[Quality of life of ostomates in Germany]

BACKGROUND

The presence of an ostomy may have a serious impact on the quality of life (QoL). The aim of this study was to evaluate the QoL of ostomates in Germany.

METHOD

An online survey was performed using the validated Gastrointestinal Quality of Life Index (GIQLI) by Eypasch et al. Ostomates ≥ 18 yrs. with an ostomy duration ≥ 3 months were eligible to participate.

RESULTS

Completed questionnaires from 519 participants (79.3 % female) with a median age of 50 yrs. (range 19-83 yrs.) and a median ostomy duration of 3 yrs. (range 3 months-58 yrs.) were analyzed. The most common indications for an ostomy were Crohn's disease (36.5 %), colorectal cancer (19.8 %) and ulcerative colitis (18.2 %). The mean GIQLI-Score in the study population was 94.8 ± 24.6, with higher scores corresponding with better QoL and healthy individuals reach 125.8. Limitations were recorded with regard to sleep, tiredness, energy level, endurance, fitness and sexuality. Individuals with a stoma due to Colitis (103,0 ± 24,5), colorectal cancer (99,2 ± 21,7) and Crohn's (95,0 ± 22,8) had the highest mean GIQLI-scores amongst all ostomates.

DISCUSSION

The findings of this study confirm that ostomates have a reduced QoL compared to the healthy population. Amongst all ostomates, those with colitis, colorectal cancer and Crohn's have a better QoL compared to ostomy carriers with other diagnoses.

Microsatellite instability is highly prevalent in older patients with colorectal cancer

Background

Clinical guidelines suggest screening of colorectal cancer (CRC) for microsatellite instability (MSI). However, microsatellite instability-high (MSI-H) CRC is not rare in older patients. This study aimed to investigate the prevalence of MSI-H CRC in an unselected population in an age-based manner.

Material and methods

A retrospective analysis of data from patients undergoing radical surgery for CRC was performed. Only cases with results from MSI testing using immunochemistry (IHC) were analyzed. Age-based analyses were performed using two cut-off ages: 50 years. as stated in Amsterdam II guidelines, and 60 years. as outlined in the revised Bethesda criteria.

Results

The study population included 343 (146 female and 197 male) patients with a median age of 70 years (range 21-90 years). The prevalence of MSI-H tumors in the entire cohort was 18.7%. The prevalence of MSI-H CRC was 22.5% in the group ≤50 years vs. 18.2% in the group >50 years using the age limit in the Amsterdam II guidelines. MSI-H CRC was present in 12.6% of the group aged ≤60 years compared to 20.6% in the control group >60 years.

Conclusion

MSI screening of CRC based on age alone is associated with negative selection of a relevant number of cases. MSI-H CRC is also common in elderly patients, who may be negatively selected secondary to an age-based screening algorithm. Following the results of this study, screening based on clinical criteria should be omitted in favor of systematic screening as is already internationally practiced.

SEVTAR-A multicenter randomized controlled trial to investigate the impact of prophylactic endoluminal placed vacuum sponge for prevention of anastomotic leakage after low rectal resections

Background

Low anterior resection for rectal cancer is commonly associated with a diverting stoma. In general, the stoma is closed 3 months after the initial operation. The diverting stoma reduces the rate of anastomotic leakage as well as the severeness of a potential leakage itself. Nevertheless, anastomotic leakage is still a life-threatening complication and might reduce the quality of life in the short and long term. In case of leakage, the construction can be converted into a Hartmann situation or it could be treated by endoscopic vacuum therapy or by leaving the drains. In recent years, endoscopic vacuum therapy has become the treatment of choice in many institutions. In this study, the hypothesis is to be evaluated, if a prophylactic endoscopic vacuum therapy reduces the rate of anastomotic leakage after rectal resections.

Methods

A multicenter parallel group randomized controlled trial is planned in as many as possible centers in Europe. The study aims to recruit 362 analyzable patients with a resection of the rectum combined with a diverting ileostoma. The anastomosis has to be between 2 and 8 cm off the anal verge. Half of these patients receive a sponge for 5 days, and the control group is treated as usual in the participating hospitals. There will be a check for anastomotic leakage after 30 days. Primary end point is the rate of anastomotic leakages. The study will have 60% power to detect a difference of 10%, at a one-sided alpha significance level of 5%, assuming an anastomosis leakage rate of 10%-15%.

Discussion

If the hypothesis proves to be true, anastomosis leakage could be reduced significantly by placing a vacuum sponge over the anastomosis for 5 days.

Trial registration

The trial is registered at DRKS: DRKS00023436. It has been accredited by Onkocert of the German Society of Cancer: ST-D483. The leading Ethics Committee is the Ethics Committee of Rostock University with the registration ID A 2019-0203.

A vector-encoded bispecific killer engager to harness virus-activated NK cells as anti-tumor effectors

Treatment with oncolytic measles vaccines (MV) elicits activation of immune cells, including natural killer (NK) cells. However, we found that MV-activated NK cells show only modest direct cytotoxic activity against tumor cells. To specifically direct NK cells towards tumor cells, we developed oncolytic measles vaccines encoding bispecific killer engagers (MV-BiKE) targeting CD16A on NK cells and carcinoembryonic antigen (CEA) as a model tumor antigen. MV-BiKE are only slightly attenuated compared to parental MV and mediate secretion of functional BiKE from infected tumor cells. We tested MV-BiKE activity in cocultures of colorectal or pancreatic cancer cells with primary human NK cells. MV-BiKE mediate expression of effector cytokines, degranulation and specific anti-tumor cytotoxicity by NK cells. Experiments with patient-derived pancreatic cancer cultures indicate that efficacy of MV-BiKE may vary between individual tumors with differential virus permissiveness. Remarkably, we confirmed MV-BiKE activity in primaryhuman colorectal carcinoma specimens with autochthonous tumor and NK cells.This study provides proof-of-concept for MV-BiKE as a novel immunovirotherapy to harness virus-activated NK cells as anti-tumor effectors.

Risk factors for therapy failure after surgery for perianal abscess in children

Purpose

The role of surgery in managing perianal abscesses in the pediatric population is debatable, and data on recurrence risk is rare. This study aimed to evaluate the efficiency of surgery for a perianal abscess in children and identify parameters that predict recurrence.

Methods

We performed a retrospective review of all children younger than age 14 requiring surgery for a perianal abscess from 2000 to 2018.

Results

Out of 103 enrolled patients, 27 (26%) had recurrent perianal disease. Recurrences appeared after a median of 5 months (range: 1-18 months), in 12 cases as perianal abscess and 15 cases as fistula in ano. Anal fistula probing was performed in 33% of all patients, of which 16 (15%) underwent fistulotomy. In univariate analysis, older age (p = 0.034), fistula probing (p = 0.006) and fistulotomy (p = 0.009) was associated with treatment success. History of perianal abscess, multilocal occurrence, and the presence of enteric flora in wound swabs was associated with treatment failure (p = 0.002, OR = 0.032). In multivariate analysis, anal fistula probing was independently associated with treatment success (p = 0.019, OR = 22.08), while the history of perianal abscess was associated with treatment failure (p = 0.002, OR = 0.032).

Conclusion

Our study identified probing for fistula as a predictor of therapy success, while the history of perianal abscess was identified as a predictor of treatment failure. Therefore, in all children with perianal abscess, fistula probing and if present, fistulotomy should be performed.

