European Surgery

Revisiting Barrett’s Esophagus

First description of an acquired internal hernia: a case report Summary Background An internal hernia is defined as a protrusion from intestines or other abdominal organs through a congenital or acquired aperture within the peritoneal cavity. Internal hernia are rare, with an incidence of less than 1%. Mostly, they are located paraduodenal (Treitz hernia) and show mortality rates up to 50%. Case presentation We describe the case of a 26-year-old man presenting with acute bowel obstruction and a history of surgical treatment for a congenital diaphragmatic hernia. Methods Clinical examination and computed tomography (CT) scan were interpreted as intestinal obstruction. Exploratory laparotomy resulting in an appendectomy, small intestine resection, and lysis of adhesions was performed. Results In situ, an atypical appendix fused to the spleen was detected, forming an aperture within the peritoneal cavity with protrusion and strangulation of the small intestine. The small intestine specimen sent to pathology confirmed necrotic small intestine mucosa. Conclusion We present the first description of a young man with an internal hernia due to an intraperitoneal aperture formed by his appendix fused to the spleen. Internal hernia are difficult to diagnose but should be included in the differential diagnosis in cases of intestinal obstruction. CT should be performed in cases of suspicion. Surgical intervention shouldn’t be delayed in order to reduce the high morbidity and mortality rates.

Laparoscopic Heller myotomy after Roux-en-Y gastric bypass Summary Background Achalasia is a rare motility disorder of the esophagus and laparoscopic Heller myotomy (LHM) is the standard of care for symptom relief. The onset of achalasia in obese patients after Roux-en-Y gastric bypass (RYGB) is rare, the diagnosis is difficult, and the treatment is challenging. Methods We reviewed the hospital charts of a patient presenting with achalasia after RYGB. A review of the pertinent literature was performed. Results A 51-year-old female was admitted to our department for a 10-month history of progressive dysphagia, regurgitation, and weight loss. She previously underwent laparoscopic RYGB for morbid obesity. The upper gastrointestinal endoscopy showed a dilated esophagus with increased resistance at the gastroesophageal junction. The barium swallow study revealed the classical “mouse-tail” appearance of the esophagogastric junction with delayed esophageal emptying. High-resolution manometry (HRM) was suggestive of a type II achalasia with esophageal body pan-pressurization. The patient underwent LHM. The overall operative time was 95 min and intraoperative blood loss was negligible. The postoperative course was uneventful and the patient was discharged on postoperative day 2. At 24-month follow-up, the patient has complete remission of symptoms. Conclusion Development of achalasia in obese patients after RYGB is rare. The presence of pathognomonic symptoms should always raise clinical suspicion, while HRM is essential to confirm the diagnosis. To date, there is no robust evidence for the more appropriate treatment of esophageal achalasia after RYGB. In these patients, LHM seems feasible, safe, and effective in symptom relief.

Surgery for Hilar cholangiocarcinoma: the Newcastle upon Tyne Liver Unit experience Summary Background Hilar cholangiocarcinoma (HCCA) arises from the confluence of the common hepatic duct and has a poor prognosis. If resectable, an extended left (eLH) or right hemihepatectomy (eRH) is usually required to provide oncological clearance. We reviewed outcomes for patients with HCCA managed at our centre. Methods Electronic records of patients referred to our centre for HCCA were retrospectively reviewed. The Kaplan–Meier method was used to estimate overall survival (OS) with the log rank test used for significance (p < 0.05). A Cox regression was performed to ascertain factors that may influence survival. Results 156 HCCA patients were identified (44 resected versus 112 non-resected). Resected patients had longer OS compared to non-resected patients (50.3 versus 9.8 months, p < 0.001). Patients who underwent an eLH (n = 15) had significantly longer OS at 3 years compared to eRH patients (67.7 vs. 42.1%, respectively; p = 0.007). An eLH was an independent predictor of survival (HR 0.43, p = 0.04). Lymph node positivity (n = 23, hazard ratio 1.72, p = 0.027) and the presence of microvascular invasion (n = 28, hazard ratio 1.78, p = 0.047) were independent predictors of mortality. The frequency of lymph node positivity and microvascular invasion did not differ between eLH and eRH patients (p > 0.05). Conclusion Patients undergoing an eLH for HCCA have significantly better long-term outcomes compared to those undergoing eRH, independent of other pathological variables. The functional liver remnant (FLR) is usually smaller following eRH, resulting in a higher risk of post-operative liver failure. Combining CT volumetry with PVE may result in better prediction and optimisation of the FLR in the context of eRH for HCCA. Novel findings An extended left hemihepatectomy is an independent predictor of survival; investigation into the precise interaction between left- and right-sided resections and pre- and post-embolization liver volume is warranted.

