Repeated hepatic resection for colorectal liver metastases: is this concept safe and feasible?

Background

The beneficial outcomes of hepatectomy in patients with colorectal metastases have encouraged the attempts of repeated hepatectomy in patients with recurrent disease. Although studies have provided encouraging results regarding perioperative outcomes and survival rates following repeated hepatectomy, it remains unclear whether the reported outcomes reflect the therapeutic results of redo hepatectomy or rather reflect the effect of selection bias. The aim of this study was to investigate differences among patients who underwent single and repeated hepatectomy and to hereby identify prognostic factors that contribute to the premises of repeated resection.

Methods

Patients who underwent hepatectomy due to colorectal metastases were listed in a retrospective database. Study participants were divided into a single partial hepatectomy group, a multiple partial hepatectomies group, and into subgroups of two or more than two hepatectomies.

Results

A total of 338 patients with 439 partial liver resections were included in the analysis. The overall survival rate after 1, 3, and 5 years was 89%, 56%, and 36%, respectively. The survival benefit in patients who underwent multiple partial liver resections versus those with a single partial resection was 10%, 16%, and 4% after 1, 3, and 5 years, respectively. Repeated hepatectomy was not associated with increased rates of surgical and non-surgical complications.

Conclusion

Beneficial outcomes have been found in terms of median overall survival and perioperative morbidity in patients with recurrence of colorectal hepatic metastases after partial and tissue-sparing repeated liver resections.

A Biologic Surgical Implant in Complex Abdominal Wall Repair: 3-Year Follow-Up Results of a Multicentric Prospective Study

Purpose

Despite the advancements in the reinforcement and closure techniques available, complex abdominal wall reconstruction (CAWR) remains a challenging surgical undertaking with considerable risk of postoperative complications. Biological meshes were developed that may help to complement standard closure techniques and offer an alternative to synthetic meshes, which carry significant risks with their use in complex cases.

Patients and Methods

A total of 114 patients underwent surgical treatment for CAWR with a Permacol™ (a biologic surgical implant). The study objective was to evaluate the short-term (6 months), mid-term (12–24 months), and long-term (36 months) clinical outcomes (through 36 months) associated with the use of a biologic surgical implant in these cases.

Results

The cumulative hernia recurrence rate was 18.7% (17/91) at 24 months and 22.4% (19/85) at 36 months. Twelve (14.1%) subjects required reoperation for hernia repair within 36 months for repair of recurrent hernias. Between 6- and 36-months post-surgery, patients reported improvement in their Carolina comfort scale (CSS) measures of severity of pain, sensation of mesh, and movement limitations.

Conclusion

A biologic surgical implant can provide long-term benefit to complex abdominal wall repairs in patients staged grade III according to the Ventral Hernia Working Group (VHWG).

[Patient satisfaction after thyroidectomy - the width of the scar is more important than the length]

OBJECTIVE

 To avoid a scar on the neck, alternative methods of thyroidectomy have been developed. The aim of our study was to determine the significance of the scar and the factors influencing satisfaction after classical thyroidectomy in the long term.

MATERIAL AND METHODS

 228 patients who underwent partial or total thyroidectomy for benign thyroid disease between 2001 and 2014 participated in a telephone interview. In addition to patient satisfaction, demographic data, the subjective appearance of the scar, and subjective complaints were recorded.

RESULTS

 93.8 % of the patients were satisfied with the treatment. Female and younger patients tended to be more dissatisfied than both male and older patients. The mean scar length was 6.03 ± 2.36 cm and the mean scar width was 2.01 ± 1.46 mm. The length of the scar did not affect satisfaction. In contrast, patients with a wider prominent or conspicuously stained scar were significantly more dissatisfied. Patients who suffered from symptoms such as pressure or difficulty swallowing postoperatively were also significantly more dissatisfied. Cosmetic problems affect satisfaction more than functional problems.

CONCLUSIONS

 Satisfaction after thyroidectomy is good in the long term. Whether satisfaction can be further improved by using an alternative or minimally invasive procedure is questionable. These procedures may be an alternative for younger and female patients or those who focuses on cosmetics.

[Surgical treatment of colorectal carcinoma in the elderly]

Colorectal carcinoma is one of the most frequent tumor entities worldwide. The treatment of elderly and mostly polymorbid patients is an outstanding challenge in view of the demographic change with a continuously aging community. Due to the demographic changes the numbers of elderly (>65 years) and very old (≥80 years) patients are steadily increasing in surgical cohorts. This has resulted in higher morbidity and mortality rates in comparison to younger patients, with increased wound healing and cardiovascular complications but with comparable numbers of anastomotic insufficiency. Multivariate analysis revealed age ≥80 years, higher ASA status and emergency operations as independent risk factors for increased in-hospital mortality. With respect to the localization of colorectal cancer a shift to the right has been observed with increasing patient age. Whether minimally invasive surgical techniques can reduce postoperative morbidity and mortality rates in elderly patients requires further evaluation. Nevertheless, a reduction of both was reported without compromising the oncological result. Elderly patients require individualized treatment modalities, which take the extent of comorbidities and personal environment into consideration. So far, the cohort of octogenarians has not been adequately considered in current guidelines; therefore, geriatric expertise is recommended to be able to make a better assessment of benefit-risk ratios, as age itself has no impact on the decision for therapy.

