Cold Atmospheric Plasma Is a Promising Alternative Treatment Option in Case of Split Skin Graft Failure.

Cold atmospheric plasma (CAP) has shown promising potential in promoting wound healing. This case report presents the successful application of CAP in a 42-year-old female patient with extensive wound healing disorders and superinfections following the excision of an abscess in the left thoracic region. After several failed split skin graft attempts, the implementation of CAP led to significant improvements in wound healing. This report highlights the wound healing-promoting effects of CAP and discusses its potential mechanisms of action.

Abdominal Morphologic Changes in MRI during Gastric Balloon Therapy.

INTRODUCTION: Adiposity and excessive weight are on the rise in western industrialized countries. In cases where conservative measures fail and surgical interventions are not (yet) desired, gastric balloon therapy has proven to be a safe and reversible endoscopic method. METHODS: Aside from weight progression under gastric balloon therapy and by using MRI, our research paper describes the behavior of different abdominal body fat compartments at the beginning and at the end of the gastric balloon therapy. Additionally, the volume of the left liver lobe as well as the fill volume and performance of the gastric balloon were analyzed over the duration of treatment. For assessing potential impacts of weight reduction on the muscle mass, we determined the area of the m. psoas on a comparable cross-sectional area at the beginning and at the end of the therapy. RESULTS: We were able to verify a significant reduction of the layer of subcutaneous fat, adipose capsule of the kidney, and intra-abdominal fatty tissue during the therapy. The volume of the left liver lobe was shrinking in addition to a muscle loss during the balloon therapy. The volume of the gastric balloon remained stable (not hyperinflation). There were variable gas bubbles in the gastric balloon. CONCLUSION: The gastric balloon is a temporary and successful option for weight reduction by reducing body fat, liver volume, but also muscle mass.

Gastric Balloon Implantation as Part of Morbid Adiposity Therapy Changes the Structure of the Stomach Wall.

PURPOSE: The implantation of a gastric balloon (also known as intragastric balloon) is an established and reversible endoscopic procedure for adiposity therapy. Structural changes of the stomach wall are expected to occur with gastric balloon implantation; however, until now these changes have rarely been investigated. METHODS: We compared the histological structure of the stomach wall after gastric-sleeve resection in a group of patients following gastric balloon implantation and a group without previous gastric balloon implantation. RESULTS: Following gastric balloon implantation, the tunica muscularis was found to be significantly thicker than without gastric balloon implantation. The enlarging of the tunica muscularis is not caused by hyperplasia of the leiomyocytes, but by hypertrophy of the leiomyocytes and an increase in collagen fibers (fibrosis). CONCLUSION: A longer-lasting hypertrophy of the tunica muscularis, particularly in the corpus, should be taken into account when surgical treatment follows gastric balloon implantation. The staple suture height should be adjusted to the altered tissue composition since reduced tissue elasticity must be expected due to fibrosis.

A case of giant retroperitoneal lymphangioma and IgG4-positive fibrosis: Causality or coincidence?

Several chronic inflammatory diseases have been found to be a subtype of IgG4-related disease, all of which have a typical clinical and histological change, which is based in particular on an overexpression of IgG4 and subsequent fibrosis. At least a part of the retroperitoneal fibrosis, which was originally classified as idiopathic, seems to be assigned to IgG4-related disease. Lymphangiomas are benign, cystic tumors that rarely occur in adults. However, there is no firm association with IgG4-related disease described in the literature to date. This report is about a patient suffering from acute renal failure due to a giant retroperitoneal cyst. Surgical resection remains incomplete in the iliac vessel area due to severe fibrosis and histology revealed features of both lymphangioma and IgG4+ fibrosis. The case description is followed by a brief overview of IgG4-related disease and a consideration of whether lymphangiomas might be assigned to this topic.

Efficacy and Safety of Endoscopic Full-Thickness Resection in the Colorectum: Results From the German Colonic FTRD Registry.