No surgeon is an island, no echo stands alone

Enhanced recovery after colorectal surgery: the clinical and economic benefit in elderly patients Summary Background We performed this study to investigate the feasibility and clinical and financial benefit of an enhanced recovery after surgery (ERAS) protocol in elderly patients undergoing colorectal resections. Methods Patients over the age of 65 undergoing open colorectal resections at the department of surgery of the Motol University Hospital in Prague between January 2015 and August 2017 were included in the study. Patients who received ERAS perioperative care formed the ERAS group and patients who received standard perioperative care formed the control group. Adherence to the ERAS protocol, hospitalisation length, readmission rate, 30-day postoperative morbidity and mortality, and treatment costs were analysed. Results Seventy-four patients were included in the ERAS group and sixty-one in the control group. Patient and surgical characteristics were similar in the two groups. An adherence of 83.8% to the ERAS protocol was achieved. Recovery parameters were improved and hospital stay length was shortened, while readmission rate, morbidity and mortality. Although not statistically significant, treatment costs were reduced by an average of €1187 per patient. Conclusion We showed that our enhanced recovery after colorectal surgery protocol in elderly patients is feasible, effective, safe and reduces treatment costs.

Management of blunt hepatic and splenic trauma in Austria: a national questionnaire study Summary Background Treatment of hepatic and splenic injuries has significantly evolved over the past 30 years: Non-operative management (NOM) has increasingly become standard of care for the majority of patients in specialised centres. However, patient selection and details of practical management such as time to reinitiating oral intake, duration of restricted activity, or necessity of repeated imaging are still a matter of debate. This national multicentre questionnaire study aims to give a cross-sectional overview of current management of blunt liver and splenic trauma in Austrian hospitals. Methods The survey was addressed to all Austrian surgical departments and trauma units. After three months, responses were electronically and anonymously recorded, data were analysed using descriptive statistics. Data collection involved electronic-based questionnaires comprising questions on centre structure, selection criteria for NOM and practical aspects of consecutive treatment. Results In total, a 60% response rate could be achieved, and 24% of all contacted centres filled out the full questionnaire completely. A widespread shift to NOM within recent years could be observed. More than 70% of injuries were treated conservatively. Forty percent of hospitals currently follow a clinical algorithm. Further details about specific questionnaire results are presented, revealing diverse approaches in a number of treatment aspects. Conclusion Non-operative management is the standard of care for blunt hepatic and splenic injuries in Austria. In many clinically relevant questions there is still a lack of consensus. Based on this experience, national standard protocols may be generated for systematisation of care in blunt liver and spleen trauma.

Exploring the limits of hepatic surgery for alveolar echinococcosis—10-years’ experience in an endemic area of Austria Summary Background Hepatic alveolar echinococcosis is a slow-growing, destructive parasitosis for which radical surgical resection is currently the only curative treatment. In case of complications by infiltrated vascular or biliary structures, interventional techniques are used. Pharmacotherapy is recommended postoperatively and for inoperability. The rare zoonotic occurs in the northern hemisphere and still poses a challenge in diagnostic and therapeutic management. Based in an endemic area in Austria, we evaluated a decade of surgical treatment for alveolar echinococcosis (AE) at our department. Methods Clinical data of patients undergoing hepatic resection for AE at our department between 2005 and 2014 were collected. Every diagnosis was again verified by histology and PCR. The PNM staging of preoperative imaging was done in six-eye principle. This study was approved by the local Ethics Committee of the Medical University Innsbruck (registration number 20170307-1537). Results Nine of 12 patients had an R0 resection. In one case, cure was achieved by a combination of surgery and radiofrequency ablation, one patient had R2 resection due to unexpected AE spread and another patient underwent salvage operation with lethal outcome. Three patients experienced early postoperative complications. Late postoperative complications included incisional hernia and cholestatic hepatopathy. 9 patients have been disease free for a mean period of 6 years. Conclusion The relevance and perioperative risks of an extensive AE resection and avoidance of R2 resections are reflected in the present study. Determination of PNM stage and evaluation of in-all resectability build the foundation for successful surgical treatment even in an advanced AE stage.