Acute Cholecystitis

Background

The treatment of acute cholecystitis has been controversially discussed in the literature as there are no high-evidence-level data yet for determining the optimal point in time for surgical intervention. So far, the laparoscopic removal of the gallbladder within 72 h has been the most preferred approach in acute cholecystitis.

Methods

We conducted a systematic review by including randomized trials of early laparoscopic cholecystectomy for acute cholecystitis.

Results

Based on a few prospective studies and two meta-analyses, there was consent to prefer an early laparoscopic cholecystectomy for patients suffering from acute calculous cholecystitis while the term ‘early’ has not been consistently defined yet. So far, there is new level 1b evidence brought forth by the so-called ‘ACDC’ study which has convincingly shown in a prospective randomized setting that immediate laparoscopic cholecystectomy – within a time frame of 24 h after hospital admission – is the smartest approach in ASA I-III patients suffering from acute calculous cholecystitis compared to a more conservative approach with a delayed laparoscopic cholecystectomy after an initial antibiotic treatment in terms of morbidity, length of hospital stay, and overall treatment costs. Concerning critically ill patients suffering from acute calculous or acalculous cholecystitis, there is no consensus in treatment due to missing data in the literature.

Conclusion

Laparoscopic cholecystectomy for acute cholecystitis within 24 h after hospital admission is a safe procedure and should be the preferred treatment for ASA I-III patients. In critically ill patients, the intervention should be determined by a narrow interdisciplinary consent based on the patient's individual comorbidities.

Anal sphincter function after total mesorectal excision is comparable to that of healthy subjects: results of a matched pair analysis

AIM

The aim of this paper was to compare healthy subjects and patients after total mesorectal excision concerning anal resting/squeeze pressure and surface-electromyography of the sphincter.

METHODS

Forty patients (9 female/31 male) after total mesorectal excision due to low or middle rectal cancer were compared to a sex-, age- and BMI-matched group of healthy volunteers by means of anorectal pull-through manometry using a microtip-transducer system and by means of endoanal surface electromyography using a bipolar plug electrode.

RESULTS

Resting pressure (59.2 ± 3.1 mmHg vs. 68.3 ± 4.3 mmHg; P=0.056) and squeeze pressure (127.3 ± 3.2 mmHg vs. 128.9 ± 4.6 mmHg; P=0.78) were comparable between patients after total mesorectal excision and healthy volunteers whereas surface electromyography amplitude (9.5 ± 0.4 µV vs. 13.9 ± 0.6 µV; P=0.01) was significant lower in patients after total mesorectal excision compared to healthy subjects. Correlation between squeeze and resting pressure as well as between squeeze pressure and surface electromyography were weaker in patients after total mesorectal excision compared to healthy controls.

CONCLUSION

Objective measurable sphincter pressure after total mesorectal excision seems to be comparable to that of healthy subjects whereas surface-electromyography is significant higher in healthy subjects.

Intrahepatic cholangiocarcinoma in a transplant liver--selective internal radiation therapy followed by right hemihepatectomy: report of a case

Intra- or extrahepatic cholangiocarcinomas are the second most common primary liver malignancies behind hepatocellular carcinoma. Whereas the incidence for intrahepatic cholangiocarcinoma is rising, the occurrence of extrahepatic cholangiocarcinoma is trending downwards. The treatment of choice for intrahepatic cholangiocarcinoma remains liver resection. However, a case of liver resection after selective internal radiation therapy in order to treat a recurrent intrahepatic cholangiocarcinoma in a transplant liver is unknown in the literature so far. Herein, we present a case of a patient undergoing liver transplantation for Wilson’s disease with an accidental finding of an intrahepatic cholangiocarcinoma within the explanted liver. Due to a recurrent intrahepatic cholangiocarcinoma after liver transplantation, a selective internal radiation therapy with yttrium-90 microspheres was performed followed by right hemihepatectomy. Four years later, the patient is tumor-free and in a healthy condition.

