Systematic review and comparison of national and international guidelines on diverticular disease.

PURPOSE: Diverticular disease is common and of increasing medical and economical importance. Various practice guidelines on diagnostic and treatment on this disease exist. We compared current guidelines on the disease in order to identify concordant and discordant recommendations. METHOD: Eleven national and international guidelines on diverticular disease published over the last 10 years have been identified by a systematic literature review on PubMed and compared in detail for 20 main and 51 subtopics. RESULTS: The available evidence for the most aspects was rated as moderate or low. There was concordance for the following items: Diagnosis of diverticulitis should be confirmed by imaging methods (10 of 10 guidelines). Mild forms may be treated out-patient (10/10). Abscesses are treated non-surgically (9/9). Elective surgery should be indicated by individual patient-related factors, only, and be performed laparoscopically (10/10, 9/9 respectively). Main differences were found in the questions of appropriate classification, imaging diagnostic (computed-tomography versus ultra-sound), need for antibiotics in out-patient treatment and mode of surgery for diverticular perforation. Despite growing evidence that antibiotics are not needed for treating mild diverticulitis, only 3/10 guidelines have corresponding recommendations. Hartmann's procedure has been abandoned several years ago and is now recommended for feculent peritonitis by the three most recent guidelines. In contrast, laparoscopic lavage without resection is not recommended anymore. CONCLUSION: There are dissents in the recommendations for central aspects regarding the diagnostic and treatment of diverticular disease in recently published guidelines.

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.

Lymph node harvest in single incision laparoscopic surgery for colorectal malignancy.

AIM: Single incision laparoscopic surgery (SILS) has not been sufficiently evaluated with respect to its oncological equivalence to conventional laparoscopic or open surgery. METHOD: Of 507 patients who had SILS for colorectal diseases in our institution, 87 had segmental resection for colorectal adenocarcinoma. For each of the surgical specimens the number of lymph nodes which can be expected to be identified by the pathologist was calculated using the ACPGBI lymph node harvest model, which was developed from a nationwide database of 5845 surgical specimens. The predicted number of lymph nodes was compared with the number identified in our SILS specimens. RESULTS: The median predicted number of lymph nodes was 11 (4.5-14.8) compared with 18 (5-44) in the SILS specimens (P < 0.001). In all subgroups analysed for various operations, the lymph node harvest in the SILS specimens was significantly higher than predicted. CONCLUSION: In terms of lymph node harvest SILS seems to be comparable to conventional open or laparoscopic surgery.

Differences in ano-neorectal physiology of ileoanal and coloanal reconstructions for restorative proctectomy.

OBJECTIVE: Restorative proctectomy with straight coloanal anastomosis (CAA) and restorative proctocolectomy with ilealpouch-anal anastomosis (IPAA) are options for maintaining bowel integrity after rectal resection. The aim of this study was to compare clinical function and anorectal physiology in patients treated with CAA and IPAA. METHOD: Three-dimensional vector-manometry and neorectal volumetry were performed in straight CAA [53 patients (34 male)] and IPAA [61 patients (39 male)] for ulcerative colitis. Function was assessed using a 14 day incontinence diary. RESULTS: Function was similar in both groups, but neorectal compliance and threshold volumes for sensation, urge and maximum tolerated volume (MTV) were significantly higher after IPAA than after CAA. Mean pressure, vector volume and sphincter symmetry at rest were significant determinants of continence in both groups but squeeze pressure did not correlate significantly with function in either group. Threshold volume, MTV, and compliance were significantly correlated with frequency of defecation in patients with IPAA but not with CAA. CONCLUSION: A strong consistent resting anal sphincter pressure is one determinant of continence after both IPAA and CAA. Squeeze pressures do not influence the functional result. In IPAA but not CAA, the neorectum has a reservoir function which correlates with the postoperative frequency of defaecation.

Laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy for diverticular disease? A prospective randomized trial on postoperative pain and analgesic consumption.

