Laparoscopic cholecystectomy: first, do no harm; second, take care of bile duct stones

A bile duct injury (BDI) rate of 0.2 % was reported in the era when open cholecystectomy (OC) was the standard [5]. Currently, LC BDI rates ranging from 0.2 to 0.5 % are more the norm in large population-based studies [6–9]. Although the laparoscopic BDI rate may be lessening with the passage of time, BDI is still more likely with LC than with OC, and remains a real danger in the learning curve of every surgeon [10].
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Woran wir sterben

Unter dem Titel "Global Burden of Disease" wurden erstmals 1992 alle Menschen erfasst, die innerhalb des Jahres gestorben waren. Außerdem beschrieb die Studie die wichtigsten Risikofaktoren für die Gesundheit. Im Dezember 2012 wurde nun, zwanzig Jahre später, eine Folgestudie veröffentlicht, basierend auf den knapp 53 Millionen Todesfällen des Jahres 2010. Das Fazit: Die Bevölkerung ist in der Zwischenzeit deutlich gesünder geworden. Infektionskrankheiten wurden zurückgedrängt, dafür sterben mehr Menschen an Altersgebrechen und Zivilisationsleiden. Mehr

Porzellangallenblase

A 45-year-old woman was hospitalized with a seven-day history of fever and pain in the right upper abdomen. Ultrasonography (Panel A) showed gallstones (large arrows), including one in the cystic duct, leading to an enlargement of the gallbladder (diameter about 5 cm) and calcification of the wall (small arrows). Computed tomography (Panel B) confirmed the presence of calcification of the gallbladder wall, or porcelain gallbladder (small arrow), and gallstones (large arrow). The patient declined cholecystectomy, which is the usual treatment, and was treated with antibiotics. Two weeks later, the fever and pain had resolved. A large, solitary calcification in the right upper abdomen may indicate disease of the gallbladder, adrenal glands, kidneys, lungs, or chest wall. With respect to the diagnosis of porcelain gallbladder, ultrasonography is as sensitive as abdominal radiography and computed tomography. Patients with a calcified gallbladder have an increased risk of gallbladder cancer.

Leberhämangiom

A 46-year-old woman had a one-year history of abdominal distention. Physical examination showed an upper-abdominal mass extending from the right hypochondrium to 10 cm below the umbilicus. Laboratory studies disclosed thrombocytopenia (platelet count, 127,000 per cubic millimeter), prolongation of the prothrombin time (to 14.6 seconds), and a decrease in the fibrinogen level (to 80 mg per deciliter). The peripheral-blood smear showed anisocytosis. A computed tomographic scan showed a large, low-density mass in the right lobe of the liver (arrowhead), with prominent compression of the inferior vena cava (arrow). The patient underwent a right hepatic lobectomy. The mass was a cavernous hemangioma measuring 35 by 30 by 8 cm and weighing 4900 g. Three years after surgery, the patient was doing well and had not had a recurrence. Cavernous hemangioma is the most common benign hepatic tumor. It typically occurs in women. Lesions measuring more than 4 cm in diameter are known as "giant hemangiomas" and often cause symptoms such as vague abdominal distention and pain. The constellation of giant hemangioma, thrombocytopenia, and localized consumption coagulopathy is known as the Kasabach-Merritt syndrome.

Caput medusae

A 47-year-old man with a seven-year history of compensated hepatic cirrhosis due to chronic hepatitis B infection presented for routine evaluation. Physical examination revealed a firm liver and mild splenomegaly. There were mildly tortuous veins on his abdominal wall, especially above the umbilicus. For four years, his condition remained stable, but venous dilatations gradually became more prominent around the umbilicus. These venous dilatations represent portal hypertension with backflow from the left portal vein, through the paraumbilical veins in the falciform ligament, and then to the periumbilical systemic veins in the abdominal wall. Color Doppler ultrasonography confirmed subcutaneous collateral veins on the anterior abdominal wall near the umbilicus that had originated from the dilated paraumbilical veins.