The role of cryosurgery in the treatment of colorectal liver metastases: a matched-pair analysis of cryotherapy vs. liver resection

BACKGROUND/AIMS

Although liver resection is the gold standard for patients with colorectal liver metastases (CRLM), only 15-20% of the patients are candidates for surgery. As ablative therapies may extend this low rate of curative option, the aim of the present study was to analyze the impact of cryosurgery (cryo) on survival of patients with CRLM compared to liver resection (Phx).

METHODOLOGY

In a matched-pair analysis, patients undergoing Phx or cryo were compared (n = 39 each). Analysis included pre-, peri-and postoperative data and follow-up for tumor-free and overall survival. Survival was estimated by Kaplan-Meier method.

RESULTS

Out of 124 patients undergoing 143 cryosurgical procedures, 39 patients could be identified undergoing single liver cryo procedure for CRLM with a curative approach. Matching of these patients with a Phx cohort, patients undergoing Phx revealed better overall (20 vs. 46 months) and tumor-free survival (7.8 vs. 33.6 months) than patients with cryo.

CONCLUSIONS

Liver resection is strongly recommended for patients with CRLM compared to cryosurgery.

Hepatic resection of non-colorectal and non-neuroendocrine liver metastases - survival benefit for patients with non-gastrointestinal primary cancers - a case-controlled study

PURPOSE

Whereas resection of colorectal liver metastases is gold standard, there is an ongoing debate on benefit of resection of non-colorectal (NCRC) and non-neuroendocrine (NNEC) liver metastases.

METHODS

The potential survival benefit of patients undergoing resection of NCRC or NNEC liver metastases was investigated. Data from a prospectively maintained database were reviewed over a 7-year period. Kaplan-Meier method was used for the evaluation of outcome following resection.

RESULTS

101 patients underwent 116 surgical procedures for synchronous and metachronous NCRC or NNEC liver metastases with a morbidity of 23% and a mortality of ∼1%. 11 patients underwent repeated liver resection procedures. Overall 5-year survival after liver resection was 30% depending on primary tumour site. Median survival was significantly increased after resection of hepatic metastases from non-gastrointestinal primaries compared to gastrointestinal primaries. Resection of hepatic metastases from non-gastrointestinal primaries resulted in significantly increased median survival compared to exploration only. Patients with hepatic metastases from gastrointestinal primaries did not benefit from hepatic surgery.

CONCLUSION

Hepatic resection for liver metastases from NCRC or NNEC cancers is a save treatment procedure. However, the decision to perform surgery should depend on the primary cancer. Especially patients with liver metastases from non-gastrointestinal primaries profit from hepatic surgery.

Impact of meteorological conditions on abdominal aortic aneurysm rupture: evaluation of an 18-year period and review of the literature

OBJECTIVE

To examine the influence of local meteorological conditions on the onset of ruptured abdominal aortic aneurysms (AAA).

METHODS

A review of 6551 consecutive days with a total of 191 ruptured AAA was performed between January, 1994 and December, 2011. Days with and without ruptured AAA were compared considering local meteorological data. A systematic review of the literature was performed.

RESULTS

Atmospheric pressure, cloudiness, relative humidity, precipitation, and water vapor pressure were comparable at event and nonevent days. The 4-day variance of atmospheric pressure prior to event days was significantly higher compared to nonevent days. Maximal and average temperature and water vapor pressure were significant lower at event days. Binary regression analysis identified a higher 4-day variance in atmospheric pressure as an independent factor for ruptures.

CONCLUSIONS

Further studies-collected at different geographic and climate areas-are necessary to prove that meteorological conditions may trigger the incidence of ruptured AAA.

Octreotide prophylaxis is not beneficial for biochemical activity and clinical severity of postoperative pancreatic fistula after pancreatic surgery

BACKGROUND

Prospective randomized trials indicate that prophylactic octreotide treatment does not decrease the incidence of postoperative pancreatic fistula (POPF). The aim of this study was to analyze if octreotide prophylaxis could decrease the severity grade of POPFs after pancreatic surgery.

METHOD

Seventy-eight of 684 patients undergoing pancreatic resection with POPF were included in the study. Prophylactic octreotide treatment was started immediately after surgery and was performed in 22 patients, whereas 56 patients had no octreotide treatment and served as controls. Lipase activity was measured in the abdominal drainage on postoperative days (POD) 3, 5 and 7. Primary endpoints of the study were clinical severity of the POPF and lipase activity in the drainage.

RESULTS

There was no significant difference concerning length of postoperative hospital stay. Lipase activity in the abdominal drainage was not influenced by octreotide prophylaxis at POD 5 or 7 compared to POD 3. Multivariate analysis showed that the risk to develop a type B or C fistula in the octreotide group was independent of the kind of operation and the consistency of the pancreas (RR = 3.4; CI = 1.0-11.7; p = 0.050 and RR = 6.3; CI = 1.4-29.6; p = 0.019).