An unusual case of a tension pneumothorax

A total intra-thoracic stomach describes the case of a complete herniation of the stomach into the thoracic cavity. Symptoms may vary from mild to an acute life-threatening situation in case of perforation or bleeding, requiring emergency surgery. Here we describe the case of a gastric perforation leading to a tension pneumothorax and concomitant pleural empyema due to a giant hiatal recurrence after previous surgery. Multidisciplinary management involving thoracic surgeons helped in achieving the best clinical outcome for the patient.

Computer-aided clinical image analysis as a predictor of sentinel lymph node positivity in cutaneous melanoma

BACKGROUND

Delays in sentinel lymph node (SLN) biopsy may affect the positivity of non-SLNs. For these reasons, effort is being directed at obtaining reliable information regarding SLN positivity prior to surgical excision. However, the existing tools, e.g., dermoscopy, do not recognize statistically significant predictive criteria for SLN positivity in melanomas.

AIM

To investigate the possible association of computer-assisted objectively obtained color, color texture, sharpness and geometry variables with SLN positivity.

METHODS

We retrospectively reviewed and analyzed the computerized medical records of all patients diagnosed with cutaneous melanoma in a tertiary hospital in Germany during a 3-year period. The study included patients with histologically confirmed melanomas with Breslow > 0.75 mm who underwent lesion excision and SLN biopsy during the study period and who had clinical images shot with a digital camera and a handheld ruler aligned beside the lesion.

RESULTS

Ninety-nine patients with an equal number of lesions met the inclusion criteria and were included in the analysis. Overall mean (± standard deviation) age was 66 (15) years. The study group consisted of 20 patients with tumor-positive SLN (SLN+) biopsy, who were compared to 79 patients with tumor-negative SLN biopsy specimen (control group). The two groups differed significantly in terms of age (61 years vs 68 years) and histological subtype, with the SLN+ patients being younger and presenting more often with nodular or secondary nodular tumors (P < 0.05). The study group patients showed significantly higher eccentricity (i.e. distance between color and geometrical midpoint) as well as higher sharpness (i.e. these lesions were more discrete from the surrounding normal skin, P < 0.05). Regarding color variables, SLN+ patients demonstrated higher range in all four color intensities (gray, red, green, blue) and significantly higher skewness in three color intensities (gray, red, blue), P < 0.05. Color texture variables, i.e. lacunarity, were comparable in both groups.

CONCLUSION

SLN+ patients demonstrated significantly higher eccentricity, higher sharpness, higher range in all four color intensities (gray, red, green, blue) and significantly higher skewness in three color intensities (gray, red, blue). Further prospective studies are needed to better understand the effectiveness of clinical image processing in SLN+ melanoma patients.

Novel Group C Oncolytic Adenoviruses Carrying a miRNA Inhibitor Demonstrate Enhanced Oncolytic Activity In Vitro and In Vivo

Oncolytic adenoviruses (OAd) represent an attractive treatment option for cancer. Clinical efficacy of commonly utilized human adenovirus type 5 (Ad5)-based oncolytic viruses is limited by variable expression levels of the coxsackie- and adenovirus receptor (CAR) in tumor cells and high prevalence of neutralizing antibodies against human Ad5. However, previous studies have highlighted alternative human Ad types as promising candidates for oncolytic therapy. In this study, we generated novel OAds based on Ad1, -2, -5, and -6 derived from species C Ads. These OAds contain a 24-bp deletion in the early gene E1A for tumor selective replication and express the RNAi inhibitor P19. We examined these OAds for in vitro anticancer activity on various cancer cell lines derived from lung, colon, gynecologic, bone, and pancreatic carcinoma. In most surveyed cell lines, OAds based on Ad1, -2, and -6 demonstrated higher cell lysis capability compared with Ad5, suggesting enhanced oncolytic potential. Moreover, enhanced oncolytic activity was associated with P19 expression in a cell type-dependent manner. We further explored a A549 tumor xenograft mouse model to compare the novel OAds directly with Ad5 and H101, an oncolytic adenovirus used in clinical trials. These P19-containing OAds based on Ad1, -2, and -6 showed significantly decelerated tumor progression compared with H101, indicating better antitumor potency in vivo. Our studies provide a novel path for OAd development based on alternative Ad types with improved effectiveness by RNA interference suppression.

OUP accepted manuscript

Background

Symptomatic haemorrhoids are a common anorectal disorder. The aim of the study was to investigate whether the omission of tamponade dressings after haemorrhoidectomy reduces postoperative pain without increasing the risk of severe bleeding.

Method

This was an open-label, randomized clinical trial conducted at 14 German hospitals. All patients with third- or fourth-degree haemorrhoids undergoing haemorrhoidectomy were considered eligible for selection in the intervention (no dressing) or control group (tamponade applied). Two co-primary outcomes were analysed by testing hierarchically ordered hypotheses. First, maximum pain intensity within 48 h after surgery was compared between the groups (superiority). This was followed by an analysis of severe bleeding complications, defined as any bleeding requiring surgical re-intervention within 7 days (non-inferiority). Secondary outcomes included health-related quality of life, patient satisfaction, haemoglobin levels, and adverse events.

Results

Out of 950 patients screened, 754 were randomized and 725 received intervention (366 patients in the intervention and 359 patients in the control group). In the group with tamponade dressings, median pain intensity on the 0 to 10 scale was 6 (interquartile range (i.q.r.) 4–7). Patients without tamponade dressings reported significantly less pain (median 5 (i.q.r. 3–7), P < 0.001). In each group, five patients (1.4 per cent) experienced severe bleeding. The absolute difference for the severe bleeding rate was −0.03 per cent with the 90 per cent confidence interval ranging from −1.47 per cent to +1.41 per cent, in line with the non-inferiority aim. No significant between-group difference was found for secondary outcomes.

Conclusions

The practice of inserting tamponade dressings after haemorrhoidectomy correlates with increased postoperative pain and does not provide benefits in terms of reduced postoperative bleeding.

Registration number

DRKS00011590

Candida albicans Osteochondromyelitis after Gastroesophageal Surgery: Two Case Reports

Candida osteochondromyelitis is a rare complication after thoracoabdominal surgery. We herein report two such cases after uncomplicated thoracoabdominal surgery, who presented with chronic postsurgical site infection and fistula. CT scans showed fistulas reaching the costochondral areas of the fifth rib. Inflammatory parameters were not elevated. Both patients were treated successfully after the initiation of systemic antimycotic treatment and surgical debridement. We conclude that C. albicans infections should always be considered in cases of chronic postoperative surgical site infections after thoracoabdominal surgery. Additional risk factors do not need to be present. Appropriate therapy consists of the application of systemic antimycotics and surgical debridement.

Computer-aided clinical image analysis for non-invasive assessment of tumor thickness in cutaneous melanoma

Objective

Computerized clinical image analysis is shown to improve diagnostic accuracy for cutaneous melanoma but its effectiveness in preoperative assessment of melanoma thickness has not been studied. The aim of this study, is to explore how melanoma thickness correlates with computer-assisted objectively obtained color and geometric variables. All patients diagnosed with cutaneous melanoma with available clinical images prior to tumor excision were included in the study. All images underwent digital processing with an automated non-commercial software. The software provided measurements for geometrical variables, i.e., overall lesion surface, maximum diameter, perimeter, circularity, eccentricity, mean radius, as well as for color variables, i.e., range, standard deviation, coefficient of variation and skewness in the red, green, and blue color space.

