Optimizing quantitative fluorescence angiography for visceral perfusion assessment.

BACKGROUND: Compromised tissue perfusion is a significant risk factor for anastomotic leakage after intestinal resection, leading to prolonged hospitalization, risk of recurrence after oncologic resection, and reduced survival. Thus, a tool reducing the risk of leakage is highly warranted. Quantitative indocyanine green angiography (Q-ICG) is a new method that provides surgeons with an objective evaluation of tissue perfusion. In this systematic review, we aimed to determine the optimal methodology for performing Q-ICG. METHOD: A comprehensive search of the literature was performed following the PRISMA guidelines. The following databases were searched: PubMed, Embase, Scopus, and Cochrane. We included all clinical studies that performed Q-ICG to assess visceral perfusion during gastrointestinal surgery. Bias assessment was performed with the Newcastle Ottawa Scale. RESULTS: A total of 1216 studies were screened, and finally, 13 studies were included. The studies found that intensity parameters (maximum intensity and relative maximum intensity) could not identify patients with anastomotic leakage. In contrast, the inflow parameters (time-to-peak, slope, and t1/2max) were significantly associated with anastomotic leakage. Only two studies performed intraoperative Q-ICG while the rest performed Q-ICG retrospectively based on video recordings. Studies were heterogeneous in design, Q-ICG parameters, and patient populations. No randomized studies were found, and the level of evidence was generally found to be low to moderate. CONCLUSION: The results, while heterogenous, all seem to point in the same direction. Fluorescence intensity parameters are unstable and do not reflect clinical endpoints. Instead, inflow parameters are resilient in a clinical setting and superior at reflecting clinical endpoints.

SOCIAL AND ECONOMIC ASPECTS OF SIMULTANEOUS OPERATIONS ON ABDOMINAL ORGANS.

The article presents an analysis of 107 cases of simultaneous operations of big volume with main stage as gastric resections (gastrectomy) or large intestine resections and mean volume interferences as cholecystectomy and removal of abdominal hernias. It was stated, that simultaneous operations compared with two steps treatment of combined surgical diseases obtained the high economical efficacy. This efficacy was determined by a single - stage routine presurgical examination, single anesthetic management, less medical expenses for medication and laboratory - instrumental studies in postoperative period, significant shortening the terms of hospitalization and disability terms. The authors proposed formulas to evaluate the economiс efficacy of simultaneous operations in system of paid medical service and system of rendering medical aid using paid medical insurance. The efficacy of large operations was 40 766 rubles and in case of mean volume interventions - 25 382 rubles for the paid medical system. The economical efficacy of simultaneous operations of large and mean volume was the same in the system of obligatory medical insurance. It consisted of 19 737,5 or 22 920,1 rubles and depended on the degree of operative anaesthetic risk of the second intervention in two steps treatment of patients.

[Preoperative management for malnourished patients in abdominal surgery. Practical treatment regimen for reduction of perioperative morbidity]. / Präoperatives Management bei Mangelernährten in der Viszeralchirurgie : Praktischer Behandlungspfad zur Reduktion perioperativer Morbidität.

The incidence of malnutrition in oncological and visceral surgical units can be high. The screening of malnourished patients is very important, especially in the preoperative setting. The available published literature provides crucial knowledge about the risks inherent to malnutrition and subsequent perioperative morbidity and mortality. The preoperative screening of malnourished patients followed by a subsequent renutrition is the key to decreasing rates of postoperative morbidity and mortality. The data and guidelines given by the European Society of Parenteral and Enteral Nutrition (ESPEN) in 2006 for the preoperative nutritional conditioning are clear and give no doubt regarding the necessity of preparation of malnourished patients for elective abdominal surgery. Despite this fact, the observance and application of these guidelines among German surgical units remain low. To fill this void a model of systematic screening and treatment of malnutrition in the preoperative setting for elective abdominal surgery was created and implemented at the university hospital of Oldenburg. A practical treatment regimen was designed to prepare malnourished patients within 2-3 weeks before elective surgery. Initial results regarding the feasibility of preoperative home renutrition therapy were moderate but encouraging. The success of such a conditioning process depends on cooperation between the surgical unit, the general practitioner (GP) and the homecare environment. In the German healthcare system the prescription of home nutrition (i.e. enteral feeding) can lead to the prescription limits of a GP being exceeded and has to be justified to the medical insurance company in each case. This article presents a simple yet applicable way of screening and preparing malnourished patients a few weeks prior to elective surgery. Therefore, simple tools which can be promptly used in daily clinical life, especially in the outpatient surgical consultations prior to elective visceral surgery are proposed.

[Medical care unit -- a suitable instrument for ambulatory patient-adequate care and performance-related remuneration]. / Medizinisches Versorgungszentrum - geeignetes Instrument der ambulanten patientenadäquaten Versorgung und leistungsgerechten Vergütung.