CONCLUSION

Octreotide prophylaxis after pancreatic surgery has no beneficial effect on clinical severity of POPF.

[A giant non-parasitic liver cyst as a prominent epigastric mass in an obese patient]

HISTORY AND ADMISSION FINDINGS

A 62-year-old, obese male patient was referred because of an increasing prominent epigastric mass and bloated feeling. An epigastric hernial defect was clinically excluded.

INVESTIGATIONS

Abdominal imaging by ultrasound and CT-scan demonstrated a giant liver cyst in the left lobe of 20 cm in diameter with a displacement of the stomach. Endoscopy showed an external compression of the stomach. Cystic echinococcosis was excluded by serology.

TREATMENT AND COURSE

Laparoscopic deroofing of the cyst resulted in immediate freedom of symptoms. The further course was uneventful. The patient was discharged one day after the operation.

CONCLUSION

Liver cysts may become symptomatic by intestinal compression syndromes or - occasionally - as a prominent abdominal mass. Laparoscopic deroofing is the golden standard of symptomatic non parasitic liver cysts and is associated with a good clinical outcome.

A comparative evaluation of ablations produced by high-frequency coagulation-, argon plasma coagulation-, and cryotherapy devices in porcine liver

INTRODUCTION

Hepatic resection is the only curative treatment option for primary or metastatic malignancies of the liver. Although R1 resections can also lead to prolonged survival, the main surgical goal is complete tumor resection (R0). To achieve this, additional treatment of the resection margin with ablation devices is discussed. Using a porcine in vivo model, we therefore analyzed the effect of different ablation devices on depth and completeness of hepatic parenchymal cell destruction.

METHODS

Swabian-Hall strain pigs underwent ablation on the surface of the right, middle, or left liver lobe using seven different types of high-frequency (HF)-, cryotherapy (Cryo)-, or argon plasma coagulation (APC) devices. Penetration depth and volume were analyzed from histological sections. Severity of parenchymal cell destruction was assessed by a histomorphological score.

RESULTS

The greatest penetration depth was achieved with Cryo (10.4 ± 1.7 mm), whereas HF and APC exhibited a smaller penetration depth. However, HF and APC compared to Cryo achieved complete destruction of the intralobular architecture and hepatocellular morphology depending on the application time and the adjusted power.

CONCLUSION

HF, APC, and Cryo applied to the liver surface induce different parenchymal penetration depth and cell destruction. HF and APC are considered to be standard surgical instruments and therefore recommended as standard treatment, whereas Cryo may be used only if particularly deep penetration is required.

Normative values in anorectal manometry using microtip technology: a cohort study in 172 subjects

PURPOSE

The aims of this study were to obtain normative values in resting/squeeze pressure and surface electromyography (s-EMG) in anorectal manometry using microtip technology and to determine the relationship between objective measurable values, gender and age in a cohort with no anorectal disorders.

METHODS

One hundred seventy-two white central European subjects (106 males/66 females) were recruited prior to left colonic or upper rectal surgery and studied by anorectal rapid pull-through manometry with a microtip transducer system and endoanal s-EMG using a bipolar plug electrode. s-EMG patterns were determined as plateau, peak and decrease by a blinded co-investigator. Objective measurable sphincter pressures and s-EMG values were correlated with gender, age and s-EMG patterns.

RESULTS

Squeeze pressure, voluntary pressure as well as s-EMG amplitude and its area under the curve were significantly lower in women compared to men (p < 0.001 each), whereas resting pressure showed no gender differences. s-EMG patterns were strongly influenced by gender. Male patients showed significantly more plateau pattern whereas peak pattern was significantly more often in women. In both genders, the peak pattern was associated with significant higher squeeze pressures. In all measurements, we found considerable inter-individual variations being higher in elder patients. There was no manometric parameter correlating with age.

CONCLUSIONS

Gender is the strongest factor influencing objective measurable manometric data for healthy men and women. There are significant gender differences concerning squeeze patterns. All manometric values should be interpreted in the context of gender and of methodology used. Large prospective cohort studies matched for gender are necessary to clarify the effect of ageing on anal sphincter strength.

Giant midoesophageal diverticulum--case report and review of the literature

INTRODUCTION

Midoesophageal diverticula >4cm in size are a medical rarity with a dozen reported cases so far. Usually, midoesophageal diverticula tend to be of small size and asymptomatic.

CASE REPORT

We herein present a case of a woman suffering from a midoesophageal diverticulum in a very large dimension--never described in the current literature before--who successfully underwent surgical resection via thoracotomy.

