[How does the surgical society (DGAV) support the continuing medical training in general and visceral surgery?]

The medical councils (Ärztekammern) develop the contents of the further training regulations with the support of the specialist society. The hospitals with the training supervisors have to implement these contents for the trainees in continuing education and confirm the acquisition of competence for the individual tasks. Surveys of young surgeons in recent years have shown that many participants do not receive structured continuing education, so that there is general dissatisfaction. Therefore, the German Society for General and Visceral Surgery (DGAV) is required to provide assistance to its members to improve continuing education in the departments. For example, the DGAV organizes more than 100 surgical courses annually on all topics of visceral surgery, anatomy, skills courses and revision courses with the Further Education and Advanced Training Quality Center (WeiFoQ). This year a continuing education curriculum was developed over the 6‑year continuing education period, so that a structured continuing education is achievable. The contents of the continuing education regulations are included in this continuing education curriculum with explanations, video clips, and graphics, thus providing quick information on each individual surgical clinical picture. A digital surgical catalog provides a quick overview of the status of personal continuing education. It is planned to set up an interface to the eLogbook of the medical councils.

[Impact of the COVID pandemic on treatment of bariatric patients in Germany-An analysis of the national StuDoQ/MBE register]

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic the standard inpatient care of patients was restricted to increase overall and intensive care capacity reserves for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected persons.

OBJECTIVE

This article presents the impact of the COVID-19 pandemic on the surgical and postoperative care of bariatric patients in Germany.

MATERIAL AND METHODS

A statistical analysis of the national StuDoQ/MBE register data for the period from 1 May 2018 until 31 May 2022 was performed.

RESULTS

Throughout the entire study period there was a continuous increase in documented operations, which continued even during the COVID-19 pandemic. A significant intermittent decline in surgery performed was observed only during the imposition of first lockdown in the months of March to May 2020, with a minimum number of 194 cases performed monthly in April 2020. The pandemic had no measurable effect on the surgically treated patient population, the type of surgical procedure, the perioperative and postoperative outcomes and follow-up care.

CONCLUSION

Based on the results of the StuDoQ data and the current literature, it can be deduced that bariatric surgery can be carried out with no increased risk during the COVID-19 pandemic and the quality of postoperative care is not impaired.

[Advanced training of general and visceral surgeons in life-saving emergency surgery : Results of a survey among participants of a surgery course]

Hintergrund

Die geringe Anzahl operativ zu versorgender Körperhöhlenverletzungen erfordert ein Umdenken in der chirurgischen Aus- und Weiterbildung. Ein entsprechendes Kursformat wird seit 2014 über die DGAV angeboten. Um Berechtigung, Bedarf, Nutzen und Erfolg eines solchen Kursformates zu erheben, erfolgte eine Evaluation durch die bisherigen Kursteilnehmer.

Material und Methoden

Kursevaluation und zusätzliche Onlinebefragung der bisherigen Kursteilnehmer hinsichtlich Alter, Geschlecht, Ausbildungsstand, Fachrichtung, Versorgungsstufe des Krankenhauses, notfallchirurgischer Erfahrungen, der Häufigkeit chirurgischer Notfallversorgungen, Teilnahme an anderen Kursformaten, Erfahrungen nach der Kursteilnahme, Einschätzung der aktuellen Fort- und Weiterbildungssituation und Finanzierung solcher Kurse.

Ergebnisse

Insgesamt 142 Kursteilnehmer evaluierten ihre Kursteilnahme, zusätzlich beantworteten 83 den Onlinefragebogen. Über 90 % berichteten von einem nachhaltigen positiven Einfluss des Kurses auf ihr notfallchirurgisches Handeln. Mehr als die Hälfte konnte von konkreten Notfallsituationen berichten, die sie aufgrund der Kursteilnahme besser bewältigen konnten. In der Notfallversorgung erfahrene Chirurgen bewerteten den eigenen Lernerfolg durch die Kursteilnahme signifikant häufiger positiv als ihre weniger erfahrenen Kollegen. Keinen Einfluss auf den Lernerfolg hatten eine Ober- oder Chefarztposition, die Versorgungsstufe des Krankenhauses, das Alter oder Geschlecht der Teilnehmer. Die Mehrheit der antwortenden Chirurgen befürwortet die Integration eines solchen Kursformates in die chirurgische Weiterbildung und fordert hierzu eine finanzielle Unterstützung.

Schlussfolgerung

Kursformate, in denen notfallchirurgische Strategien und Fähigkeiten vermittelt werden, sind etabliert und werden sehr positiv evaluiert. Die Fort- und Weiterbildung in notfallchirurgischen Fähigkeiten und Kenntnissen liegt im gesellschaftlichen Interesse und zumindest anteilig auch in ihrer Verantwortung.

[Quality indicators for colon cancer surgery : Evidence-based development of a set of indicators for the outcome quality]

BACKGROUND

Quality assessment in surgery is gaining in importance. Although sporadic recommendations for quality indicators (QI) in oncological colon surgery can be found in the literature, these are usually not systematically derived from a solid evidence base. Moreover, reference ranges for QI are unknown.

OBJECTIVE

The aim of this initiative was the development of evidence-based QI for oncological colon resections by an expert panel invited by the German Society of General and Visceral Surgery (DGAV). Reference ranges from the literature and reference values from the Study, Documentation, and Quality Center (StuDoQ)|Colon Cancer Register were compared in order to deduce recommendations which are tailored to the German healthcare system.

RESULTS

Based on the most recent scientific evidence and agreed by expert consensus, five QI for oncological colon surgery were defined and evaluated according to the QUALIFY tool. Mortality, MTL30 (mortality, transfer to another acute care hospital, or length of stay ≥30 days), anastomotic leakage requiring reintervention, surgical site infections necessitating reopening of the wound and ≥12 lymph nodes in the specimen qualified as QI owing to their relevance, scientific nature, and practicability. Based on the results of the systematic literature search and the statistical analysis of the StuDoQ|Colon Cancer Register, preliminary reference values are proposed for each QI.

CONCLUSION

The presented set of QI seems appropriate for quality assessment of oncological colon surgery in the context of the German healthcare system. The validity of the QI and the reference values must be reviewed within the framework of their implementation. The StuDoQ|Colon Cancer Register provides a suitable infrastructure for collecting clinical data for quality assessment and risk adjustment.

MTL, a composite measure for objectively profiling hospitals on surgical performance in colorectal cancer surgery

PURPOSE

MTL is a composite outcome measure based on routine administrative data defined as (a) postoperative mortality and/or (b) postoperative transfer to another hospital and/or (c) length of hospital stay ≥ the prespecified time period. Aim of the present study was to investigate MTL for profiling hospitals on surgical performance in colorectal cancer surgery, using data from the national registers of the German Society of General and Visceral Surgery (DGAV) and to determine the time interval for length of stay with the highest accuracy regarding major complications (Clavien-Dindo grade ≥ 3).