Development of single-port cholecystectomy: results of a case-control study matched to one surgeon

Background: Single-port laparoscopic cholecystectomy is an evolving technique which is now widely established. Up until now, the safety of the procedure and a respective learning curve have not been adequately reported in most studies. The aim of this study was to demonstrate that single-port cholecystectomy is a safe procedure, with a positive learning curve from a case-control study matched to one surgeon.
Methods: One hundred single-port cholecystectomies performed by one surgeon (AB) were retrospectively matched to 100 patients who underwent conventional laparoscopic cholecystectomy carried out by the same surgeon. The two groups were matched in respect of surgical indication, gender, age, and body mass index. The groups were compared with respect to operation time, use of additional trocars, analgesics required in the post anesthesia care unit, postoperative complications, and duration of hospital stay.
Results: No significant difference was found between the two groups with respect to postoperative complications and stay in hospital. The operation time increased slightly in the single-port group. Directly after the operation, the analgesic use required in the post anesthesia care unit was higher in the single-port group. Consumption of analgesics on the surgical ward was very similar in each group. In respect to the learning curve, the operation time and use of additional trocars showed a positive trend, starting with the thirtieth operation.
Conclusion: Single-port cholecystectomy is a feasible and safe procedure in a specialist setting. The procedure can be done under the same safety rules as those for conventional laparoscopic cholecystectomy. Considering the learning curve, starting with the thirtieth operation, a positive trend was seen. Long-term studies will be needed to establish the incidence and rate of incisional hernias.
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Challenge of Primary Tumor Management in Patients With Stage IV Colorectal Cancer

Optimal first-line therapy of patients who present with primary intact, unresectable stage IV colorectal cancer is controversial. Despite limited data, there are strong biases for either up-front primary tumor resection or for first-line systemic chemotherapy. The argument for up-front primary tumor resection is based on the desire to avoid potential complications of the intact primary tumor (IPT) such as bleeding, obstruction, or tumor perforation. Indeed the concern regarding the risk of primary tumor–related complications during systemic therapy, particularly with bevacizumab, has led both surgical and medical oncologists to advocate primary tumor resection at the time of diagnosis.^{1,2  Mehr}

Gallenstein-Ileus

A 71-year-old woman with a history of metabolic syndrome, asymptomatic gallstones, and metastatic breast cancer (treated with capecitabine), was referred to our hospital for nausea, vomiting, constipation, and abdominal pain. Mehr

Leberverletzungen - operative versus non-operative Versorgung

Successful Nonoperative Management of the Most Severe Blunt Liver Injuries

Gwendolyn M. van der Wilden et al

Arch Surg. 2012;147(5):423-428. doi:10.1001/archsurg.2012.147

Hypothesis  Grade 4 and grade 5 blunt liver injuries can be safely treated by nonoperative management (NOM).
Design  Retrospective case series.
Setting  Eleven level I and level II trauma centers in New England.
Patients  Three hundred ninety-three adult patients with grade 4 or grade 5 blunt liver injury who were admitted between January 1, 2000, and January 31, 2010.
Main Outcome Measure  Failure of NOM (f-NOM), defined as the need for a delayed operation.
Results  One hundred thirty-one patients (33.3%) were operated on immediately, typically because of hemodynamic instability. Among 262 patients (66.7%) who were offered a trial of NOM, treatment failed in 23 patients (8.8%) (attributed to the liver in 17, with recurrent liver bleeding in 7 patients and biliary peritonitis in 10 patients). Multivariate analysis identified the following 2 independent predictors of f-NOM: systolic blood pressure on admission of 100 mm Hg or less and the presence of other abdominal organ injury. Failure of NOM was observed in 23% of patients with both independent predictors and in 4% of those with neither of the 2 independent predictors. No patients in the f-NOM group experienced life-threatening events because of f-NOM, and mortality was similar between patients with successful NOM (5.4%) and patients with f-NOM (8.7%) (P = .52). Among patients with successful NOM, liver-specific complications developed in 10.0% and were managed definitively without major sequelae.
Conclusions  Nonoperative management was offered safely in two-thirds of grade 4 and grade 5 blunt liver injuries, with a 91.3% success rate. Only 6.5% of patients with NOM required a delayed operation because of liver-specific issues, and none experienced life-threatening complications because of the delay.

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Handreichungen zur Selbstheilung

...Hatte man lange geglaubt, dass man nur etwas "wollen" muss, um eine Verhaltensänderung zu erzielen, so hat uns die moderne Hirnforschung eines Besseren belehrt. Zu mehr als neunzig Prozent sind es Gefühle und unbewusste Prozesse, die unseren Körper steuern...
Rober Jütte
FAZ 24. Januar 2012, Nr 20 Seite 30

