Rectal Cancer: Are 12 Lymph Nodes the Limit?

Lymph node dissection is a crucial element of oncologic rectal surgery. Many guidelines regard the removal of at least 12 lymph nodes as the quality criterion in rectal cancer. However, this recommendation remains controversial. This study examines the factors influencing the lymph node yield and the validity of the 12-lymph node limit. Patients with rectal cancer who underwent low anterior resection or abdominoperineal amputation between 2000 and 2010 were analyzed. In total, 20,966 patients from 381 hospitals were included. Less than 12 lymph nodes were found in 20.53% of men and 19.31% of women (p = 0.03). The number of lymph nodes yielded increased significantly from 2000, 2005 and 2010 within the quality assurance program for all procedures. The univariate analysis indicated a significant (p < 0.001) correlation between lymph node yield and gender, age, pre-therapeutic T-stage, risk factors and neoadjuvant therapy. The multivariate analyses found T3 stage, female sex, the presence of at least one risk factor and neoadjuvant therapy to have a significant influence on yield. The probability of finding a positive lymph node was proportional to the number of examined nodes with no plateau. There is a proportional relationship between the number of examined lymph nodes and the probability of finding an infiltrated node. Optimal surgical technique and pathological evaluation of the specimen cannot be replaced by a numeric cut-off value.

Vacuum-assisted closure (VAC) for postoperative secondary peritonitis: Effect on bacterial load as well as local and systemic cytokine response (initial results).

BACKGROUND: It is still a matter of debate what the best management of peritonitis is following eliminating the source of infection. This particularly concerns the amplitude of local and systemic inflammatory response as well as bacterial clearence at the infectious site. AIM: To investigate the effects of vacuum-assisted closure (VAC) vs. relaparotomy on demand (ROD) onto the i) severity and course of disease, ii) surgical outcome, iii) intraperitoneal bacterial load as well as iv) local and systemic inflammatory and immune response in postoperative secondary peritonitis. METHODS: Over a defined time period, all consecutive patients of the reporting surgical department with a secondary peritonitis (assessed by Mannheim's Peritonitis Index [MPI] and APPACHE II score) were enrolled in this systematic unicenter clinical prospective observational pilot study reflecting daily surgical practice and as a contribution to internal quality assurance. Patients were subclassified into VAC or ROD group according to surgeon's individual decision at the time point of primary surgical intervention with the intent to sanitize the source of infection. Early postoperative result was assessed by 30-d and in-hospital mortality. Bacterial load was characterized by microbiological culture of intraperitoneal fluid collection obtained on postoperative days (POD) 0 (primary surgical intervention), 1, 4, 7, 10, 13 and following description of the microbial spectrum including semiquantitative assessment of bacterial load. Local and systemic inflammatory and immune response was determined by ELISA-based analysis of CrP, PCT and the representative cytokines such as TNF-α, IL-1ß, IL-6, IL-8, and IL-10 of serum and peritoneal fluid samples. RESULTS: Over a 26-months investigation period, 18 patients (sex ratio, male:female=9:9) were eligible for study criteria: n=8 were enrolled in the VAC (m:f=4:4) and n=10 in the ROD group (m:f=5:5). With regard to early postoperative results represented by mortality, there is no significant difference between both patients groups. Despite the relatively low number of cases enrolled in this study, a trend for more severe findings associated with the VAC group could be detected based on MPI score. There was also a trend of higher APACHE II scores in the VAC group from the 7th POD on and, in addition, patients of this group had a longer hospital stay. For patients with persisting infection, there were no relevant differences comparing VAC therapy and ROD. Cytokines released, in particular, at the beginning of the inflammation cascade with proinflammatory characteristics, showed higher values within the peritoneal fluid whereas CrP and PCT were found to be higher within the serum samples. Summary & Conclusion: Comparing data of various local and systemic inflammatory and immune parameters, there were only a few correlations. This may indicate a compartimentation of the inflammatory process within the abdominal cavity. Based on the observed inter-individual variation of this pilot study data, the clinically applicable benefit appears questionable. In this context, a reliable effect of VAC therapy onto reduction of bacterial burden within the abdominal cavity could not clearly be detected.

Surgical Quality in Rectal Cancer Management: What Can Be Achieved by a Voluntary Observational Study?