METHODS

All patients undergoing colorectal cancer resection between January 2010 and February 2017 were included. MTL rates were calculated and compared to well-established single outcome measures using multivariate regression analysis. For each outcome measure, postoperative complications were tested regarding their predictability.

RESULTS

Data from 14,978 patients were analyzed. Length of stay was significantly prolonged if postoperative complications occurred (p < 0.0001). Thirty-day mortality and the indication for a transfer to another hospital mainly resulted from cardiopulmonary complications. MTL occurs significantly more often than any of the single-outcome parameters. The time interval of 22 days demonstrated the highest accuracy regarding severe complications (Clavien-Dindo grade ≥ 3).

CONCLUSIONS

MTL reflects the complete spectrum of postoperative complications. Compared to individual surgical outcome parameters, MTL may have a better discriminatory power and is therefore suitable to mirror surgical quality. Because of its high accuracy regarding surgical major morbidity, 22 days is the best cut-off for length of stay within the German healthcare system.

Variation in pancreatoduodenectomy as delivered in two national audits

Background

Nationwide audits facilitate quality and outcome assessment of pancreatoduodenectomy. Differences may exist between countries but studies comparing nationwide outcomes of pancreatoduodenectomy based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation.

Methods

Anonymized data from patients undergoing pancreatoduodenectomy between 2014 and 2016 were extracted from the German Society for General and Visceral Surgery StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit, and compared using descriptive statistics. Univariable and multivariable risk analyses were undertaken.

Results

Overall, 4495 patients were included, 2489 in Germany and 2006 in the Netherlands. Adenocarcinoma was a more frequent indication for pancreatoduodenectomy in the Netherlands. German patients had worse ASA fitness grades, but Dutch patients had more pulmonary co-morbidity. Dutch patients underwent more minimally invasive surgery and venous resections, but fewer multivisceral resections. No difference was found in rates of grade B/C postoperative pancreatic fistula, grade C postpancreatectomy haemorrhage and in-hospital mortality. There was more centralization in the Netherlands (1·3 versus 13·3 per cent of pancreatoduodenectomies in very low-volume centres; P &lt; 0·001). In multivariable analysis, both hospital stay (difference 2·49 (95 per cent c.i. 1·18 to 3·80) days) and risk of reoperation (odds ratio (OR) 1·55, 95 per cent c.i. 1·22 to 1·97) were higher in the German audit, whereas risk of postoperative pneumonia (OR 0·57, 0·37 to 0·88) and readmission (OR 0·38, 0·30 to 0·49) were lower. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality.

Conclusion

This comparison of the German and Dutch audits showed variation in case mix, surgical technique and centralization for pancreatoduodenectomy, but no difference in mortality and pancreas-specific complications.

Risk factors for reoperation after ileostomy reversal - Results from a prospective cohort study

BACKGROUND

Ileostomy reversal is frequently performed in abdominal surgery. Postoperative complications after ileostomy reversal are encountered in around 20% of patients. Data regarding risk factors for reoperation after ileostomy closure are scarce. The purpose of this prospective trial was to determine risk factors for operative revision after ileostomy closure.

MATERIALS AND METHODS

This is an additional post hoc analysis of a two center prospective trial. After enrollment, patient characteristics and intraoperative details were analyzed. Patients were followed up at one postoperative visit before discharge and at a three months postoperative visit by standardized questionnaire. All reoperations occurring in the three months period after surgery were analyzed, and immediate reoperations which were directly related to the ileostomy reversal were analyzed separately.

RESULTS

118 patients with elective ileostomy reversal were included in the trial. 12 out of 106 patients (11.3%) underwent any reoperation within three months after surgery (Clavien-Dindo grade IIIb). On multivariate analysis, anemia was associated with any reoperation p = 0.004; OR 6.93 (95% CI 1.37-30.07). Six out of 114 patients (5.3%) required an immediate reoperation (small bowel perforation, anastomotic leakage, postoperative ileus, deep wound infection) due to surgical complications directly related to the ileostomy reversal. Higher body mass index and anemia were associated with immediate reoperations (BMI: p = 0.038; OR 0.73 (95% CI 0.55-0.98); anemia: p = 0.001; OR 25.50 (95% CI 3.87-168.21).

CONCLUSION

Surgical complications after ileostomy reversal occurred to a substantial extent. Rate of reoperations was associated with anemia and high body mass index. Optimizing patients in terms of preoperative hemoglobin and BMI may reduce surgical complications after ileostomy closure.

Necessity of subcutaneous suction drains in ileostomy reversal (DRASTAR)-a randomized, controlled bi-centered trial

PURPOSE

Data regarding length of hospital stay of patients undergoing ileostomy reversal are very heterogeneous. There are many factors that may have an influence on the length of postoperative hospital stay, such as postoperative wound infections. One potential strategy to reduce their incidence and to decrease hospital stay is to insert subcutaneous suction drains. The purpose of this study was to examine the influence of the insertion of subcutaneous suction drains on hospital stay and postoperative wound infections in ileostomy reversal. Risk factors for postoperative wound infection were determined.

METHODS

This is a randomized controlled two-center non-inferiority trial with two parallel groups. The total length of hospital stay as primary endpoint and the occurrence of a surgical site infection, the colonization of the abdominal wall with bacteria, and the occurrence of hematomas/seromas as secondary endpoints were monitored.

RESULTS

One hundred eighteen patients with elective ileostomy reversal were included. Fifty-nine patients were randomly assigned to insertion of a subcutaneous suction drain, and 59 patients were randomly assigned to receive no drain. After 3 months of follow-up, 50 patients in the group with drain and 53 patients in the group without drain could be analyzed. Median total length of hospital stay was 8 days in the SD group and 9 days in the group without SD (p = 0.17). Fourteen percent of patients with SD and 17 % without SD developed SSI, p = 0.68. Multivariate analysis revealed anemia (p < 0.01), intraoperative bowel perforation (p = 0.02) and resident (p = 0.04) or fellow (p = 0.048) performing the operation as risk factors for SSI.

CONCLUSIONS

This trial shows that the omission of subcutaneous suction drains is not inferior to the use of subcutaneous suction drains after ileostomy reversal in terms of length of hospital stay, surgical site infections, and hematomas/seromas.

[Natural orifice transluminal endoscopic surgery in Germany: Data from the German NOTES registry]

BACKGROUND

The German NOTES registry (GNR) was initiated by the German Society for General and Visceral Surgery (DGAV) as a treatment and outcome database for natural orifice transluminal endoscopic surgery (NOTES).

AIM

The aim of this study was the descriptive analysis of all GNR data collected over a 5-year period since its start in 2008 with more than 3000 interventions.

MATERIAL AND METHODS

The GNR is an online database with voluntary participation available to all German-speaking clinics. Demographic data, therapy details, complications and data on the postoperative course of patients are recorded. All cases in the GNR between March 2008 and November 2013 were included in the analysis.

