Liver regeneration: a spotlight on the novel role of platelets and serotonin

The development of novel approaches in liver surgery in the last decade has saved the lives of a large number of patients via resection of liver tumours previously thought to be non-resectable. Concurrently, living donor liver transplantation has emerged as one of the ways of lowering mortality on the waiting lists. These breakthroughs demanded a rigorous understanding of the mechanisms of liver regeneration after partial hepatectomy. Based on our previous studies on blood platelets and cold ischaemic injury, platelets and serotonin have attracted attention due to their theoretical potential contribution to liver regeneration. Both platelets and serotonin have been proven to be crucially involved in liver regeneration after partial hepatectomy. This review article provides an overview on the process of liver regeneration, with emphasis on its molecular basis and the coordinate contribution of several cells to restoring the organ's original volume and function. The role of platelets and serotonin is highlighted as novel contributors in this process

Parastomal hernia incarceration due to migrated intragastric balloon

The temporary placement of intragastric balloons is a common method to achieve rapid weight loss before planned metabolic surgery. We report the case of a 48-year-old morbidly obese patient. Ten years ago the patient underwent emergency sigmoidectomy with creation of a double-barreled ileostomy for perforated diverticulitis. Over time he developed a giant parastomal hernia. For preoperative weight reduction before planned restoration of intestinal continuity, an intragastric balloon was inserted 3years ago. The patient was admitted to our emergency department with peritonism and a septic shock. After computed tomography showing small bowel ileus, laparotomy was performed, revealing marked ischemia of incarcerated small and large intestine. Only postoperatively was the intragastric balloon found in the resected small bowel, causing a mechanical ileus with consecutive incarceration of the bowel. We review the literature on complications due to the migration of intragastric balloons. This clinical case gives a fair warning of the possible deleterious outcome of intragastric balloons, especially in hernia patient

Role of serotonin in the hepato-gastroIntestinal tract: an old molecule for new perspectives

Abstract.: Beside its role as a neurotransmitter in the central nervous system, serotonin appears to be a central physiologic mediator of many gastrointestinal (GI) functions and a mediator of the brain-gut connection. By acting directly and via modulation of the enteric nervous system, serotonin has numerous effects on the GI tract. The main gut disturbances in which serotonin is involved are acute chemotherapy-induced nausea and vomiting, carcinoid syndrome and irritable bowel syndrome. Serotonin also has mitogenic properties. Platelet-derived serotonin is involved in liver regeneration after partial hepatectomy. In diseased liver, serotonin may play a crucial role in the progression of hepatic fibrosis and the pathogenesis of steatohepatitis. Better understanding of the role of the serotonin receptor subtypes and serotonin mechanisms of action in the liver and gut may open new therapeutic strategies in hepato-gastrointestinal disease

A challenging hernia: primary venous aneurysm of the proximal saphenous vein

Introduction: Primary venous aneurysm is a rare, but essential consideration in the differential diagnosis of an inguinal and femoral hernia. Methods: We report a case of a 43-year-old man who was referred for evaluation and treatment of a femoral hernia. Results: The patient presented with a 3-month history of an asymptomatic tumor on his right upper inner thigh. Physical examination noted a non-tender, non-indurated tumor. Conclusion: Surgical exploration demonstrated a primary venous aneurysm of the proximal saphenous vei

Was ist "evidence based" in der Adipositaschirurgie?