PURPOSE: Laparoscopic-assisted sigmoidectomy is an attractive but sometimes challenging operative technique for the treatment of diverticulitis of the sigmoid colon. The aim of this study was to compare, with respect to early postoperative analgesic demand and postoperative pain, laparoscopic-assisted sigmoidectomy with a laparoscopic-facilitated technique. In the laparascopic-facilitated technique, the sigmoid colon is removed conventionally via a cosmetically inconspicuous incision after prior laparoscopic mobilization. PATIENTS AND METHODS: Patients subjected to elective sigmoidectomy for diverticulitis were randomized to either laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy. All patients had piritramide-based, patient-controlled analgesia. The cumulative postoperative consumption over 96 hours was defined as the primary end point. Postoperative pain, fatigue, pulmonary function, and resumption of bowel function were secondary endpoints. RESULTS: : Forty-five patients were randomized according to the protocol to laparoscopic-assisted sigmoidectomy (n = 22) or laparoscopic-facilitated sigmoidectomy (n = 23). The analgesic consumption between the two groups was equivalent (61.3 (9-171) mg piritramide/96 hours vs. 64.3 (18-150) mg piritramide/96 hours; P = 0.827). Patients with laparoscopic-assisted sigmoidectomy had lower pain levels on Day one and Day two. Cumulative pain levels over 96 hours and over the whole 7-day observation period, however, were not significantly different, although postoperative fatigue and pulmonary function were significantly different. Duration of surgery was slightly shorter for laparoscopic-assisted sigmoidectomy (127 (47-200) vs. 135 (60-239) minutes; P = 0.28), but recovery of bowel activity was faster after laparoscopic-facilitated surgery. There was no significant difference in morbidity. CONCLUSION: Overall, the postoperative outcome was roughly equivalent after both techniques of laparoscopic sigmoidectomy. Therefore, laparoscopic-facilitated sigmoidectomy could be considered as an alternative to laparoscopic-assisted sigmoidectomy in technically difficult cases of diverticulitis subjected to laparoscopic surgery.

ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation.

Enhanced recovery of patients after surgery ("ERAS") has become an important focus of perioperative management. From a metabolic and nutritional point of view, the key aspects of perioperative care include: Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1980. The guideline was discussed and accepted in a consensus conference. EN is indicated even in patients without obvious undernutrition, if it is anticipated that the patient will be unable to eat for more than 7 days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days. In these situations nutritional support should be initiated without delay. Delay of surgery for preoperative EN is recommended for patients at severe nutritional risk, defined by the presence of at least one of the following criteria: weight loss >10-15% within 6 months, BMI<18.5 kg/m(2), Subjective Global Assessment Grade C, serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction). Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

[Hybrid TAMIS total mesorectal excision. A new perspective in treatment of distal rectal cancer - Technique and results]. / Hybrid-TAMIS totale mesorektale Exzision. Neue Perspektive in der Behandlung des distalen Rektumkarzinoms - Technik und Ergebnisse.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) represents a promising technique for total mesorectal excision (TME) with respect to radicalness and preservation of function. There are only few publications in the literature describing results in patients with distal rectal cancer. METHODS: Between May 2013 and March 2015, 24 selected patients with a rectal carcinoma < 6 cm from the anal verge underwent a laparoscopically assisted TAMIS TME (Hybrid-TAMIS TME) procedure. This prospective observational study was conducted to examine the safety of the technique and the quality of TME surgery in distal rectal cancer and to assess the short-term postoperative outcome. RESULTS: The median age of patients (18 male and 6 female) at the time of surgery was 57 years (range 35-77 years) and 7 patients (29 %) had a body mass index (BMI) > 30 kg/m(2). Specimen excision was carried out transanally in 19 patients. Pathological grading of TME specimens was good in 22 (92 %) and moderate in 2 cases. After neoadjuvant radiochemotherapy a complete pathological remission was identified in five patients. The median distal resection margin was 7 mm (range 2-30 mm), the median circumferential resection margin was 6 mm (range <1 mm-30 mm) and in 2 patients the tumor was ≤ 1 mm from the positive circumferential margin. A colonic reservoir was created in 19 patients (79 %) and no 30-day mortalities occurred. Morbidity was 29 %, including 1 anastomotic leak, 2 hematomas and 1 neurogenic bladder. CONCLUSION: Hybrid-TAMIS TME for distal rectal cancer is safe and can provide a sphincter-preserving high-quality TME in difficult cases. Studies with long-term follow-up assessing oncological and functional results are mandatory.

[Contraction of the hip and fecal drainage via a fistula tract 30 years after "appendectomy"]. / Stuhlfistel und Hüftgelenkskontraktur 30 Jahre nach "Blinddarmoperation".