RESULTS

From a total of 3150 data sets 2992 (95 %) were valid and suited for the analysis. Hybrid transvaginal cholecystectomy was the most frequently used procedure (88.7 %), followed by hybrid transvaginal/transgastric appendectomy (6.1 %) and hybrid transvaginal/transrectal colon procedures (5.1 %). Intraoperative complications occurred in 1.6 %, postoperative complications in 3.7 % and conversions were reported in 1.5 %. Intraoperative bladder injuries and postoperative urinary tract infections were identified as method-specific complications of transvaginal procedures. Bowel injuries occurred as a rare (0.2 %) but potentially serious complication of transvaginal operations.

CONCLUSION

The German surgical community ensures a safe and responsible introduction of the new NOTES operation techniques with its active participation in the GNR. Despite an overall low complication rate, the high number of procedures in the GNR permitted the identification of method-specific complications. This knowledge can be used to further increase the safety of NOTES in practice.

[Are there too many conferences for general and visceral surgery in Germany? : A survey of DGAV members]

BACKGROUND

Human and financial resources are increasingly bound due to economic pressure and the working hours Act whereby the already restricted further training times are further limited. The industry also has less funding available for sponsorship of conferences and workshops. Against this background the question arises whether a reduction or focusing of the conferences is necessary; therefore, the aim of this survey was to obtain an opinion from members of the German Society of General and Visceral Surgery (DGAV) and possibly to derive a need for action to submit to the board members.

METHODS

From 7 February to 18 March 2015 an online survey was conducted by the DGAV with their members regarding the number of necessary congress events in Germany.

RESULTS

A total of 670 responses were received (return rate 16 %). In total, 56 % of participants felt that there are too many conferences. A differentiation according to the position of the respondent and the level of the associated hospital resulted in the following: 69.3 % of the participating head physicians (HP) shared this opinion, compared to 48.6 % of senior physicians (SP) and 34.4 % of residents (RP). Of the participants from basic and standard care hospitals (B/SC) 50 % shared this opinion, compared to 59.2 % from maximum care hospitals (MC) and 63.6 % from university hospitals (UH). In addition, a total of 75 % of the participants (HP 82.9 %, SP 78.4 %, RP 70.5 %) were in favor of keeping the congress of the DGAV (annual meeting of the German Society for Digestive and Metabolic Diseases in conjunction with the Autumn meeting of the DGAV) in its previous form, regardless of the underlying level of care of the associated hospital (B/SC 77 %, MC 79 %, UC 68 %).

CONCLUSION

More experienced surgeons in particular tended to favor a reduction of events with a focus on the major conferences; however, younger colleagues preferred a wider spectrum of meetings. In order to comply with both positions a wide range of events should be continued to be provided in the future so that surgeons can choose which to attend according to the individual preferences.

[Stump closure in laparoscopic appendectomy. Influence of endoloop or linear stapler on patient outcome]

BACKGROUND

Even though laparoscopic appendectomy is one of the most frequent procedures in abdominal surgery, the technique of appendiceal stump closure is still not standardized. The aim of this retrospective study was to analyze the effect of the use of endoloops or linear staplers for appendiceal stump closure concerning surgical site infections (SSI) and intra-abdominal abscesses (IAA).

PATIENTS AND METHODS

All laparoscopic appendectomies between January 1st 2007 and May 31st 2010 were split into an endoloop group (ELG) and a linear stapler group (LSG). The groups were compared with respect to the outcome parameters SSI and IAA.

RESULTS

A total of 430 appendectomies were performed in the study period of which 105 operations were conducted laparoscopically. In this study 47.6 % (n = 50) were alloted to the LSG and 52.4 % (n = 55) to ELG. In LSG 3.1 % (n = 1) developed an SSI versus 10.0 % (n = 4, p = 0.254) in ELG. No IAAs occurred in LSG compared to 2 (5.1 %, p = 0.499) in ELG.

CONCLUSION

The use of EL for appendiceal stump closure is safe and cost effective for low-grade appendicitis but high-grade appendicitis should be treated with LS.

[The competent surgeon. Bridging the gap between undergraduate final year and postgraduate surgery training]

Competency-based frameworks rely on relevant professional competency rather than formal regulations. The transitional phase between final year undergraduate and common trunk postgraduate medical training is characterized by an increase of professional responsibility whereby previously acquired knowledge, skills and abilities have to be merged and applied to patients. Undergraduate and postgraduate training programs should ensure a successive transfer of responsibility for medical practice to final year students and young residents depending on individual competence. The concept of entrustable professional activities (EPA) represents a curricular concept based on concrete medical tasks which may be assigned to the responsibility of the trainee.

Therapy of complicated Crohn's disease during pregnancy--an interdisciplinary challenge

BACKGROUND

Severe courses of Crohn's disease (CD) during pregnancy are rare. However, if occurring, the risk of miscarriage and low birth weight is increased. At present, only limited data is available on the treatment of CD during pregnancy. In particular, there are no standard guidelines for surgical therapy. Nevertheless, surgery is often unavoidable if complications during the course of the disease arise.

PURPOSE

This study provides a critical overview of conventional and interventional treatment options for CD complications during pregnancy and analyses the surgical experience gained thus far. For illustrative purposes, clinical cases of three young women with a severe clinical course during pregnancy are presented.

METHODS

After treatment-refractory for conservative and interventional measures, surgery remained as the only treatment option. In all cases, a split stoma was created after resection to avoid anastomotic leaks that would endanger the lives of mother and child. The postoperative course of all three patients was uneventful, and pregnancy remained intact until delivery. No further CD specific medication was required before birth.

CONCLUSIONS

The management of CD patients during pregnancy requires close interdisciplinary co-operation between gastroenterologists, obstetricians, anaesthetists and visceral surgeons. For the protection of mother and child treatment should thus be delivered in a specialised centre. This article demonstrates the advantages of surgical therapy by focusing on alleviating CD complaints and preventing postoperative complications.

[Safety of resection of symptomatic and asymptomatic Meckel's diverticulum and literature review]

BACKGROUND

Meckel's diverticulum (MD) is the most common diverticulum of the small bowel and an important finding in surgical practice. The aim of this study was to assess the safety of the resection of symptomatic and asymptomatic MD concerning postoperative complications. As MD are relatively rare, an overview of the literature is given.

PATIENTS AND METHODS

All patients with MD at the department at general surgery of the Charité - Campus Benjamin Franklin between 1996 and 2010 were assessed. An analysis for symptomatic and incidental MD was performed for incidence, indication, intraoperative findings, histology and postoperative outcome.

RESULTS

An MD was intraoperatively found in 71 of 29 682 patients (0.2 %). Of these, a symptomatic MD occurred in 26 patients (37 %). A symptomatic MD was causal in 6 of 7 patients with gastrointestinal bleeding (GIB, p = 0.005). All symptomatic MD and 30 (67 %) asymptomatic MD were resected. Ectopic gastric mucosa was found significantly more frequently in patients with symptomatic MD (p = 0.001). Patients with asymptomatic MD and resection had less complications as a trend (p = 0.057).

CONCLUSION

Ectopic mucosa is more frequent in symptomatic MD, especially in bleeding MD. MD should always be considered in GIB of unknown origin. Resection of incidental MD can be recommended in patients without contraindications such as peritonitis, cancer, ascites or immunosuppression.