Zusammenfassung: Seit den 1990er Jahren gilt in den USA der Konsens, dass die bariatrische Chirurgie die beste Therapie zur Erzielung eines lang anhaltenden Gewichtsverlustes wie auch zur Behandlung der adipositasassoziierten Komorbiditäten ist. In der Folge kam es zu einem regelrechten Boom in der bariatrischen Chirurgie. Diese Entwicklung wurde zusätzlich beschleunigt durch das Aufkommen der laparoskopischen Techniken, welche die Morbidität des Eingriffes deutlich verkleinerten. Eine einheitliche Vorgehensweise und Verfahrenswahl existiert bis zum heutigen Zeitpunkt nicht. Vergleichende Studien zwischen verschiedenen Verfahren sind rar und die wissenschaftliche Evidenz zur Therapie der Fettleibigkeit ist mager. Allgemein wird anerkannt, dass die Abklärung im Vorfeld einer Operation interdisziplinär im Team erfolgt und dass die behandelnden Ärzte eine lebenslange Nachsorge der Patienten sicherstellen müssen. Der bariatrisch-chirurgische Eingriff sollte heute primär laparoskopisch durchgeführt werden, da dadurch die Folgen des offenen Zuganges wie Wundinfekt- und Narbenhernienraten massiv gesenkt werden. Die verschiedenen Verfahren beinhalten restriktive, malabsorptive und kombinierte Wirkmechanismen. Rein restriktive Verfahren wie das Magenbanding sind den kombinierten und malabsorptiven Verfahren in Bezug auf den erzielbaren Gewichtsverlust unterlegen. Ebenfalls werden Komorbiditäten wie der Diabetes mellitus und die arterielle Hypertonie durch letztere Methoden wirkungsvoller behandelt. Diese Erkenntnisse sollten daher die Grundlage zur Verfahrenswahl bei der chirurgischen Behandlung der morbiden Adipositas bilde

Laparoscopy for small bowel obstruction: the reason for conversion matters

Background: Although laparoscopy is associated with reduced hospital stay, early recovery, and decreased morbidity compared with open surgery, it is not well established for the treatment of small bowel obstruction (SBO). Methods: This study analyzed a prospective nationwide database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery. Results: From 1995 to 2006, 537 patients underwent laparoscopy for SBO. Matted adhesions were the main cause of obstruction (62.6%). Intraoperative complications occurred for 9.5% of the patients. Postoperative morbidity was 14% and mortality 0.6%. Within 30days, 13 patients (2.4%) were readmitted because of early recurrence or complications. The conversion rate was 32.4%. The conversions resulted from inability to visualize the site of obstruction or matted adhesions (53.4%), intraoperative complications (21.3%), and small target incisions for resection (25.3%). Emergency operations were associated with higher conversion rates (43.6% vs 19.8%; p<0.001) but not with significantly more postoperative complications (15.2% vs 11.9%; p=0.17). Intraoperative complications and conversion were associated with significantly increased postoperative morbidity (39.2% vs 11.3%; p<0.001 and 24.7% vs 8.3%; p<0.001, respectively). Reactive conversion due to intraoperative complications was associated with the highest postoperative complication rate (48.6%). Morbidity for preemptive conversion due to impaired visualization/matted adhesions or a small-target incision was significantly lower (20% and 26.1%; p=0.02 and p<0.001, respectively). American Society of Anesthesiology (ASA) scores higher than 2 also were associated with postoperative morbidity (p<0.001). However, multivariate regression analysis showed that reactive conversion was the only independent risk factor for postoperative morbidity (p<0.001; odds ratio, 3.97; 95% confidence interval, 1.83-8.64). Conclusions: Laparoscopic management of SBO is feasible with acceptable morbidity and low mortality but with a considerable conversion rate. Early conversion is recommended to reduce postoperative morbidit

High secondary failure rate of rebanding after failed gastric banding

Background: Over the last decade, more than 130,000 laparoscopic adjustable gastric bandings (LAGB) have been performed for the treatment of morbid obesity. Nowadays, longer follow-up data are available in the literature and increasing numbers of late complications and treatment failures of gastric banding have been reported. The aim of the present study was the long-term evaluation of two different rescue operations after failed LAGB: conversion to laparoscopic Roux-en-Y bypass (LRYGB) versus laparoscopic gastric rebanding. Methods: Between January 1997 and November 2002, 74 consecutive patients underwent either laparoscopic gastric rebanding (n = 44) or LRYGB (n = 30) after failed LAGB. There were 14 men and 60 women, with a median age of 42 (23-60) years. The indication for reoperation was an increasing body mass index (BMI) and band-related complications such as pouch dilatation, band slippage, and penetration after LAGB. Rebandings were done by preference during the initial period of the study and LRYGB was the treatment of choice during the latter period. The success of the rescue operation was assessed by postoperative changes in the BMI, improvements of co-morbidities, and the need for further reoperations (secondary failure). The median follow-up was 36 months (range, 24-60 months). Results: Patients who underwent LRYGB had a significantly better weight loss than patients with a rebanding operation (mean −6.1 versus +1.5 BMI points). In addition, the LRYGB patients showed a significantly better control of serum cholesterol during the long term follow-up (−0.6 versus +0.1 mmol/l). Almost half of the patients (45%) in the rebanding group needed a further operative revision, whereas only 20% underwent reoperation after rescue LRYGB. Thus, the secondary failure rate in the rebanding group was significantly higher compared to the bypass group (p = 0.028). Conclusions: The present long-term study confirms our previous finding that LRYGB is a better treatment than rebanding after failed laparoscopic gastric banding regarding weight loss and treatment of co-morbidities. During the long-term follow-up the reoperation rate due to secondary failure became significantly higher in the rebanding group. We therefore recommend that LRYGB should be preferred as rescue procedure after failed laparoscopic adjustable gastric bandin