Results

One hundred fifty-six lesions were included in the final analysis. The mean tumor thickness was 1.84 mm (range 0.2–25). Melanoma thickness was strongly correlated with overall surface area, maximum diameter, perimeter and mean lesion radius. Thickness was moderately correlated with eccentricity, green color and blue color. We conclude that geometrical and color parameters, as objectively extracted by computer-aided clinical image processing, may correlate with tumor thickness in patients with cutaneous melanoma. However, these correlations are not strong enough to reliably predict tumor thickness.

The role of saline irrigation prior to wound closure in the reduction of surgical site infection: a systematic review and meta-analysis

Background

Surgical site infection (SSI) describes an infectious complication of surgical wounds. Although SSI is thought to be preventable, it still represents a major cause of morbidity and substantial economic burden on the health system. Wound irrigation (WI) might reduce the level of bacterial contamination, but current data on its role in reducing or preventing SSI is conflicting. Our aim was to investigate the effectiveness of WI with normal saline prior to wound closure for the reduction of SSI in patients undergoing abdominal surgery.

Methods

We conducted a systematic literature search in MEDLINE, EMBASE, and CENTRAL from inception to present, and cross-checked the reference lists of all included primary studies and relevant systematic reviews. (Quasi-) randomized controlled trials (RCTs) investigating the rate of SSI when using normal saline vs. no irrigation prior to wound closure following abdominal surgery were included. Primary outcome was the rate of SSI, secondary outcome the mean length of hospital stay (LOS).

Results

Four RCTs including a total of 1194 patients were included for analysis. All studies compared wound irrigation with normal saline with no wound irrigation prior to wound closure. Their risk of bias was moderate. The relative risk of developing a SSI was lower when wound irrigation with normal saline was performed prior to wound closure although the effect was not statistically significant (risk ratio 0.73, 95%-confidence level: 0.37 to 1.43). Similarly, there was no difference in the LOS amongst both intervention arms.

Conclusion

This systematic review could not identify an advantage for routine irrigation of abdominal wounds with normal saline over no irrigation prior to wound closure in preventing or reducing the rate of SSI.

Systematic review registration

PROSPERO registry number CRD42018082287.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13037-020-00274-2.

Correlation of perioperative biochemical variables with single adenoma weight in patients with primary hyperparathyroidism

BACKGROUND

Single parathyroid adenoma is the main cause of primary hyperparathyroidism (PHPT), with surgery remaining the gold standard for its treatment. The ability to preoperatively predict the parathyroid adenoma size and could facilitate the decision about the extent of surgical exploration. It is reasonable to hypothesize that the perioperative levels of PHPT-related variables (i.e. calcium, parathormone, phosphate) may predict the adenoma weight or/and demonstrate whether the adenoma is successfully removed or not. Aim of this study is to explore the relationship between perioperative biochemical values and adenoma weight. Secondarily, we investigated the relationship between adenoma weight and uni-/bilateral neck exploration.

METHODS

Retrospective study of all patients undergone surgery for primary hyperparathyroidism due to single adenoma in a tertiary university hospital in Germany during a 6-year period. Following variables were analyzed: preoperative serum calcium, phosphorus and parathormone, intraoperative parathormone before and after adenoma excision, intraoperative PTH decrease, postoperative serum calcium and parathormone (PTH_postop-pg/ml), calcium and PTH decrease. Bivariate correlations were calculated by the Spearman's correlation test at the 95% significance level.

RESULTS

A total of 339 patients were included in the study. The median age of the patients was 60 years (range 21-90) and 77% were females. The median adenoma weight was 1 g (range 0.1-11). Adenoma weight correlated strong with maximum adenoma diameter (r = 0.72, p < 0.05), moderate with preoperative parathormone (r = 0.44) and parathormone decrease (r = 0.27), whereas there was no correlation with the intraoperative PTH decrease (r = 0.02). There was also a borderline (moderate to weak) correlation with pre- and postoperative calcium levels (r = 0.21 and r = 0.23 respectively) and a negative borderline correlation with phosphorus (r = - 0.21). Patients who required bilateral neck exploration, had significantly lighter adenomas (median weight 0.8 g vs 1.1 g, p = 0.005).

CONCLUSIONS

We conclude that preoperative PTH levels may only serve as an approximate guide to adenoma weight, as direct preoperative prediction is not possible. Serum calcium levels, PTH and calcium decrease correlate only weak with adenoma weight. Patients who require bilateral neck exploration, have significantly (20-25%) lighter adenomas.

Efficacy of conservative treatment of perianal abscesses in children and predictors for therapeutic failure

BACKGROUND

The optimal management of perianal abscess in children is controversial.

PURPOSE

To evaluate the efficiency of conservative treatment of perianal abscess in children and identify parameters that predict therapy failure.

METHODS

All cases of children younger than 14 years of age with perianal abscesses between 2001-2016 were evaluated.

RESULTS

Of the 113 enrolled patients, 64 underwent subsequent surgery for advanced disease (primary surgery group). Conservative treatment was initiated in 49 patients (primary conservative group) but was stopped because of inefficiency in 25 patients, who were referred for surgery after a median 7.03 days (range, 2 to 16 days). The other 24 patients (48%) initially achieved complete remission after conservative treatment, but 10 were readmitted after a median 34 months (range, 3 to 145 months) with recurrent disease. There were no significant differences in permanent success after conservative treatment between infants (10 of 29, 34%) and older children (4 of 20 [20%], P=0.122). Overall, conservative treatment alone was effective in only 14 of 113 patients. Recurrence after surgery occurred in 16 patients (25%) in the primary surgery group and 11 patients (22%) in the primary conservative group (P=0.75). Univariate analysis of predictors for conservative treatment failure revealed inflammatory values (C-reactive protein and white blood count, P=0.017) and abscess size (P=0.001) as significant parameters, whereas multivariate analysis demonstrated that only abscess size (odds ratio, 3.37; P=0.023) was significant.

CONCLUSION

Conservative treatment of perianal abscess is permanently efficient in only a minority of children but is not associated with a higher recurrence rate after subsequent surgery. Abscess size is a predictor for therapy failure.

Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients

BACKGROUND

Groin hernia repair constitutes a very common procedure in general surgery. Minimal invasive closure of groin hernia has evolved to become the standard means of closure. However, there seems to be a gender-associated discrimination with regard to endoscopic groin hernia repair. We investigated the rate of endoscopic closure in female patients undergoing groin hernia closure.

MATERIALS AND METHODS

A retrospective analysis of the data of patients undergoing elective groin hernia repair within a four-year period from 2013 to 2016 was performed. The rate of endoscopic hernia repair was calculated for both genders.

RESULTS

Eight hundred and forty-six patients including 94 females and 752 males were included for analysis. The female group was significantly older compared to the male group (68.0 vs. 61.0 yrs, P=0.02). The rate of endoscopic groin hernia repair was significantly lower in the female group compared to in the male cohort (30% vs. 60%, P=0.001). The overall duration of surgery was 74.0min in the female cohort and 93.0min in the male group, P=0.001. However, there was no statistically significant difference amongst both groups with regard to the duration of surgery for endoscopic repair: 78.0min in the female group and 89.0min in the male group, P=0.67.

CONCLUSION

Findings from this retrospective collective suggests that, there might be some degree of sex discrimination with regard to endoscopic groin hernia repair in favor of the male population.

Intestinal Ostomy

BACKGROUND

About 100 000 ostomy carriers are estimated to live in Germany today. The creation of an ostomy represents a major life event that can be associated with impaired quality of life. Optimal ostomy creation and proper ostomy care are crucially important determinants of the success of treatment and of the patients' quality of life.