BACKGROUND: The question of whether a medical care unit is an appropriate tool for outpatient care has been discussed for a long time. Our aim is to investigate whether the MCU is an effective instrument for outpatient care and adequate performance-related remuneration. MATERIAL AND METHODS: This retro- and prospective overview of the work included statements on legal foundations for medical care units, for reimbursement of services in medical care units, the development of medical care centres in Germany and a listing of the specific advantages and disadvantages of an MCU. This article focuses on the generally applicable facts and complements them with examples from general, visceral and vascular surgery. The main quantitative data on medical centre statistics come from different publications of the National Association of Statutory Health Insurance for Physicians. RESULTS: From a legal point of view the instrument MCU allows the participating of ambulatory and stationary care in the framework of medical care contracts. This has been especially extended for stationary applications, including the spectrum of possibilities that can contribute under certain circumstances for the provision of medical care in underdeveloped regions. Freelancers can benefit primarily from financial risk and minimising bureaucratic routine. The remuneration for services performed in the MCU is analogous to that of other ambulatory care providers. Basically, there are no disadvantages, but a greater design freedom and opportunities for the generation of aggregates are visible. The number of MCU in Germany has quadrupled in the last five years, indicating an establishment of an outpatient care landscape. MCU offers from the patient's perspective, providers and policy specific advantages and disadvantages. Indeed the benefits outweigh the disadvantages, but this is not yet verified by qualitative studies. CONCLUSION: The question of the appropriateness of medical care units as outpatient care instrumentation must be considered differentially. Under current conditions it appears suitable for ensuring the MCU and the supplement of care supply. Whether a value can be generated in the quality of care of patients, however, has to be examined separately, as there are no valid data so far. The same applies to economic assessments of costs and benefits from an economic perspective.

[Formation of centers in general and abdominal surgery -- necessity or trend?]. / Zentrenbildung in der Allgemein- und Viszeralchirurgie - Notwendigkeit oder Trend?

The introduction of the DRG (diagnosis-related groups) system as basis for reimbursement in the German health-care system has led to a mentality of quality orientation and verification of therapeutic results. An immediate result was the formation of medical "centres" on rather different levels and consequently the inauguration of institutions, authorities, and organisations to review these centres. Finally, a range of certifications was installed in order to stratify the rather diverse aims of different centres. This review critically evaluates the current situation in the field of general and abdominal surgery in Germany.

[The assessment of modification of prosthesis fixation method on visceral interposition during laparoscopic abdominal hernia reconstruction]. / Ocena wplywu modyfikacji techniki mocowania protez na ryzyko interpozycji trzewi podczas laparoskopowej naprawy przepuklin brzusznych.

UNLABELLED: During laparoscopic abdominal hernia repair (LAHR) there is a discrepancy in relative position of mesh and fixation points during the procedure (while abdominal cavity is distended with gas) and afterwards. Therefore, after the surgery the prosthesis becomes corrugated, and tension develops in suture anchoring points. One of the proposed solutions of this problem is to place stabilizing sutures outside the mesh edges and to tie them after emptying the abdominal cavity of CO2. However, due to lack of visualization, viscera entrapment between the mesh and integuments may occur during this stage of surgery. The aim of the study was to assess the effect of fixation technique modification on the risk of visceral interposition between the mesh and integuments and deformation of prostheses fixated this way. MATERIAL AND METHODS: The study was performed in an experimental animal model (12 pigs) by implanting laparoscopically two 6.6x6 cm mesh fragments per animals and tying fixation sutures after emptying the abdominal cavity of CO2. After 6 weeks, visceral interposition between mesh and integuments and such fixated fragments corrugation were assessed. RESULTS: Visceral dislocation between parietal and visceral surface was absent in all 24 assessed meshes, despite fixation under no visual guidance. There were no mesh deformities between anchoring points. CONCLUSIONS: The analysed modification of laparoscopic abdominal hernia repair does not create risk of internal organ interposition between the prosthesis and integuments and prevents mesh from being corrugated.

[Preoperative assessment in visceral surgery]. / Bilan préopératoire en chirurgie viscérale.

The purpose of preoperative assessment is to evaluate the patient's health status, to address known or unidentified co-morbidities and to perform adequate complementary exams if necessary. On the other hand, it allows to prepare and protect the patient in order to reduce perioperative risk. The assessment consists of patient's history and physical examination, both focusing on cardiovascular and respiratory assessment. Complementary exams have to be chosen selectively depending on the patient's risk factors and the type of surgery. They are indicated if their result leads to a potential patient's benefit only, either by a modification in anesthetic and/or surgical management or by introduction of a pharmacological strategy, adequate and maximal if necessary, especially for cardioprotection.

[A method for reassessment of cost-intensive cases in visceral surgery. Results of project by the German Society for Visceral Surgery]. / Methode zur Abbildung kostenintensiver Fälle in der Viszeralchirurgie. Ergebnisse des DRG-Projekts der Deutschen Gesellschaft für Viszeralchirurgie.

