Anorectal angle at rest predicting successful sacral nerve stimulation in idiopathic fecal incontinence-a cohort analysis.

PURPOSE: Sacral nerve stimulation is an effective treatment for patients suffering from fecal incontinence. However, less is known about predictors of success before stimulation. The purpose of this study was to identify predictors of successful sacral nerve stimulation in patients with idiopathic fecal incontinence. METHODS: Consecutive female patients, receiving peripheral nerve evaluation and sacral nerve stimulation between September 2008 and October 2014, suffering from idiopathic fecal incontinence were included in this study. Preoperative patient's characteristics, anal manometry, and defecography results were collected prospectively and investigated by retrospective analysis. Main outcome measures were independent predictors of treatment success after sacral nerve stimulation. RESULTS: From, all in all, 54 patients suffering from idiopathic fecal incontinence receiving peripheral nerve evaluation, favorable outcome was achieved in 23 of 30 patients after sacral nerve stimulation (per protocol 76.7%; intention to treat 42.6%). From all analyzed characteristics, wide anorectal angle at rest in preoperative defecography was the only independent predictor of favorable outcome in multivariate analysis (favorable 134.1 ± 13.9° versus unfavorable 118.6 ± 17.1°). CONCLUSIONS: Anorectal angle at rest in preoperative defecography might present a predictor of outcome after sacral nerve stimulation in patients with idiopathic fecal incontinence.

Impact of incisional negative pressure wound therapy on perineal wound healing after abdominoperineal rectum extirpation.

INTRODUCTION: Perineal wound healing disorders are one of the major complications following abdominoperineal rectum extirpation. METHODS AND RESULTS: We evaluated the impact of an "incisional negative pressure wound therapy" (iNPWT) system after abdominoperineal rectum extirpation in six patients. All patients had a neoadjuvant radiochemotherapy with 50.4 Gy and 5-FU. Five of the six patients (83%) experienced complication-free healing of the perineal wound after 5 to 12 days of iNPWT. One patient developed a wound healing disorder 8 days after abdominoperineal rectum extirpation during current iNPWT. DISCUSSION: Use of an iNPWT system can be of favor after abominoperineal rectum extirpation.

Sphincter-sparing intersphincteric rectal resection as an alternative to proctectomy in long-standing fistulizing and stenotic Crohn's proctitis?

PURPOSE: Long-standing fistulizing and stenotic proctitis (LFSP) in Crohn's disease (CD) indicates the end stage of the disease. Definitive diversion such as proctectomy is considered to be the only surgical option. The impact of intersphincteric sphincter-sparing anterior rectal resection (IAR) as an alternative to proctectomy is unclear. The aim of this study was to evaluate feasibility, morbidity, outcome, and quality of life (QL) in patients with LFSP undergoing intended IAR. PATIENTS AND METHODS: Out of a single institution database, 15 patients with LFSP intended for surgery from 856 patients with CD were selected for follow-up analyses. RESULTS: In 12/15 cases, IAR was carried out while 3/15 patients underwent primary proctectomy due to malignancy (n = 2) or due to patient's wish (n = 1). In one case, IAR revealed unexpected malignancy, which led to secondary proctectomy. In patients with IAR, complete healing of fistulas and stenosis was observed in 46% (n = 5) while 36% (n = 4) of patients showed relapse of fistula and 18% (n = 2) developed restenosis. Ileostomy closure was performed in seven patients from which six patients remained stoma free. QL and fecal incontinence measured by standardized scoring systems were unchanged while stool frequency was reduced after IAR in patients with ileostomy closure. The rate of malignancy in this cohort was 20% (n = 3). CONCLUSION: LFSP in CD was associated with 20% of malignant transformation. Although IAR fails to improve QL, it is a suitable procedure for the treatment of fistulas and stenosis associated with acceptable healing rates and can avoid a permanent stoma.

Neurostimulated levator augmentation--a new approach in restoring continence.