Einladung zur 9. Tagung der Rhein-Main-AG Minimal Invasive Chirurgie

Einladung zur 9. Tagung der Rhein-Main-AG Minimal Invasive Chirurgie

Oesophagusvaricen-Blutung

A 52-year-old man with cirrhosis associated with alcohol abuse presented to the emergency department with hematemesis and lightheadedness, which had developed 3 hours earlier, after binge drinking. He had no history of decompensated liver disease and took no medications. During the physical examination, he was alert and oriented, with a pulse rate of 140 beats per minute and a blood pressure of 90/60 mm Hg. Spider angiomata and ascites were present. Results of laboratory tests showed a hematocrit of 21%. The alanine aminotransferase level was 47 U per liter, the aspartate aminotransferase level was 102 U per liter, the albumin level was 2.6 g per deciliter, the total bilirubin level was 2.3 mg per deciliter (39 µmol per liter), the direct bilirubin level was 1.4 mg per deciliter (24 µmol per liter), and the prothrombin time was 15.4 seconds. The patient was hospitalized, and he underwent volume resuscitation and was given omeprazole and octreotide.

Emergency upper endoscopy showed active bleeding from esophageal varices (video), which was controlled with band ligation. Hemorrhage from esophageal varices is a severe complication of cirrhosis with portal hypertension. After band ligation, the patient's condition stabilized, with no further bleeding.

Torrazza-Perez and Carreno NEJM 362 (5): e13, Figure 1 February 4, 2010

Lobby Watch: The drinks industry

The Portman Group
Claire Harkins, doctoral candidate
1 Department of Geography and Sociology, University of Strathclyde, Glasgow G1 1XN
c.harkins@strath.ac.uk
When it comes to alcohol awareness, is the government under the influence of the drinks industry?
The stated aim of the Portman Group is to promote social responsibility in the alcohol industry, with a particular focus on responsible marketing. Established in 1989, it claims to "show leadership on best practice in the area of alcohol responsibility" and to "foster a balanced understanding of alcohol-related issues."1 2
Its former chief executive, Jean Coussins, rejected any suggestion that the group "represent[s] the industry" or acts as a "trade association or lobby group."3 However, the evidence of its involvement in research and policy consultations indicates that it is not independent of the industry and that it lobbies on behalf of the industry.
In its statements the group emphasises individual responsibility, blaming a minority of heavy drinkers for alcohol related problems. This ignores many aspects of alcohol related harm and is inconsistent with the evidence base that supports current public health thinking.4 5 The group recently flexed its muscles in the debate around the Scottish government’s plans to introduce a minimum price per unit of alcohol—a policy that is supported by public health professionals worldwide but that has been criticised by the group.4 6 7 The group also attacked8 recent work from Sheffield University that found that minimum pricing in England and Wales would reduce the number of deaths directly attributable to alcohol by 3400 and the number of unnecessary hospital admissions by 100 000 a year.5 The chief medical officer for England, Liam Donaldson, supported the Sheffield University findings and minimum pricing in his annual report on public health.9 The group claims that alcohol advertising has no effect on the level of sales and therefore is not a driver of consumption but only of brand choice.8 It subsequently criticised Sir Liam, the BMA, and Alcohol Concern for their evidence based calls for such a ban.10 11
The Portman Group was set up by the alcohol industry, reportedly at the suggestion of a Tory peer.12 Twenty years later the same companies (Bacardi, Beverage Brands UK, Carlsberg UK, Coors UK, Diageo GB, InBev, Pernod Ricard, and Scottish & Newcastle) continue to finance the group. Its directors are all alcohol industry executives.13
The group’s influence on the UK government was evident in the 2004 alcohol strategy for England and Wales.14 The final strategy ignored government commissioned testimony from a group of 17 independent experts who called for restrictions on alcohol pricing and availability. Instead the Portman Group was the only "alcohol misuse" group cited in the final report. Alex Stevens, at the European Institute of Social Services at the University of Kent, said that the strategy adopted the "language and ideas of the alcohol industry . . . This seems a clear example where external pressure on government by a powerful group has influenced the use of evidence in policy."15
In 1994 the group was shown to have paid academics £2000 (2200; $3200) each to write anonymous critiques of a report from the World Health Organization that opposed the alcohol industry’s position on effective alcohol control policies.16 17 Professor Tom Babor of the University of Connecticut, one of the most respected experts working in the field of addictions and public health, commented: "When one begins to see scientists with industry connections being encouraged to attack independent researchers, industry supported commentators attacking publicly supported policy makers and commercial interests trying to set the research agenda, this is not only a cause for concern, but a recipe for disaster."18
Existing alcohol policy and the government’s close relations with the alcohol industry came in for criticism in the parliamentary health select committee’s recent report on alcohol, which stated: "We are concerned that government policies are much closer to, and too influenced by, those of the drinks industry and the supermarkets than those of expert health professionals."19 The Portman Group’s chairman, Seymour Fortescue, accepted that alcohol related harm is growing but argued that consumption was falling and advocated persevering with the current strategy of educational campaigns and targeted measures towards binge drinkers and alcohol dependent consumers.20 This position contradicts a growing body of evidence that overall consumption is too high and that educational campaigns are of limited practical use.19 The select committee report is valuable to those fighting for coherent and effective alcohol policy, not least for its endorsement of a public health centred approach to alcohol control. However, the alcohol industry and trade organisations such as the Portman Group are well placed in UK policy circles to defend their position. The UK still has some way to go before the sentiments expressed in the select committee’s recent report are translated into a policy that provides effective alcohol control.
Cite this as: BMJ 2010;340:b5659
Lobby Watch is a regular column that looks at people and organisations who have an influence on public health and on how health care is delivered. It is put together with the help of the public interest research team at Strathclyde University and those who work on the Spin Profiles website (www.spinprofiles.org).