Long-term follow-up after incisional hernia repair: are there only benefits for symptomatic patients?

INTRODUCTION

Incisional hernias are among the most frequent complications in visceral surgery and are currently considered to be an indication for surgery in all cases, regardless of the patient's symptoms. However, it still remains unclear to what extent surgery actually results in improvement according to objective (e.g., less pain or dysesthesia) or subjective criteria (e.g., less discomfort or better cosmetic result). The purpose of this prospective study was to identify patients who derive objective and subjective benefit from surgical repair.

MATERIALS AND METHODS

This prospective study included patients who underwent open incisional hernia repair with mesh implantation from December 2006 to April 2009. Data were collected before and 18 months after surgery. Pain intensity was rated on the numerical analog scale (NAS) pre- and postoperatively. Patients were divided into oligosymptomatic (NAS 0-3) and symptomatic (NAS 4-10) groups based on their preoperative pain level, and the postoperative outcome of the two groups was compared by standardized questionnaire.

RESULTS

Ninety patients were prospectively enrolled, 45 (50 %) of each gender. Prior to surgery, 43 patients (47.8 %) were oligosymptomatic, and 47 (52.2 %) reported clinically relevant pain. Eighteen months after surgery, 7.5 % of the oligosymptomatic patients complained of clinically relevant pain; its rate remained unchanged. The symptomatic group showed a significant reduction in clinically relevant pain from 100 % to 14.0 %, (p < 0.001). The percentage of patients with clinically relevant dysesthesia was 12.5 % in the oligosymptomatic and 20.9 % in the symptomatic group 18 months postoperatively. The overall recurrence rate was 13.3 % after 18 months without difference in both groups. A reduction in discomfort in the surgical area was reported by 77.5 % of the oligosymptomatic and 79.1 % of the symptomatic patients.

CONCLUSIONS

Symptomatic patients definitely profit from surgical repair in the long-term course. However, the notable postoperative rate of clinically relevant pain and dysesthesia in oligosymptomatic patients and their high recurrence rate cast doubt on whether they really benefit from surgical repair. The remarkable degree of subjective satisfaction in oligosymptomatic patients should not be underestimated.

Locally recurrent colorectal cancer: results of surgical therapy

PURPOSE

Up to 20 % of colorectal cancer patients develop recurrent disease despite standardized surgical techniques and multimodal treatment strategies. Radical resection is the central component of curative therapy in these cases. The aim of this study was to evaluate treatment results in patients with locoregionally recurrent colorectal cancer.

METHODS

From January 1995 to December 2007, surgery was performed for recurrent colorectal cancer in 82 patients who had undergone curative (R0) resection of their primary tumor. Assessment included patient, tumor and treatment characteristics, postoperative complications, and time without re-recurrence; recurrence-free and overall survival rates were calculated according to the Kaplan-Meier method.

RESULTS

Resection was performed in 60 of the 82 patients (73 %), repeat R0 resection in 52 % (31/60). Patients had a postoperative morbidity of 39 % (31/82), a relaparotomy rate of 13 % (11/82), and a lethality of 7 % (6/82). Forty-eight percent of all surgically-treated patients received a permanent stoma. Re-recurrence was seen in 52 % (16/31). R0 resection was associated with a 5-year survival rate of 35 % (11/31).

CONCLUSIONS

Extensive reinterventions often enable repeat R0 resection. Despite relevant morbidity, the lethality appears to be acceptable. Decisive for the prognosis is re-recurrence.

[Simulation training in surgical education - application of virtual reality laparoscopic simulators in a surgical skills course]

BACKGROUND

Training and simulation are gaining importance in surgical education. Today, virtual reality surgery simulators provide sophisticated laparoscopic training scenarios and offer detailed assessment methods. This also makes simulators interesting for the application in surgical skills courses. The aim of the current study was to assess the suitability of a virtual surgery simulator for training and assessment in an established surgical training course.

MATERIALS AND METHODS

The study was conducted during the annual "Practical Course for Visceral Surgery" (Warnemuende, Germany). 36 of 108 course participants were assigned at random for the study. Training was conducted in 15 sessions over 5 days with 4 identical virtual surgery simulators (LapSim) and 2 standardised training tasks. The simulator measured 16 individual parameters and calculated 2 scores. Questionnaires were used to assess the test persons' laparoscopic experience, their training situation and the acceptance of the simulator training. Data were analysed with non-parametric tests. A subgroup analysis for laparoscopic experience was conducted in order to assess the simulator's construct validity and assessment capabilities.

RESULTS

Median age was 32 (27 - 41) years; median professional experience was 3 (1 - 11) years. Typical laparoscopic learning curves with initial significant improvements and a subsequent plateau phase were measured over 5 days. The individual training sessions exhibited a rhythmic variability in the training results. A shorter night's sleep led to a marked drop in performance. The participants' different experience levels could clearly be discriminated ( ≤ 20 vs. > 20 laparoscopic operations; p ≤ 0.001). The questionnaire showed that the majority of the participants had limited training opportunities in their hospitals. The simulator training was very well accepted. However, the participants severely misjudged the real costs of the simulators that were used.

CONCLUSIONS

The learning curve on the simulator was successfully mastered during the course. Construct validity could be demonstrated within the course setting. The simulator's assessment system can be of value for the assessment of laparoscopic training performance within surgical skills courses. Acceptance of the simulator training is high. However, simulators are currently too expensive to be used within a large training course.

Abdominal resection rectopexy with an absorbable polyglactin mesh: prospective evaluation of morphological and functional changes with consecutive improvement of patient's symptoms

BACKGROUND

The pathophysiology of rectal prolapse and intussusception has not yet been clarified. This is reflected in the multiplicity of surgical procedures. The aim of this prospective study was to measure morphological and functional changes of the pelvic floor and the rectum before and after resection rectopexy.

METHODS

A total of 21 patients (mean age 60 years; 2 men, 19 women) with manifest rectal prolapse and rectoanal intussusception underwent sigmoidectomy and rectopexy with an absorbable polyglactin mesh graft. The following analyses were performed preoperatively and, on average, 15 months (range 6-21 month) postoperatively: radiologic defecography, rectal volumetry, sphincter manometry, and evaluation of clinical symptoms.

RESULTS

Postoperatively there was no patient with rectal prolapse, and only one with an intussusception. Rectal compliance increased from 6.4 to 10.2 ml/mmHg. Rectal volumetry showed a decrease of the thresholds for the sensation of "desire to defecate" and "maximal tolerated volume" (100-75 ml, 175-150 ml). Postoperatively, there was a higher level of the pelvic floor during contraction. The anorectal angle, vector volume, radial asymmetry, sphincter length, and resting and squeezing pressures were unchanged. Surgery improved rectal evacuation (p = 0.03), continence (p = 0.01), stool consistency (p = 0.03), and warning period (p = 0.01). Patients' personal assessment showed an improved overall satisfaction.