PURPOSE: Restoration of continence remains a major challenge in patients after abdominoperineal rectal excision (APE) or with end-stage fecal incontinence. A new surgical technique, the neurostimulated levator augmentation, was introduced for pelvic floor augmentation using dynamic graciloplasty in order to restore anorectal angulation. The aim of this study was to assess feasibility and efficiency. METHODS: From November 2009 to March 2014, n = 17 patients underwent neurostimulated levator augmentation (n = 10 after APE, n = 5 intractable idiopathic fecal incontinence, n = 2 traumatic anal amputation). Gracilis muscle was transposed through the obturator foramen into the pelvic cavity, positioned in a U-shaped sling behind the rectum, fixed to the contralateral os pubis to restore anorectal angulation, and then conditioned by neurostimulation. Questionnaires analyzing function and quality of life were administered. RESULTS: For neurostimulated levator augmentation, four patients suffered from complications that needed operative intervention (n = 3 wound infection, n = 1 colon perforation); three pharmacological treatment and two complications needed no further invasive intervention. One patient died due to causes unrelated to the operation, and no complication required intensive care management. Fecal incontinence in patients with idiopathic incontinence improved significantly after surgery as well as incontinence episodes, urgency, and disease-specific quality of life through all dimensions. Generic quality of life was significantly better after surgery in all patients. After median follow-up of 17 months (2-45), all but one patient would undergo the procedure again. CONCLUSIONS: Neurostimulated levator augmentation was feasible in all patients with acceptable morbidity. It may represent a new therapeutic option in selected patients with intractable fecal incontinence.

Single-port cholecystectomy in obese patients: our experience and a review of the literature.

PURPOSE: The objective of the present study was to compare the postoperative outcomes between obese and normal-weight patients undergoing single-port cholecystectomy (SPC) for gallstone disease. METHODS: A prospectively maintained SPC-database was retrospectively analyzed, and the outcomes of obese [body mass index (BMI) ≥30 kg/m(2)] and normal-weight patients were compared. All patients underwent SPC using the reusable X-Cone™ device. RESULTS: A total of 100 patients underwent SPC between July 2009 and September 2011. Seventeen obese patients (17 %) (median BMI 33.9 kg/m², range 30.0-38.8) were compared to 83 normal-weight patients (median BMI 24.1 kg/m², range 17.3-29.5). The length of the operation (median 75.5 min, range 42-156 vs. median 72.0 min, range 42-129; p = 0.51), conversion rate (N = 2 vs. N = 0; p = 1), postoperative complication rate (9.6 vs. 11.8%; p = 0.68), and postoperative hospital stay (median 3 days, range 1-14 vs. median 3 days, range 2-5; p = 0.74), were comparable for the normal-weight and obese patients. CONCLUSION: The postoperative outcome of obese patients after SPC is not inferior to that of normal-weight patients undergoing the same operation. Therefore, the BMI should not be considered a key criterion in the patient selection for single-port surgery.

Single-port laparoscopic cholecystectomy versus standard multiport laparoscopic cholecystectomy: a case-control study comparing the long-term quality of life and body image.

PURPOSE: To study the postoperative quality of life and body image of patients who underwent either single-port cholecystectomy (SPC) or standard multiport laparoscopic cholecystectomy (SMLC) in a long-term assessment. METHODS: Fifty patients who underwent SPC using the reusable X-Cone™ Laparoscopic Device were compared with a matched group (age, sex, body mass index) of 50 patients after SMLC. The health-related quality of life (HRQOL) and body image at 17 months postoperatively (median, range 9-23) was analysed by means of the Short-Form 12 Health Survey and the Body Image Questionnaire, respectively. RESULTS: Both patient groups had comparable baseline characteristics, clinical courses, and postoperative complication rates. SPC patients were significantly more satisfied with the cosmetic result of their scar at 17 months postoperatively, in comparison to SMLC patients (cosmetic scale: 22.6 ± 2.8 vs. 19.5 ± 3.7, p < 0.001). However, the HRQOL did not differ between the SPC and SMLC patients (physical component scale: 50.0 ± 8.9 vs. 48.8 ± 9.4, p = 0.48; mental component scale: 53.8 ± 6.5 vs. 51.3 ± 8.5, p = 0.10). CONCLUSION: Although the overall postoperative HRQOL was comparable, this study suggests that the cosmetic result of SPC after complete wound healing is superior to the standard multiport laparoscopic procedure.

Early-elective single-incision laparoscopic sigmoidectomy for perforated diverticulitis using a totally reusable single-port device.

