[Physical Strain after Abdominal Surgery - Results of a Patient Survey]. / Belastbarkeit nach abdominellen Eingriffen ­ Ergebnisse einer Patientenbefragung.

INTRODUCTION: Incision hernias are common complications after abdominal surgery and affect the recommendations on postoperative physical strain, as it is thought that excessively early strain causes incisional hernias. However, there is no evidence to justify this. This study evaluates the effect of postoperative strain on the risk of incisional hernia. MATERIALS AND METHODS: Patients with a laparoscopy (LS) or laparotomy (LT) were asked to complete a questionnaire on postoperative strain, complaints and quality of life. Patients with hernia surgery, or open abdomen therapy for complicated courses (Clavien-Dindo > III) were excluded. RESULTS: 393 patients completed the questionnaire (43.6%). 274 were LS and 128 LT. The incidence of incisional hernias was 5.2% (LS) and 18.0% (LT, p = 0.001). Incisional hernia patients were younger and more commonly males. 30.5% of incisional hernia patients did not return to normal physical strain postoperatively. Abdominal binders did not affect the hernia rate. The incisional hernia patients showed decreased quality of life scores in both mental and physical domains. CONCLUSION: Early postoperative physical strain was not a risk factor for incisional hernia development in this study. However, prospective studies are needed to create necessary evidence to recommend earlier postoperative return to normal physical strain.

Traumatic diaphragmatic rupture: epidemiology, associated injuries, and outcome-an analysis based on the TraumaRegister DGU®.

INTRODUCTION: Traumatic diaphragmatic rupture is a rare injury in the severely injured patient and is most commonly caused by blunt mechanisms. However, penetrating mechanisms can also dominate depending on regional and local factors. Traumatic diaphragmatic rupture is difficult to diagnose and can be missed by primary diagnostic procedures in the resuscitation room. Initially not life-threatening, diaphragmatic ruptures can cause severe sequelae in the patient's long-term course if untreated. The objective of this study was to assess the epidemiology, associated injuries, and outcome of traumatic diaphragmatic ruptures based on a multicenter registry-based analysis. MATERIAL AND METHODS: Data from all patients enrolled in the TraumaRegister DGU® between 2009 and 2018 were retrospectively analyzed. That multicenter database collects data on prehospital, intra-hospital emergency, intensive care therapy, and discharge. Included were all patients with a Maximum Abbreviated Injury Scale (MAIS) score of 3 or above and patients with a MAIS score of 2 who died or were treated in the intensive care unit, for whom standard documentation forms had been completed and who had sustained a diaphragmatic rupture (AIS score of 3 or 4). The data has been analyzed using descriptive statistics and chi-square test or Mann-Whitney U test. RESULTS: Of the 199,933 patients included in the study population, 687 patients (0.3%) had a diaphragmatic rupture. Of these, 71.9% were male. The mean patient age was 46.1 years. Blunt trauma accounted for 73.5% of the injuries. Primary diagnosis was established in the resuscitation room in 93.1% of the patients. Multislice helical computed tomography (MSCT) was performed in 82.7% of the cases. Rib fractures were detected in 60.7% of the patients with a diaphragmatic injury. Patients with diaphragmatic rupture had a higher mean Injury Severity Score (ISS) than patients without a diaphragmatic injury (32.9 vs. 18.6) and a higher mortality rate (13.2% vs. 9.0%). CONCLUSIONS: In contrast to the literature, primary diagnostic procedures in the resuscitation room detected relevant diaphragmatic ruptures (AIS ≥ 3) in more than 90% of the patients in our study population. In addition, complex associated serial rib fractures are an important diagnostic indicator.

Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®.

INTRODUCTION: Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma. METHODS: Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene. RESULTS: The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004). CONCLUSION: DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.

Recommendations on Postoperative Activities After Abdominal Operations and Incisional Hernia Repair-A National and International Survey.