INTRODUCTION: Endoscopic full-thickness resection (EFTR) is a powerful option for resection of colorectal lesions not amenable to conventional endoscopic resection. The full-thickness resection device (FTRD) allows clip-assisted EFTR with a single-step technique. We report on results of a large nationwide FTRD registry. METHODS: The "German colonic FTRD registry" was created to further assess efficacy and safety of the FTRD System after approval in Europe. Data were analyzed retrospectively. RESULTS: Sixty-five centers contributed 1,178 colorectal FTRD procedures. Indications for EFTR were difficult adenomas (67.1%), early carcinomas (18.4%), subepithelial tumors (6.8%), and diagnostic EFTR (1.3%). Mean lesion size was 15 × 15 mm and most lesions were pretreated endoscopically (54.1%). Technical success was 88.2% and R0 resection was achieved in 80.0%. R0 resection was significantly higher for subepithelial tumor compared with that for other lesions. No difference in R0 resection was found for smaller vs larger lesions or for colonic vs rectal procedures. Adverse events occurred in 12.1% (3.1% major events and 2.0% required surgical treatment). Endoscopic follow-up was available in 58.0% and showed residual/recurrent lesions in 13.5%, which could be managed endoscopically in most cases (77.2%). DISCUSSION: To date, this is the largest study of colorectal EFTR using the FTRD System. The study demonstrated favorable efficacy and safety for "difficult-to-resect" colorectal lesions and confirms results of previous studies in a large "real-world" setting. Further studies are needed to compare EFTR with other advanced resection techniques and evaluate long-term outcome.

Early removal of urinary drainage in patients receiving epidural analgesia after colorectal surgery within an ERAS protocol is feasible.

BACKGROUND: ERAS guidelines recommend early removal of urinary drainage after colorectal surgery to reduce the risk of catheter-associated urinary tract infections (CAUTI). Another recommendation is the postoperative use of epidural analgesia (EA). In many types of surgery, EA was shown to increase the risk of postoperative urinary retention (POUR). This study determines the impact of early urinary catheter removal on the incidence of POUR and CAUTI under EA after colorectal surgery. METHODS: Eligible patients were scheduled for colorectal surgery within the local ERAS protocol between April 2015 and September 2016. Urinary drainage was removed on the first postoperative day while EA was still in place (early removal group (ER)). The incidences of POUR and CAUTIs were recorded prospectively. Results were compared with a historical control (CG), which was operated between October 2013 and March 2015. RESULTS: POUR occurred significantly more often in the ER (ER 7.8%; CG 2.6%), while CAUTIs were significantly less frequent in the ER (13.8%) compared with the CG (30.4%). Patients who developed POUR were characterised by a significantly higher rate of abdominoperineal resections, by a higher frequency of rectal cancer, and a higher male-to-female ratio compared with patients who did not develop POUR. CONCLUSION: Early removal of urinary drainage after colorectal surgery while EA is still in place is feasible; it reduces the incidence of CAUTI but increases the risk of POUR. Thus, screening for POUR in patients with failure to void after six to 8 h is mandatory under these clinical conditions.

Over-the-Scope Clip Closure of Pancreatico-Colonic Fistula Secondary to Acute or Chronic Pancreatitis: A Case Series.

Introduction: Pancreatico-colonic fistula (PCF) is a rare adverse effect secondary to severe acute or chronic pancreatitis and potentially life-threatening because of abdominal sepsis. Over-the-scope clip (OTSC®) system is a recently developed endoscopic device and has been successfully used for bleeding and perforations of the gastrointestinal tract. We hereby report a series of patients with PCFs in whom OTSC was used. Materials and Methods: From January 2011 to December 2018, we retrospectively collected data on cases of PCFs with endoscopic treatment using the OTSC system. After conservative management, the endoscopic intervention was carried out on patients in deep sedation by single skilled operators. Results: A total of 9 patients were enrolled and patients were treated with 14/6 t-type OTSC. PCF occurred secondary to chronic (n = 5) and acute pancreatitis (n = 4). There were no adverse effects related to the endoscopic procedure itself. Further endoscopic evaluation was performed 8 weeks later and revealed a successful fistula closure in 4 patients with chronic pancreatitis (80%) and in 2 patients with acute pancreatitis (50%). An insufficient fistula closure was observed in 3 cases because of dislocation of the OTSC and an additional surgical procedure was required. Conclusion: The OTSC system seems to be safe and effective in short-term management of PCFs because of acute or chronic pancreatitis in addition to the already established nonsurgical therapy. However, the OTSC closure of PCFs in patients with acute pancreatitis seems to be associated with a higher failure rate. To sum up, more evidence and long-term studies are needed to determine the criteria for the use of OTSC in closure of PCFs owing to acute or chronic pancreatitis.