DISCUSSION

If symptomatic, common symptoms are dysphagia and regurgitation. The risk of malignant transformation is low. Treatment of midoesophageal diverticula is based on size and symptoms of the patient. Asymptomatic or small diverticula detected during routine endoscopy can be followed-up without further therapy, whereas symptomatic or large diverticula should be treated surgically by resection. Myotomy should be performed if any motility disorder is evident. Open as well as minimal invasive approach by thoracoscopical surgery is both feasible.

[Benchmarking surgical resources--a work sampling analysis at a German university hospital]

INTRODUCTION

Work densification caused by lack of young surgeons with increased clinical documentation keeps surgeons busy. It is proven by many studies that surgeons work significantly longer hours per week and deal with a larger amount of medical and non-medical documentation than staff members in conservative disciplines. The aim of the study was to investigate surgeons work distribution in a surgical university department and to evaluate by means of a work sampling analysis whether it can be standardised and slimmed down by systematic use of IT-supported, process-managed work-flow. In addition the data obtained are compared wuith those from other studies on similar topics.

METHODS

Based on the results of an independent pilot observational study, 21 surgeons (14 residents, 7 staff surgeons) had to document over a 10-day period in a self-observation once in an hour their actual activity in a two dimensional matrix concerning medical activity (13 items) and patient contact (5 items). After the study, each physician had to estimate his/her own work distribution. Real percentages of the self-observation study were compared to the physicians' estimates of work distribution. IT-supported clinical pathways have been implemented since 2004 in our department.

RESULTS

Over a ten-day evaluation period (1830 observation points), surgeons spent 30.2% of their activity in the operating theatre or on direct patient care. During 13.9% they were in meetings and they spent 10.8% of their time on documentation. Time needed for studying medical records (9.2%) and ward rounds (9.0%) ranged in a similar way. There was a significant accordance of estimated and real work distribution concerning the 5 most frequent daily activities. In only 14% there was no direct patient relationship.

CONCLUSION

Application of work sampling analysis in surgery is a valid procedure for the evaluation of work flows in the course of personal observations. Surgeons working time in a hospital is limited. To achieve a maximum of direct patient care, clinical documentation has to be optimised by process automatisation within the context of IT-supported clinical pathways. Surgeons are able to estimate very exactly the distribution of their daily activities so that data of working time estimations is valuable.

Evidence for tumor cell spread during local hepatic ablation of colorectal liver metastases

INTRODUCTION

The aim of the present study was to analyze the impact of cryosurgery (CRYO) on liver metastases compared to other thermoablative techniques. In a rat liver metastases model, evidence for tumor cell spread was analyzed comparing CRYO, radiofrequency ablation (RFA), and laser-induced thermotherapy (LITT).

METHODS

In an experimental study, we compared cell spillage in the washout of isolated perfused rat livers undergoing thermal ablation. Within the same model, CC531-GFP rat liver tumors were treated with CRYO, RFA, or LITT and the number of vital tumor cells within the perfusate was measured. Matrix metalloproteinases (MMP-2, MMP-9) were analyzed after in vivo ablation of rat colorectal liver metastases in the third experimental model.

RESULTS

Our data showed pronounced washout of cells after CRYO with a higher amount of intravascular cells and cell detritus compared to RFA and LITT. Only the effluent fluid of cryosurgery-treated livers revealed GFP-stained tumor cells. MMP-2 and MMP-9 expression was significantly higher after cryosurgery than after RFA and LITT.

CONCLUSION

When using thermoablative techniques, intravascular metastatic cell spillage is highest in CRYO, and increased expression of matrix metalloproteinases may further facilitate tumor cell spread. Therefore, RFA and LITT may be preferable whenever surgical resection of liver tumors is impossible.

Parenchyma-preserving hepatic resection for colorectal liver metastases

BACKGROUND

Hepatic resection of colorectal liver metastases is the only curative treatment option. As clinical and experimental data indicate that the extent of liver resection correlates with growth of residual metastases, the present study analyzes the potential benefit of a parenchyma-preserving liver surgery approach.

METHODS

Data from a prospectively maintained database of patients undergoing liver resection for colorectal metastases were reviewed. Evaluation of outcome was performed using the Kaplan-Meier method. Correlations were calculated between clinical-pathological variables.

RESULTS

One hundred sixty-three patients underwent 198 liver resections for colorectal metastases: 26 major hepatectomies, 65 minor anatomical resections, 78 non-anatomical resections, as well as 29 combinations of minor anatomical and non-anatomical procedures. Overall 1-, 3-, and 5-year survival was 93%, 62%, and 40%, respectively. Patients with repeated liver resections had a 5-year survival of 27%. Interestingly, large dissection areas were associated with a significant reduction of the 5-year survival rate (33%). Five-year survival after major hepatectomy was not significantly reduced.

