ECSPECT prospective multicentre registry for single-port laparoscopic colorectal procedures.

BACKGROUND: The international multicentre registry ECSPECT (European Consensus of Single Port Expertise in Colorectal Treatment) was established to evaluate the general feasibility and safety of single-port colorectal surgery with regard to preoperative risk assessment. METHODS: Consecutive patients undergoing single-port colorectal surgery were enrolled from 11 European centres between March 2010 and March 2014. Data were analysed to assess patient-, technique- and procedure-dependent parameters. A validated sex-adjusted risk chart was developed for prediction of single-port colorectal surgery-related conversion and complications. RESULTS: Some 1769 patients were enrolled, 937 with benign and 832 with malignant conditions. Procedures were completed without additional trocars in 1628 patients (92·0 per cent). Conversion to open surgery was required in 75 patients (4·2 per cent) and was related to male sex and ASA fitness grade exceeding I. Conversions were more frequent in pelvic procedures involving the rectum compared with abdominal procedures (8·1 versus 3·2 per cent; odds ratio 2·69, P < 0·001). Postoperative complications were observed in a total of 224 patients (12·7 per cent). Independent predictors of complications included male sex (P < 0·001), higher ASA grade (P = 0·006) and rectal procedures (P = 0·002). The overall 30-day mortality rate was 0·5 per cent (8 of 1769 patients); three deaths (0·2 per cent; 1 blood loss, 2 leaks) were attributable to surgical causes. CONCLUSION: The feasibility and safety, conversion and complication profile demonstrated here provides guidance for patient selection.

Treatment of small (< 2 cm) umbilical hernias: guidelines and current trends from the Herniamed Registry.

INTRODUCTION: Based on meta-analyses and registry data, the European Hernia Society and the Americas Hernia Society have published guidelines for the treatment of umbilical hernias. These recommend that umbilical hernia should generally be treated by placing a non-absorbable (permanent) flat mesh into the preperitoneal space with an overlap of the hernia defect of 3 cm. Suture repair should only be considered for small hernia defects of less than 1 cm. Hence, the use of a mesh in general is subject to controversial debate particularly for small (< 2 cm) umbilical hernias. This analysis of data from the Herniamed Registry now presents data on the treatment of small (< 2 cm) umbilical hernias over the past 10 years. METHODS: Herniamed is an Internet-based hernia registry in which hospitals and surgical centers in Germany, Austria and Switzerland can voluntarily enter data on their routine hernia operations. Between 2010 and 2019, data were entered into the Herniamed Registry by 737 hospitals/surgery centers on a total of 111,765 patients with primary elective umbilical hernia repair. The prospective data were analyzed retrospectively for each year and statistically compared. Due to a higher number of cases, the years 2013 and 2019 were compared for the perioperative outcome and the years 2013 and 2018 for 1-year follow-up. Fisher's exact test was applied for unadjusted analyses between the years, using a significance level of alpha = 5%. For post hoc tests of single categories, a Bonferroni adjustment for multiple testing was implemented. RESULTS: A mesh technique was used to treat 45.4% of all umbilical hernias. The proportion of small (< 2 cm) umbilical hernias in the total collective of umbilical hernias was 55.6%. Suture repair was used consistently over the 10-year period to treat around 75% of all small (< 2 cm) umbilical hernias. Preperitoneal mesh placement as recommended in the guidelines was used only in 1.8% of cases. Between 2013 and 2019, stable values of 2 and 0.7% were observed for the postoperative complications and complication-related reoperations, respectively, with no relevant effect identified for the surgical technique. At 1-year follow-up, significantly higher rates of pain at rest (2.6 vs. 3.3), pain on exertion (5.7 vs. 6.6), and recurrences (1.3 vs. 1.8) (all p < 0.05) were identified for 2018 compared with 2013. CONCLUSIONS: A suture technique is still used to treat 75% of patients with small (< 2 cm) umbilical hernias. The pain and recurrence rates are significantly less favorable for 2018 compared with 2013.