CONCLUSIONS

Resection rectopexy is a reliable method for treating rectal prolapse and rectoanal intussusception with clear improvement of the patient's clinical symptoms. The restored anorectal function can be attributed to improved rectal compliance, a lower sensory threshold, an elevation of the pelvic floor during squeezing, and an improved rectal evacuation.

Management and results of complications after anterior resection with colonic pouch reconstruction for rectal cancer

AIM

Colonic J-pouch reconstruction is widely carried out during low anterior resection. The aim of this observational study was to describe the complications and evaluate the results of adverse event management.

METHOD

A total of 128 patients underwent an elective anterior resection with colorectal or coloanal J-pouch reconstruction for primary rectal cancer between January 1997 and December 2008.

RESULTS

The overall mortality was 1.6%. Three (2.3%) patients developed pouch necrosis, one of whom died. The rate of anastomotic leakage was 11.7%. Other major complications included intra-abdominal abscess (3.1%), haemorrhage (0.8%) and abdominal dihiscence (0.8%). In all cases of anastomotic leakage, the pouch was salvaged, with 80% of patients undergoing surgical revision with relaparotomy and transanal suture. Patients with pouch necrosis underwent relaparotomy with removal of the pouch and a terminal colostomy. In all cases of intra-abdominal abscess without anastomotic leakage, radiologically controlled percutaneous drainage was carried out.

CONCLUSION

Anal function can usually be saved after anastomotic leakage by salvage surgery without increase in mortality.

Hepatic arterial infusion in the treatment of liver metastases with PEG liposomes in combination with degradable starch microspheres (DSM) increases tumor 5-FU concentration. an animal study in CC-531 liver tumor-bearing rats

The regional application of cytostatics in liver metastases leads to increased concentrations in the tumor tissue. The effect of flow retardation by temporary occlusion and drug targeting with liposome encapsulation (PEG liposomes) on tumor 5-fluorouracil (5-FU) concentrations was investigated.

MATERIALS AND METHODS

Tumor-bearing rats were submitted to i.v. or intraarterial (i.a.) therapy with liposome-encapsulated or non-encapsulated 5-FU. The i.a. groups were additionally treated with or without Spherex® degradable starch microspheres (DSM). The tumor 5-FU concentrations were determined by high-performance liquid chromatography (HPLC) as area under the curve (AUC).

RESULTS

A comparison with i.v. in administered 5-FU yielded the following increases tumor concentrations: 5-FU-PEG liposomes i.v. 27-fold, 5-FU i.a. 19-fold, 5-FU i.a. + DSM 1760-fold, 5-FU-PEG liposomes i.a. 110-fold, 5-FU-PEG liposomes i.a. + DSM 7665-fold.

CONCLUSION

Liver intratumoral 5-FU concentration increases to >7,500 times that following i.v. administration by a combination of regional administration via the hepatic artery with temporary embolization by DSM and drug targeting by liposome-encapsulated 5-FU.

Improvement of biodistribution with PEGylated liposomes containing docetaxel with degradable starch microspheres for hepatic arterial infusion in the treatment of liver metastases: a study in CC-531 liver tumor-bearing WAG RIJ rats

AIM

To improve the drug concentration in liver metastases, docetaxel was encapsulated in polyethyleneglycol-liposomes and administered regionally with degradable starch microspheres (DSM).

MATERIALS AND METHODS

A rodent model of solitary metastasis (CC-531 adenocarcinoma) was studied. The animals were randomized into six groups and treated with 15 ng/kg docetaxel: I: intravenous (i.v.). II: PEG-liposomes i.v.; III: intraartial (i.a.) via the hepatica artery; IV: i.a.) + DSM; V: PEG-liposomes i.a.; and VI: PEG-liposomes i.a. + DSM. The docetaxel concentration in the serum, liver and liver tumor at defined times (5, 15, 30, 60,120 240 min and 24 h) was measured using HPLC.

RESULTS

The area under the concentration (AUC) versus time curves showed an 11-fold higher concentration in the tumor tissue when comparing the docetaxel-PEG-liposomes i.a. + DSM group to the i.v. group (p<0.01).

CONCLUSION

Compared to intravenous therapy, i.a. therapy with docetaxel-PEG-liposomes + DSM results in higher tumor tissue concentrations.

Predictors of permanent ileostomy after restorative proctocolectomy

BACKGROUND

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a surgical approach for ulcerative colitis and familial adenomatous polyposis. This study evaluated predictors of the need for a permanent ileostomy to identify patients at high risk of IPAA failure.

METHODS

This was a retrospective analysis of patients who underwent proctocolectomy and IPAA between 1997 and 2008. A logistic regression model was used for multivariable analysis of potential risk factors.

RESULTS

Proctocolectomy was combined with IPAA in 185 patients, of whom 169 had a loop ileostomy formed. IPAA and ileostomy closure were successful in 162 patients (87.6 per cent). Reasons for not closing the ileostomy included pouch failure (16 patients), patient choice (5) and death (2). Thus one in eight patients had a permanent ileostomy after planned IPAA. Age was the major predictor of the need for a permanent ileostomy in multivariable analysis (P = 0.002) with a probability of more than 25 per cent in patients aged over 60 years. However, advancing age was associated with colitis, co-morbidity, obesity and corticosteroid use.

CONCLUSION

The probability of the need for a permanent ileostomy after IPAA increases with age.

[Experiences from more than 2,100 hernia repair operations. How has the therapy changed in the last 15 years?]

INTRODUCTION

Inguinal hernia (IH) surgery has changed fundamentally during the last 25 years due to tension-free repair, minimally-invasive approaches and growing influence of economy in medical decision making. Aim of the study was the documentation and analysis of changes in IH surgery during the last 15 years in our patient cohort.

MATERIAL AND METHODS

Patients undergoing elective or emergency inguinal/femoral hernia repair from January 1995 to December 2009 were included in the study. Analysis of patient data was carried out by prospective online recording.

RESULTS

A total of 1,908 patients with 2,124 IHs were treated in the study period and the number of IH repairs decreased continuously. The number of recurrent hernias peaked in 2005-2009 with 16.4%. The average preoperative hospital stay decreased from 2.4 to 0.4 days and the postoperative hospital stay from 7.0 to 3.3 days. The percentage of suture repairs declined from 54.9% in 1995 to 4.1% in 2009 and the percentage of open tension-free repairs rose to 52.9% in 1998. In the following years the majority of repairs were performed by minimally invasive procedures but in 2009 the percentage of conventional hernia repairs exceeded the rate of minimally invasive repairs.

CONCLUSION

The main reason for these changes is the implementation of diagnosis-related groups which hampers inpatient repair of "simple" inguinal hernias, favors short hospital stay and does not adequately reimburse minimally invasive repairs.