CONCLUSION

For colorectal liver metastases, minor resections offer a prolonged survival compared to major hepatectomies. As patients with stage IV colorectal disease are candidates for repeat resections, preservation of hepatic parenchyma is of increasing importance in the setting of multi-modal and repeated therapy approaches.

Gastrectomy with isoperistaltic jejunal parallel pouch in a 15-year-old adolescent boy with gastric adenocarcinoma and autosomal recessive agammaglobulinemia

A 15-year-old adolescent boy with autosomal recessive agammaglobulinemia underwent endoscopy because of unexplained growth failure and malnutrition. Esophagogastroduodenoscopy revealed antropyloric stenosis, and a biopsy showed an invasive gastric adenocarcinoma. Chronic atrophic corpus gastritis type A and Helicobacter pylori were also identified. Abdominal magnetic resonance imaging confirmed the stenosis resulting from a semicircular intramural tumor without obvious local or distant metastatic spread. Gastrectomy with an extended lymphadenectomy was performed. Esophagoduodenal continuity was restored by an interposed jejunal parallel pouch developed from the first jejunal loop. Oral feeding was supplemented by parenteral nutrition via a Broviac catheter, and the patient is well 4 months later. Several cases of gastric cancer have been reported in children with hereditary agammaglobulinemia. Thus, endoscopy is mandatory in such patients with gastrointestinal symptoms to identify and treat tumors before metastasis occurs. Total gastrectomy, extended lymphadenectomy, and reconstruction using a jejunal reservoir with maintenance of duodenal continuity should be considered.

The nightknife©: evaluation of efficiency and quality of bipolar vessel sealing

BACKGROUND

Nightknife(©) is a novel reusable bipolar vessel sealing device. In the present study we analyzed its efficiency and quality of vessel sealing in comparison to a standard instrument (LigaSure™).

MATERIALS AND METHODS

Mesenteric veins and arteries of 5 Swabian-Hall pigs were sealed by means of Nightknife and LigaSure. Thermal performance of both devices was assessed by dynamic thermography. Analysis of the sealed vessels included the determination of seal failure rates and heat-associated macroscopic tissue appearance.

RESULTS

The overall sealing rate of Nightknife was significantly higher than that of LigaSure (95.8% versus 87.0%; P=.012). This was associated with a more pronounced thermal spread (8.22±0.13 versus 7.12±0.10 mm; P=.012) and tissue desiccation (2.15±0.06 versus 1.86±0.07; P=.003). Moreover, sealing time (12.30±0.17 versus 7.72±0.17 seconds; P=.038) and tissue temperature (93.73°C±0.69°C versus 66.71°C±2.18°C; P=.001) were significantly higher with the use of Nightknife. Logistic regression analysis revealed that the degree of tissue desiccation correlated with the overall sealing success.

CONCLUSION

Nightknife is as appropriate as LigaSure for the successful sealing of mesenteric vessels despite significant differences in tissue alterations and sealing time between the two devices.

Bronchobiliary fistula: a rare complication of hepatic endometriosis

OBJECTIVE

To report the case and surgical therapy of a patient with bilioptysis after vaginal delivery, caused by bronchobiliary fistula. Histologic analysis revealed endometrial glands embedded in the decidual stroma neighboring the liver and the lung.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 39-year-old patient, 7 days after vaginal delivery, without endometrial history.

INTERVENTION(S)

Synchronous liver and lung resection of a bronchobiliary fistula by laparotomy and a transdiaphragmatic approach.

MAIN OUTCOME MEASURE(S)

For complicated brochobiliary fistula caused by endometriosis, radical surgical treatment is mandatory.

RESULT(S)

Histopathologic analyses confirmed the presence of clusters of endometrial glands embedded in the decidual stroma that were neighboring the liver, and perifistulous lung tissue was shown to contain biliary pigment absorbed by macrophages and their derivatives.

CONCLUSION(S)

Hepatic and perihepatic endometriosis can cause a bronchobiliary fistula. Exacerbation of the symptoms can be triggered by high estrogen levels, physiologically dominating the last trimester. For such a rare case, surgery is mandatory.

[Reduced time-frame for ward rounds and patient satisfaction]

INTRODUCTION

The introduction in 2006 of the European legislation restricting physicians work-ing hours has had a dramatic impact on working conditions. This restriction called for a marked improvement in hospital workflow, leading to a reduction of time spent on ward rounds. We conducted an opinion survey assessing patient satisfaction in the area of markedly reduced ward rounds.

MATERIALS AND METHODS

By January 2009, the time-frame allowed for morning ward rounds had been reduced by 33 % from 45 to 30 min. At the same time, the attendance of the senior staff surgeon was declared mandatory on each ward round. We conducted a prospective study, assessing patient satisfaction over a period of 3 months.