Laparoscopic-endoscopic Rendezvous Procedures for Upper Gastrointestinal Tumors Guided by Laser-supported Reverse Diaphanoscopy: A Modified Technique.

INTRODUCTION: Precisely locating benign upper gastrointestinal tumors during laparoscopic-endoscopic surgery remains difficult and inaccurate. We describe reverse laser-supported diaphanoscopy (RLSD) for locating gastrointestinal tumors during laparoscopic surgery and present prospective evaluation results of the first cases. MATERIALS AND METHODS: We studied 13 patients [women:men=7:6; mean age, 67 (range, 41 to 83) y] who underwent gastroscopic-laparoscopic rendezvous procedures during 2015 to 2018. Surgery duration, marking duration, and specimen resection size were recorded. The largest and smallest specimen resection margins were measured. RESULTS: After locating tumors using RLSD, patients underwent successful resections. Histopathologic examination confirmed 5 cases of gastrointestinal stromal tumor; 3, neuroendocrine tumors; 2, heterotopic pancreatic tissue; 1, leiomyoma; 1, adenoma; 1, hyperplastic polyp. We employed 4 to 6 marks, depending on tumor location and size. The average marking duration was 14 minute (1 to 21 min); the average surgery duration, 73 minute (37 to 143 min). The smallest resection median margin was 2.0 mm (1.0 to 5.0 mm); the largest, 7.0 mm (2.0 to 12.0 mm). CONCLUSIONS: RLSD precisely locates gastric benign tumors during laparoscopic-endoscopic rendezvous procedures.

Endoscopic full-thickness resection for early colorectal cancer.

BACKGROUND AND AIMS: Current international guidelines recommend endoscopic resection for T1 colorectal cancer (CRC) with low-risk histology features and oncologic resection for those at high risk of lymphatic metastasis. Exact risk stratification is therefore crucial to avoid under-treatment as well as over-treatment. Endoscopic full-thickness resection (EFTR) has shown to be effective for treatment of non-lifting benign lesions. In this multicenter, retrospective study we aimed to evaluate efficacy, safety, and clinical value of EFTR for early CRC. METHODS: Records of 1234 patients undergoing EFTR for various indications at 96 centers were screened for eligibility. A total of 156 patients with histologic evidence of adenocarcinoma were identified. This cohort included 64 cases undergoing EFTR after incomplete resection of a malignant polyp (group 1) and 92 non-lifting lesions (group 2). Endpoints of the study were: technical success, R0-resection, adverse events, and successful discrimination of high-risk versus low-risk tumors. RESULTS: Technical success was achieved in 144 out of 156 (92.3%). Mean procedural time was 42 minutes. R0 resection was achieved in 112 of 156 (71.8%). Subgroup analysis showed a R0 resection rate of 87.5% in Group 1 and 60.9% in Group 2 (P < .001). Severe procedure-related adverse events were recorded in 3.9% of patients. Discrimination between high-risk versus low-risk tumor was successful in 155 of 156 cases (99.3%). In Group 1, 84.1% were identified as low-risk lesions, whereas 16.3% in group 2 had low-risk features. In total, 53 patients (34%) underwent oncologic resection due to high-risk features whereas 98 patients (62%) were followed endoscopically. CONCLUSIONS: In early colorectal cancer, EFTR is technically feasible and safe. It allows exact histological risk stratification and can avoid surgery for low-risk lesions. Prospective studies are required to further define indications for EFTR in malignant colorectal lesions and to evaluate long-term outcome.

Retrieval of a self-expanding metal stent after migration and incorporation in the omental bursa, using a gastroscopic-transgastric laparoscopic rendezvous technique.