Predicting the site of origin of tumors by a gene expression signature derived from normal tissues

Multiple expression signatures for the prediction of the site of origin of metastatic cancer of unknown primary origin (CUP) have been developed. Owing to their limited coverage of tumor types and suboptimal prediction accuracy on distinct tumors, there is still room for alternative CUP gene expression signatures. Whereas in past studies, CUP classifiers were trained solely on data from tumor samples, we now use expression patterns from normal tissues for classifier training. This approach potentially avoids pitfalls related to the representation of genetically heterogeneous tumor subtypes during classifier training. Two expression data sets of normal human tissues have been reanalyzed to derive an expression signature for liver, prostate, kidney, ovarian and lung tissues. In reciprocal validation, classifiers trained on either data set achieved overall accuracies greater than 97%. Classifiers trained on combined expression data from both normal tissue data sets were able to predict the site of origin in a cohort of 652 primary tumors with approximately 90% accuracy. Prediction accuracies of primary cancer-based classifiers were in the same range, as determined by cross-validation on this cohort. For individual tumor types, normal tissue-based classifiers achieved sensitivities in the range of 64-99% and specificities in the range of 92-100%. Primary origins for 12 of 20 metastases were predicted correctly, with false predictions highlighting the need for accurate sample preparation to avoid contaminations by metastases-surrounding tissue. We conclude that gene expression patterns of normal tissues harbor phenotypic information that is retained in tumors and can be sufficient to recover the type of primary tumor from expression patterns alone.

The vasculitis in IBD is associated with the degree of inflammation

The role of vasculitis in the pathogenesis of IBD remains unclear. The aim of this study was to evaluate the detection rate of vasculitis in patients with IBD, its location in the intestinal wall layers and whether it occurs dependent of the degree of inflammation. Immunohistological staining with the endothelial cell marker CD31 and the pan-T cell marker CD3 was performed in 56 colonic specimens of Crohn's disease, in 43 of ulcerative colitis, and in 5 of colon cancer. Quantification of the degree of inflammation was done using a histological colitis score. There was no sign of vasculitis in the healthy intestinal wall layers. In Crohn's disease, specimens with minor inflammatory activity (score 0-2) disclosed no vasculitis. Vasculitis was observed in 82% of the specimens with an inflammatory degree of 3 and in 100% with an inflammatory degree of 4. Vasculitis was detected in all intestinal wall layers altered by inflammation. A direct association between vasculitis and granulomas was observed in only 5% of the specimens with an inflammatory degree of 4. All ulcerative colitis specimens evidenced an inflammatory degree between 2 and 4. No vasculitis was found in specimens with an inflammatory degree of 2, but in 57% with an inflammatory degree of 3 and in 100% with an inflammatory degree of 4. Vasculitis is only detectable in the mucous membrane changed by inflammation. Thus, the vasculitis in IBD is exclusively observed in the intestinal wall layers altered by inflammation. The extent of vasculitis depends on the degree of inflammation. An association between vasculitis and granuloma in Crohn's disease is seen in 5% of the cases.

["Practical course for visceral surgery in Warnemünde" 10 years on. Significance and benefits of a surgical training course]

BACKGROUND

Skill courses for surgery offer a good but cost and personnel-intensive possibility to obtain practical and theoretical knowledge by the employment of a close teacher-pupil contact of a large group of surgeons. The goal of the study presented here was to evaluate the satisfaction and benefits of the practical course for visceral surgery in Warnemünde after 10 years of course experience.

MATERIAL AND METHODS

All participants in the annual course for visceral surgery were included since 1999. During this 1-week course conventional and laparoscopic exercises are performed under direct guidance of an experienced tutor. The participants are divided into 3 groups based on their surgical experience (e.g. <3 years, 3-5 years, >5 years). All participants received a standardised questionnaire before and after successful course completion for the collection of relevant data (e.g. demography, training, surgical experience and course evaluation).

RESULTS

A total of 1,062 participants (435 female, 627 male, mean age 37 years) participated in the course. The average surgical experience of the participants was 5 years. Of the participants 489 came from a hospital of basic medical care, 499 from a hospital of maximum medical care and 74 from a university hospital. Of the participants 96% had no or only little experience with skill courses (1,020 out of 1,065) and 827 participants had no or only few possibilities for training outside of the operation room (78%). The conventional part of the course was evaluated by 77% of the participants as very good and by 50% as very good for the laparoscopic part. Only 8.3% of the participants were willing to finance the costs of the course by themselves.

CONCLUSIONS

The practical course for visceral surgery leads to a subjective success in learning. Participation in the course leads to a high satisfaction and offers a cost-intensive possibility for a standardised surgical training. But there are too few experiences with skill courses and possibilities for surgical training outside the operation room so far.

WITHDRAWN: Predicting the site of origin of tumors by a gene expression signature derived from normal tissues

Multiple expression signatures for the prediction of the site of origin of metastatic cancers of unknown primary origin (CUP) have been developed. Owing to their limited coverage of tumor types and suboptimal prediction accuracy on distinct tumors there is still room for alternative CUP gene expression signatures. Whereas in past studies CUP classifiers were solely trained on data from tumor samples, we now use expression patterns from normal tissues for classifier training. This approach potentially avoids pitfalls related to the representation of genetically heterogeneous tumor subtypes during classifier training. Two expression data sets of normal human tissues have been reanalysed to derive an expression signature for liver, prostate, kidney, ovarian and lung tissues. In reciprocal validation classifiers trained on either data set achieved overall accuracies greater than 97%. Classifiers trained on combined expression data from both normal tissue data sets were able to predict the site of origin in a cohort of 652 primary tumors with approximately 90% accuracy. Prediction accuracies of primary cancer-based classifiers were in the same range as determined by cross-validation on this cohort. For individual tumor types, normal tissue-based best-centroid classifiers achieved sensitivities ranging from 71 to 99% and specificities ranging from 91 to 99%. Primary origins for 12 of 20 metastases were predicted correctly with false predictions highlighting the need for accurate sample preparation to avoid contaminations by metastases-surrounding tissue. We conclude that gene expression patterns of normal tissues harbor phenotypic information that is retained in tumors and can be sufficient to recover the type of a primary tumor from expression patterns alone.Oncogene advance online publication, 16 November 2009; doi:10.1038/onc.2009.398.

Staging anal cancer: prospective comparison of transanal endoscopic ultrasound and magnetic resonance imaging

PURPOSE

The staging of anal cancer is extremely important for therapy and prognosis. Transanal endoscopic ultrasound and magnetic resonance imaging are routinely applied. The aim of this prospective comparative study is to evaluate whether tumor staging is concordant between these techniques.

METHODS

Forty-five anal cancer patients underwent endoscopic ultrasound and magnetic resonance imaging. Histological confirmation was obtained in all patients. The two test methods were compared with the kappa concordance index and sensitivity for the initial method of tumor detection was calculated. For six patients who were operated upon because of tumor progression, the results were evaluated against the histological tumor stage.

RESULTS

High concordance was found in the assessment of tumor size and nodal status (kappa index 0.63 and 0.77). Cancer patients were correctly identified with 100% sensitivity (45/45) by endoscopic ultrasound and with 88.9% (40/45) sensitivity by magnetic resonance imaging. In the six operated patients, T stage was correctly assessed in four of six patients by endoscopic ultrasound and in three of six patients by magnetic resonance imaging.