RESULTS

86 patients with an average age of 56.7 years were repeatedly questioned by a single investigator. Average length of hospital stay was 7.2 days. Patients expected ward rounds to average 5.3 min, which was significantly higher than actually observed. However, an overall patient satisfaction of above 80 % could be measured.

CONCLUSION

In spite of the reduced time spent on ward rounds, a high level of overall patient satisfaction can be obtained due to the regular attendance of a senior staff surgeon. Process management is furthermore endorsed by the routine -application of clinical pathways in patient management.

Impact of IT-supported clinical pathways on medical staff satisfaction. A prospective longitudinal cohort study

INTRODUCTION

Clinical pathways (CPs) have been evaluated with regard to process optimization, economic effects, quality of care, patient satisfaction and staff satisfaction. IT- (information technology) supported CPs, integrated within the HIS (hospital information system), have been implemented in our department in 2004 for the first time world-wide. Herein, we describe the effect of this new concept on medical staff satisfaction.

METHODS

A prospective anonymous and voluntary survey with standardized questionnaires was performed annually from 2006 until 2009 evaluating staff satisfaction concerning CPs. Questions comprised satisfaction with the software, staff's attitude towards CPs and the impact of CPs on work-related processes.

RESULTS

Within the observation period the term "clinical pathways" became more common among doctors and nurses. Knowledge of the aims of CPs increased significantly in nursing staff (43.4-74.5%), whereas doctor's knowledge was on a constant high level. Standardization, process facilitation and cost effectiveness were the most claimed goals of CPs. Comprehensibility of the single steps within CPs was on a constant high level over the observation period. Generally, graphical layout and usability of CPs ranged on a very high satisfaction level. Acceptability of IT-supported CPs is independent from staffs computer knowledge.

CONCLUSIONS

Staff satisfaction with IT-supported CPs needs to take into account the job characteristics of the different professional groups. IT-supported CPs are leading to a high staff satisfaction, the aims of CPs are widely understood by medical employees. IT-supported CPs may ameliorate staff satisfaction and thereby enhance workflow efficiencies.

Reduced neorectal capacitance is a more important factor for impaired defecatory function after rectal resection than the anal sphincter pressure

OBJECTIVE

The role of the diverse anorectal diagnostic tools like manometry and determination of the preception threshold and the maximal tolerable volume is still a matter of debate. Currently, there is a scarcity of physiological data in the long-term follow-up of patients who underwent sphincter-preserving rectal resection. The aim of this study was therefore to perform these anorectal physiological measurements and to correlate the determined parameters with a faecal incontinence score.

METHOD

In 45 patients, anorectal manometry, electromyography (EMG) and neorectal volume measurements were performed 21.6 +/- 1.4 months after rectal resection. Additionally, patients answered questions to help in the determination of a modified faecal incontinence score.

RESULTS

More than half of the patients had more than four bowel movements per day and suffered from defecatory urgency, evacuation and discrimination problems. Manometric data were not related to any functional deficits. In contrast, perception threshold and maximal tolerable volume were correlated with the faecal incontinence score.

CONCLUSION

Defecatory problems especially after radiochemotherapy are still common after rectal resection and the satisfactory functionality post resection should not be oversimplified to just the number of bowel movements. A precondition of an adequate defecation is not only the integrity of the sphincter muscles, but also the recovery of the rectal reservoir function.

Randomized clinical trial of efficacy and costs of three dissection devices in liver resection

BACKGROUND

In recent decades a variety of instruments for liver dissection has become available. This randomized controlled trial analysed the efficacy and costs of three different liver dissection devices.

METHODS

Ninety-six patients without cirrhosis undergoing liver resection were randomized to either ultrasonic dissection, waterjet dissection or dissecting sealer (32 in each group). Patients were unaware of the device used. The primary endpoint was dissection speed. Secondary endpoints were intraoperative blood loss, morbidity and mortality, and costs of dissection devices, staplers and haemostatic agents.

RESULTS

Dissection was slower with the dissecting sealer (P = 0.004 versus waterjet dissector). The difference was more pronounced for extended resections (mean(s.e.m.) 1.62(0.36) cm(2)/min versus 3.42(0.53) and 3.63(0.51) cm(2)/min for ultrasonic and water dissectors respectively; P = 0.037). Costs were significantly higher for the dissecting sealer when atypical or segmental resections were performed. Four patients died after extended resections; postoperative complications did not differ between groups.

CONCLUSION

The dissecting sealer is slower than the ultrasonic dissector or water dissector. The three devices are equally safe in terms of blood loss, transfusions and postoperative complications. Ultrasonic and water dissectors might be more favourable economically than the dissecting sealer.

REGISTRATION NUMBER

ISRCTN52294555 (http://www.controlled-trials.com).

