Clinical experiences derived from implementation of an easy to use concept for treatment of wound healing by secondary intention and guidance in selection of appropriate dressings.

The main objective of this case-cohort-type observational study conducted at different Surgical Departments of the Charité-Universitätsmedizin in Berlin was to evaluate the sequential use concept first described by Systagenix Wound Management in 2007. Fifty-two patients with different wound healing by secondary intention were treated for 7 weeks at the Charité-Universitätsmedizin in Berlin. A multidisciplinary team worked together to reach consensus in wound assessment; in classification of infection status according to the criteria described by European Wound Management Association (EWMA); in treatment protocol and on dressings to be used to 'cover' wounds. Before dressing application, all wounds were cleaned from debris. Following the sequential use concept, wounds classified as stages 2 and 3 were dressed with SILVERCEL(®) and TIELLE(®) or TIELLE PLUS(®) to 'clean' the wounds. After 2-3 weeks, treatment was changed to PROMOGRAN PRISMA(®) and TIELLE(®) to 'close and cover' wounds, thus providing optimal wound healing. Wounds classified as non infected were dressed with PROMOGRAN PRISMA(®) and TIELLE(®) during the complete treatment period. Patients were asked to evaluate the treatment using a simplified questionnaire developed at the Charité-Universitätsmedizin in Berlin. Wounds comprised 37 surgical procedures, 8 chronic mixed ulcer, 4 pressure sores, 1 diabetic foot ulcer, 1 venous leg ulcer, and 1 mixed arterial/venous ulcer. At baseline, 12 wounds were classified as stage 3, 38 wounds as stage 2 and 2 wounds as stage 1. After 7 weeks of treatment, all patients showed a positive clinical response to the sequential use treatment. Results of wound size showed a high significant progression of wound healing expressed with a profound reduction of wound area (P in all measurements <0·001, chi-square test) and improved granulation. This study summarises the clinical experiences derived from the evaluation of the sequential use concept in the daily clinical practice of wound treatment. On the basis of the wound healing results, patients' evaluation of treatment and the clinicians' and staff experiences, this concept was implemented at different Surgical Departments of the Charité-Universitätsmedizin in Berlin.

Socioeconomic factors, hazardous alcohol consumption, and smoking in patients with minor trauma in an inner-city emergency department.

Emergency Department (ED) patients show a high prevalence of hazardous alcohol consumption and smoking. The objective of this study was to determine if socioeconomic factors and smoking status help to optimize screening for hazardous alcohol consumption (HAC) in patients with minor trauma. A survey was conducted in an ED in an inner-city university hospital. A total of 2562 patients with minor trauma were screened for HAC (≥ 8 points in men and ≥ 5 points in women on the Alcohol Use Disorders Identification Test), smoking status, and socioeconomic factors. The median age of participants was 32 years, with 62.1% being male. A total of 84.2% of patients had an Injury Severity Score of 1, indicating minor trauma. Overall, 23.5% of patients showed a pattern of HAC, whereas 46.2% were current smokers. Compared to patients without HAC, those with HAC were characterized by lower incomes, no partnership, living in a single-household, and being unemployed. The strongest discriminative variable for HAC for patients aged ≤ 53 years was smoking status. Gender differences played a role only in patients older than 53 years. Although socioeconomic factors showed a non-equal distribution in patients with respectively without HAC, solely age, gender, and smoking status may provide a successful stratification for alcohol screening and intervention in these patients.

Taurolidine reduces the tumor stimulating cytokine interleukin-1beta in patients with resectable gastrointestinal cancer: a multicentre prospective randomized trial.

BACKGROUND: The effect of additional treatment strategies with antineoplastic agents on intraperitoneal tumor stimulating interleukin levels are unclear. Taurolidine and Povidone-iodine have been mainly used for abdominal lavage in Germany and Europe. METHODS: In the settings of a multicentre (three University Hospitals) prospective randomized controlled trial 120 patients were randomly allocated to receive either 0.5% taurolidine/2,500 IU heparin (TRD) or 0.25% povidone-iodine (control) intraperitoneally for resectable colorectal, gastric or pancreatic cancers. Due to the fact that IL-1beta (produced by macrophages) is preoperatively indifferent in various gastrointestinal cancer types our major outcome criterion was the perioperative (overall) level of IL-1beta in peritoneal fluid. RESULTS: Cytokine values were significantly lower after TRD lavage for IL-1beta, IL-6, and IL-10. Perioperative complications did not differ. The median follow-up was 50.0 months. The overall mortality rate (28 vs. 25, p = 0.36), the cancer-related death rate (17 vs. 19, p = .2), the local recurrence rate (7 vs. 12, p = .16), the distant metastasis rate (13 vs. 18, p = 0.2) as well as the time to relapse were not statistically significant different. CONCLUSION: Reduced cytokine levels might explain a short term antitumorigenic intraperitoneal effect of TRD. But, this study analyzed different types of cancer. Therefore, we set up a multicentre randomized trial in patients undergoing curative colorectal cancer resection. TRIAL REGISTRATION: ISRCTN66478538.

Robotic-assisted laparoscopic and thoracoscopic surgery with the da Vinci system: a 4-year experience in a single institution.