CONCLUSION

The results of endoscopic ultrasound strongly coincide with those of magnetic resonance imaging. Endoscopic ultrasound may be superior to magnetic resonance imaging for detection of small superficial tumors. However, magnetic resonance imaging is needed for N staging.

[Continent ileoanal reservoir--a surgical challenge]

The optimization of surgical techniques has made it possible to now treat patients with deep-seated rectal cancer by performing deep anterior rectal resection with coloanal anastomosis while avoiding a permanent stoma. To prevent a high bowel movement frequency and limited continence with an imperative need to empty the bowel, the coloanal pouch operation was developed to construct a rectal substitute. Nowadays, patients with ulcerative colitis or familial adenomatous polyposis of the colon undergo proctocolectomy as the definitive treatment for their underlying disease. Continuity is restored by creating an ileoanal reservoir. This contribution describes the surgical indications and pathophysiological changes for the colon J-pouch and ileoanal reservoir. In addition, explanations of the surgical techniques for both procedures are presented. The functional results are compared with those of other reconstruction options and discussed, taking our own results into consideration.

[Minimally invasive surgery and the economics of it. Can minimally invasive surgery be cost efficient from a business point of view?]

Minimally invasive surgery (MIS) is now accepted as equally valid as the use of a standard access in some areas of surgery. It is not possible to decide whether this access is economically worthwhile and if so for whom without a full economic cost-benefit analysis, which must take account of the hospital's own characteristics in addition to the cost involved for surgery, staff, infrastructure and administration. In summary, the main economic advantage of MIS lies in the patient-related early postoperative results, while the main disadvantage is that the operative material costs are higher. At present, the payment made for each procedure performed under the DRG system includes 14-17% of the total cost for materials, regardless of the access route and of the technical sophistication of the operation. The actual material costs are greater by a factor of 2-50 for MIS than for a conventional procedure. The task of the hospital is thus to lower the costs for material and infrastructure; that of industry is to offer less expensive alternatives; and that of our politicians, to implement better remuneration of the material costs.

Differential expression of genes encoding tight junction proteins in colorectal cancer: frequent dysregulation of claudin-1, -8 and -12

BACKGROUND AND AIMS

As integral membrane proteins, claudins form tight junctions together with occludin. Several claudins were shown to be up-regulated in various cancer types. We performed an expression analysis of genes encoding tight junction proteins to display differential gene expression on RNA and protein level and to identify and validate potential targets for colorectal cancer (CRC) therapy.

PATIENTS AND METHODS

Amplified and biotinylated cRNA from 30 microdissected CRC specimen and corresponding normal tissues was hybridized to Affymetrix U133set GeneChips. Quantification of differential protein expression of claudin-1, -8 and -12 between normal and corresponding tumour tissues was performed by Western blot analyses. Paraffin-embedded CRC tissue samples, colon cancer cell lines and normal tissue microarray were analysed for protein expression of claudin-1 by immunohistochemistry (IHC).

RESULTS

Claudin-1 (CLDN1) and -12 (CLDN12) are frequently overexpressed in CRC, whereas claudin-8 (CLDN8) shows down-regulation in tumour tissue on RNA level. Quantification of proteins confirmed the overexpression of claudin-1 in tumour tissues, whereas changes of claudin-8 and -12 were not significantly detectable on protein level. IHC confirmed the markedly elevated expression level of claudin-1 in the majority of CRC, showing membranous and intracellular vesicular staining.

CONCLUSIONS

Differential expression of genes encoding claudins in CRC suggests that these tight junction proteins may be associated to and involved in tumorigenesis. CLDN1 is frequently up-regulated in large proportion of CRC and may represent potential target molecule for blocking studies in CRC.

Improving laser-induced thermotherapy of liver metastases--effects of arterial microembolization and complete blood flow occlusion

INTRODUCTION

A prerequisite for an oncologically curative application of laser-induced thermotherapy (LITT) of liver metastases is complete tumor destruction. This increased effectiveness was achieved experimentally by combining LITT with interrupted hepatic perfusion. The aim of this study was to evaluate whether an interventional selective arterial microembolization might be as effective as complete blood flow occlusion using an open Pringle's maneuver.

PATIENTS AND METHODS

We included patients with unresectable colorectal liver metastases. LITT was performed without interrupted hepatic perfusion (control group) compared to LITT in combination with interrupted perfusion either by embolization of intraarterial degradable starch microspheres (DSM) (percutaneous access) or by complete hepatic inflow occlusion (Pringle's maneuver; open access). Online monitoring was performed using intraoperative ultrasound or MRI. Volumetric techniques were used to assess metastases and postinterventional lesions.

RESULTS

Fifty-six patients with 104 metastases (control group (25), DSM (37), and Pringle (42)) were treated. The preinterventional tumor volumes were significantly smaller than the postinterventional lesion volumes (control group: 9.8 vs. 25.3 cm3; DSM: 9.5 vs. 65.4 cm3; Pringle: 12.9 vs. 76.5 cm3). The morbidity rate was 21.4% without treatment-related mortalities. After 6 months follow-up, tumor recurrence was diagnosed in 6 patients (control group (4), LITT with DSM (1), and Pringle (1)).

CONCLUSIONS

Combining LITT with blood flow occlusion leads to a significant increase in lesion size. The application of DSM offers a safe and effective alternative to the open access with Pringle's maneuver. Compared to LITT-monotherapy, this modality achieves significantly larger thermal lesions with the need of fewer applications.

Phase II study of regional chemotherapy using the hypoxic abdominal perfusion technique in advanced abdominal carcinoma. 5-FU pharmacokinetics, complications and outcome

The aim of this study was to verify the rationale of a hypoxic abdominal perfusion (HAP) technique for the perfusion of 5-FU, mitomycin C and cisplatin in patients with inoperable, recurrent abdominal cancer.

PATIENTS AND METHODS

In a phase II study, 59 patients with various non-resectable abdominal tumours were treated with 102 perfusions by the HAP-technique. The HAP-technique was performed by using double-balloon arterial-venous catheters that selectively isolated the abdominal vascular section and perfusion was provided by an extracorporal pump for 20 min. Thirty-four patients with unresectable colorectal cancer, 11 with unresectable gastric cancer, eight with unresectable pancreatic cancer and six with cancer of the gall bladder were included. They were treated with a combination of 5-fluorouracil (5-FU 1 g/m(2)), mitomycin C (MMC, 10 mg/m(2)) plus cisplatin (50 mg/m(2)) infused into the isolated abdominal compartment. The cytostatic concentration of 5-FU was determined intrainterventionally within the systemic and regional compartment. Toxicity- and procedure-related complications were documented. Tumour responses were assessed by computer tomography.

