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Open access

Uwe Will, Frank Fueldner, Anne-Kathrin Mueller and Frank Meyer

A Prospective Study on Endoscopic Ultrasonography Criteria to Guide Management in Upper GI Submucosal Tumors

Endoscopic ultrasonography (EUS) can differentiate between impression and submucosal tumor (SMT) but it is not known whether EUS criteria can reliably guide management.

The aim of this prospective study was to assess an approach to recommend removal versus follow-up investigation based on clinical and EUS criteria, with respect to the predictive values to recognize malignancy versus benign lesions.

Material and methods. Over a 7-years time period, all patients referred for the EUS assessment of submucosal upper GI lesions were prospectively enrolled. Extraluminal impressions diagnosed with EUS were not further considered. If submucosal tumors seen with EUS were clearly symptomatic or one of several parameters (tumor size >3 cm, irregular margins, inhomogeneous echotexture and/or enlarged lymph nodes) were found, resection was recommended. The remaining cases were subjected to EUS follow-up.

Results. Of cases with 241 submucosal lesions, 65 had impressions and 176 had true submucosal lesions. Of the latter, 29 cases had non-neoplastic lesions (cysts, varices). In 59 cases, removal was deemed necessary due to clinical symptoms and suspicious findings in conventional endoscopy. These subjects underwent either surgical (originating layer, muscularis propria) or endoscopic resection (submucosal origin): 35.6% were malignant, more frequently in the surgical group (41.6% vs 20%). However, in 52.5% (n=31) of the 59 cases with no severe symptoms and true SMT, EUS suggested removal because of their additional criteria. Eighteen patients (12.2%) refused SMT removal and even regular EUS-based follow-up investigation. Clinical follow-up investigation by the family practitioner did not show frank malignancy in these cases (retransferal not registered). Follow-up investigation with EUS was recommended in 70 cases (mean follow-up period, 5 years; range, 1-7 years). The pattern remained unchanged in 67/70, and 2 of the 3 cases with changes underwent surgery for benign leiomyoma (patient refusal, n=1 with no change in the one-year follow-up MRI).

Conclusions. An EUS strategy based on defined characteristics to remove SMT with no severe symptoms and suspicious finding in the conventional endoscopy shows a good adherence to the recommended approach and has a reasonable positive predictive value for malignancy (88%). Clinical symptoms alone or with endoscopic finding are frequently too vague to decide for a reasonable SMT resection. The chosen EUS criteria are valuable to: 1) achieve the primary resection of all potentially malignant SMT and 2) avoid to overlook them as shown by the results of the follow-up investigations with no detected malignant lesion.

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

Guenter Weiss and Frank Meyer


An exemplary rare case of neurogenic pulmonary edema induced by intracranial hemorrhage was reported including diagnostic and therapeutic implications as well as management recommendations. A 35-year old man who was treated first by a neurosurgical approach because of a subarachnoid hemorrhage (bore hole trepanation) and subsequently on a surgical intensive care unit because of severe postoperative hemodynamic, cardiocirculatory, and pulmonary disruptions. To monitor cardiopulmonary condition and treatment effects, a Swan-Ganz catheter was placed in the pulmonary artery, since after trepanation, a critical cardiopulmonary status developed during postoperative mechanical ventilation and catecholamine administration. This condition was indicated by neurogenic pulmonary edema detected by control chest X-ray film and high oxygen load in the inspiratory air required for sufficient arterial oxygenation. After use of high positive end-exspiratory pressure (PEEP) (initially directed against neurogenic lesion), adaptation of initial dobutamine doses, initiation of norepinephrine administration, and substitution of fluids, the patient's blood pressure finally rose sufficiently to sustain regular cerebral blood perfusion and achieve better arterial oxygenation. Thus, the patient‘s cardiopulmonary condition stabilized and temporary cardiac insufficiency could be overcome. Subsequently, it became possible to decrease PEEP according to requirements to prevent or limit cerebral edema and to diminish catecholamine doses.

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

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


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

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

Hagen Boenigk, Frank Meyer, Andreas Koch and Ingo Gastinger

The aim of the study

Acute appendicitis, one of the most frequent emergencies in general surgery, has been repeatingly investigated with regard to specific aspects such as medical history, clinical symptoms, the perioperative management and follow up.

was to investigate relevant and combined determinants for the perioperative management of acute appendicitis a systematic clinical prospective unicenter observational study was conducted. A representative patient cohort was studied (n=9,991; middle Europe) to reflect daily surgical practice through a time period of 27 years divided into 3 separate periods and the frequency of specific categories (e.g., characteristics of the medical history, clinical and intraoperative findings as well as complications), their correlation and relative risk factors for the disease as well as prognosis.

Results. 1. The wound abscess rate was 10.9%. Perforation, surgical intervention in time, acute, gangrenous and chronic appendicitis, age, accompanying diseases such as obesity, arterial hypertension, diabetes mellitus, sex, and missing pathological finding intraoperatively had a significant impact on the postoperative development of a wound abscess. 2. The longer the specific appendicitis-associated medical history was, the more frequent a perforated appendicitis occurred, greater the appendectomy (AE) rate in a non-inflamed appendix and higher the rate of required second interventions. 3. The average hospital stay was 11 days. 4. There was a significantly decreased percentage of patients with no pathological finding intraoperatively at the appendix vermiformis (p<0.001), who underwent AE, in particular, through the last investigation period from 1997 to 2000 onto only 6.8% (1974-1985, 15.5%; 1986-1996, 10.3%). 5. The mortality was 0.6%, with no significant difference comparing male and female patients (p=1), the three investigation periods (p=0.077), or the patients with AE in non-inflamed appendix (0.4%) and AE in acute appendicitis (0.6%; p=0.515). The study showed a positive, partially significant quality improvement within the presenting clinic with regard to a decreased rate of AE in non-inflamed appendix, wound abscess rate and, in particular, to mortality. Despite this, there is a trendy increase of the perforation rate in the investigated cohort.

Conclusion. Quality control remains indispensable for the assessment of the disease´s surgical treatment. A further significant improval of this control might be achieved by multicenter studies and multifactorial evaluations.

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

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.