BACKGROUND: Single-port access (SPA) is an emerging concept in minimally invasive colorectal surgery. The authors report their experience using SPA sigmoidectomy as an early-elective approach to complicated diverticulitis with paracolic abscess. METHODS: Between September 2009 und April 2010, 4 patients underwent SPA sigmoidectomy for Hinchey-I diverticulitis using the reusable X-Cone device. RESULTS: After a median time of antibiotic treatment of 8 days, SPA sigmoidectomy was performed successfully in all patients. The median operative time was 200 minutes (range, 187-221 minutes). No intraoperative or postoperative complications were recorded; the median postoperative hospital stay was 7 days (range, 5-7 days). No incisional hernias were observed at midterm follow-up (median, 11.5 months; range, 8-14 months). CONCLUSIONS: When performed by an experienced laparoscopic surgeon, early-elective SPA sigmoidectomy is a feasible and safe approach to complicated diverticulitis. The reusability of the X-Cone device ensures that the costs of the procedure are not high.

Single-port laparoscopic cholecystectomy with the x-cone: a feasibility study in 9 pigs.

OBJECTIVE: Virtually any port system for single-port laparoscopic surgery is for single usage only. The aim of this study was to trial the novel and completely reusable port X-Cone in order to perform a cholecystectomy by one infraumbilical incision. METHODS: Single access cholecystectomies were performed in 9 anesthetized domestic pigs in nonsurvival studies. Only one infraumbilical incision was performed for placing the reusable, multichannel steel port system. A newly developed angulated forceps was used besides regularly used instruments in laparoscopic surgery. RESULTS: The gallbladder was successfully removed in 9 pigs. At postmortem examination, the clips placed on the cystic duct and the cystic artery. No bile leakage was found at the operative field. CONCLUSION: Single-port cholecystectomy with the reusable X-Cone single-port system is safe and feasible. No additional incisions were needed. The system is ergonomically designed, easy to handle, and the learning curve for cholecystectomy is steep.

H+-Conducting Aromatic Multiblock Copolymer and Blend Membranes and Their Application in PEM Electrolysis.

As an alternative to common perfluorosulfonic acid-based polyelectrolytes, we present the synthesis and characterization of proton exchange membranes based on two different concepts: (i) Covalently bound multiblock-co-ionomers with a nanophase-separated structure exhibit tunable properties depending on hydrophilic and hydrophobic components' ratios. Here, the blocks were synthesized individually via step-growth polycondensation from either partially fluorinated or sulfonated aromatic monomers. (ii) Ionically crosslinked blend membranes of partially fluorinated polybenzimidazole and pyridine side-chain-modified polysulfones combine the hydrophilic component's high proton conductivities with high mechanical stability established by the hydrophobic components. In addition to the polymer synthesis, membrane preparation, and thorough characterization of the obtained materials, hydrogen permeability is determined using linear sweep voltammetry. Furthermore, initial in situ tests in a PEM electrolysis cell show promising cell performance, which can be increased by optimizing electrodes with regard to binders for the respective membrane material.

Early Ileocecal Resection Is an Effective Therapy in Isolated Crohn's Disease.

Despite the increasing incidence and prevalence of Crohn's Disease (CD), no curative options exist and treatment remains complex. While therapy has mainly focused on medical approaches in the past, growing evidence reveals that in cases of limited inflammation, surgery can suffice as an alternative primary treatment. We retrospectively assessed the disease course and outcomes of 103 patients with terminal Ileitis who underwent primary surgery (n = 29) or received primary medical treatment followed by surgery (n = 74). Primary endpoint was the need for immunosuppressive medication after surgical treatment (ileocecal resection, ICR) during a two-years follow-up. Rates for laparoscopic ICR were enhanced in case of early surgery, but no differences were seen for postoperative complications. In case of immunosuppressive medication, patients with ICR at an early state of disease needed significantly less anti-inflammatory medication during the two-year postoperative follow-up compared to patients who were primarily treated medically. Furthermore, in a subgroup analysis for patients with localized ileocecal disease manifestation, early surgery consistently resulted in a decreased amount of medical therapy postoperatively. In conclusion primary ICR is safe and effective in patients with limited CD, and the need for immunosuppressive medication during the postoperative follow-up is low compared to patients receiving surgery at a later stage of disease.

Hepatic angiomyolipoma: A case report and literature review.