METHODS

This article is based on pertinent publications retrieved by a selective search in PubMed, GoogleScholar, and Scopus, and on the authors' experience.

RESULTS

Intestinal stomata can be created using either the small or the large bowel. More than 75% of all stomata are placed as part of the treatment of colorectal cancer. The incidence of stoma-related complications is reported to be 10-70%. Skin irritation, erosion, and ulceration are the most common early complications, with a combined incidence of 25-34%, while stoma prolapse is the most common late complication, with an incidence of 8-75%. Most early complications can be managed conservatively, while most late complications require surgical revision. In 19% of cases, an ostomy that was initially planned to be temporary becomes permanent. Inappropriate stoma location and inadequate ostomy care are the most common causes of early complications. Both surgical and patient-related factors influence late complications.

CONCLUSION

Every step from the planning of a stoma to its postoperative care should be discussed with the patient in detail. Preoperative marking is essential for an optimal stoma site. Optimal patient management with the involvement of an ostomy nurse increases ostomy acceptance, reduces ostomy-related complications, and improves the quality of life of ostomy carriers.

Routine preoperative mechanical bowel preparation with additive oral antibiotics is associated with a reduced risk of anastomotic leakage in patients undergoing elective oncologic resection for colorectal cancer

BACKGROUND

Anastomotic leakage (AL) following colorectal resection is a serious issue. AL in oncologic patients might negatively affect the overall survival. Recently, mechanical bowel preparation with additive oral antibiotics (MBP + AB) prior to surgery has been suggested as a means of reducing AL. However, it is unclear whether this positive effect is secondary to MBP alone or secondary to the additive oral antibiotic (MBP + AB). The aim of this study was to investigate the effect of mechanical bowel preparation with additive oral antibiotics (MBP + AB) and without additive oral antibiotics (MBP - AB) on the rate of AL following colorectal resection for cancer.

MATERIALS AND METHODS

Patients undergoing surgical management for colorectal cancer with anastomosis from January 2014 till September 2017 were included for analysis. Cases undergoing MBP + AB were included in the study group. Patients undergoing MBP - AB were included in the control group. Both groups were compared with regard to the rate of AL.

RESULTS

Four hundred and ninety-six patients: 125 undergoing MBP + AB and 371 undergoing MBP - AB were included for analysis. Significantly, more male patients were included in the MBP - AB group compared to the MBP + AB group: 60.1% vs. 45.6% respectively (p = 0.03). Both groups were similar with regard to age distribution and clinicopathological findings (p > 0.05). The rate of AL was significantly higher in the control group (MBP - AB) compared to study group (MBP + AB) (9.1% vs. 4.0%, p = 0.03).

CONCLUSION

Mechanical bowel preparation with additive oral antibiotics prior to elective colorectal resection with anastomosis significantly reduces the risk of AL. Therefore, mechanical bowel preparation with additive non-absorbable oral antibiotics should be recommended in all cases prior to elective colorectal surgery.

The role of saline irrigation prior to wound closure in the reduction of surgical site infection: protocol for a systematic review and meta-analysis

BACKGROUND

Surgical site infection describes an infectious complication of surgical wounds. This single complication is thought to occur in close to 20% of surgical cases. This complication has been described in all kinds of surgical procedure including minimally invasive procedures. Wound irrigation is frequently used as a means of reducing surgical site infection. However, there is lack of solid evidence to support routine wound irrigation. The aim of this review is to provide evidence for the efficacy of routine wound irrigation with normal saline in preventing surgical site infection. The rate of surgical site infection in cases with and without wound irrigation will be analyzed.

METHODS/DESIGN

Systematic literature searches will be conducted to identify all published and unpublished studies. The following databases will be searched for citations from inception to present: MEDLINE (via PubMed), Embase (via Embase), and CENTRAL (via the Cochrane library). The search strategy will be developed by the research team in collaboration with an experienced librarian and checked by a referee according to the Peer Review of Electronic Search Strategies (PRESS) guideline. A draft of the PubMed search strategy could be (irrigation[tiab] OR "Therapeutic Irrigation"[mesh] OR lavage[tiab]) AND (saline[tiab] OR "Sodium Chloride"[mesh] OR sodium chloride[tiab]) NOT ("Comment" [Publication Type] OR "Letter" [Publication Type] OR "Editorial" [Publication Type]). No time limits will be set. The reference lists of eligible articles will be hand searched. Relevant data will be extracted from eligible studies using a previously designed data extraction sheet. Relative risks will be calculated for binary outcomes and mean differences or standardized mean differences, if necessary, for continuous outcomes. For all measures, 95% confidence levels will be calculated. Both arms would be compared with regard to the rate of surgical site infection within 30 days following surgery. We will report the review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

DISCUSSION

This review aims at investigating the value of routine wound irrigation using normal saline in preventing surgical site infection.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42018082287.

Extra nodular metastasis is a poor prognostic factor for overall survival in node-positive patients with colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is the second leading cause for cancer-related death in industrialized nations. Nodal involvement has been identified as a relevant prognostic feature in CRC. Extra nodal metastasis (ENM) describes the spread of malignant cells beyond the nodal capsule. ENM is thought to be an independent risk factor for poor survival. This study examined ENM as an independent risk factor for poor overall survival in patients with node-positive CRC.

MATERIALS AND METHODS

Data from a prospectively maintained CRC database was retrospectively analyzed. Blinded slides of patients with stage III and IV CRC following radical surgical resection were re-examined for the presence of ENM. The effect of ENM on overall survival was examined using Kaplan-Meier curves.

RESULTS

One hundred forty-seven cases with node-positive CRC (UICC stages III and IV) including 78 cases with ENM were included for analysis. ENM was seen in 60 patients with colon cancer (58.8%) and in 18 patients with rectal cancer (40%), p = 0.033. ENM-positive patients had a significantly higher odd for cancer-related death compared to ENM-negative patients ratio of [OR 0.44: 0.22-0.88, CI 95%, p = 0.021], p = 0.02. The median overall survival was significantly longer in patients without ENM, 51.0 ± 33 vs. 30.5 ± 42 months, p = 0.02.

CONCLUSION

Extra nodal metastasis is an independent prognostic factor in patients with node-positive colorectal cancer. Extra nodal metastasis is associated with high odds of tumor-related mortality and poor overall survival.

The Treatment of Critically Ill Patients With Acute Cholecystitis

BACKGROUND

Besides cholecystectomy (CC), percutaneous cholecystostomy (PC) has been recommended for the management of critically ill patients with acute cholecystitis. However, solid evidence on the benefit of PC in this subgroup of patients is lacking.

METHODS

In accordance with the PRISMA guidelines for systematic reviews, we systematically searched the Cochrane Library, CINAHL, MEDLINE, Embase, and Scopus for relevant studies published between 2000 and 2014. Two investigators independently screened the studies included.

RESULTS

Six studies with a total of 337 500 patients (PC 10 045, CC 327 455) were included for meta-analysis. Significant differences in favor of CC were recorded with regard to the rate of mortality (OR 4.28, [1.72 to 10.62], p = 0.0017), length of hospital stay (OR 1.41, [1.02 to 1.95], p = 0.04), and the rate of readmission for biliary complaints (OR 2.16, [1.72 to 2.73], p<0.0001). There was no statistically significant difference between both intervention arms with regard to complications (OR 0.74, [0.36 to 1.53], p = 0.42) and re-interventions (OR 7.69, [0.68 to 87.33], p = 0.10).

