[Damage to implants due to high-frequency electrocautery : analysis of four fractured hip endoprostheses shafts]. / Implantatschädigung durch Einsatz eines Hochfrequenzmessers : Analyse von vier Hüftendoprothesenschaftbrüchen.

In revision surgery of joints, high-frequency electrocauterization instruments are used for homeostasis and dissection of soft tissue. If there is contact of these instruments with the metal implants, flashover can occur. This can lead to thermal microstructural changes in the material and as a consequence may reduce the fatigue strength of the implant. Four cases of hip revision surgeries were analysed. In all cases flashovers occurred and secondarily, the titanium hip endoprosthesis stem broke in the neck section of the prosthesis. The conducted investigations showed that contact between the high-frequency instrument and the anterolateral aspect of the endoprosthesis neck had occurred. Electrothermal implant damage was found in the broken area. If in hip revision surgery the stem is not to be replaced, contact between high-frequency instruments and the metal implant should be avoided.

Incisional hernia rate 3 years after midline laparotomy.

BACKGROUND: Incisional hernia is the most frequent long-term complication after visceral surgery, with an incidence of between 9 and 20 per cent 1 year after operation. Most controlled studies provide only short-term follow-up, and the actual incidence remains unclear. This study evaluated the incidence of incisional hernia up to 3 years after midline laparotomy in two prospective trials. METHODS: Three-year follow-up data from the ISSAAC (prospective, multicentre, historically controlled) and INSECT (randomized, controlled, multicentre) trials focused on the rate of incisional hernia 1 and 3 years after surgery. Differences between the two groups were compared using t tests for continuous data and the χ2 test for categorical data. RESULTS: Analysis of 775 patients included in the two trials suggested that the incisional hernia rate increased significantly from 12.6 per cent at 1 year to 22.4 per cent 3 years after surgery (P < 0.001), a relative increase of more than 60 per cent. CONCLUSION: This follow-up of two trials demonstrated that 1 year of clinical follow-up for detection of incisional hernia is not sufficient; follow-up for at least 3 years should be mandatory in any study evaluating the rate of postoperative incisional hernia after midline laparotomy.

Evaluation of the International Study Group of Pancreatic Surgery definition of delayed gastric emptying after pancreatoduodenectomy in a high-volume centre.

BACKGROUND: Delayed gastric emptying (DGE) is a common complication after pancreatoduodenectomy. The International Study Group of Pancreatic Surgery (ISGPS) definition of DGE has not been evaluated and validated in a high-volume centre. METHODS: Complete data sets including assessment of gastric emptying were identified from a database of patients undergoing pancreatoduodenectomy between 2001 and 2008. Factors associated with DGE (grades A, B and C) were assessed by univariable and multivariable analyses. RESULTS: DGE occurred in 340 (44.5 per cent) of 764 patients. Median hospital stay was significantly prolonged in patients with DGE: 13, 21 and 40 days for grades A, B and C respectively versus 11 days for patients without DGE. DGE was associated with prolonged intensive care unit (ICU) admission (at least 2 days): 20.6, 28.6 and 61.8 per cent of those with grades A, B and C respectively versus 9.4 per cent of patients without DGE. Factors independently influencing DGE grade A were female sex, preoperative heart failure and major complications (grade III-V). Validation of the DGE definition revealed that DGE grades A and B were associated with interventional treatment in 20.1 and 44.4 per cent of patients. CONCLUSION: The ISGPS DGE definition is feasible and applicable in patients with an uneventful postoperative course. Major postoperative complications and ICU treatment, however, might limit its usefulness. The identified risk factors for DGE are not amenable to perioperative improvement.

[German general and visceral surgery: positioning within the international scientific community]. / Deutsche Allgemein- und Viszeralchirurgie: Positionierung im internationalen wissenschaftlichen Vergleich

BACKGROUND: Assessment of scientific performance is critical for selection committees and research funding. The present work evaluated the standing of German surgical research within the international community. METHODS: A database analysis was performed in December 2009 using the ISI Web of Science. RESULTS: The highest impact factor of surgical journals is currently 8.460 with a median impact of all journals of 1.369. Leading academic surgeons have an h-index of more than 60. German surgeons are within the top five leading researchers in the fields of surgery for esophageal and pancreatic cancer, thyroid, hernia, and liver/kidney transplantation. Among the 50 institutions with most publications on a particular topic, 4-5 German centers are mostly represented. The top positions are in total decisively occupied by leading universities in the USA. CONCLUSION: On the basis of scientific parameters German surgical research can compete with leading international centers in certain fields, but should aim to increase the overall impact of research by publishing more in journals with above average impact factors.