Assessment of potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair: a registry-based multivariable analysis of 31,965 patients.

INTRODUCTION: How best to treat a small (< 2 cm) umbilical hernia continues to be the subject of controversial debate. The recently published guidelines for treatment of umbilical hernias from the European Hernia Society and Americas Hernia Society recommend open mesh repair for defects ≥ 1 cm. Since the quality of evidence is limited for hernias with defect sizes smaller than 1 cm, suture repair can be considered. To date, little is known about the potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair. This multivariable analysis of data from the Herniamed Registry now aims to assess these factors. METHODS: The data of patients with primary elective umbilical hernia repair and defect size < 2 cm entered into the Herniamed Registry from September 1, 2009 to December 31, 2018 were analyzed to assess through multivariable analysis all confirmatory pre-defined potential influencing factors on the primary outcome criteria intraoperative and postoperative complications, general complications, complication-related reoperations, recurrence rate and rates of pain at rest, pain on exertion and chronic pain requiring treatment at 1-year follow-up. RESULTS: 31,965 patients (60%) met the inclusion criteria. The proportion of suture repairs was 78.6% (n = 25,119), of open mesh repairs 15.2% (n = 4853), and of laparoscopic mesh repairs 6.2% (n = 1993). Compared with open mesh repair, suture repair had a highly significantly unfavorable association with the recurrence rate (OR = 1.956 [1.463; 2.614]; p < 0.001). Female gender also had an unfavorable relation to the recurrence rate (OR = 1.644 [1.385; 1.952]; p < 0.001). Compared with open mesh repair, open suture repair had a highly significantly favorable association with the rate of postoperative complications (OR = 0.583 [0.484; 0.702]; p < 0.001) and complication-related reoperations (OR = 0.567 [0.397; 0.810]; p = 0.002).While laparoscopic IPOM showed a favorable relationship with the postoperative complications and complication-related reoperations, it demonstrated an unfavorable association with the intraoperative complications, general complications, recurrence rate and pain rates. CONCLUSION: Suture repair continues to be used for 78% of umbilical hernias with a defect < 2 cm. While suture repair has a favorable influence on the rates of postoperative complications and complication-related reoperations, it has a higher risk of recurrence. Female gender also has an unfavorable influence on the recurrence rate. Laparoscopic IPOM appears to be indicated only in settings of obesity (BMI ≥ 30).

Single incision laparoscopic sigmoid colon resections without visible scar: a novel technique.

OBJECTIVE: On the way to 'no-scar' techniques we developed a novel method for colorectal resection utilizing three intraumbilical trocars which results in a nonvisible postoperative scar. METHOD: Two female patients (Age: 56a, 42a) underwent laparoscopic colorectal resection for diverticulitis and infiltrating endometriosis of the rectosigmoid colon, respectively. The entire operation was carried out transumbilically following the standardized principles of colorectal resection. RESULTS: The operative time was 110 and 180 min, respectively. No intraoperative adverse events or significant perioperative complication was noticed. The specimen measured 22 and 18 cm in length respectively. Estimated blood loss was minimal in both cases. Oral diet was resumed on postoperative day one. Patients were discharged on postoperative day 7 and day 6, respectively. At follow-up, patients presented with an optimal cosmetic result without apparent scarring. CONCLUSION: For the first time, a novel laparoscopic technique for sigmoid colon resection utilizing a single intraumbilical approach is presented. This new method allows further reduction of the surgical trauma and obviates any visible scar.

The inguinal region revisited: the surgical point of view : An anatomical-surgical mapping and sonographic approach regarding postoperative chronic groin pain following open hernia repair.