RESULTS

5-FU concentration was 16.3-fold higher within the regional compared to the systemic compartment at its maximum, and the area under the curve (AUC) was 7.9 times larger. During the procedure two major complications were experienced (1x perforation of the A. iliaca, lx deep vein thrombosis), no deaths occurred during surgery or in the postoperative period. Minimal systemic and local toxicities were observed (WHO grade III-IV 1%, grade I-II 33%). No complete response but 22 partial responses were observed. Median survival was 15.5 months for colorectal cancer, 12. 5 months for gastric cancer, 12.7 months for pancreatic cancer and 7.8 months for gall bladder cancer.

CONCLUSION

The hypoxic abdominal perfusion is a safe and effective palliative treatment for patients with unresectable advanced colorectal, gastric and pancreatic carcinoma. The HAP has not shown promising results for advanced gall bladder cancer. These encouraging clinical results require further evaluation.

Hepatic arterial infusion (HAI). Comparison of 5-fluorouracil, folinic acid, interferon alpha-2b and degradable starch microspheres versus 5-fluorouracil and folinic acid in patients with non-resectable colorectal liver metastases

BACKGROUND

The prognosis of patients with advanced colorectal tumor is poor. Therefore, other therapy regimes for non-resectable hepatic metastases are necessary. In this prospective study, two regional chemotherapy protocols were compared.

PATIENTS AND METHODS

An arterial port system was implanted in 64 patients. Sixty patients were assigned to the two therapy protocols for hepatic arterial infusion (HAI): protocol A (n=24): 5-FU/FA (300 mg/m2 folinic acid and 600 mg/m2 5-fluorouracil daily for 5 days with a 14-day interval); protocol B (n=36): 5-FU/FA/IFN/DSM (450 mg starch microspheres (DSM) with 5 million IU recombinant interferon (IFN), alpha 2b 500 mg/m2 FA and 600 mg/m2 5-FU).

RESULTS

The response rate was 50% in protocol A patients and 69.4% in protocol B. The median times for disease progression were 11 months for protocol A and 20 months for protocol B (p = 0.038), while median survival times of 14 months and 26 months, respectively, were obtained (p = 0.015). There were no significant differences in terms of toxic side-effects. Major toxicity problems were observed in 12% of the protocol A-treated patients and in 11% of the protocol B-treated patients.

CONCLUSION

Combination therapy with HAI-5-FU/FA/IFN/DSM was superior to HAI-5FU/FA, with a high response rate (69% vs. 55%) and few toxic side-effects. These findings suggest that these combinations should be evaluated in larger studies as first- or second-line therapy in patients with hepatic metastases of colorectal cancer.

Ergebnisse der multiviszeralen Resektion des primären kolorektalen Karzinoms

BACKGROUND

In about 10 % of all patients with colorectal cancer, the primary invention already discloses adhesions or infiltration of adjacent organs. En bloc resection of the tumor-bearing bowel segment with adjacent organs is done to give patients a chance for curation, since intraoperative differentiation is not possible. The aim of this study is characterization of the patient population as well as evaluation of the morbidity and mortality associated with this type of extensive intervention.

METHOD

Between 1/95 and 6/04, we analyzed all patients with progressive primary colorectal cancer, who underwent multivisceral surgery with en bloc resection of at least one other organ. The target parameters were tumor characteristics as well as postoperative morbidity and mortality.

RESULTS

A total of 1 001 patients with colorectal cancer underwent surgery. 101 patients (10 %) required multivisceral resection. In 17 % the indication was exigent. About 70 % of the interventions involved the colon. Tumor perforation was seen in 17 % of patients with colon cancer and 16 % with rectal cancer. Resection of the inner genitals was most frequent in both colon and rectal cancer (26 and 84 %) followed by small bowel resection (21 %) and partial bladder resection (19 %). Other organs play a secondary role in rectal cancer while partial bladder resection (20 %) and abdominal wall resection (14 %) is observed more frequently in colon cancer. Resection of parenchymatous organs (kidney, suprarenal gland, spleen, pancreas, liver) and others like the stomach is quite rare in colon cancer. Actual tumor infiltration (T4 situation) was observed in 51 % of patients with colon cancer and in 64 % of those with rectal cancer. Local R0 resection (97 vs. 96 %) was successfully performed in nearly all colon and rectal cancer patients. The surgical major complication rate was 9 % in colon cancer and 19 % in rectal cancer. The mortality rate was 4 %.

CONCLUSION

Multivisceral en-bloc resection enables local R0 resection in the majority of cases with primary colorectal cancer. Despite sometimes extensive surgery, this type of procedure is associated with an acceptable morbidity and mortality. Since long-term survival is comparable to that in the T category (T3 or T4), multivisceral en-bloc resection is not only justified but also absolutely required in interventions with curative intention.

Can laparoscopically assisted sigmoid resection provide uncomplicated management even in cases of complicated diverticulitis?

BACKGROUND

Laparoscopically assisted sigmoid resection has become an accepted method for treating uncomplicated diverticulitis. This prospective study aimed to compare the results of laparoscopic sigmoid resection for uncomplicated and complicated sigmoid diverticular disease used to check the indication for the complicated stages of diverticulitis.

METHODS

All patients who underwent laparoscopic resection for sigmoid diverticulitis at the authors' hospital between 1999 and 2005 were divided into two groups: group 1 (uncomplicated diverticular disease) and group 2 (complicated diverticular disease). The exclusion criteria specified generalized peritonitis, signs of sepsis, and extensive previous abdominal surgery.

RESULTS

Of the 203 patients (108 men and 95 women) who underwent laparoscopically assisted resection during the examination period, 112 were assigned to group 1 and 91 to group 2. Differences in favor of group 1 were found for the duration of surgery (154 vs 166 min), the conversion rate (1.8% vs 9.9%), the postoperative wound infections (2.7% vs 13.2%), and the postoperative hospitalization period (12.3 +/- 3.9 vs 15.0 +/- 5.6 days). No significant differences were seen in any other areas such as completion of nutritional buildup (4.6 vs 5.0 days) or time until the first postoperative bowel movement (2.8 vs 3.3 days). Total postoperative morbidity (16.1% vs 26.4%; p = 0.10) tended to be increased in group 2, but this difference was not statistically significant.

CONCLUSIONS

Laparoscopic sigmoid resection can be performed for patients who have complicated diverticulitis without significantly increasing their overall morbidity. This group of patients could benefit from the advantages of the minimally invasive procedure despite a longer operating time and a higher conversion rate.

[Emergency management of thoracic trauma]

Thoracic injuries are a major cause of mortality during the "golden hour" of trauma. Many patients with chest trauma die after reaching the hospital. Less than 10% of all blunt thoracic injuries require a thoracotomy, and many potentially life-threatening conditions can be relieved by simple procedures, such as chest tube insertion.Thus, many cases of traumatic deaths due to chest injury may be prevented by prompt diagnosis and a standardized therapeutic approach in the emergency room. A high index of suspicion for lethal injury patterns, based on the mechanism of trauma and the clinical presentation, is a crucial prerequisite for an adequate initial assessment and management of patients with chest trauma. The worldwide implementation of standardized diagnostic and therapeutic guidelines, such as the "Advanced Trauma Life Support" (ATLS) protocol, has led to a significant reduction of early deaths attributed to thoracic injuries.