CONCLUSION

The benefit of percutaneous cholecystostomy (PC) over cholecystectomy (CC) in the management of critically ill patients with acute cholecystitis could not be proven in this systematic review.

Surgical retrieval of a swallowed denture in a schizophrenic patient: a case report

Background

Accidental foreign body ingestion is a common phenomenon in children between 6 months to 6 years of age. In adults, foreign body ingestion is commonly observed in the geriatric population and in patients with psychiatric disorders. Over 80% of ingested foreign bodies pass uneventfully through the intestinal tract. Endoscopic retrieval is needed in about 20% while surgical intervention is indicated in less than 1%. Herein we report an extremely rare case of esophagocutaneous fistula following operative retrival of an impacted denture in the esophagus with spontaneous healing within 3 weeks. A similar case to the best of our knowledge has so far not been reported previously.

Case presentation

A case of accidental ingestion of a dental prosthesis in a 35-year old schizophrenic patient is presented. The patient was referred to our department after accidentally swallowing one of his dental prosthesis. Surgical retrieval was indicated after two unsuccessful endoscopic retrieval attempts. The denture was retrieved following a longitudinal incision of the esophagus via a left cervical approach. The postoperative course was complicated by a clinically suspected esophagocutaneous fistula which was managed conservatively via nothing per os with enteral feeding via a nasogastric tube. Secretion ceased 3 weeks later and a fistula could not be found on contrast enhanced radiographic examination with gastrographin®.

Conclusion

Esophagocutaneous fistula represents a rare but serious complication following foreign body ingestion. An interdisciplinary management including an early surgical consultation should be considered in patients with foreign body impaction in the esophagus following failure of endoscopic retrieval.

New trend in colorectal cancer in Germany: are young patients at increased risk for advanced colorectal cancer?

Background

The role of colonoscopy in the screening of colorectal cancer (CRC) has been unequivocally established. In Germany, screening colonoscopy with full insurance reimbursement is available for individuals aged 55 and above, and/or for persons with well-known risk factors for CRC. However, advanced CRC is not uncommon in individuals below 55 years. This study was designed to investigate the incidence of advanced CRC in patients < 55 years.

Methods

A retrospective analysis of data from a prospectively maintained CRC database of a university hospital in Germany was performed. Using the recommended age for screening colonoscopy as cutoff, the study population was divided into two groups: < 55 years (study group) and ≥ 55 years (control group). Both groups were compared with regard to the extent of CRC using the UICC stages. Only surgically managed patients were included for analysis. Advanced CRC was defined as UICC stage III or IV.

Results

Complete follow-up data was available for 609 patients treated between 2009 and 2013. The study group included 83 patients, 42 females and 41 males with a median age of 48.0 ± 10 years, while the control group was made up of 526 patients, 230 females and 296 males with a median age of 75.5 ± 8.3 years. Both groups were comparable with regard to gender distribution, p = 0.24. Significantly more patients from the study group were diagnosed with advanced CRC in comparison to the control group, 56.6 vs. 43.9%, p = 0.03. There was no statistically significant difference amongst both groups with respect to cancer-related mortality, 10.8 vs. 12.5%, p = 0.66.

Conclusion

Patients below the recommended age for screening colonoscopy might be at increased risk for advanced CRC. There is need to decrease the recommended age for screening colonoscopy to prevent CRC or enable an early diagnosis in patients below 55 years.

Tissue sublimation follow transarterial embolization of a follicular nodular hyperplasia of the liver-report of a case

Background

Follicular nodular hyperplasia (FNH) is a common benign liver tumor for which conservative management is indicated. Surgical or interventional management is indicated in symptomatic cases. Transarterial embolization (TAE) has been extensively used to manage unresectable liver tumors. Sublimation describes a change of physical state from solid to gas. Hepatic tissue sublimation following TAE has so far not been reported in medical literature.

Case presentation

A 30 year - old male patient presenting with pain to the upper abdomen due to a large FNH was managed with TAE. Routine radiographic control on post-intervention day one was within normal limits. Imaging due to right upper quadrant pain with fever and elevated inflammatory markers and liver enzymes on day two after TAE revealed a marked reduction of the FNH accompanied by the presence of a large volume of gas collection without signs of abscess formation. This change of state from solid to gas without sign of abscess formation within 2 days after TAE was described as hepatic tissue sublimation. The patient was managed conservatively and discharge 12 days after TAE.

Conclusion

Tissue sublimation has hardly been reported in medical literature. This to the best of our knowledge is the first documented case of hepatic tissue sublimation following TAE.

Can the Preoperative Serum Lactate Level Predict the Extent of Bowel Ischemia in Patients Presenting to the Emergency Department with Acute Mesenteric Ischemia?

Purpose. Early recognition of acute mesenteric ischemia (AMI) can be challenging. Extensive bowel necrosis secondary to AMI is associated with high rates of mortality. The aim of this study was to investigate the association between preoperative serum lactate level and the extent of bowel ischemia in patients with AMI. Methods. Data of patients with abdominal pain and elevated serum lactate undergoing emergency laparotomy for suspected AMI within 24 hours of presentation was retrospectively abstracted. The length of the ischemic bowel segment was compared with the preoperative serum lactate level. Results. 36 female and 39 male patients, with median age 73.1 ± 12.3 years, were included for analysis. The median preoperative lactate was 2.96 ± 2.59 mmol/l in patients with ≤50 cm, 6.86 ± 4.08 mmol/l in patients with 51-100 cm, 4.73 ± 2.76 mmol/l in patients with >100 cm ischemic bowel, and 14.07 ± 4.91 mmol/l in the group with multivisceral ischemia. Conclusion. Although elevated serum lactate might permit an early suspicion and thus influence the clinical decision-making with regard to prioritization of surgery in patients with suspected AMI, a linear relationship between serum lactate and the extent of bowel ischemia could not be established in this study.

Improving the Preoperative Diagnostic Accuracy of Acute Appendicitis. Can Fecal Calprotectin Be Helpful?

Background

Is the patient really suffering from acute appendicitis? Right lower quadrant pain is the most common sign of acute appendicitis. However, many other bowels pathologies might mimic acute appendicitis. Due to fear of the consequences of delayed or missed diagnosis, the indication for emergency appendectomy is liberally made. This has been shown to be associated with high rates of negative appendectomy with risk of potentially serious or lethal complications. Thus there is need for a better preoperative screening of patients with suspected appendicitis.

Methods

This prospective single center single-blinded pilot study was conducted in the Department of surgery at the HELIOS Universitätsklinikum Wuppertal, Germany. Calprotectin was measured in pre-therapeutic stool samples of patients presenting in the emergency department with pain to the right lower quadrant. Fecal calprotectin (FC) values were analyzed using commercially available ELISA kits. Cut-off values for FC were studied using the receiver-operator characteristic (ROC) curve. The Area under the curve (AUC) was reported for each ROC curve.

Results

The mean FC value was 51.4 ± 118.8 μg/g in patients with AA, 320.9 ± 416.6 μg/g in patients with infectious enteritis and 24.8 ± 27.4 μg/g in the control group. ROC curve showed a close to 80% specificity and sensitivity of FC for AA at a cut-off value of 51 μg/g, AUC = 0.7. The sensitivity of FC at this cut-off value is zero for enteritis with a specificity of 35%.

Conclusion

Fecal calprotectin could be helpful in screening patients with pain to the right lower quadrant for the presence of acute appendicitis or infectious enteritis with the aim of facilitating clinical decision-making and reducing the rate of negative appendectomy.