Endoscopic retroperitoneal neurectomy for chronic pain after groin surgery.

BACKGROUND: Chronic postoperative pain after inguinal surgery remains a difficult problem. The role of minimally invasive surgery in this complex setting is still unexplored. METHODS: Between January 1997 and January 2007, 34 men and five women with a mean(s.d.) age of 47(16) years underwent endoscopic retroperitoneal neurectomy (ERN) for chronic neuropathic groin pain due to genitofemoral nerve with or without ilioinguinal nerve entrapment. Follow-up data were obtained 1 and 12 months after surgery. RESULTS: At both timepoints after ERN, the severity of chronic postoperative groin pain at rest and during daily activities, and the rate of occupational disability, were significantly decreased in 27 of the 39 patients compared with preoperative values (all P < 0.001). CONCLUSION: ERN for chronic postoperative genitofemoral nerve entrapment neuropathy was successful in the majority of patients selected for the procedure. This minimally invasive approach allows simultaneous neurectomy of genitofemoral and ilioinguinal nerves.

[Strategy for avoidance of negative appendectomies]. / Strategien zur Vermeidung negativer Appendektomien.

Appendectomy is the most commonly performed emergency surgical procedure. Even in the era of laparoscopic surgery and modern computed tomography, the rate of negative appendectomies, defined as the removal of a non-inflamed appendix, remains high (10-15%). The general problem and incidence, as well as the influence of modern diagnostic modalities on the rate of negative appendectomies are of particular clinical relevance. Several clinical scoring systems have been developed, but they did not find their way into the daily clinical routine. A proposed diagnostic algorithm could support further efforts to reduce the rate of negative appendectomies. The risk of overtreatment in the reduction of the negative appendectomy rate might potentially lead to acceptance of a higher perforation rate.

No relevant difference in quality of life and functional outcome at 12 months' follow-up-a randomised controlled trial comparing robot-assisted versus conventional laparoscopic Nissen fundoplication.

PURPOSE: The present randomised pilot trial was designed to compare robot-assisted (RALF) and conventional laparoscopic fundoplication (CLF) focussing on post-operative quality of life (QOL) and functional outcome. Any long-lasting advantages for patients in this regard could be a justification for the use of RALF for the treatment of gastroesophageal reflux disease (GERD). METHODS: Forty patients with GERD were randomised to either RALF or to CLF. During a follow-up period of 12 months, patients' QOL and functional outcome were investigated using disease-specific questionnaires. RESULTS: There were no significant differences in the mean QOL (1.3 versus 1.1; P = 0.374) and functional outcome (1.27 versus 1.3; P = 0.913) between both groups. Minor side effects such as bloating and persistent diarrhoea were present in four patients of each group. CONCLUSION: The present study did not show any benefit for RALF over CLF regarding QOL and functional outcome at 12 months' follow-up.

[Differentiated therapy for intraductal papillary mucinous neoplasms]. / Differenzierte Therapie der intraduktalen papillären muzinösen Neoplasie.

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are of increasing interest in the field of pancreatic surgery ever since their first description as an individual pancreatic tumor entity in 1982. The decision for surgical or conservative management is based on the adenoma-carcinoma sequence and the differentiation into main-duct or branch-duct IPMN. Invasive IPMN forms (carcinoma in situ and invasive carcinoma) and in particular noninvasive IPMNs (adenoma and borderline tumors) reveal significantly better survival rates than ductal adenocarcinoma of the pancreas.

Expression of the CXCR6 on polymorphonuclear neutrophils in pancreatic carcinoma and in acute, localized bacterial infections.

