wound management.

Material and methods. The representative case series includes four patients with abdomino-thoracic penetrating trauma (two impalements and two stabbings), who were treated in a surgical university hospital (tertiary) centre during a 12-month period.

Results. 1. A man was impaled on a steel pipe, which entered the body above the right kidney and behind the liver through the mediastinum via the right thorax, passing the heart and aortic arch up to the left clavicle. The rod was removed via sternotomy and median laparotomy. Only the left subclavian vein required repair. Postoperatively, a residual lesion of the left brachial plexus caused temporary pneumonia. 2. A leg of a collapsing chair drilled into a woman's left foramen obturatorium and exited the body at the right anterior iliac spine. At a regional hospital, the chair leg was removed and the canal caused by gluteal penetration was excised. Exploratory laparotomy revealed peritonitis resulting from a perforated ileum. The injury was repaired with segmental resection and anastomosis. Postoperative right inguinal wound necrosis necessitated excision and vacuum-assisted closure sealing. The patient has residual paresthesia in her left leg resulting from a sacral plexus lesion. 3. During an altercation, a man was stabbed twice in the right thorax. The right pulmonary lobe, the diaphragm, and the liver dome between segment VIII and V were injured. The patient also had a large scalp avulsion at the left and right parietooccipital site and transection of the biceps muscle at the middle third of the right humerus. The chest injuries, approached via right subcostal incision and right anterior thoracotomy were managed with liver packing (two towels, removed after 2 days), suture of the diaphragm, and pleural drainage. 4. A man was stabbed in the left thorax, resulting in pneumothorax and lesions of the diaphragm and left third of the transversal colon, and the neck, resulting in lesions of the pharynx and internal jugular vein. These injuries were approached with left thoracic drainage and suture of the colon and diaphragm lesions. Subsequent right thoracotomy was required to treat right pleural empyema caused by bronchopneumonia as a consequence of blunt thoracic trauma. In addition, the patient required relaparotomy to drain an abscess within the Douglas space and Billroth II gastric resection to control recurrent Forrest-Ia bleeding.

Conclusions. Penetrating abdomino-thoracic injuries demand immediate life-saving measures, transfer to a trauma centre, appropriate resuscitative care, prompt diagnosis, and surgical intervention by an interdisciplinary team of abdominal, vascular, and cardiac surgeons. If these measures are provided, outcomes are maximized, mortality is minimized, and permanent damage can be avoided.

Open access

Jőrg Arend, Doerthe Kuester, Albert Roessner, Hans Lippert and Frank Meyer

Both gastrointestinal stromal tumors (GIST) and liposarcoma originate from mesenchymal tissue. Their coincidence requires a specific expertise in the diagnostic and therapeutic management.

An unusual exemplary case is described representing a 47-year old female patient with a gastric GIST and a monstrous retroperitoneal liposarcoma with infiltration of the left kidney. The gastric tumor lesion was removed with a tangential resection of the gastric wall; the retroperitoneal tumor lesion was resected including the left kidney. Both tumors were resected with no macroscopic tumor residual. The technically difficult surgical intervention did not show any postoperative complication, and the postoperative course was also uneventful. The complete tumor resection is the treatment of choice in mesenchymal tumors (aim: R0). Depending on histologic tumor classification, resection status and tumor sensitivity, a subsequent radiation and/or chemotherapy is necessary, which allowed to achieve a postoperative tumor-free survival of 6 years including a good quality of life.

Open access

Benjamin Garlipp, Jens Schwalenberg, Daniela Adolf, Hans Lippert and Frank Meyer

Epidemiology, Surgical Management and Early Postoperative Outcome in a Cohort of Gastric Cancer Patients of a Tertiary Referral Center in Relation to Multi-Center Quality Assurance Studies

The aim of the study was to analyze epidemiologic parameters, treatment-related data and prognostic factors in the management of gastric cancer patients of a university surgical center under conditions of routine clinical care before the onset of the era of multimodal therapies. By analyzing our data in relation with multi-center quality assurance trials [German Gastric Cancer Study - GGCS (1992) and East German Gastric Cancer Study - EGGCS (2004)] we aimed at providing an instrument of internal quality control at our institution as well as a base for comparison with future analyses taking into account the implementation of evolving (multimodal) therapies and their influence on treatment results.

Material and methods. Retrospective analysis of prospectively gathered data of gastric cancer patients treated at a single institution during a defined 10-year time period with multivariate analysis of risk factors for early postoperative outcome.