Background: There is no conclusive data on postoperative recommendations after abdominal and hernia surgery, and there is significant variation in the literature on that question. Thus, this study evaluates the status quo of recommendations of postoperative activity restriction after abdominal surgery. Materials and Methods: A national (German) and international survey of general surgeons on postoperative recommendations after abdominal and hernia surgery was pooled and analyzed. Results: A total of 74.6% recommended postoperative reduced activity for 2 weeks or less after laparoscopy. For midline laparotomy, 48.8% considered a reduced activity of 4 weeks or less to be sufficient. A majority from the national survey recommended more than 4 weeks instead (60.2%), whereas only 31.5% from the international survey did so (p = 0.000). In the pooled analysis, 258 of 450 (57.3%) rated 4 weeks or less suitable. However, the recommendations differed significantly between the surveys (4 weeks or less: a national survey, 47.1% vs. international survey, 64.6%; p = 0.000). Conclusion: There was substantial variation in the given recommendations. However, we found no evidence against immediate mobilization, reduced physical activity, and lifting for up to 2 weeks after laparoscopic surgery and for up to 4 weeks after open abdominal surgery and open incisional/ventral hernia repair in uncomplicated and standard cases. There might be individual and socioeconomic benefits to allow patients to return to their whole personal level of activity and work without putting them at risk of complications. Due to lack of evidence, both retrospective and prospective, controlled studies are in need to develop reliable recommendations.

The Significance of Visceral Protection in Preventing Enteroatmospheric Fistulae During Open Abdomen Treatment in Patients With Secondary Peritonitis: A Propensity Score-matched Case-control Analysis.

OBJECTIVE: To evaluate the influence of a visceral protective layer (VPL) on the formation of enteroatmospheric fistulae (EAF) in open abdomen treatment (OAT) for peritonitis. BACKGROUND: EAF formation is a severe complication of OAT. Despite the widespread use of OAT, there are no robust evidence-based recommendations for preventing EAF. METHODS: A total of 120 peritonitis patients with secondary peritonitis as a result of a perforation of a hollow viscus or anastomotic insufficiency who had undergone OAT were included, and 14 clinical parameters were recorded in prospective OAT databases at 2 tertiary referral centers. For this analysis, patients with a VPL were assigned to the treatment group and those without a VPL to the control group. Propensity Score (PS) matching was performed. Known risk factors in OAT such as malignant disease, mortality, emergency operation, OAT duration, and fascial closure were matching variables. The influence of VPL on EAF formation was statistically evaluated using logistic regression analysis. RESULTS: With 34 patients in each group, no notable differences were identified with regard to age, sex, underlying disease, mortality, emergency operation, fascial closure, and OAT duration. Overall, a mortality rate of 22.1% for OAT due to peritonitis was observed. Mean OAT duration was approximately 9 days, and secondary fascial closure was achieved in more than two-thirds of all patients. Fascial traction was used in more than 75% of cases. EAF formation was significantly more frequent in the control group (EAF formation: VPL group 2.9% vs control 26.5%; P = 0.00). In the final regression analysis, the use of VPL resulted in a significant reduction in the risk of EAF formation (odds ratio 0.08; 95% confidence interval 0.01-0.71, P = 0.02), which translates to a relative risk reduction of 89.1%. CONCLUSION: VPL effectively prevents EAF formation during OAT in patients with peritonitis. We recommend the consistent use of VPL as part of a standardized OAT treatment algorithm.

Terrorist attacks: common injuries and initial surgical management.

Terrorism-related incidents and shootings that involve the use of war weapons and explosives are associated with gunshot and blast injuries. Despite the perceived threat of terrorism, these incidents and injuries are rare in Germany. For this reason, healthcare providers are unlikely to have a full understanding of the special aspects of managing these types of injuries. Until a clear and complete picture of the situation is available after a terrorist or shooter incident, tactical and strategic approaches to the clinical management of the injured must be tailored to circumstances that have the potential to overwhelm resources temporarily. Hospitals providing initial care must be aware that the first patients who are taken to medical facilities will present with uncontrollable bleeding from injuries to the trunk and body cavities. To improve the outcome of these patients in extremis, the aim of the index surgery is to stop the bleeding and control the contamination. Unlike damage control surgery, which is tailored to the patient's condition, tactical abbreviated surgical care (TASC) is first and foremost adapted to the overall situation. Once the patients are stabilised and all information on the situation is available, the surgical management and reconstruction of gunshot and blast injuries can follow the principles of damage control (DC) and definitive early total care (ETC). The purpose of this article is to provide an overview of the pathophysiology of gunshot and blast injuries, wound ballistics, and the approach and procedures of successful surgical management.

Lack of Standardized Advice on Physical Strain Following Abdominal Surgery.