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Hydropneumothorax

A 47-year-old man with a history of cirrhosis associated with alcohol abuse presented with a 2-day history of shortness of breath. Before this symptom developed, he had been treated with repeated thoracentesis of the right side for cirrhosis-associated hydrothorax. On pulmonary examination, breath sounds were absent on the right side, and a succussion splash was audible in the right upper chest when the patient was gently shaken. Chest radiography showed hydropneumothorax with a collapsed right lung and an adjacent thoracic air–liquid level, which was probably the result of repeated thoracentesis. The patient was treated with chest-tube placement and diuretics. An analysis of the pleural effusion revealed transudative fluid without evidence of infection or cancer. The chest drain was removed 1 week later, after reexpansion of the lung.

NEJM Volume 362:e9 January 21, 2010 Number 3

10. Deutscher Lebertag - Testen Sie Ihre Leber!

Leberkrankheiten können jeden treffen. Sie sind in der Allgemeinbevölkerung weit verbreitet und kein Phänomen, das nur Randgruppen betrifft. Tückisch ist, dass die Leber keine Schmerzsignale aussendet. Symptome von Lebererkrankungen sind oft unspezifisch: Hierzu gehören ständige Müdigkeit, Konzentrationsstörungen und Druckgefühl im rechten Oberbauch. Viele Leberkrankheiten werden deshalb erst spät erkannt.

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Siehe auch http://www.lebertag.org/

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Traumatische Zwerchfellruptur mit intrathorakaler Hernierung der Leber

A 24-year-old man who had been wearing a seatbelt while driving a car involved in a high-speed motor vehicle crash was taken by ambulance to a local hospital, where his condition was stabilized and from which he was transferred by air to a regional trauma center. Upon arrival at the trauma center, he was immediately taken to the operating room for repair of a partial aortic transection. His other injuries included right rib fractures, right hemopneumothorax and pulmonary contusion, grade 4 liver laceration, grade 2 splenic laceration, and fracture of the right kidney. After resolution of the right hemopneumothorax, an elevated right hemidiaphragm was seen on a postoperative chest radiograph, a finding that suggested traumatic diaphragmatic rupture (Panel A, arrow). A computed tomographic scan confirmed the diaphragmatic rupture and showed that the dome of the liver had herniated into the right hemithorax (Panel B, arrow). The patient underwent laparotomy, at which time the liver was reduced into the abdomen and the diaphragm was repaired. The patient subsequently improved and was discharged home 50 days after the accident.

NEJM Volume 360:e7 January 29, 2009 Number 5

Spiderman...

A 55-year-old man with end-stage liver disease associated with alcohol abuse was evaluated for liver transplantation. He had a history of refractory ascites and hepatic encephalopathy. On physical examination, we noted muscle atrophy, jaundice, ascites, and numerous spider angiomas (Panel A). Eight months later, the patient underwent successful liver transplantation, when he had a score of 21 on the Model for End-Stage Liver Disease (MELD) scale (ranging from 6 to 40, with higher scores indicating greater severity of disease). Six months after transplantation, he was clinically well without evidence of organ dysfunction or infection, and most of the spider angiomas had disappeared (Panel B).
Spider angiomas can be seen in healthy children and pregnant women. In such cases, angiomas are few in number and resolve with time or a normalization of estrogen levels. Numerous spider angiomas are more common in patients with chronic liver disease and consist of a central arteriole from which numerous small venules radiate, resembling a spider's legs. Possible mechanisms of formation include arteriolar vasodilatation, neovascularization from angiogenic factors such as vascular endothelial growth factor, direct effects of alcohol, and estrogen excess due to inadequate hepatic metabolism.

NEJM Volume 360:280 January 15, 2009 Number 3