Results. From 04/01/1993 through 03/31/2003, a total of 328 gastric cancer patients were treated. In comparison with the EGGCS cohort there was a larger proportion of patients with locally advanced and proximally located tumors. 272 patients (82.9%) underwent surgery with curative intent; in 88.4% of these an R0 resection was achieved (EGGCS/GGCS: 82.5%/71.5%). 68.2% of patients underwent preoperative endoluminal ultrasound (EUS) (EGGCS: 27.4%); the proportion of patients undergoing EUS increased over the study period. Diagnostic accuracy of EUS for T stage was 50.6% (EGGCS: 42.6%). 77.2% of operated patients with curative intent underwent gastrectomy (EGGCS/GGCS: 79.8%/71.1%). Anastomotic leaks at the esophagojejunostomy occurred slightly more frequently (8.8%) than in the EGGCS (5.9%) and GGCS (7.2%); however, postoperative morbidity (36.1%) and early postoperative mortality (5.3%) were not increased compared to the multi-center quality assurance study results (EGGCS morbidity, 45%); EGGCS/GGCS mortality, 8%/8.9%). D2 lymphadenectomy was performed in 72.6% of cases (EGGCS: 70.9%). Multivariate analysis revealed splenectomy as an independent risk factor for postoperative morbidity and ASA status 3 or 4 as an independent risk factor for early postoperative mortality. The rate of splenectomies performed during gastric cancer surgery decreased substantially during the study period.

Conclusions. Preoperative diagnostics were able to accurately predict resectability in almost 90% of patients which is substantially more than the corresponding results of both the EGGCS and the GGCS. In the future, more wide-spread use of EUS will play an increasing role as stage-dependent differentiation of therapeutic concepts gains acceptance. However, diagnostic accuracy of EUS needs to be improved. Our early postoperative outcome data demonstrate that the quality standard of gastric cancer care established by the EGGCS is being fulfilled at our institution in spite of distinct characteristics placing our patients at higher surgical risk. Besides being a valuable instrument of internal quality control, our study provides a good base for comparison with ongoing analyses on future developments in gastric cancer therapy.

Open access

Andrej Udelnow, Manfred Schönfelder, Peter Würl, Zuhir Halloul, Frank Meyer, Hans Lippert and Paweł Mroczkowski

The aim of the study.

The overall survival (OS) of patients suffering From various tumour entities was correlated with the results of in vitro-chemosensitivity assay (CSA) of the in vivo applied drugs.

Material and methods. Tumour specimen (n=611) were dissected in 514 patients and incubated for primary tumour cell culture. The histocytological regression assay was performed 5 days after adding chemotherapeutic substances to the cell cultures. n=329 patients undergoing chemotherapy were included in the in vitro/in vivo associations. OS was assessed and in vitro response groups compared using survival analysis. Furthermore Cox-regression analysis was performed on OS including CSA, age, TNM classification and treatment course.

Results. The growth rate of the primary was 73-96% depending on tumour entity. The in-vitro response rate varied with histology and drugs (e.g. 8-18% for methotrexate and 33-83% for epirubicine). OS was significantly prolonged for patients treated with in vitro effective drugs compared to empiric therapy (log-rank-test, p=0.0435). Cox-regression revealed that application of in vitro effective drugs, residual tumour and postoperative radiotherapy determined the death risk independently.

Conclusions. When patients were treated with drugs effective in our CSA, OS was significantly prolonged compared to empiric therapy. CSA guided chemotherapy should be compared to empiric treatment by a prospective randomized trial.

Open access

Olof Jannasch, Christian Voigt, Kirsten Reschke, Hans Lippert and Paweł Mroczkowski

Abstract

The aim of the study was to compare preoperative findings, serum levels of calcium and parathormone (PTH) and outcome of patients undergoing surgery for primary hyperparathyroidism (pHPT) aged over 70 years with younger patients.

Material and methods. Between January 1, 1996 and September 30, 2011 186 patients underwent surgery for pHPT. Patient data were collected from chart reviews and an electronically stored database. Groups were defined as patients aged 70 years or older and patients younger than 70 years. Outcome comparison included operation time, tumor size, pre- and postoperative serum levels of calcium and PTH and length of stay in hospital. Complications were defined as clinical and laboratory signs of hypocalcemia, persistent elevated serum calcium, temporary or persistent recurrent laryngeal nerve paralysis, bleeding with need for reoperation, surgical site infection or need of tracheotomy.

Results. Parathyroidectomy alone was performed in 39.2% of patients. In 60.8% partial or total thyroidectomy was conducted simultaneously. More older patients had history of stroke and/or suffered from diabetes. Preoperative serum calcium and PTH did not differ between groups, but older patients displayed higher postoperative serum calcium (p=0.01). No significant differences between the two groups were observed regarding duration of surgery, surgical success rates, postoperative complications and hospitalization time.