INTRODUCTION: Hepatic angiomyolipoma (HAML) is a rare mesenchymal liver tumour which belongs to the family of perivascular epithelioid cell tumours (PEComas). It is typically composed of blood vessels, smooth muscle, and adipose cells, and shows strong immunoreactivity for HMB-45. PRESENTATION OF THE CASE: A 57-year-old woman was referred to our hospital with an unclear liver lesion. A fine needle biopsy revealed a suspicion of hepatic angiomyolipoma with extramedullary haematopoiesis. Preoperative imaging revealed a tumour 17 cm in diameter in the left liver lobe segments II and III. A lobectomy of the left lobe segments II and III was performed. The pathological diagnosis of hepatic angiomyolipoma was obtained. DISCUSSION: Variations in the predominance of the tissue components in HAML impedes diagnosis based on imaging alone. The most promising evidence of HAML is the histological identification of lipomatous, myomatous, and angiomatous tissue combined with immunohistochemical positivity for HMB-45. Although the tumour is considered benign, some cases have been described with malignant behaviour. Surgical resection should be considered in case of symptoms, inconclusive biopsy, or growth in follow-up. Other surgical indications may include aggressive patterns such as vascular invasion, p53 immunoreactivity, or rapidly proliferating tumour cells. CONCLUSION: HAML is a rare liver tumour. In patients with symptoms, uncertain diagnosis, or tumour growth, surgical resection should be performed according to oncological criteria.

Perioperative management of anticoagulant therapy.

About 10% of patients taking a chronic, oral anticoagulant therapy require an invasive procedure that can be associated with an increased risk for peri-interventional or perioperative bleeding. Depending on the risk for thromboembolism and the risk for bleeding, the physician has to decide whether the anticoagulant therapy should be interrupted or continued. Patient characteristics such as age, renal function and drug interactions must be considered. The perioperative handling of the oral anticoagulant therapy differs according to the periprocedural bleeding risk. Patients requiring a procedure with a minor risk for bleeding do not need to pause their anticoagulant therapy. For procedures with an increased risk for perioperative bleeding, the anticoagulant therapy should be adequately paused. For patients on a coumarin derivative with a high risk for a thromboembolic event, a perioperative bridging therapy with a low molecular weight heparin is recommended. Due to an increased risk for perioperative bleeding in patients on a bridging therapy, it is not recommended in patients with a low risk for thromboembolism. For patients taking a non-vitamin K oral anticoagulant, a bridging therapy is not recommended due to the fast onset and offset of the medication.

The Incidence of Trocar Site Hernia After Single-Port Laparoscopic Cholecystectomy-A Single Center Analysis and Literature Review.

BACKGROUND: Single-port laparoscopic cholecystectomy (SLC) requires a larger initial umbilical incision than conventional multiport laparoscopic cholecystectomy (MLC). In this retrospective analysis study we compared the demographics, clinical data, and incidence of postoperative trocar site hernias (TSH) in patients undergoing SLC with those in patients undergoing MLC. PATIENTS AND METHODS: A total of 161 patients were included in this study. Of these patients, 104 underwent MLC, 57 SLC. Patients in the MLC group were operated on using the four-trocar technique, patients in the SLC-port group using a fully reusable multi-trocar port system (X-Cone™). The earliest follow-up point was 12 months, the average follow-up period was 16.4 months (range 12-24 mos). The follow-up examinations for all patients consisted of a review of their medical history, a thorough physical examination, and an ultrasound examination of all existing trocar site scars. RESULTS: Patients in the SLC group had a lower mean American Society of Anesthesiologists score and a lower mean body mass index compared to patients in the MLC group. The average operating time was shorter for the patients in the SLC group, but the difference was not statistically significant. Ten (9.6%) patients in the MLC group and 3 (5.3%) in the SLC group developed a TSH (p = .55). CONCLUSIONS: At midterm follow-up the incidence of umbilical incisional hernias was not greater for SLC compared to MLC. The incidence of TSH after MLC was significantly higher than expected.

Small bowel volvulus after transabdominal preperitoneal hernia repair due to improper use of V-Loc™ barbed absorbable wire - do we always "read the instructions first"?