Endoscopic drainage is a widely used treatment for pancreatic pseudocysts. Drainage-related complications may be related directly to the procedure or may occur later as stents migrate or erode into adjacent structures. Migration of a self-expanding metal stent into peritoneal cavity and incorporation in the omental bursa is rare. When endoscopic retrieval fails a combined laparoscopic-endoscopic (rendezvous technique) approach offers an alternative to open surgery. We report a case of successful gastroscopic-transgastric laparoscopic removal of a stent that was dislocated into the omental bursa after a ½ year observation period.

Evaluation of short-term and long-term results after laparoscopic antireflux surgery: esophageal manometry and 24-h pH monitoring versus quality of life index.

PURPOSE: The objective of this long-term study is to compare data on postoperative quality of life with objective functional measurements in patients with gastroesophageal reflux disease who have undergone laparoscopic antireflux surgery. METHODS: Between 1995 and 2005, 162 patients with gastroesophageal reflux disease underwent laparoscopic surgery. A minimum of 4 years after surgery, 60 patients were contacted at random, 29 of whom agreed to follow-up examination. The following examinations were performed preoperatively, 6 months postoperatively, and 4-12 years postoperatively: esophageal manometry, 24-h gastroesophageal pH-metry, and assessment of patient quality of life based on the gastrointestinal quality of life index (GIQLI). RESULTS: The number of postsurgical reflux episodes was reduced significantly, both at 6 months and at 4 or more years after surgery. The number of episodes dropped from 183 before surgery to 58 at 6 months after surgery and remained constant ≥ 4 years later. Surgery also produced a significant drop in reflux time, seen both 6 months and ≥ 4 years later. Six months after surgery, the median reflux time had fallen from 134 min (preoperatively) to 27 min, and at ≥ 4 years it was still significantly reduced at 35 min. Sphincter length (median preoperative length, 3 cm; median postoperative length (at 6 months and at ≥ 4 years), 4 cm) and sphincter pressure (median preoperative pressure, 3 mmHg; median at 6 months, 12 mmHg; median at ≥ 4 years, 10.9 mmHg) were significantly improved by surgery as well. Finally, surgery produced an improvement in quality of life. The median preoperative GIQLI was 102, while at 6 months after surgery it was 113 and at ≥ 4 years after surgery it was 124. CONCLUSION: Laparoscopic fundoplication guarantees long-term improvement in symptoms and quality of life for patients suffering from gastroesophageal reflux disease. The effectiveness of reflux surgery can thus be demonstrated by long-term quality of life assessments and postoperative functional measurements. No statistically significant correlation between total score (DeMeester) and GIQLI could be demonstrated.

Single-port versus standard laparoscopic resection for a gastric benign tumor in gastroscopic-laparoscopic rendezvous procedures using a laser-supported diaphanoscopy.

In this study, the standard laparoscopic technique versus the single-port approach was evaluated for the excision of benign gastric tumors using tissue-sparing laser-supported diaphanoscopy for localization. The first group consisted of 10 patients suffering from benign gastric tumors treated by standard laparoscopic resection. The second group included 10 patients treated using the single-port technique. All procedures were successfully completed. Histopathologic examination confirmed 15 cases of gastrointestinal stromal tumor, 3 cases of lipoma, 1 case of leiomyoma, and 1 case of high-grade dysplasia. There was no statistically significant difference for the operation times between both groups. Comparison of the largest and smallest resection margins achieved using the standard laparoscopic technique and single-port techniques showed no statistically significant differences between the groups. During follow-up, all patients were evaluated using the total body image and cosmesis questionnaire. Although scores of all body-image functions were similar, independent of laparoscopic technique, scores of all cosmetic functions in patients operated using the single-port technique showed a statistically significant higher degree of satisfaction with the scar (P<0185). The postoperative pain scores evaluated by the visual analog scale score were not significantly different between 2 groups. The single-port technique was found to be a feasible option for the resection of submucosal or mucosal tumors. However, this method is not intended to replace standard laparoscopic resections.

Pre-study protocol MagPEP: a multicentre randomized controlled trial of magnesium sulphate in the prevention of post-ERCP pancreatitis.