PURPOSE: Inguinodynia or chronic post-herniorrhaphy pain, defined as pain lasting longer than 3 months after open inguinal hernia repair, has become the most important complication after inguinal surgery and therefore compromises the patient´s quality of life. A major reason for inguinodynia might be the lack of neuroanatomical knowledge and suboptimal "management" of the nerves during surgery. METHODS: We present a detailed neuroanatomic mapping of the inguinal region by dissection including the most important surgical landmarks with all nerves confirmed by immunohistochemistry, ultrasound guided visualization of the iliohypogastric, ilio-inguinal, and genital branch of the genitofemoral nerve, and a practical (preoperative) algorithm for clinical management. RESULTS: Surgically and ultrasonographically relevant structures ("landmarks") in open hernia repair are the anterior-superior iliac spine, pubic tubercle, Camper´s fascia (superficial layer of the superficial abdominal fascia), External oblique aponeurosis, Internal oblique muscle, Transversus abdominis muscle, superficial inguinal ring, external spermatic fascia, cremasteric fascia with cremaster muscle fibers, internal spermatic fascia, cremasteric vein (=external spermatic vein = "blue line"), ductus deferens, pampiniform plexus, inguinal ligament and the inferior epigastric vessels. CONCLUSION: A detailed understanding of inguinal anatomy is an indispensable basic requirement for all surgeons to perform inguinal ultrasonography as well as open inguinal hernia repair, avoiding complications, especially postoperative inguinodynia.

Epidermolysis bullosa acquisita in an 18-year-old African-American male: a case report.

An 18-year-old African-American male with epidermolysis bullosa acquisita presenting as vesico-bullous lesions over the fingers, elbows and knees following minimal trauma is reported. There was no underlying systemic disease, and he responded to administration of dapsone and prednisone.

Properties of several protein kinases that copurify with rat spinal cord neurofilaments.

Several protein kinases that copurify with neurofilaments (NF) were identified and each kinase was assessed for its ability to phosphorylate NF proteins. NFs were isolated using an axonal flotation procedure and the kinases were extracted from NFs with 0.8 M KCl. NF kinases were incubated with peptide substrates for selected protein kinases, [32P]ATP and protein kinase cofactors and inhibitors to characterize the kinases. Using peptide substrates, three types of kinase were identified, and a fourth was identified using NF protein as substrate. The first three kinases were the catalytic subunit of cAMP-dependent protein kinase, calcium-calmodulin dependent protein kinase II and a cofactor-independent kinase that phosphorylated prepro VIP sequence 156-170 and was inhibited by heparin. Using NF proteins as substrate, a fourth kinase was identified which was cofactor-independent and was not inhibited by heparin. Neither cofactor-independent kinase was casein kinase II. NF proteins were phosphorylated in vitro on serine and threonine, primarily by the two cofactor-independent kinases. Using [alpha-32P]8-N3ATP for affinity labeling, one kinase of 43,800 Da was identified. Thus, in addition to cAMP-dependent protein kinase and calcium-calmodulin dependent protein kinase II, two kinases have been found which are primarily responsible for NF phosphorylation in vitro and are cofactor-independent.

Immunological characterization of the region of tau protein that is bound to Alzheimer paired helical filaments.

Tau protein is known to be present in the paired helical filaments (PHFs) of Alzheimer brains. This study investigated the fragments of tau protein that remain bound to pronase-treated PHFs and conditions that lead to the release of these tau fragments from the core structure of the PHF. Antibody 423 reacted with PHFs and with fetal rat tau but not with adult rat tau, pig tau, or recombinant human tau. Three other antibodies that react with the tubulin binding region of tau only reacted with PHFs after they were disrupted with formic acid or guanidine. Other antibodies that recognize tau sequences C terminal to the tubulin binding region also recognized pronase-treated PHFs. Antibodies SMI34 and T3P that recognize phosphorylated epitopes were reactive with pronase-treated PHFs. Tau fragments from the PHF were solubilized by acid or guanidine treatment. These findings suggest that the fragments of tau that are bound to PHFs and protected from pronase digestion include sequences from the tubulin binding region to the C terminus of tau. In addition, some of these sequences appear to be conformationally or post-translationally modified.

Incidental paraduodenal hernia found during laparoscopic colectomy.