The chemokine receptor CXCR6 has been described on lymphoid cells and is thought to participate in the homing of activated T-cells to non-lymphoid tissue. We now provide evidence that the chemokine receptor CXCR6 is also expressed by activated polymorphonuclear neutrophils (PMN) in vivo: Examination of biopsies derived from patients with pancreatic carcinoma by confocal laser scan microscopy revealed a massive infiltration of PMN that expressed CXCR6, while PMN of the peripheral blood of these patients did not. To answer the question whether CXCR6 expression is a property of infiltrated and activated PMN, leucocytes were collected from patients with localized soft tissue infections in the course of the wound debridement. By cytofluorometry, the majority of these cells were identified as PMN. Up to 50% of these PMN were also positive for CXCR6. Again, PMN from the peripheral blood of these patients were nearly negative for CXCR6, as were PMN of healthy donors. In a series of in vitro experiments, up-regulation of CXCR6 on PMN of healthy donors by a variety of cytokines was tested. So far, a minor, although reproducible, effect of tumour necrosis factor (TNFalpha) was seen: brief exposure with low-dose TNFalpha induced expression of CXCR6 on the surface of PMN. Furthermore, we could show an increased migration of PMN induced by the axis CXCL16 and CXCR6. In summary, our data provide evidence that CXCR6 is not constitutively expressed on PMN, but is up-regulated under inflammatory conditions and mediates migration of CXCR6-positive PMN.

[Gastrointestinal stromal tumors (GIST). Surgical therapy]. / Gastrointestinale Stromatumoren (GIST). Chirurgische Therapie.

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasms of the gastrointestinal tract. GIST occur predominantly in the stomach and less frequently in the extraduodenal small bowel, the colon, and the rectum; rarely, GIST can be found in the esophagus and the duodenum. Due to their biological behavior, the primary treatment goal for localized primary GIST is complete resection, without the need for lymphadenectomy or wide resection margins. Thus, gastric wedge resections and segmental resections of the small bowel are the most common surgical procedures for treating primary GIST. Surgical therapy of extensive primary tumors or of metastatic or recurrent GIST should be integrated into a multimodal therapeutic concept that includes targeted therapy with tyrosine kinase inhibitors, such as imatinib.

Systematic review and meta-analysis of the effect of portal triad clamping on outcome after hepatic resection.

BACKGROUND: The effect of portal triad clamping (PTC) on outcome after hepatic resection is uncertain. METHODS: A systematic literature search was conducted to detect randomized controlled trials (RCTs) assessing the effectiveness and safety of PTC alone and of PTC with ischaemic preconditioning (IPC) of the liver. Studies on clamping of the inferior vena cava or hepatic veins were excluded. Endpoints included postoperative overall morbidity and mortality, cardiopulmonary and hepatic morbidity, blood loss, transfusion rates and alanine aminotransferase (ALT) levels. Meta-analyses were performed using a random-effects model. RESULTS: Eight RCTs published between 1997 and 2006 containing a total of 558 patients were eligible for final analysis. The design of the identified studies varied considerably. Analyses of endpoints revealed no difference between intermittent PTC and no PTC. Meta-analyses of PTC with and without previous IPC revealed no differences, but postoperative ALT levels were significantly lower with IPC. CONCLUSION: On currently available evidence, the routine use of PTC does not offer any benefit in perioperative outcome after liver resection. It cannot be recommended as a standard procedure.

[Multicentric randomised controlled trials in Germany: overview and interim analysis 1 year after inclusion of in the rubric "Clinical Trials"]. / Rekrutierende multizentrische chirurgische Studien in Deutschland : Zwischenbilanz ein Jahr nach Einführung der Rubrik.

BACKGROUND: For 1 year now, German surgical multicentric randomised controlled trials (MRCT) in Germany may be included under the heading "Clinical Trials" in our monthly updated trial list. MATERIAL AND METHODS: Quantitative and qualitative analysis of MRCT presented in the trial list was performed to give an overview and interim statement 1 year after implementation of the journal heading "Clinical Trials". RESULTS: In 1 year, the study list increased from four to eleven MRCT and the numbers of randomized patients from 396 to 1511. The MRCT show distinct differences regarding funding sources and reimbursement for participating centres per patient included. The study protocols of four of 11 MRCT were published in scientific journals. CONCLUSION: The new regular heading gives important details about ongoing surgical trials in Germany. The steady growth of trials and recruited patients demonstrates the practicability of randomized controlled trials in surgery.