BACKGROUND: In Germany as elsewhere, standardized recommendations are lacking on the avoidance of physical exertion to protect the abdom - inal wall in patients who have recently undergone abdominal surgery. It is unclear how much stress the abdominal wall can withstand and how long the patient should be exempted from work. The goal of this review is to determine whether there are any standardized, evidence-based recommendations for postoperative care from which valid recommendations for Germany can be derived. METHODS: We systematically searched the literature for evidence-based recommendations on exertion avoidance after abdominal surgery, as well as for information on the extent to which postoperative abdominal wall stress contributes to incisional hernia formation. We then created a questionnaire on recommendation practices and sent it to all of the chiefs of general and visceral surgery services that were listed in the German hospital registry (1078 chiefs of service as of June 2016). RESULTS: All 16 of the included studies on postoperative exertion avoidance contained low-level evidence that could only be used to formulate weak recommendations ("can," rather than "should" or "must"). Some 50 000 incisional hernia repair procedures are performed in Germany each year, with a reported incidence of 12.8% in the first two years after surgery. The scientifically documented risk factors for incisional herniation are related to techniques of wound closure, the suture materials used, wound infections, and the patient risk profile. From the biological point of view, the abdominal wall regains full, normal resistance to exertional stress 30 days after a laparotomy with uncomplicated healing. Most incisional hernias (>50%) arise 18 months or more after surgery; they are more common in patients who have avoided exertion for longer periods of time (more than 8 weeks). Our questionnaire was returned by 386 surgical clinics. The responses showed that 78% of recommendations were based on personal experience only. The recommendations varied widely; exertion avoidance was recommended for as long as 6 months. CONCLUSION: The dilemma of a deficient evidence base for postoperative exertion avoidance to protect the abdominal wall should be resolved with the much higher-quality evidence available from hernia research, which concerns the patient population with the biologically least favorable starting conditions. Based on our analysis of the available literature in light of the biomechanical principles of abdominal wall healing, we propose a new set of recommendations on postoperative exertion avoidance after abdominal surgery, with the goal of eliminating excessively protracted exertion avoidance and enabling a timely return to work.

Prophylactic Onlay Mesh Implantation During Definitive Fascial Closure After Open Abdomen Therapy (PROMOAT): Absorbable or Non-absorbable? Methodical Description and Results of a Feasibility Study.

Introduction: Incisional hernia development after open abdomen therapy (OAT) remains a common complication in the long run. To demonstrate the feasibility, we describe our method of prophylactic onlay mesh implantation with definitive fascial closure after open abdomen therapy (PROMOAT). To display the feasibility of this concept, we evaluated the short-term outcome after absorbable and non-absorbable synthetic mesh implantation as prophylactic onlay. Material and Methods: Ten patients were prospectively enrolled, and prophylactic onlay mesh (long-term absorbable or non-absorbable) was implanted at the definitive fascial closure operation. The cohort was followed up with a special focus on incisional hernia development and complications. Results: OAT duration was 21.0 ± 12.6 days (95% CI: 16.9-25.1). Definitive fascial closure was achieved in all cases. No incisional hernias were present during a follow-up interval of 12.4 ± 10.8 months (range 1-30 months). Two seromas and one infected hematoma occurred. The outcome did not differ between mesh types. Conclusion: The prophylactic onlay mesh implantation of alloplastic, long-term absorbable, or non-absorbable meshes in OAT showed promising results and only a few complications that were of minor concern. Incisional hernias did not occur during follow-up. To validate the feasibility and safety of prophylactic onlay mesh implantation long-term data and large-scaled prospective trials are needed to give recommendations on prophylactic onlay mesh implantation after OAT.

[Characteristics and Treatment Strategies for Penetrating Injuries on the Example of Gunshot and Blast Victims without Ballistic Body Armour in Afghanistan (2009 - 2013)]. / Besonderheiten und Versorgung penetrierender Verletzungen am Beispiel von Schuss- und Explosionsopfern ohne ballistischen Körperschutz in Afghanistan (2009 ­â€Š2013).