PURPOSE: Countries with nationwide quality programmes in colorectal cancer report an improved outcome. In Germany, a self-organized and self-financed observational quality assurance project exists, based on voluntary participation. The object of the present study was to ascertain whether this nationwide project also improves the outcome of colorectal cancer. METHODS: The German Quality Assurance in Colorectal Cancer Project started in 2000 and by 2012 contained 85,000 patients. Inclusion criteria for the study were participation for the entire period of 13 years and treatment of rectal cancer. The following parameters were analysed: (1) patient related: age, gender, ASA classification, T-stage, and N-stage, (2) system related: frequency of preoperative CT and MRI, and (3) outcome related: CRM status, complications, and hospital mortality. RESULTS: Forty-one of the 345 hospitals treating 11,597 patients fulfilled the inclusion criteria. The median age increased from 67 to 69 years (p = 0.002). ASA stages III and IV increased from 32.0% to 37.6% (p = 0.005) and from 2.0% to 3.3% (p = 0.022), respectively. The use of CT rose from 67.2% to 88.8% (p < 0.001) and that of MRI from 5.0% to 35.2% (p < 0.001). The proportion of patients suffering from complications decreased from 7.9% to 5.3% (p < 0.001) for intraoperative and from 28.0% to 18.6% (p < 0.001) for postoperative surgical complications, but general postoperative complications increased from 25.8% to 29.5% (p = 0.006). The distribution of histopathological stage, anastomotic leakage, and in-hospital mortality did not change significantly. CONCLUSION: Participation in a quality assurance project improves compliance with treatment standards, especially for diagnostic procedures. An improvement of surgical results will require further investment in training.

A rare case of perforated "sub-hepatic appendicitis" - a challenging differential diagnosis of acute abdomen based on the combination of appendicitis and maldescent of the caecum.

Unusual locations of the appendix vermiformis can result in delay in appropriate diagnosis and treatment of appendicitis. So an inflamed appendix in a sub-hepatic caecum caused by caecal maldescent for example can mimic cholecystitis, the pain being localized in the right upper quadrant. Here, we present a case of perforated sub-hepatic appendicitis with peritonitis, requiring open ileocaecal resection. Review of the existing literature has demonstrated that this pathology is uncommon, yet not so rare as one might presume. In conclusion, surgeons should be aware of this possibility in the diagnostic and therapeutic management of acute abdomen.

Risk factors, short and long term outcome of anastomotic leaks in rectal cancer.

BACKGROUND: An anastomotic leak (AL) after colorectal surgery is one major reason for postoperative morbidity and mortality. There is growing evidence that AL affects short and long term outcome. This prospective German multicentre study aims to identify risk factors for AL and quantify effects on short and long term course after rectal cancer surgery. METHODS: From 1 January 2000 to 31 December 2010 381 hospitals attributed patients to the prospective multicentre study Quality Assurance in Colorectal Cancer managed by the Otto-von-Guericke-University Magdeburg (Germany). Included were 17 867 patients with histopathologically confirmed rectal carcinoma and primary anastomosis. Risk factor analysis included 13 items of demographic patient data, surgical course, hospital volume und tumour stage. RESULTS: In 2 134 (11.9%) patients an AL was diagnosed. Overall hospital mortality was 2.1% (with AL 7.5%, without AL 1.4%; p < 0.0001). In multivariate analysis male gender, ASA-classification ≥III, smoking history, alcohol history, intraoperative blood transfusion, no protective ileostomy, UICC-stage and height of tumour were independent risk factors. Overall survival (OS) was significantly shorter for patients with AL (UICC I-III; UICC I, II or III - each p < 0.0001). Disease free survival (DFS) was significantly shorter for patients with AL in UICC I-III; UICC II or UICC III (each p < 0.001). Rate of local relapse was not significantly affected by occurrence of AL. CONCLUSIONS: In this study patients with AL had a significantly worse OS. This was mainly due to an increased in hospital mortality. DFS was also negatively affected by AL whereas local relapse was not. This emphasizes the importance of successful treatment of AL related problems during the initial hospital stay.

German Bowel Cancer Center: An Attempt to Improve Treatment Quality.