Cholecystocolonic fistula prevents upper intestinal obstruction by a large gallstone after perforation into the duodenum

BACKGROUND

Bilioenteric fistulas are rare complications of cholecystolithiasis that are associated with high morbidity and mortality and mainly appear in elderly patients.

CASE PRESENTATION

This is the report of a patient suffering from cholecystoduodenal fistula with additional cholecystocolonic fistula.

DISCUSSION

This cholecystocolonic fistula provoked a short bowel syndrome with symptomatic diarrhea and prevented an upper gastrointestinal ileus caused by the large perforated gallstone into the duodenum. This interesting constellation has not been described in literature yet.

ELR+ CXC chemokine expression in benign and malignant colorectal conditions

BACKGROUND

CXCR2 chemokine ligands CXCL1, CXCL5 and CXCL6 were shown to be involved in chemoattraction, inflammatory responses, tumor growth and angiogenesis. Here, we comparatively analyzed their expression profile in resection specimens from patients with colorectal adenoma (CRA) (n = 30) as well as colorectal carcinoma (CRC) (n = 48) and corresponding colorectal liver metastases (CRLM) (n = 16).

METHODS

Chemokine expression was assessed by microdissection, quantitative real-time PCR (Q-RT-PCR), the enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry (IHC).

RESULTS

In contrast to CXCL6, we demonstrated CXCL1 and CXCL5 mRNA and protein expression to be significantly up-regulated in CRC and CRLM tissue specimens in relation to their matched tumor neighbor tissues. Moreover, both chemokine ligands were demonstrated to be significantly higher expressed in CRC tissues than in CRA tissues thus indicating a progressive increase in the transition from the premalignant condition to the development of the malignant status. Although a comparative analysis of the CXCL1/CXCL5 protein expression profiles in CRC patients revealed that the absolute expression level of CXCL1 was significantly higher in comparison to CXCL5, mRNA- and protein overexpression of CXCL5 in CRC and CRLM tissues was much more pronounced (80- and 60- fold in CRC tissues, respectively) in comparison to CXCL1 (5- and 3.5- fold in CRC tissues, respectively).

CONCLUSION

Our results demonstrate a significant association between CXCL1 and CXCL5 expression with CRC and CRLM suggesting for both chemokine ligands a potential role in the progression from CRA to CRC and thus, in the initiation of CRC.

[Influence of IT-supported clinical pathways on patient satisfaction at a surgical department of a university hospital]

BACKGROUND

Clinical pathways (CPs) are considered to be a device of clinical process management, which describe the optimal way of a special type of patient with its diagnostic and therapeutic medical treatment. Apart from these economic aspects CPs can make a contribution to an optimization of the health quality management as well as to an improvement of medical staffs and patients satisfaction. In our hospital clinical pathways supported by information technology (IT-supported CPs) were implemented world-wide for the first time in a running Hospital Information System (SAP/i.s.h.med) and used by routine. The aim of the study was to investigate the influence of IT-supported CPs on patient satisfaction.

MATERIAL AND METHODS

The patient satisfaction was examined BEFORE introduction of IT-supported CPs by standardized questionnaires in 64 Patients (45f/19m, median age: 64,9 +/- 1,24 years) and in 62 patients (38f/24m, median age: 63,3 +/- 1,49 years) AFTER introduction of IT-supported CPs by standardized questionnaires. Different CPs were selected and grouped by simple, middle and high complexity, each to benign and malignant illnesses.

RESULTS

By introduction of IT-supported CPs patient satisfaction can be improved. CPs already evaluated as very good before introduction of CPs could be improved only slightly, whereas badly evaluated CPs exhibited a large optimization potential.

CONCLUSION

On the one hand patient satisfaction may be improved by the introduction of CPs. On the other hand CPs- when IT-supported- do not result unavoidably in an industrial medicine. This subjective estimate of the patient contributes to a better customer-and patient-oriented quality management, whereby an appropriate optimization of the recognized deficits can be simply realized by IT-supported CPs.

Streik im öffentlichen Dienst

BACKGROUND

In 2006 the longest strike so far in the German health service occurred. Contrary to most hospitals in public authorities, the medical doctors of the University Hospital of Homburg/Saar did not participate in the strike, leading to pronounced tensions between patients, strikers and medical staff.

MATERIAL AND METHODS

The effect of the strike on operating room (OR) management, medical personnel resource planning, and surgical training were compared with the remaining period of the year 2006.

RESULTS

Elective surgical procedures were accomplished significantly more frequently by more qualified surgeons, leading to shorter OR time; surgical training was performed significantly less. The rate of emergency operations and the care of tumor patients increased significantly during the strike.

CONCLUSION

Surgical training was neglected during the strike. Transferring non-job-related tasks to medical doctors and expanding their working time allowed optimal utilization of the limited resources.