[Wrong site surgery : Incidence, risk factors and prevention]

BACKGROUND

Wrong site surgery defines a category of rare but totally preventable complications in surgery and other invasive disciplines. Such complications could be associated with severe morbidity or even death. As such complications are entirely preventable, wrong site surgery has been declared by the World Health Organization to be a "never event".

MATERIAL AND METHODS

A selective search of the PubMed database using the MeSH terms "wrong site surgery", "wrong site procedure", "wrong side surgery" and "wrong side procedure" was performed.

RESULTS

The incidence of wrong site surgery has been estimated at 1 out of 112,994 procedures; however, the number of unreported cases is estimated to be higher. Although wrong site surgery occurs in all surgical specialities, the majority of cases have been recorded in orthopedic surgery. Breakdown in communication has been identified as the primary cause of wrong site surgery. Risk factors for wrong site surgery include time pressure, emergency procedures, multiple procedures on the same patient by different surgeons and obesity. Check lists have the potential to reduce or prevent the occurrence of wrong site surgery.

CONCLUSION

The awareness that to err is human and the individual willingness to recognize and prevent errors are the prerequisites for reducing and preventing wrong site surgery.

Calprotectin could be a potential biomarker for acute appendicitis

BACKGROUND

Acute appendicitis is a common cause for a visit to the emergency department and appendectomy represents the most common emergency procedure in surgery. The rate of negative appendectomy however has remained high despite modern diagnostic apparatus. Therefore, there is need for a better preoperative screening of patients with suspected appendicitis. Calprotectin represents a predominant protein in the cytosol of neutrophil granulocytes and has been extensively investigated with regard to bowel pathologies. This study investigates the expression of calprotectin in the lumen of the vermiform appendix of patients undergoing appendectomy for suspected appendicitis.

METHODS

Appendix specimens from patients undergoing emergency appendectomy for suspected acute appendicitis were examined. Acute appendicitis was confirmed on histopathology. The qualitative expression of calprotectin in the vermiform appendix specimens was analyzed using specific calprotectin antibodies.

RESULTS

Vermiform appendix specimens from 52 patients (22 female and 30 male) including 11 with uncomplicated and 41 with complicated appendicitis were analyzed. Strong immunostainings were achieved with calprotectin antibody in the lumen of all specimens irrespective of the extent of appendicitis. Immunostaining was negative in the uninflamed appendix.

CONCLUSIONS

High calprotectin activity could be demonstrated within the lumen of vermiform appendix specimens following appendectomy for acute appendicitis. The high luminal accumulation of calprotectin-carrying cells could be interpreted as an invitation to study the expression of calprotectin in stool as a new diagnostic aid in patients with suspected appendicitis.

Aquaporin-1 and 8 expression in the gallbladder mucosa might not be associated with the development of gallbladder stones in humans

BACKGROUND

Cholecystolithiasis is a highly prevalent condition in the Western world. Gallbladder stone-related conditions represent the second most common gastrointestinal pathology. Cholesterol stones represent over 80% of gallstones. Cholesterol stones develop secondary to crystallization of bile cholesterol. Water resorption from gallbladder bile via aquaporin in the gallbladder mucosa might play a role in the development of cholesterol stones. This study investigated the expression of Aquaporin-1 (AQP1) and Aquaporin-8 (AQP8) in the human gallbladder mucosa and their possible association with the formation of gallbladder stones.

METHODS

The expression of AQP1 and AQP8 in the gallbladder mucosa was examined via immunohistochemical staining. The expression of both AQP1 and AQP8 in the gallbladder mucosa of stone carriers (study group) was compared to that of nonstone carriers (control group).

RESULTS

Eighty-four gallbladder specimens from 44 male (52·2%) and 40 female (47·6%) patients were analysed. The study group included 47 specimens from stone carriers, while 37 specimens from stone-free gallbladders were included in the control group. Immunostaining for both AQP1 and AQP8 was positive in 80 cases. AQP1 was expressed both over the apical and intercellular membrane, while AQP8 was expressed only over the apical membrane. A similar distribution was recorded in specimens from the cystic duct. Immunostaining with AQP1 was generally stronger in comparison with AQP8. No significant (P > 0·05) relationship was found between aquaporin expression and the presence or absence of gallbladder stones.

CONCLUSION

AQP1 and AQP8 are both expressed in the gallbladder and cystic duct mucosa. However, their role in the development of gallbladder stones is still to be proven.

Gastric outlet obstruction secondary to solid-pseudopapillary neoplasm of the pancreas in an eight year old child. Report of a case

Background

Solid pseudopapillary neoplasm is a rare cystic tumor of the exocrine pancreas. Abdominal pain or discomfort is the most common symptom, usually in young females.

Case presentation

Herein we report the case of an 8 - year old child presenting with symptoms of gastric outlet obstruction.

Conclusion

A solid pseudopapillary neoplasm of the pancreatic caput was diagnosed and surgically removed.

Critically ill patients with acute cholecystitis are at increased risk for extensive gallbladder inflammation

Background

Acute cholecystitis is a common diagnosis and surgery is the standard of care for young and fit patients. However, due to high risk of postoperative morbidity and mortality, surgical management of critically ill patients remains a controversy. It is not clear, whether the increased risk of perioperative complications associated with the management of critically ill patients with acute cholecystitis is secondary to reduced physiologic reserve per se or to the severity of gallbladder inflammation.

Methods

A retrospective analysis of prospectively collected data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a university hospital over a three-year-period was performed. The ASA scores at the time of presentation were used to categorize patients into two groups. The study group consisted of critically ill patients with ASA 3 and 4, while the control group was made up of fit patients with ASA 1 and 2. Both groups were compared with regard to perioperative data, postoperative outcome and extent of gallbladder inflammation on histopathology.

Results

Two hundred and seventeen cases of acute cholecystitis with complete charts were available for analysis. The study group included 67 critically ill patients with ASA 3 and 4, while the control group included 150 fit patients with ASA 1 and 2. Both groups were comparable with regard to perioperative data. Histopathology confirmed severe cholecystitis in a significant number of cases in the study group compared to the control group (37 % vs. 18 %, p = 0.03). Significantly higher rates of morbidity and mortality were recorded in the study group (p < 0.05). Equally, significantly more patients from the study group were managed in the ICU (40 % vs. 8 %, p = 0.001).

Conclusion

Critically ill patients presenting with acute cholecystitis are at increased risk for extensive gallbladder inflammation. The increased risk of morbidity and mortality seen in such patients might partly be secondary to severe acute cholecystitis.

A proposal for a preoperative clinical scoring system for acute cholecystitis

BACKGROUND

Acute cholecystitis is a common diagnosis for which surgery is usually indicated. However, the heterogeneity of clinical presentation makes it difficult to standardize management. The variation in clinical presentation is influenced by both patient-dependent and disease-specific factors. A preoperative clinical scoring system designed to included patient-dependent and clinical factors might be a useful tool in clinical decision making.

METHODS

The data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a university hospital were retrospectively reviewed. Patient-dependent factors (age, sex, body mass index, and American Society of Anesthesiologists score) and disease-specific factors (history of biliary colics, white blood count, C-reactive protein, and gallbladder wall thickness) were used to compute a clinical score between zero and nine for each patient. Cholecystitis was classified as mild (score ≤ 3), moderate (4 ≤ score ≤ 6), or severe (score ≥ 7).