A 46-year-old female was admitted with increasing fecal drainage via a fistula tract in the right inguinal region. She had a history of surgery for appendicitis 30 years previously, from which there was disturbed wound healing resulting in a blunt fistula, and the patient suffered from contraction of the right hip. Computed tomographic scan and ultrasound demonstrated an inflammatory mass in the right inguinal region. Colonoscopy demonstrated a stenosis of the rectosigmoid junction but did not provide any further specific information. Surgery revealed the presumed diagnosis of complicated Crohn's disease, but an advanced squamous cell carcinoma was also identified. The patient died 23 months later due to generalized tumor. Although malignant transformation of a fistula tract is rare, this case demonstrates that long-standing fistulas should be cured as far as possible without significant morbidity. In the case of incurable fistulas, malignancy must definitely be excluded if the clinical appearance of the fistula changes.

Percutaneous endoscopic tracheostomy.

Bedside percutaneous tracheostomies are increasingly performed. This avoids patient transport to the operating room. Complications of this procedure are largely related to the blind nature of the technique. After laboratory studies, 4 patients underwent percutaneous endoscopic guided tracheostomy in a selective clinical trial. There were no procedure-related complications. Endoscopic guidance ensures precise low tracheostomy position, prevents paratracheal tube misplacement, and avoids inadvertent injuries.

Analysis of 5-OH-indoles in human gut biopsy tissues by reversed-phase high-performance liquid chromatography with fluorimetric detection.

A method was devised for the rapid simultaneous determination of major indoles in human gut tissues. Analysis with picomol detection limits was done by HPLC on a C(18) reversed-phase column with fluorimetric detection at 276/350 nm. This simple method for which there is no necessity of derivatization or purification was validated for routine analysis of small mucosa samples (less than 4 mg fresh weight) obtainable during endoscopy. A comprehensive list of 5-OH-indole compounds in human gut tissue is presented.

Analysis of tryptophan, tyrosine and related dipeptides in mouse brain by isocratic high-performance liquid chromatography with switchable wavelength fluorescence detection.

Tryptophan (Trp) and tyrosine (Tyr) are pharmacologically active compounds which, after administration of adequate doses, are increased in level in the brain, and stimulate neurotransmitter synthesis. Trp and Tyr containing dipeptides were tested as possible substitutes with regard to the effect on precursor level in the brain. Glycyltryptophan, alanyl-tryptophan and glycyl-tyrosine were intravenously applied to young female mice and the brain levels of dipeptides, Trp and Tyr measured 30 min after application. Neurotransmitter precursor levels in the brain increased similarly in all cases. The results suggest that the dipeptides are as effective as the single amino acids and may be superior because of their better solubility.

[Immediate postoperative enteral feeding with an elemental diet (Survimed) using a new application form of the so-called fine needle catheter jejunostomy. A prospective study]. / Unmittelbare postoperative enterale Ernährung mit der Elementardiät (Survimed) mittels neuer Applikationsform einer sogenannten Feinnadel-Katheter-Jejunostomie (FNKJ). Eine prospektive Studie.

In a prospective study (n = 50) the clinical usefulness of a fine-needle-catheter-jejunostomy based on the method of Delany et al. [1] was studied. In all cases the jejunostomy was inserted intraoperatively without difficulty and without complication. The set used (Intestofix) consisted of one polyurethan-catheter (75 cm length), 2.1 mm inner diameter) and of two hollow needles constructed as split-cannulas. This system has been proved in our study to be simple, rapid and safe. Patient's tolerance of the feeding was, however, unsatisfactory; diarrhea occurred on the 5th postoperative day in 35% of all patients, in addition we observed inconvenient belching (42.5%) and sensation of repletion (25%). There may be different causes for these uncomfortable symptoms; for example application schedule or the composition of food. We think that the operation itself exerts an important influence upon patient's tolerance because patients without operation but under the same conditions tolerate the nutrition via jejunostomy better than those in our study (with concomitant operation).

[Single-port colonic surgery : techniques and indications]. / Single-Port-Kolonchirurgie : Techniken und Indikationen.

Colonic surgery is feasible with the single-port technique using standard laparoscopic instruments. Operative time and complication rates are comparable to conventional standard laparoscopic procedures. Position of instruments (crossed over) and orientation are somewhat different and need to be trained and practiced. In this patient collective 200 colon resections covering the complete spectrum of colonic surgery were done in our department. Of these 120 patients were operated on because of sigma diverticulitis. The average operative time was 149 min whereby 6 patients (5.0%) had to be converted to an open procedure, 12 (10.0%) patients had early complications, of which 6 (5.0%) had minor wound complications which were treated conservatively and 4 (3.3%) patients had late complications (2 stenoses and 2 hernias) during the mean follow-up time of 7.5 months (range 6-14 months). The cosmetic effect was very good and functional results were good. Single-port colon operations are the least invasive procedure available at the moment.