CT and operative images for evaluation of right colectomy with extended D3 mesenterectomy anterior and posterior to the mesenteric vessels Summary Background Surgical techniques like complete mesocolic excision (CME) and D3 mesenterectomy, D3 refering to the N3 lymph node groups central in the mesentery removed at surgery, were introduced without proper evaluation of the lymphadenectomy. The aim of this study was to measure the vascular stumps and evaluate the extent and quality of lymphadenectomy after right colectomy with extended D3 mesenterectomy anterior/posterior to the mesenteric vessels. We also compared the investigation methods. Methods Residual vascular stumps were measured using three-dimensional (3D) reconstructed anatomy from follow-up computed tomography (CT) datasets and images taken during surgery. The quality of central lymphadenectomy was evaluated on the images. Results In total, 31 patients (15 females), median age 67 years (50–78), with stage I (n = 7), stage II (n = 13), and stage III (n = 11) disease, were operated. Tumor locations were: 14 (45%) in the cecum, ten (32%) in the ascending colon, three (10%) in the hepatic flexure, and four (13%) in the transverse colon. The middle colic artery (MCA) was divided at its origin (13 patients) or its right branch (18 patients). Median lengths (range) of residual vascular stumps measured on 3D reconstructed CT and photographic images taken during surgery were: right colic artery: 0.0 mm (0.0–1.8)/0.0 mm (0.0–1.1), ileocolic artery: 0.0 mm (0.0–7.2)/0.0 mm (0.0–3.0), ileocolic vein: 0.0 mm (0.0–7.5)/0.0 mm (0.0–0.0), MCA: 0.0 mm (0.0–18.1)/1.0 mm (0.0–8.0), and right branch of the MCA: 0.0 mm (0.0–1.8)/0.0 mm (0.0–2.0). There was no significant difference between average lengths measured with the two techniques. The extent of lymphadenectomy was deemed acceptable in all patients. No differences in stump lengths were found in patients with different vascular crossing patterns in the central mesentery and presumably different degree of difficulty at surgery. Conclusion The results demonstrate very short residual vascular stumps and together with operative photographs provide objective evidence for superior lymphadenectomy in right colectomy with extended D3 mesenterectomy.

Post-esophagectomy diaphragmatic hernia—a case series Summary Background Herniation of abdominal viscera through the esophageal hiatus is a rare complication following surgery for esophageal malignancies. This complication sometimes occurs suddenly and leads to a severe postoperative course. Methods We present three cases of post-esophagectomy diaphragmatic hernia operated for cancer of the lower esophagus. All patients underwent initial upper gastrointestinal (GI) endoscopy and biopsies for diagnosis. Staging was done by contrast computed tomography (CT) of the chest/abdomen/pelvis. Patients underwent neoadjuvant chemotherapy followed by surgery. Results No patients had previous hiatal hernias prior to surgery, and full crural sling dissections were carried out in all cases. The three cases vary in clinical presentation and show imaging findings of diaphragmatic hernias with variable visceral contents. Conclusion While differences in pressure between the abdominal and thoracic cavities are important, the size of the hiatal defect is something that can be influenced surgically. As with all oncological surgery, safe resection margins are essential without adversely affecting anatomical structure and function. The commonest cause is excessive widening of the esophageal hiatus during surgery and, therefore, narrowing the hiatus to fit the conduit can prevent this complication.