BACKGROUND: Acute pancreatitis is the most common complication of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In spite of continuing research, no pharmacologic agent capable of effectively reducing the incidence of ERCP-induced pancreatitis has found its way into clinical practise. A number of experimental studies suggest that intrapancreatic calcium concentrations play an important role in the initiation of intracellular protease activation, an initiating step in the course of acute pancreatitis. Magnesium can act as a calcium-antagonist and counteracts effects in calcium signalling. It can thereby attenuate the intracellular activation of proteolytic digestive enzymes in the pancreas and reduces the severity of experimental pancreatitis when administered either intravenously or as a food supplement. METHODS: We designed a randomized, double-blind, placebo-controlled phase III study to test whether the administration of intravenous magnesium sulphate before and after ERCP reduces the incidence and the severity of post-ERCP pancreatitis. A total of 502 adult patients with a medical indication for ERCP are to be randomized to receive either 4930 mg magnesium sulphate (= 20 mmol magnesium) or placebo 60 min before and 6 hours after ERCP. The incidence of clinical post-ERCP pancreatitis, hyperlipasemia, pain levels, use of analgetics and length of hospital stay will be evaluated. CONCLUSIONS: If magnesium sulphate is found to be effective in preventing post-ERCP pancreatitis, this inexpensive agent with limited adverse effects could be used as a routine pharmacological prophylaxis. TRIAL REGISTRATION: Current Controlled Trials ISRCTN46556454.

Laparoscopic partial splenectomy using a detachable clamp with and without partial splenic embolisation.

BACKGROUND: In many centres, the laparoscopic total splenectomy is a well-established routine procedure. However, the crucial immunological role of the spleen in combating bacterial infections, in particular pneumonias, has led to a search for splenic-preserving techniques whenever possible. Yet, laparoscopic partial splenectomies are still rarely described possibly due to difficulties in controlling intra-operative parenchymal bleeding during splenic transection. METHODS: Here, we present a case series of laparoscopic partial splenectomies using a new technique. The main splenic artery and vein were temporarily clamped using a detachable clip. Transection of the spleen was possible working with the LigaSure™ instrument. After transection, the margin was sealed with a collagen fleece. In one case of a haemangioma, the patient underwent a radiological coil embolisation of the feeding arteries of the splenic pole in question. This was done 4 weeks prior to surgery and included embolisation of the tumour. RESULTS: Three patients (2 males, 1 female, mean age 58.3 years) have been successfully treated using a detachable clamp. The pre-surgical mean size of the spleen was 8.0 × 16.7 cm (range 6 × 14-11 × 22 cm). The removed specimens had a mean size of 4.2 × 5.5 cm (range 2.5 × 4.0-5.0 × 6.5 cm). The time of surgery averaged 144 min (range 110-187 min). Blood loss was minimal thereby avoiding the need for blood transfusions. The post-surgical course was uneventful; patients were discharged 5 days following surgery. Histopathology showed a benign splenic haemangioma, a benign splenic hamartoma and the presence of Hodgkin's disease stage III. CONCLUSIONS: The technique of laparoscopic partial splenectomy and, in certain patients, pre-surgical partial splenic embolisation is safe and effective for patients with localised diseases of the spleen. This approach combines the benefits of the minimal surgical access with saving a significant amount of splenic tissue, thereby preserving the immune function of the spleen.

Single-incision laparoscopic surgery as an option for the laparoscopic resection of an urachal fistula: first description of the surgical technique.

BACKGROUND: Persistent urachal sinuses or fistulas are rare but may potentially cause various symptoms and lead to repeated operations. Both laparoscopic and open surgery have been used for the resection of the urachus. METHODS: This report describes the first case of an external urachal fistula with recurrent infections and discharge of the umbilicus treated by complete resection using single-incision laparoscopic surgery (SILS). This involved a laparoscopic single-incision three-trocar-technique, leaving the infected site of the umbilicus untouched. RESULTS: Healing of the umbilicus was uneventful and complete. To date, the authors have not seen any recurrence of the fistula or its symptoms. CONCLUSIONS: Remnants of the urachus should be considered in cases of recurrent infections or discharge of the umbilicus. The SILS procedure is an excellent option for the radical resection of the remnant urachus. Compared with the standard laparoscopic approach, it requires only one incision, decreasing the risks compared with those of several trocars. At the same time, the patient benefits from the better cosmetic result.