This paper describes a rare right paraduodenal hernia discovered during an elective laparoscopic colon resection. Our patient was a 60-year-old Asian man with a history of multiple bouts of diverticulitis and a lifelong history of mild constipation and postprandial abdominal pain. Prior CT scans and preoperative barium enema confirmed the diagnosis of diverticular disease, and no other abnormalities were appreciated. At laparoscopic exploration, a right paraduodenal hernia was found with complete herniation of the small intestine under the ascending colon and hepatic flexure. The unclear anatomy prompted conversion to an open laparotomy. This allowed safe reduction of the hernia and sac excision. Adhesions were lysed to relieve a partial duodenal obstruction, and a Ladd's procedure was performed to correct the incomplete rotation. Additionally, a sigmoid colectomy was performed. After prolonged ileus, the patient was discharged on postoperative day 14. At 6-month follow-up, the patient was asymptomatic and doing well.

Combined radio-carpal and mid-carpal dislocation. A case report.

We describe a case of combined volar dislocation of the lunate and dorsal dislocation of the remainder of the carpus. Such a combination is probably very rare and the possible mechanism of injury is discussed.

[Chronic renal failure: when do patients need a nephrologist?]. / Niereninsuffizienz--wann braucht es den Nephrologen?

Renal insufficiency is a fairly frequent problem, whether it is due to a kidney disease per se or to an extrarenal disease or to a combination of both. In contrast, chronic renal failure requiring renal replacement therapy is a rare condition in the practitioner's office. Considering this, the question is important to the practitioner, when in the course of the disease there is need for referral to a nephrologist. In this context two main questions have to be raised: first, is the disease curable or at least partially reversible (depending on the etiology of the renal disease) and second, when has the time arrived to prepare the patient for a renal replacement therapy. The cooperation with a nephrologist has to be sought early enough in order to choose the best moment for these actions. There are several European and American studies dealing with these problems and proving the benefit of a timely referral and a timely start of treatment. We extract some of the relevant data considering own data collected at the University Hospital of Berne (Inselspital), Switzerland.

[Pruritus--also a challenge in internal medicine]. / Pruritus--auch eine internistische Herausforderung.

Generalized or localized itch without primary skin manifestations may be the presenting symptom of serious internal diseases. Five characteristic cases of pruritus are discussed: Hodgkin's disease, primary sclerosing cholangitis, polycythemia vera, iron deficiency (with pica), and uremia. Other important causes must be considered; all forms of cholestasis, including primary biliary cirrhosis, drug-induced, pregnancy-related, and extrahepatic cholestasis; other hematologic and malignant disorders such as non-Hodgkin's lymphoma, leukemia, multiple myeloma, solid tumors, and myelodysplastic syndromes; metabolic and endocrine diseases, most notably diabetes mellitus, hyperthyroidism, hypothyroidism, and carcinoid syndrome; focal neurologic diseases such as brain tumors, cerebral infarctions and multiple sclerosis; adverse drug reactions without rash; infectious diseases, especially parasitic and HIV infections. A diagnostic laboratory screening for pruritus of undetermined origin is suggested.

[The spontaneous, non-traumatic chylothorax. Therapy by means of pleurectomy and decortication]. / Der spontane, nicht-traumatische Chylothorax. Heilung durch Pleurektomie und durch Dekortikation

Two cases of chronic spontaneus chylothorax were successfully treated by small thoracotomy with parietal pleurectomy or decortication after unsuccessful needle aspiration and intercostal tube drainage with suction. In the one case the chylous effusion occurred spontaneously 29 years after extrapleural pneumothorax. The tuberculosis was long cured. In the other, apparently idiopathic case, the chylothorax on the left side disappeared completely after pleurectomy. Six months later a chylous effusion appeared on the right side. Mediastinoscopy then revealed an oatcell carcinoma in lymph nodes without a primary pulmonary tumor. One year after radiotherapy the patient died in heart failure. No primary tumor was found. Residual chylothorax was present only on the right side.