Background. Colorectal cancer remains the second most common cause of death from malignancies, but treatment results show high diversity. Certified bowel cancer centres (BCC) are the basis of a German project for improvement of treatment. The aim of this study was to analyze if certification would enhance short-term outcome in rectal cancer surgery. Material and Methods. This quality assurance study included 8197 patients with rectal cancer treated between 1 January 2008 and 31 December 2010. We compared cohorts treated in certified and noncertified hospitals regarding preoperative variables and perioperative outcomes. Outcomes were verified by matched-pair analysis. Results. Patients of noncertified hospitals had higher ASA-scores, higher prevalence of risk factors, more distant metastases, lower tumour localization, lower frequency of pelvic MRI, and higher frequencies of missing values and undetermined TNM classifications (significant differences only). Outcome analysis revealed more general complications in certified hospitals (20.3% versus 17.4%, p = 0.03). Both cohorts did not differ significantly in percentage of R0-resections, intraoperative complications, anastomotic leakage, in-hospital death, and abdominal wall dehiscence. Conclusions. The concept of BCC is a step towards improving the structural and procedural quality. This is a good basis for improving outcome quality but cannot replace it. For a primary surgical disease like rectal cancer a specific, surgery-targeted program is still needed.

Nosocomial Infections and Microbiologic Spectrum after Major Elective Surgery of the Pancreas, Liver, Stomach, and Esophagus.

BACKGROUND: The majority of infections treated by surgeons are nosocomial infections (NI). The frequency of these infections in relation to the organ operated on as well as the organisms involved are not well defined. Detailed knowledge of these issues is essential for optimal care of surgical patients. This study aimed to determine infection rates and the responsible pathogens after major elective surgery of the pancreas, liver, stomach, and esophagus. METHODS: Between January 1, 2005 and August 31, 2007, the records of all patients of the Department of General, Abdominal and Vascular Surgery, University Hospital Magdeburg (Germany) with elective resection of the pancreas, liver, stomach, and esophagus were evaluated retrospectively. Study parameters were: Patient number, age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, indication for resection, operation duration, length of stay (LOS) in the intensive care unit (ICU) and in hospital, mortality, organ-related rate and kind of NI, and microbiologic spectrum. Nosocomial infections were defined as: Surgical site infection (U.S. Centers for Disease Control and Prevention [CDC] 1 or 2) and intra-abdominal infection (CDC 3), urinary tract infection, clinical sepsis, blood stream and catheter-related infection, respiratory tract infection, and pneumonia. RESULTS: A total of 358 patients were included: 150 (42%) with pancreas resection, 91 (25%) with liver resection, 105 (29%) with gastric resection, and 12 (3%) with esophagus resection. Median LOS in the ICU for all groups was 48.8 h (interquartile range [IQR] 24.9-91.8 h), median LOS in hospital was 16 d (IQR 13-23 d), and in-hospital mortality was 4.5%. Patients with NI had significantly greater in-hospital death and prolonged stay in hospital and ICU (p<0.001). In 120 (33.5%) patients, one or more NI occurred (range, 83% in esophagus patients to 21% in liver patients). Intra-abdominal (16.5%) and surgical site infections (12.3%) were most frequent; 80.8% of the NI were culture-positive. The most frequent clinically relevant isolates were Escherichia coli (12.4%), coagulase-negative staphylococci (CoNS) (12.2%), and Enterococcus faecium (9.7%). The highest resistance rates were found for Staphylococcus aureus (methicillin-resistant S. aureus [MRSA] 29.4%) and Pseudomonas aeruginosa (23.5%). CONCLUSIONS: For patients undergoing elective surgery of the pancreas, liver, stomach, and esophagus, considerable differences in demographic factors, frequency, and kind of NI exist. The consequences of NI force surgeons to analyze pre-operative risk factors carefully, assess indications for operation thoroughly, and optimize all controllable parameters.

Involving Medical Students in Informed Consent: A Pilot Study.