RESULTS

Cholecystitis was mild in 45 cases, moderate in 105 cases, and severe in 27 cases. Among patient-dependent factors, the male gender, age >65 y, and American Society of Anesthesiologists score >2 correlated significantly with high scores, P = 0.001. Equally, high white blood count, elevated C-reactive protein, and gallbladder wall thickness >4 mm correlated significantly with high scores, P = 0.001. These findings were confirmed on multivariate analyses. High scores correlated significantly with the duration of surgery (P = 0.007), the need of intensive care unit management (P = 0.001) and the length of stay (P = 0.001). However, there was no significant association between the preoperative score and the rate of conversion (P = 0.103) or the rate of complication (P = 0.209).

CONCLUSIONS

This preoperative clinical scoring system has a potential to select patients with severe cholecystitis and therefore might be a useful tool in clinical decision making.

[Young Women - Problematic Patients in Vascular Surgery]

The treatment of peripheral arterial disease (PAD) in young women between 40 and 60 years of age represents a difficult challenge for the vascular surgeon. Excessive smoking, an early menopause and the unfavourable anatomic proportions of thinner arterial vessels or vein grafts during peripheral bypass-surgery lead to a higher rate of complications or re-occlusion following invasive therapy in comparison to male patients. A special anatomic manifestation appearing nearly only in women around the 6th decade is the so-called aortoiliac hypoplastic syndrome with a high rate of re-occlusion after balloon-dilatation or local thrombendarteriectomy and bypass grafting, respectively. Variabilities in coagulation and the undertreatment of classical risk factors of PAD by medical drugs lead to poorer results in the treatment of PAD in young women. Therefore a conservative therapy - whenever feasible - should be the first choice for treating PAD in young women.

Cholecystectomy vs. percutaneous cholecystostomy for the management of critically ill patients with acute cholecystitis: a protocol for a systematic review

BACKGROUND

Acute cholecystitis is a common diagnosis. However, the heterogeneity of presentation makes it difficult to standardize management. Although surgery is the mainstay of treatment, critically ill patients have been managed via percutaneous cholecystostomy. However, the role of percutaneous cholecystostomy in the management of such patients has not been clearly established. This systematic review will compare the outcomes of critically ill patients with acute cholecystitis managed with percutaneous cholecystostomy to those of similar patients managed with cholecystectomy.

METHODS/DESIGN

Systematic searches will be conducted across relevant health databases including the Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, Embase, and Scopus using the following keywords: (acute cholecystitis OR severe cholecystitis OR cholecystitis) AND (cholecystectomy OR laparoscopic cholecystectomy OR open cholecystectomy) AND (Cholecystostomy OR percutaneous cholecystectomy OR gallbladder drain OR gallbladder tube OR transhepatic gallbladder drain OR transhepatic gallbladder tube OR cholecystostomy tube). The reference lists of eligible articles will be hand searched. Articles from 2000-2014 will be identified using the key terms "acute cholecystitis, cholecystectomy, and percutaneous cholecystostomy". Studies including both interventions will be included. Relevant data will be extracted from eligible studies using a specially designed data extraction sheet. The Newcastle-Ottawa scale will be used to assess the quality of non-randomized studies. Central tendencies will be reported in terms of means and standard deviations where necessary, and risk ratios will be calculated where possible. All calculations will be performed with a 95 % confidence interval. Furthermore, the Fisher's exact test will be used for the calculation of significance, which will be set at p < 0.05. Pooled estimates will be presented after consideration of both clinical and methodological heterogeneity of included studies. Both interventions would be compared with regard to in-hospital mortality, 30-day mortality, procedure-dependent complications, re-intervention, length of intensive care unit (ICU) stay, length of hospital stay, re-admission, and cost of treatment. The review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

DISCUSSION

This systematic review aims at identifying and evaluating the clinical value of percutaneous cholecystostomy in the management of critically ill patients with acute cholecystitis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015016205.

Influence of MRE11, RAD50 and NIBRIN protein expression on survival in pancreatic carcinoma after curative resection

The MRE11/RAD50/NIBRIN complex, a protein complex that repairs DNA double-strand breaks, could serve as an early marker for new lesions in pancreatic cancer. We determined the expression of MRE11, RAD50 and NIBRIN, and their possible prognostic value regarding survival. Forty-one patients with ductal adenocarcinoma of the pancreas were included. All underwent curative surgery. Immunohistochemistry was performed for MRE11, RAD50 and NIBRIN. Subsequent analyses were based on a modified immunoreactive score. Statistical analysis was conducted using the statistics program "R". The mean follow-up period was 509 days. The mean age of the patients was 67±8 years, male=56%, female=44%. Eighty-seven percent underwent a Kausch-Whipple procedure, whereas a left side resection was performed in 22% of patients. Positive lymph nodes were found in 80% of cases, and patients were staged UICC IIa (12%), IIb (56%) and IV (29%). Overall significant results were found for MRE11 (p=0.02) and NIBRIN (p=0.01) expression and postoperative survival. We found a significant relation between the expression of MRE11, NIBRIN and the postoperative survival of patients with ductal adenocarcinoma. The link between the expression of the MRN complex, ATM and pancreatic cancer can be used to develop new treatment options for pancreatic carcinoma.

Fecal urge incontinence after stapled anopexia for prolapse and hemorrhoids: a prospective, observational study

BACKGROUND

Stapled anopexia was introduced as a surgical method in 1993. Long-term data with special interest in functional results and relapse symptoms are rarely presented. Urinary discomfort and problems with fecal urge incontinence are addressed as severe side effects. We present our long-term results (using data from a high-volume center) with this technique and two surgeons' experience.

METHODS

During 4 years, a total of 546 patients entered the study. For long-term evaluation, 452 patients (237 women and 215 men) were available (82.9%). Patients with recurrent hemorrhoidal prolapse and fecal incontinence were excluded. Postoperative reevaluation with physical condition was performed after 1, 6, and 24 months by means of manometry, rectoscopy, and SF-36 Health Survey Test.

RESULTS

Early postoperative urinary impairment was 7.3%. Early fecal urge incontinence rate was 3.3%. Overall perioperative complication rate was 11.1%. Within 1 month, the rate of fecal urge incontinence increased to 13.5% and decreased to 4% and 2.9% after a period of 6 and 24 months. Overall recurrence rate was 3.3%. Reoperation rate according to the primary indication was 2.9% after 24 months. The SF-36 data showed a return to normal 1 month after the procedure was performed. Overall satisfaction rate was 95.4%.

CONCLUSIONS

Our study demonstrates that stapled anopexia is a safe and secure procedure for treatment of hemorrhoidal prolapse. Fecal urge incontinence is a self-limiting side effect that with which patients need to be made familiar.

Sixty-month follow-up after endoscopic inguinal hernia repair with three types of mesh: a prospective randomized trial

BACKGROUND

This prospective, clinical, randomized, double-blind study was intended to investigate the impact of the structure and the amount of polypropylene (PP) mesh used in laparoscopic transabdominal preperitoneal hernioplastic (TAPP) on physical function and life quality.

METHODS

180 male patients with primary inguinal hernia undergoing TAPP were randomized for using a heavyweight (108 g/m(2)), double-filament PP mesh (Prolene, 10 x 15 cm, group A, n = 60), a multifilament, heavyweight variant (116 g/m(2)) of PP mesh (Serapren, 10 x 15 cm, group B, n = 60), or a composite mesh (polyglactin and PP) (Vypro II, 10 x 15 cm, group C, n = 60). We compared in terms of complications (seromas, recurrence rate) and life quality (pain development, physical function). The development of life quality was documented according to the SF-36 Health Survey. The follow-up period was 60 months.