Unexpected findings on laparoscopy for suspected acute appendicitis: a pro for laparoscopic appendectomy as the standard procedure for acute appendicitis.

PURPOSE: Evaluation of the feasibility, cost-effectiveness, time of surgery, morbidities, and other/additional findings during laparoscopy for suspected appendicitis. METHODS: Prospective evaluation of 148 laparoscopies for suspected acute appendicitis. RESULTS: Laparoscopic appendectomy was safe and cost-effective. No appendiceal stump leaks or wound infections occurred. Of the patients, 4.7% developed intra-abdominal abscesses. Mean time of all procedures was 47 min: 42 min for simple appendectomies (n = 126), 67 min for perforated appendicitis (n = 15), and 75 min for converted procedures (n = 7). Twenty-one of 148 (14.2%) patients had unexpected findings instead of appendicitis: inflamed epiploic appendices (three times), inflammatory disorders of intestine (five times), intestinal adhesions (two times), ovarian cysts (six times: one time with mesenteric lymphadenitis, one time ruptured), tubo-ovarian abscess (one time), tubal necrosis (one time), adnexitis with mesenteric lymphadenitis (one time), and acute cholecystitis (one time). These diagnoses might have been missed during conventional open appendectomy and were, if necessary, treated during laparoscopy. CONCLUSIONS: Laparoscopic appendectomy should be recommended as standard procedure for acute appendicitis.

Rectal intussusception due to re-recurrent ovarian fibrosarcoma.

BACKGROUND: Primary ovarian fibrosarcomas are very rare tumours associated with an extremely poor prognosis. Most patients relapse or die within 2 years. Because of the low incidence, it is difficult to identify prognostic factors or to establish treatment guidelines. CASE REPORT: In this report, we present a patient with the second relapse of an ovarian fibrosarcoma localised in the rectosigmoid. The tumour caused intussusception into the rectum, leading to large bowel obstruction. After complete resection of the tumour, the patient completely recovered. 28 months after primary diagnosis, follow-up did not show any signs of recurrent tumour disease. CONCLUSIONS: Reviewing the literature, it is recommended that all patients should primarily be operated on and generally be followed up closely. In patients with incomplete resection, palliative chemo- and/or radiotherapy is recommended. In our opinion, in patients with complete resection, adjuvant chemo- and/or radiotherapy should be considered. Only in patients with high-grade fibrosarcomas, adjuvant intra- or postoperative radiotherapy should be applied.

ETVARD (endoscopic transanal vacuum-assisted rectal drainage) leads to complete but delayed closure of extraperitoneal rectal anastomotic leakage cavities following neoadjuvant radiochemotherapy.

PURPOSE: The purpose of the study was to prospectively assess the impact of neoadjuvant radiochemotherapy on the formation of major anastomotic rectal leaks and treatment by endoscopic transanal vacuum-assisted rectal drainage (ETVARD). MATERIALS AND METHODS: Twenty six patients with malignancies with rectal anastomotic leaks were prospectively treated, including 14 of 26 patients following neoadjuvant radiochemotherapy. ETVARD was the first-line treatment. RESULTS: In 23 of 26 patients, ETVARD was successfully completed. In patients following neoadjuvant radiochemotherapy sizes of leakage cavities, duration of ETVARD, number of sponge exchanges, and endoscopies as well as time to closure of cavities were significantly increased (0.009 < p < 0.035) compared to patients after primary surgery. Increased age showed similar correlations, whereas the level of anastomoses did not influence these parameters. Patients without (ile)ostomies could also be treated by ETVARD. Follow-up endoscopies have not shown any major changes. CONCLUSIONS: Radiochemotherapy has a significant impact on development and treatment of major anastomotic rectal leaks. Most patients can be successfully treated by ETVARD, avoiding additional resective surgery or permanent (col)ostomies.