Conclusions. Even though older patients had more risk factors, our data suggest that there was no difference in surgical management and outcome. Decision for surgical management of pHPT should be done regardless of age.

Open access

Ingo Gastinger, Frank Meyer, Thomas Lembcke, Uwe Schmidt, Henry Ptok and Hans Lippert

Impact of Fast-Track Concept Elements in the Classical Pancreatic Head Resection (Kausch-Whipple Procedure)

The aim of the study was to determine statistically significant factors with an impact on the early postoperative surgical outcome.

Material and methods. The influence of applied fast-track components on surgical results and early postoperative outcome in 143 consecutive Kausch-Whipple procedure patients was evaluated in a single-center retrospective analysis of a prospective collection of patient-associated pre-, peri- and postoperative data from 1997-2006.

Results. The in-hospital mortality rate was 2.8% (n=4). Fast-track measures were shown to have no effect on the morbidity rate in the multi-variate analysis. Over the study period, a decrease of intraoperative infusion volume from 14.2 mL/kg body weight/h in the first year to 10.7 mL/kg body weight/h in the last year was accompanied by an increase in patients requiring intraoperative catecholamines, up from 17% to 95%. The administration of ropivacain/sufentanil via thoracic peri-dural catheter injection initiated in 2000 and now considered the leading analgesic method, was used in 95% of the cases in 2006. Early extubation rate rose from 16.6% to 57.9%.

Conclusions. Fast-track aspects in the perioperative management have become more important in several surgical procedure even in those with a greater invasiveness such as Kausch-Whipple. However, such techniques used in peri-operative management of Kausch-Whipple pancreatic-head resections had no impact on the morbidity rate. In addition, the low in-hospital mortality rate was particularly attributed to surgical competence.

Open access

Henning Dralle, Andreas Machens, Carsten Sekulla, Kerstin Lorenz, Ingo Gastinger, Pawel Mroczkowski and Hans Lippert

Prospective Multicentric Evaluation Studies for Analysis of Surgical Risk Factors in Thyroid Surgery

Open access

Guenter Weiss, Cora Wex, Hans Lippert, Jens Schreiber and Frank Meyer

Abstract

Fistula development after esophageal resection is considered as one of the most serious postoperative complications.

The authors reported a case on clinical experiences in the postoperative diagnostic and successful therapeutic management of a tracheomediastinal fistula after esophageal resection, using endoscopic application of fibrin glue.

The early approach of an anastomotic insufficiency after esophageal resection because of a squamous cell carcinoma (pT3pN0M0G2) below the tracheal bifurcation including transposition of a re-modelled gastric tube and end-to-side anastomosis 24 hours postoperatively in a 55-year old patient combined i) surgical re-intervention from the periesophageal site (reanastomosis, gastroplication, lavage, local and mediastinal drainage) and, later on, ii) extensive rinsing with consecutive endoscopic fibrin glue application into the tracheal mouth of the subsequently developed tracheomediastinal fistula as a consequence of the inflammatory changes within the surrounding tissue.

In conclusion, this approach was successful and beneficial for the patient's further postoperative course, which was associated with other complications such as pneumonia and acute myocardial infarction. The fistula closed sufficiently and permanently with no further surgical intervention at the tracheal as well as mediastinal site and allowed patient's later discharge with no further complaints or problems.

Open access

Olof Jannasch, Philip Büschel, Christin Wodner, Max Seidensticker, Roger Kuhn, Hans Lippert and Paweł Mroczkowski

Abstract

Retroperitoneal bronchogenic cysts (BC) are rare clinical entities and may mimic an adrenal mass. Laparoscopic and retroperitoneoscopic approach is widely-used in adrenal surgery. However minimally- invasive resection of a periadrenally located BC has been reported rarely.

Material and methods. A systematic review of PubMed has been performed using the following search strategy: bronchogenic cyst AND (adrenal OR retroperitoneal OR subdiaphragmatic). 18 BC being removed via minimally invasive approach have been found. Including our own case 7 were removed retroperitoneoscopically and 12 laparoscopically.

Results. An index case of a 50 year old male is presented. CT revealed 2 masses above the left adrenal area. A control demonstrated an increase in size. Retroperitoneoscopic resection was performed. Pathologic finding showed a multilocular cystic lesion with a diameter of 4cm. The cysts were lined by pseudostratified ciliated epithelium. The wall contained hyaline cartilage, seromucous glands and smooth muscle.

Conclusions. Because exact preoperative diagnosis of hormonally inactive adrenal masses is not possible surgical resection is recommended in case of tumor growth, symptoms and to obtain definitive histological diagnosis. Minimal invasive approach seems to be a safe way for resection of BC in experienced hands. There is no clear evidence if laparoscopic or retroperitoneoscopic approach is favourable