INTRODUCTION: Studies have reported that patients often sign consent documents without understanding the content. Written paperwork, audio-visual materials, and decision aids have shown to consistently improve patients' knowledge. How informed consent should be taken is not properly taught at most universities in Germany. MATERIALS AND METHODS: In this cross-sectional study, we investigated how much information about their procedure our patients retain. In particular, it should be elucidated whether an additional conversation between patients and properly prepared medical students shortly before surgery as an adjunct to informed consent can be introduced as a new teaching unit aimed to increase the understanding of surgery by patients and students. Informed consent of all patients had been previously obtained by three surgical residents 1-3 days in advance. All patients had received a copy of their consent form. The same residents developed assessment forms for thyroidectomy, laparoscopic cholecystectomy, umbilical hernia repair, and Lichtenstein procedure for inguinal hernia, respectively, containing 3-4 major common complications (e.g., bile duct injury, hepatic artery injury, stone spillage, and retained stones for laparoscopic cholecystectomy) and briefed the medical students before seeing the patients. Structured one-to-one interviews between students (n = 9) and patients (n = 55) based on four different assessment forms were performed and recorded by students. Both patients and students were asked to assess the new teaching unit using a short structured questionnaire. RESULTS: Although 100% of patients said at the beginning of their interview to have understood and memorized the risks of their imminent procedure, 5.8% (3/55) were not even able to indicate the correct part of the body where the incision would take place. Only 18.2% (10/55) of the patients were able to mention 2 or more complications, and 45.3% (25/55) could not even recall a single one. 96.4% (53/55) of the patients and 100% (9/9) of the students taking part in this teaching unit found that this exercise represents a significant improvement of clinical teaching and recommended to introduce this teaching unit as a standard on the normal wards. CONCLUSION AND OUTLOOK: Students teaching patients (SteP) appears to be an easy and cost-efficient tool to improve patients' education and students' learning. Students become aware of how difficult it is to explain surgical procedures and complications to patients and patients are better informed about their treatment. We plan to (i) introduce the STeP protocol as a standard teaching project in daily clinical routine and (ii) continue the pilot study to reach representative student and patient numbers for a possible final statement and derived recommendation.

Comparison of outcome between older and younger patients following surgery for primary hyperparathyroidism.

UNLABELLED: The aim of the study was to compare preoperative findings, serum levels of calcium and parathormone (PTH) and outcome of patients undergoing surgery for primary hyperparathyroidism (pHPT) aged over 70 years with younger patients. MATERIAL AND METHODS: Between January 1, 1996 and September 30, 2011 186 patients underwent surgery for pHPT. Patient data were collected from chart reviews and an electronically stored database. Groups were defined as patients aged 70 years or older and patients younger than 70 years. Outcome comparison included operation time, tumor size, pre- and postoperative serum levels of calcium and PTH and length of stay in hospital. Complications were defined as clinical and laboratory signs of hypocalcemia, persistent elevated serum calcium, temporary or persistent recurrent laryngeal nerve paralysis, bleeding with need for reoperation, surgical site infection or need of tracheotomy. RESULTS: Parathyroidectomy alone was performed in 39.2% of patients. In 60.8% partial or total thyroidectomy was conducted simultaneously. More older patients had history of stroke and/or suffered from diabetes. Preoperative serum calcium and PTH did not differ between groups, but older patients displayed higher postoperative serum calcium (p=0.01). No significant differences between the two groups were observed regarding duration of surgery, surgical success rates, postoperative complications and hospitalization time. CONCLUSIONS: Even though older patients had more risk factors, our data suggest that there was no difference in surgical management and outcome. Decision for surgical management of pHPT should be done regardless of age.

Retroperitoneoscopic and laparoscopic removal of periadrenally located bronchogenic cysts--a systematic review.

UNLABELLED: Retroperitoneal bronchogenic cysts (BC) are rare clinical entities and may mimic an adrenal mass. Laparoscopic and retroperitoneoscopic approach is widely-used in adrenal surgery. However minimally-invasive resection of a periadrenally located BC has been reported rarely. MATERIAL AND METHODS: A systematic review of PubMed has been performed using the following search strategy: bronchogenic cyst AND (adrenal OR retroperitoneal OR subdiaphragmatic). 18 BC being removed via minimally invasive approach have been found. Including our own case 7 were removed retroperitoneoscopically and 12 laparoscopically. RESULTS: An index case of a 50 year old male is presented. CT revealed 2 masses above the left adrenal area. A control demonstrated an increase in size. Retroperitoneoscopic resection was performed. Pathologic finding showed a multilocular cystic lesion with a diameter of 4cm. The cysts were lined by pseudostratified ciliated epithelium. The wall contained hyaline cartilage, seromucous glands and smooth muscle. CONCLUSIONS: Because exact preoperative diagnosis of hormonally inactive adrenal masses is not possible surgical resection is recommended in case of tumor growth, symptoms and to obtain definitive histological diagnosis. Minimal invasive approach seems to be a safe way for resection of BC in experienced hands. There is no clear evidence if laparoscopic or retroperitoneoscopic approach is favourable.

[Surgical site infections]. / Perioperative Prophylaxe und Therapie von Infektionen - Postoperative Wundinfektionen.