Clinical value of a combined multi-phase contrast enhanced DOPA-PET/CT in neuroendocrine tumours with emphasis on the diagnostic CT component

Objective: To assess the clinical value of multi-phase, contrast-enhanced DOPA-PET/CT with emphasis on the diagnostic CT component in patients with neuroendocrine tumours (NET). Methods: Sixty-five patients with NET underwent DOPA-cePET/CT. The DOPA-PET, multi-phase CT and combined DOPA cePET/CT data were evaluated and diagnostic accuracies compared. The value of ceCT in DOPA cePET/CT concerning lesion detection and therapeutic impact was evaluated. Sensitivities, specificities and accuracies were calculated. Histopathology and clinical follow-up served as the standard of reference. Differences were tested for statistical significance by McNemar's test. Results: In 40 patients metastatic and/or primary tumour lesions were detected. Lesion-based analysis for the DOPA-PET showed sensitivity, specificity and accuracy of 66%, 100% and 67%, for the ceCT data 85%, 71% and 85%, and for the combined DOPA cePET/CT data 97%, 71% and 96%. DOPA cePET/CT was significantly more accurate compared with dual-phase CT (p < 0.05) and PET alone (p < 0.05). Additional lesion detection was based on ceCT in 12 patients; three patients underwent significant therapeutic changes based on the ceCT findings. Conclusion: DOPA cePET/CT was significantly more accurate than DOPA-PET alone and ceCT alone. The CT component itself had a diagnostic impact in a small percentage but contributed to the therapeutic strategies in selected patient

F-18-Fluorodeoxyglucose (FDG) Positron-Emission Tomography of Echinococcus multilocularis Liver Lesions: Prospective Evaluation of its Value for Diagnosis and Follow-up during Benzimidazole Therapy

Background:: Long-term benzimidazole therapy benefits patients with non-resectable alveolar echinococcosis (AE). Methods to assess early therapeutic efficacy are lacking. Recently, AE liver lesions were reported to exhibit increased F-18-fluorodeoxyglucose (FDG) uptake in positron emission tomography (PET). To assess the value of FDG-PET for diagnosis and follow-up of AE patients. Patients/Methods:: Twenty-six consecutive patients with newly diagnosed AE were enrolled. Baseline evaluation included CT and FDG-PET. Thirteen patients (11 women; median age 50 years, range 40-76) were resected, the remaining 13 (8 women; median age 60 years, range 39-72) had non-resectable disease, were started on benzimidazoles, and CT and FDG-PET were repeated at 6, 12 and 24 months of therapy. Twelve consecutive patients with newly diagnosed cystic echinococcosis (CE) of the liver were also subjected to baseline FDG-PET. Results:: In 21/26 AE patients, baseline PET scans showed multifocally increased FDG uptake in the hepatic lesions' periphery, while liver lesions were FDG negative in 11/12 CE patients. Thus, sensitivity and specificity of FDG-PET for AE vs. CE were 81% and 92%, respectively. In 5 of 10 non-resectable patients with increased baseline FDG uptake, the intensity of uptake decreased (or disappeared) during benzimidazole therapy, in 3 by ≥2 grades within the initial 6 months. Conclusions:: FDG-PET is a sensitive and specific adjunct in the diagnosis of suspected AE and can help in differentiating AE from CE. The rapid improvement of positive PET scans with benzimidazole therapy in some patients indicates that absent FDG uptake does not necessarily reflect parasite viabilit