RESULTS

The recurrence rate (2.2% overall) during 60-month follow-up was not significantly different between the groups. Convalescence in group A was slower than in groups B and C: mean-term values of the visual scales for pain development were significantly (p < 0.05) higher, incapacity for work was 8.2 days longer, and urological adverse effects were stronger. The mean-term development of life quality was significantly lower in group A up to 12th week postoperatively. There were no significant differences between groups B and C. Beyond the 12th postinterventional week the differences diminished.

CONCLUSIONS

The composite mesh does not provide an advantage concerning physical function or pain development in comparison to the multifilament, heavyweight, pure polypropylene mesh. Independently of which mesh was implanted 5% of patients are still suffering from discomfort after 5 years.

[Groin abscesses and vascular catastrophes in intravenous drug users--strategy and results]

BACKGROUND

Drug addiction is a global medical and public health-care problem. Infections of the groin and fossa cubitalis are a common clinical problem in these patients. Severe vascular complications are rare but if they occur, therapy is difficult and requires emergency management and surgery because of bleeding problems.

METHODS

In a retrospective case series, we report on patients treated within an emergency setting in our hospital because of groin abscesses with vascular involvement between 2003 and 2006. The therapeutic concepts and results are reported and discussed in the context of a review of the international literature.

RESULTS

We report on 4 patients with a long-standing history of i. v. drug abuse (average age 33, range 29-36 years). All were hepatitis C Ag positive and HIV negative. The general health and nutritional status were not compromised, all patients had one or more DVT in their medical history. In two cases, emergency surgery with revascularisation was necessary (after 2 days in one case and 4 weeks in the other) because of septic bleeding subsequent to abscess incision. Two patients underwent primary revascularisation because of pseudoaneurysms. The grafts were a saphenous vein patch and a superficial femoral artery patch in one and deep vein segments in two cases. In two cases, a sartorius muscle flap and VAC therapy were used to cover the defect. All patients survived, minor amputation became necessary in one case.

CONCLUSION

Abscess excision and debridement have to be as complete as possible and primary revascularisation is the procedure of choice in cases of severe groin infection. In the case of large vessel involvement, abscess incision alone without revision of the vascular structures is dangerous because of subsequent complications like secondary ruptures. For this reason, these patients require intensive care and close monitoring. Successful treatment exclusively based on ligation is described in literature with regard to isolated lesions of the superficial or deep femoral artery. Because of the very common involvement of the femoral bifurcation, revascularisation is, however, necessary in most cases and should be performed with autologous grafts if possible. If complete covering of the defect is not possible, a sartorius muscle flap is a good choice. Primary wound closure can be problematic because of recurrences, therefore vacuum-assisted wound closure is a valuable addition to the overall therapeutic approach in these cases.

Comparison of a beta-blocker and an If current inhibitor in rabbits with myocardial infarction

AIM

We compared protective effects of a ss-adrenoceptor blocker (metoprolol; Met) and a If current (Ivabradine; Iva) in a rabbit model of myocardial infarction.

METHODS

Experiments were performed on 44 adult New-Zealand-White (NZW) rabbits. The effects of either metoprolol or ivabradine were assessed 15 min after experimental occlusion of a coronary artery (CAO), 28 days after CAO (drug gavage), and in vitro hearts (Langendorff apparatus). The results were compared with sham and placebo hearts.

RESULTS

Metoprolol (0.25 mg/kg) slightly reduced heart rate and left ventricular systolic function. Ivabradine (0.25 mg/kg) reduced heart rate significantly (P<0.05) (18% vs control). Both drugs provided advantages over placebo: mortality was significantly (P<0.01)smaller (6/13 Pla animals died, 2/10 Met animals, and 3/11 Iva animals), left ventricular function was better preserved after 28 days (external power; Pla; Met; Iva=56%; 76%; 74%), and dilatation (BNP) was reduced (P<0.05). In the Pla group, the ST segment was significantly (P<0.05) elevated by 0.35 mV after CAO and exhibited in 50% of the animals Q waves after 28 days, while after ivabradine or metoprolol, ST displacement and Q waves had disappeared. The uneconomic myosin isoenzyme V3 predominated in Met hearts and Iva hearts (V3/V1: 63/37% and 62/38%), while it was further increased in Pla hearts (78/21%). External efficiency was lowest in Pla hearts (1.00+/-0.50 a.u.; P<0.05) and was significantly higher both in Met hearts (4.0+/-1.8 a.u.) and in Iva hearts (3.3+/-1.6 a.u.).

CONCLUSIONS

Met and Iva seem suited for the treatment of chronic myocardial infarction.

Comparison of biomaterials: three meshes and TAPP for inguinal hernia

BACKGROUND

In laparoscopic hernia repair the use of biocompatible materials is necessary. A prospective, double-blind study was projected to compare three different meshes.

METHODS

Ninety male patients with primary inguinal hernia undergoing transabdominal preperitoneal (TAPP) implant procedures were included. Three different types of mesh were tested: a monofile, heavy-weight, rigid mesh (group A), a smooth, heavy-weight variant of polypropylene (group B), and a polyglactin/polypropylene compound mesh (group C). Complications, pain development, inability to work, physical conditions, testicular volume, and blood circulation were documented.

RESULTS

Convalescence in group A was slower than in groups B and C: Postoperative values of visual scales for pain development were higher, inability to work was 7.3 days longer, urologic effects were more severe, activities of everyday life were more reduced, and data of the German SF-36 Health Survey Test showed a significant reduction of physical condition (p < 0.05).

CONCLUSION

The compound mesh did not create more comfort for the patients than the smooth variant of the heavy-weight polypropylene mesh.

Endoscopic Thoracic Sympathectomy for Severe Hyperhidrosis: Impact of Restrictive Denervation on Compensatory Sweating

BACKGROUND

Compensatory sweating is noted frequently after sympathectomy and may be difficult to control in some patients. This prospective trial was projected to measure the impact of limited denervation on compensatory sweating while performing endoscopic thoracic sympathectomy.

METHODS

One hundred seventy-eight patients (127 female and 51 male) with severe primary hyperhidrosis unsuccessfully treated by conservative means entered the study. Group A was treated with sympathectomy from T2 to T4. In group B sympathectomy was performed from T3 to T5. Physical condition was measured after 1, 6, and 24 months by means of the SF-36 Health Survey Test.

RESULTS

Evaluation rate was 94.9%. Horner's syndrome was not detected, recurrence rate was 0.6%, and rate of persistent pneumothorax was 2.3%. Compensatory sweating was reported with 17.1% in group A and diminished to 4.9% in group B. Gustatory sweating was comparable in both groups (4.3% versus 4.9%). Satisfaction rate was 97% in patients with palmar hyperhidrosis, 95% for axillary hyperhidrosis, and 87% for facial hyperhidrosis. Discomfort originating from compensatory sweating was less than symptoms from primary hyperhidrosis 24 months after endoscopic thoracic sympathectomy in more than 90%. Only 7.1% of the entire group was not satisfied.

CONCLUSIONS

Our study demonstrates that limiting denervation beyond T2 ganglion offers good clinical results in axillary as well as palmar hyperhidrosis and may reduce the risk for compensatory sweating. In women, reduction was as high as 75% and in men, near 50%. Our impression is that severe compensatory sweating and the majority of stellate ganglion lesions occur as a result of starting sympathectomy at level T2.