Surgical site infections are the second or third most common type of nosocomial infections in Germany. For hospitals an annual incidence of 130000-160000 cases is estimated. Microbiological findings basically depend on type of surgery and wound location. A variety of risk factors is known. Discrimination of avoidable and unavoidable risk factors is the key for prevention. Most important points in prevention are perioperative prophylaxis with antibiotics 30-60 minutes prior to incision and strict asepsis in the operation room. Clinical findings include a variety of symptoms. They can be assigned to an early course or a definitive infection. However, wound scores are better applicable when comparing clinical studies. The most important therapeutic procedure is clearing the source of infection. Subsequently the wound can be closed by secondary intention or lead to open wound healing. An accompanying therapy with antibiotics is recommendable in case of advanced local or systemic infection. To document wounds is an essential part of treating wounds.

Rare coincidence of familial adenomatous polyposis and a retroperitoneal fibromyxoid sarcoma: report of a case.

PURPOSE: Familial adenomatous polyposis is an autosomal-dominant inherited disease with development of as many as thousands of adenomas within colon and rectum. All untreated patients will develop colorectal adenocarcinoma. A variety of extracolonic manifestations can occur, although malignant tumors are rare. An association of familial adenomatous polyposis and sarcomas was reported in a few cases only. METHODS: We present the exceptional case of a 24-year-old male with genetically verified familial adenomatous polyposis (deletion of 10 base pairs at position 228-237 of exon 15A). The patient underwent prophylactic subtotal proctocolectomy and ileal-pouch rectal anastomosis in 2003. Two years later, an obstruction of the left ureter caused by a retroperitoneal mass was diagnosed. RESULTS: Histopathologic findings after complete tumor resection showed a low-grade fibromyxoid sarcoma. CT scan and clinical follow-up through 15 months postoperatively revealed no recurrent tumor growth. CONCLUSIONS: To our knowledge, this is the first reported case of familial adenomatous polyposis with metachronous retroperitoneal fibromyxoid sarcoma. Proctocolectomy or total colectomy and complete tumor resection is the treatment of choice in this case. In addition to more common semimalignant retroperitoneal desmoid tumors in familial adenomatous polyposis patients, a malignant soft-tissue tumor also has to be considered for differential diagnosis.

Balser plate stabilization: an alternate therapy for traumatic sternoclavicular instability.

Traumatic instability of the sternoclavicular joint is a rare condition. It can be treated by surgical cerclage fixation, which necessitates postoperative immobilization, an approach preventing early postoperative functional rehabilitation. Balser plate stabilization is a therapeutic alternative that does not require extended periods of immobilization. From January 1, 1996, to December 31, 2000, a total of 10 trauma patients with unstable sternoclavicular joints (Allman grade III) requiring surgical management were treated with Balser plate stabilization to allow early physiotherapy. The population included 7 patients with anterior dislocations, 2 with posterior dislocations, and 1 with medial epiphysiolysis in addition to posterior dislocation. Implants were removed from 9 patients after 3 months and 1 patient after 2 months. One year or longer after the procedure, 9 of 10 patients were available for follow-up; 1 patient had moved. The results achieved with this alternative treatment are excellent. There were no cases of redislocation. The only surgical complication was a seroma that required surgical drainage. One patient had arthrosis develop. Outcome was assessed with Constant (range, 84-100; mean, 90.2 +/- 6.6) and DASH (disabilities of the arm, shoulder, and hand) (range, 4.1-16.6; mean, 8.4 +/- 1.4) scores. For the rare case of sternoclavicular joint dislocation requiring open surgical reduction and stabilization, the Balser plate technique is reliable, permits early movement, has good postoperative results, and compares favorably with alternative methods.

Expandable nail system for osteoporotic humeral shaft fractures: preliminary results.

BACKGROUND: Conventional nails rely on interlocking screws for axial and rotational stability. Such screws have poor fixation in patients with poor bone quality (osteopenia). The Fixion nail does not depend on interlocking screws-axial and rotational stability is instead achieved by nail expansion. Therefore, this nail may be better suited for patients with poor bone quality who require humeral stabilization. METHODS: The system was used to manage 25 unstable humerus shaft fractures in osteoporotic bone. An antegrade approach was used in 18 patients and a retrograde approach was used in 7 patients. RESULTS: There were no intra- or postoperative complications. Postoperatively, all fractures were stable and had healed by week 16. The mean operative time was 35 +/- 10 minutes (+/- SD) including 1.5 +/- 0.5 minutes of fluoroscopy time. CONCLUSION: The results of this study show that use of this nailing system is associated with minimal complications, predictable fracture healing, and excellent functional outcomes in a cohort of elderly patients with poor bone quality and humeral shaft fractures requiring stabilization. Further confirmation by larger prospective trials is necessary.