Since the introduction of diagnosis-related groups (DRGs) many surgical departments report inappropriate reimbursement for complex cases and a shift in costly cases. To evaluate this situation, the German Society for Visceral Surgery inaugurated the present cost calculation project. In three university hospitals for 50 cases each, we depicted possible cost separators and utilized the complete cost calculation data (so-called Paragraph 21 data set) to test these separators. We identified "admission from another hospital", "severe surgically relevant concomitant disease", and "reoperation during the same hospital admission". The last was considered the economically most significant and medically most valid factor and was submitted as a possible modification to the german DRG system. The proposed cost separator "reoperation during the same hospital admission" was introduced into the DRG system after validation and leads to better allocation of reimbursements to complex and costly cases.

[Profile and structure of future-oriented visceral surgery in a non-university environment]. / Profil und Struktur einer zukunftsorientierten Visceralchirurgie im nichtuniversitären Bereich.

A nationwide limitation of the total health care budget requires the shutdown of certain departments or complete hospitals in order to increase the budget for the surviving hospitals. This development involves surgical departments as well, which have to be re-designed for an economic future.

Can ultrasonography replace computed tomography in the initial assessment of children with blunt abdominal trauma?

The evaluation of injured children with suspected blunt abdominal trauma (BAT) is clinically challenging. Computed tomography (CT) requires that patients be sedated, stable, and transportable, and even so, it is considered the diagnostic modality of choice for children with BAT. The authors questioned whether abdominal ultrasonography (US) performed during the initial assessment of the injured child is accurate enough to replace CT in the detection of intraabdominal injury. One hundred twenty-four children with BAT aged 2 to 14 years; (average, 8.3) were admitted to the authors' institution during 1992 and 1993. Some had associated injuries (head, 60; chest, 25; extremities, 15; pelvis, 5). The indications for US were pelvic, abdominal, or lower chest trauma, tenderness, or guarding; altered consciousness; microhematuria; and/or low hemoglobin/hematocrit values. Three patients underwent abdominal CT at the time of admission. For 121 children, an emergency US examination was performed using a 3.5-MHz transducer and a portable machine. The examination evaluated the kidneys, liver, and spleen for parenchymal injuries, and the subhepatic, subphrenic, and paracolic spaces and the pelvis for evidence of free peritoneal fluid. The presence of fluid and/or parenchymal injury was interpreted as a positive US result. Twenty-eight patients had positive US findings. Ten of these had a subsequent positive CT result, eight had a normal CT result, and 10 had a negative second US result. Eleven patients (with a total of 17 visceral injuries) were treated conservatively. One patient underwent emergency surgery for liver and caval injuries. Four patients required blood transfusions. Ninety-three of the 121(78%) had a negative US result. For one of these patients, a subsequent CT scan showed a minor subcapsular splenic hematoma, which resolved spontaneously. The authors conclude that US is sensitive in detecting free peritoneal fluid or visceral injuries and is an effective screening modality. It has replaced abdominal CT in 76% of our patients with suspected BAT. In view of the reliability, simplicity, low cost, and bedside availability of US, the authors suggest that this modality be used in the initial assessment and diagnosis of children with suspected intraabdominal injury from blunt trauma.

[Risk assessment before elective visceral surgery interventions]. / Risikoevaluation vor elektiven viszeralchirurgischen Eingriffen.

AIM OF THE STUDY: Since 1988 all our patients undergoing elective general surgery entered a prospective study, with the aim of identifying risk factors, responsible for a fatal postoperative outcome. METHODS: From 1988-1992 a total of 3250 patients (mean age 52.0 years [SD +/- 16.8]), 1750 male and 1500 female have been registered. RESULTS: General complications occurred in 10.4% of patients and local complications have been registered in 10.8% of cases. 29 patients (0,89%) died within 30 days following the operative procedure. The operation per se, the ASA-classification, a history of respiratory disease and an operation for a malignant disease could be identified as risk factors for general postoperative complications. CONCLUSIONS: The study design allows us to determine risk factors in elective general surgery. These risk factors can easy be used in clinical practice to evaluate the operative risk of a planned operative procedure.

[Preoperative risk assessment in elective visceral surgery. Study design--results--perspectives]. / Präoperative Risikoeinschätzung in der elektiven Viszeralchirurgie. Studienkonzept--Resultate--Perspektiven.

Since 1988 we have been analysing all our patients undergoing elective general surgery with general or spinal anaesthesia in a prospective study, with the aim of identifying and weighing up risk factors. The risk factors have been divided into the following groups: environment, surgeon, anaesthesia, operative intervention, disease and patient, regardless of the current illness. In 1990 a total of 682 patients (mean age 51.6 years, range 14-90), 365 male and 317 female, entered on study. General complications have been recorded in 63 patients (9.2%), whereas local complications occurred in 73 patients (10.7%). The following parameters were identified as risk factors for general complications: age > or = 70 years, hypertensive blood pressure level, haematocrit < 40% (male patients), operative procedure for malignancies, reduced physical capacity, pathologic cardiac or lung history, pathologic ECG, excessive alcohol consumption, hepatosplenomegaly, foreign origin, carotid artery bruit. Five patients died within 30 days following surgery for a malignant disease. This ongoing prospective study is a valuable instrument for the definition of preoperative risk factors in elective general surgery with the objective of eliminating mortality by the end of the century.