INTRODUCTION: Transabdominal preperitoneal endoscopic hernia repair (TAPP) is part of primary surgical health care. While both, the reported recurrence rate and procedure specific morbidity are consistently low, rare serious complications occur. PRESENTIATION OF CASE: A 36-year-old male patient developed bowel obstruction three days after both-sided TAPP for inguinal hernia repair. A computer tomography scan of the abdomen revealed a small bowel volvulus in the right lower quadrant of the abdomen requiring urgent revisional surgery. Intraoperatively, the small bowel and its mesenterial vessels were found to be twisted around a 5cm long V-Loc™ barbed absorbable suturing wire. After successful laparoscopic adhesiolysis, removal of the wire and detorquing of the bowel conglomerate, resection of small intestine was not necessary. The patient's further postoperative recovery was uneventful. DISCUSSION: Due to the barbed configuration of the V-Loc™ wire, a gapless continuous suturing of the peritoneum without laparoscopic knotting is easily and fast to accomplish. In this case the recommendation of the manufacturer to shorten the wire was not strictly followed and neither had the suture stump been extraperitonealized in order to avoid such rare complications. CONCLUSION: Surgeons need to be aware of relevant "tricks and traps" of routinely performed procedures and have to know all tools and material they use very well. This case may therefore increase our attention when it comes to little things which actually do matter.

Single-port laparoscopic cholecystectomy in patients of advanced age: why not?

OBJECTIVE: To compare the perioperative outcome of elderly patients undergoing either single-port cholecystectomy (SPC) or standard multiport laparoscopic cholecystectomy (SMLC). PATIENTS AND METHODS: Patients older than 50 years who underwent SPC using the reusable X-Cone were compared with age-matched, sex-matched, and body mass index-matched patients after SMLC, and postoperative outcome was analyzed. RESULTS: Of 97 patients who underwent SPC during July 2009 and August 2011, 33 patients (34%) were older than 50 years. Baseline characteristics were comparable for either group, as was the operative time (min) (SPC: 82.7 ± 25.1 vs. SMLC: 83.9 ± 22.1; P=0.85), postoperative hospital stay (d) (SPC: 3.7 ± 1.6 vs. SMLC: 3.9 ± 1.5; P=0.61), and postoperative complication rate [SPC: 4 of 33 patients (12.1%) vs. SMLC: 3 of 33 patients (9.1%); P=1.0]. CONCLUSIONS: Our study suggests that older age might not be predictive of an inferior outcome after SPC, compared with patients who were treated with the "golden standard."

A novel technique for fundal retraction of the gallbladder in single-port cholecystectomy.

Recent reports on the feasibility and safety of single-incision cholecystectomy have challenged the conventional multiport access to the gallbladder. Nevertheless, the proximity of different instruments and the laparoscope may lead to interference that potentially compromises the safety of the operation. This article describes the use of a customary flexible restraint system for the gallbladder fundus to achieve triangulation by means of a three-instrument technique and an optimized view to the Calot's triangle.

Trocar-site hernia after single-port cholecystectomy: not an exceptional complication?

BACKGROUND: When compared with standard multiport laparoscopy, the larger fascial incision in single-port surgery (SPS) may imply a potentially increased risk of surgical-site complications, such as herniation. The long-term risk of access-site complications in SPS is still unpredictable. METHODS: Between July 2009 and May 2011, n=78 patients (n=54 females), with a median age of 42 years (range: 18-85 years), underwent single-port cholecystectomy. The median body mass index was 25.4 kg/m(2) (range: 17-39 kg/m(2)). All surgeries were performed by a single surgeon (K.K.) using a completely reusable single-port access device (X-Cone™; KARL STORZ GmbH, Tuttlingen, Germany), and fascial closure technique was comparable in all patients. The first 50 patients (n=32 females) attended a structured follow-up examination including a meticulous clinical examination and ultrasonography of the access site at a median follow-up time of 17 months (range: 9-23 months). RESULTS: We recorded postoperative complications in 5 of the 50 patients (10%) after single-port cholecystectomy. Four occurred in the early postoperative course and presented as mild wound complications. One of the 50 patients (2%) experienced a symptomatic trocar-site hernia (TSH) 4 months after surgery. No biliary complications (bile leakage, retained stones, etc.) were recorded. CONCLUSIONS: Although potentially biased by a relatively small number of patients, our study provides evidence that TSH after single-port cholecystectomy is (i) not less frequent when compared with standard laparoscopy, (ii) not as infrequent as suggested by the current literature, and (iii) not only associated with technical failure or patients' comorbidity.