Much like other countries, Germany has recently seen terrorist attacks being planned, executed or prevented at the last minute. This highlights the need for expertise in the treatment of penetrating torso traumas by bullets or explosions. Data on the treatment of firearm injuries and, even more so, blast injuries often stems from crises or war regions. However, it is difficult to compare injuries from such regions with injuries from civilian terrorist attacks due to the ballistic body protection (protective vests, body armour) worn by soldiers. Methods An analysis was performed based on data from patients who were treated in the German Military Hospital Mazar-e Sharif for gunshots or injuries from explosions in the years 2009 to 2013. The data selection was based on patients with penetrating injuries to the thorax and/or abdomen. For better comparability with civilian attack scenarios, this study only included civilian patients without ballistic body protection (body armour, protective vests). Results Out of 117 analysed patients, 58 were affected by firearms and 59 by explosive injuries of the thorax or abdomen. 60% of patients had a thoracic injury, 69% had an abdominal injury, and 25.6% had combined thoracic-abdominal injuries. Blast injury patients were significantly more affected by thoracic trauma. As regards abdominal injuries, liver, intestinal, and colonic lesions were leading in number. Patients with blast injuries had significantly more injured organs and a significantly higher ISS averaging 29. 26% of the shot patients and 41% of the blast wounded patients received Damage Control Surgery (DCS). Despite a lower ISS, gunshot victims did not have a lower total number of operations per patient. Overall mortality was 13.7% (10.3% gunshot wounds, 16.7% blast injury). The highest mortality rate (25.7%) was recorded for patients with combined thoracoabdominal injuries (vs. 8.3% for thoracic and 8.7% for abdominal injuries). The ISS of deceased patients was significantly higher at 32.9%. Conclusion Patients without ballistic protection of the torso have high mortality rates, especially when suffering thoracoabdominal blast injuries. Blast injuries frequently lead to the DCS indication. The care of firearm and blast injury patients requires knowledge and competence in the damage control procedures for thorax and abdomen.

The First Aid and Hospital Treatment of Gunshot and Blast Injuries.

BACKGROUND: When gunshot and blast injuries affect only a single person, first aid can always be delivered in conformity with the relevant guidelines. In contrast, when there is a dynamic casualty situation affecting many persons, such as after a terrorist attack, treatment may need to be focused on immediately life-threatening complications. METHODS: This review is based on pertinent publications retrieved by a selective search in Medline and on the authors' clinical experience. RESULTS: In a mass-casualty event, all initial measures are directed toward the survival of the greatest possible number of patients, in accordance with the concept of "tactical abbreviated surgical care." Typical complications such as airway obstruction, tension pneumothorax, and hemorrhage must be treated within the first 10 minutes. Patients with bleeding into body cavities or from the trunk must be given priority in transport; hemorrhage from the limbs can be adequately stabilized with a tourniquet. In-hospital care must often be oriented to the principles of "damage control surgery," with the highest priority assigned to the treatment of life-threatening conditions such as hemodynamic instability, penetrating wounds, or overt coagulopathy. The main considerations in initial surgical stabilization are control of bleeding, control of contamination and lavage, avoidance of further consequences of injury, and prevention of ischemia. Depending on the resources available, a transition can be made afterward to individualized treatment. CONCLUSION: In mass-casualty events and special casualty situations, mortality can be lowered by treating immediately life-threatening complications as rapidly as possible. This includes the early identification of patients with lifethreatening hemorrhage. Advance preparation for the management of a masscasualty event is advisable so that the outcome can be as favorable as possible for all of the injured in special or tactical casualty situations.

Tumour-associated circulating microparticles: A novel liquid biopsy tool for screening and therapy monitoring of colorectal carcinoma and other epithelial neoplasia.

Up to date, novel tools for low-cost, minimal invasive cancer surveillance, cancer screening and treatment monitoring are in urgent need. Physicians consider the so-called liquid biopsy as a possible future tool successfully achieving these ultimate goals. Here, we aimed to identify circulating tumour-associated MPs (taMPs) that could aid in diagnosing minimal-invasively the presence and follow up treatment in non-small cell lung carcinoma (NSCLC), colorectal carcinoma (CRC) and pancreas carcinoma (PaCa). Tumour-associated MPs (taMPs) were quantified after isolation by centrifugation followed by flow cytometry analysis from the serum of cancer patients with CRC (n = 52), NSCLC (n = 40) and PaCa (n = 11). Healthy subjects (n = 55) or patients with struma nodosa (thyroid nodules) (n = 43) served as negative controls. In all three types of tumour entities, the presence of tumour was associated with an increase of circulating EpCAM+ and EpCAM+CD147+ taMPs. The presence of CD147+EpCAM+ taMPs were specific to tumour-bearing patients thus allowing the specific distinction of malignancies from patients with thyroid nodules. Increased level of EpCAM single positive MPs were, in turn, also detected in patients with thyroid nodules. Importantly, EpCAM+CD147+ taMPs correlated with the measured tumour-volume in CRC patients. EpCAM+ taMPs decreased at 7 days after curative R0 tumour resection suggesting a close dependence with tumour presence. AUROC values (up to 0.85 and 0.90), sensitivity/specificity scores, and positive/negative predictive values indicated a high diagnostic accuracy of EpCAM+CD147+ taMPs. Taken together, EpCAM+CD147+ double positive taMPs could potentially serve as novel promising clinical parameter for cancer screening, diagnosis, surveillance and therapy monitoring.