PURPOSE: We set up a pilot study to evaluate the efficacy of telerobotic surgery using the da Vinci system for several procedures for which traditional laparoscopy (or thoracoscopy) is a standard approach in a single institution. METHODS: We performed fundoplications (hiatal hernia repair and antireflux surgery, n=112), upside-down stomach (14), cholecystectomy (16), gastric banding (3), colectomy (5), esophagectomy (4), sub/total gastrectomy (2), gastrojejunostomy (2), along with thymectomy (100), thoracic symatectomy (11), lobectomy (5), mediastinal parathyroidectomy (5), and left pancreatic resection (1). RESULTS: The median set up time for all procedures was reduced from 25.0 to 10.4 minutes. Conversion to traditional laparoscopy or thoracoscopy occurred in 12 cases and in open surgery in 11 cases. There was no morbidity related to the telerobotic system. CONCLUSIONS: Robotically assisted laparoscopic and thoracoscopic surgery is feasible and safe for a variety of procedures in general, visceral, and thoracic surgery.

Computer-assisted laparoscopic repair of "upside-down" stomach with the Da Vinci system.

Recently introduced telerobotic surgical systems attempt to elude the inherent limitations of traditional laparoscopic surgery. Four patients (3 male, 1 female) with mixed hiatal and paraesophageal hernias with fixed intrathoracic partial or complete displacement of the stomach were operatively treated using the Da Vinci robotic system. Tissue dissection, hiatoplasty, and anterior hemifundoplication (Dor) were performed with the telerobotic system. There were no surgical complications. The system broke down in the fourth patient due to a software defect. Advantages were seen in terms of the intrathoracic dissection of displaced stomach through a narrow hiatus, intracorporeal suturing due to 6 degrees of freedom plus grasping. At the moment, lack of the appropriate robotic instruments for abdominal surgery as well as the enormous functional cost of the robotic system are considered to be the most significant current impediment to the adoption of robotic abdominal surgery. The continuous evolution and upgrade of the system is quite promising so far. Telerobotic-assisted hiatal hernia operation is feasible with many advantages compared with the traditional laparoscopic approach, especially during the dissection in the mediastinum in patients with intrathoracic stomach. A prospective, randomized trial will be performed later to evaluate the advantages and limitations of robotic compared with traditional laparoscopy. Technological evolution will perhaps diminish the current problems and the cost associated with robotic surgery.

Does an informative video before inguinal hernia surgical repair influence postoperative quality of life? Results of a prospective randomized study.

PURPOSE: Patients undergoing surgery can be impaired in several health-related quality of life areas. As a result, a modern and effective presentation of medical information before elective surgery is of great importance. Thorough preoperative education of the patient could possibly lead to an improvement of postoperative quality of life. MATERIALS AND METHODS: In a prospective randomized study we examined the influence of a preoperative informative video on the postoperative quality of life of patients undergoing elective surgery for inguinal hernia. Quality of life was assessed with a short form questionnaire (SF-36) preoperatively, on the first postoperative day and 3, 6, and 12 months after surgery. RESULTS: From January 2004 until January 2005, 100 patients were included in the study (video group n = 50 patients, control group n = 50 patients). Quality of life was measured higher in the video group soon after surgery and until 3 months afterwards. In the same group other aspects evaluated such as "global health" and "social role" showed higher values postoperatively and resumption of preoperative activities took place earlier. No difference was detectable 6 months after surgery. CONCLUSION: Informative video presents a modern and cost-effective method for the justified and detailed education of the patient about the several pre-, intra-, and postoperative steps of an elective groin hernia operation. The higher information level and the better conditions of surgical care, as the patients perceive these, lead to a better postoperative quality of life.

Computer-assisted laparoscopic colon resection with the Da Vinci system: our first experiences.

PURPOSE: Telerobotic surgery is a developing and promising modality that highly improves the laparoscopic dexterity. We have performed more than 100 laparoscopic and thoracoscopic procedures since December 2002 with the aid of the Da Vinci robotic system. This study was designed to assess the value of robots in colonic laparoscopic surgery. We present our first cases of robotic-assisted colectomies. METHODS: Two patients underwent a telerobotic-assisted sigmoidectomy for sigmadiverticulitis. One of these cases was complicated with a sigmoid-bladder fistula. Three other patients were submitted to a colon resection for cancer: sigmoidectomy (n = 2), and right colectomy (n = 1). A four-trocar technique was used for all operations. Tissue dissection of colonic adhesions, mobilization of the colon, management of the fistula, mesenteric dissection and division, and bowel resection were fully performed with the telerobotic system. RESULTS: Three operations were completed using the Da Vinci system without any problems in acceptable times. In two patients, the operation had to be converted to laparotomy because of severe adhesions and locally extended tumor growth. Postoperative courses of all patients were uneventful. Patients were discharged between postoperative Days 9 and 20, and were well six months later. CONCLUSIONS: Colonic telerobotic surgery can be performed safely. Benefits were seen during dissection of the rectum in the small pelvis. A major limitation is a lack of a large operation field especially if there is the need to dissect a colonic flexure in the upper abdomen. The enormous costs and the lack of appropriate instruments can be a major problem in the further expansion of the telerobotic surgery.