MTL, a composite measure for objectively profiling hospitals on surgical performance in colorectal cancer surgery.

PURPOSE: MTL is a composite outcome measure based on routine administrative data defined as (a) postoperative mortality and/or (b) postoperative transfer to another hospital and/or (c) length of hospital stay ≥ the prespecified time period. Aim of the present study was to investigate MTL for profiling hospitals on surgical performance in colorectal cancer surgery, using data from the national registers of the German Society of General and Visceral Surgery (DGAV) and to determine the time interval for length of stay with the highest accuracy regarding major complications (Clavien-Dindo grade ≥ 3). METHODS: All patients undergoing colorectal cancer resection between January 2010 and February 2017 were included. MTL rates were calculated and compared to well-established single outcome measures using multivariate regression analysis. For each outcome measure, postoperative complications were tested regarding their predictability. RESULTS: Data from 14,978 patients were analyzed. Length of stay was significantly prolonged if postoperative complications occurred (p < 0.0001). Thirty-day mortality and the indication for a transfer to another hospital mainly resulted from cardiopulmonary complications. MTL occurs significantly more often than any of the single-outcome parameters. The time interval of 22 days demonstrated the highest accuracy regarding severe complications (Clavien-Dindo grade ≥ 3). CONCLUSIONS: MTL reflects the complete spectrum of postoperative complications. Compared to individual surgical outcome parameters, MTL may have a better discriminatory power and is therefore suitable to mirror surgical quality. Because of its high accuracy regarding surgical major morbidity, 22 days is the best cut-off for length of stay within the German healthcare system.

Necessity of subcutaneous suction drains in ileostomy reversal (DRASTAR)-a randomized, controlled bi-centered trial.

PURPOSE: Data regarding length of hospital stay of patients undergoing ileostomy reversal are very heterogeneous. There are many factors that may have an influence on the length of postoperative hospital stay, such as postoperative wound infections. One potential strategy to reduce their incidence and to decrease hospital stay is to insert subcutaneous suction drains. The purpose of this study was to examine the influence of the insertion of subcutaneous suction drains on hospital stay and postoperative wound infections in ileostomy reversal. Risk factors for postoperative wound infection were determined. METHODS: This is a randomized controlled two-center non-inferiority trial with two parallel groups. The total length of hospital stay as primary endpoint and the occurrence of a surgical site infection, the colonization of the abdominal wall with bacteria, and the occurrence of hematomas/seromas as secondary endpoints were monitored. RESULTS: One hundred eighteen patients with elective ileostomy reversal were included. Fifty-nine patients were randomly assigned to insertion of a subcutaneous suction drain, and 59 patients were randomly assigned to receive no drain. After 3 months of follow-up, 50 patients in the group with drain and 53 patients in the group without drain could be analyzed. Median total length of hospital stay was 8 days in the SD group and 9 days in the group without SD (p = 0.17). Fourteen percent of patients with SD and 17 % without SD developed SSI, p = 0.68. Multivariate analysis revealed anemia (p < 0.01), intraoperative bowel perforation (p = 0.02) and resident (p = 0.04) or fellow (p = 0.048) performing the operation as risk factors for SSI. CONCLUSIONS: This trial shows that the omission of subcutaneous suction drains is not inferior to the use of subcutaneous suction drains after ileostomy reversal in terms of length of hospital stay, surgical site infections, and hematomas/seromas.

Therapy of complicated Crohn's disease during pregnancy--an interdisciplinary challenge.

BACKGROUND: Severe courses of Crohn's disease (CD) during pregnancy are rare. However, if occurring, the risk of miscarriage and low birth weight is increased. At present, only limited data is available on the treatment of CD during pregnancy. In particular, there are no standard guidelines for surgical therapy. Nevertheless, surgery is often unavoidable if complications during the course of the disease arise. PURPOSE: This study provides a critical overview of conventional and interventional treatment options for CD complications during pregnancy and analyses the surgical experience gained thus far. For illustrative purposes, clinical cases of three young women with a severe clinical course during pregnancy are presented. METHODS: After treatment-refractory for conservative and interventional measures, surgery remained as the only treatment option. In all cases, a split stoma was created after resection to avoid anastomotic leaks that would endanger the lives of mother and child. The postoperative course of all three patients was uneventful, and pregnancy remained intact until delivery. No further CD specific medication was required before birth. CONCLUSIONS: The management of CD patients during pregnancy requires close interdisciplinary co-operation between gastroenterologists, obstetricians, anaesthetists and visceral surgeons. For the protection of mother and child treatment should thus be delivered in a specialised centre. This article demonstrates the advantages of surgical therapy by focusing on alleviating CD complaints and preventing postoperative complications.

[Safety of resection of symptomatic and asymptomatic Meckel's diverticulum and literature review]. / Das Meckel-Divertikel: Sicherheit der Resektion symptomatischer und asymptomatischer Befunde und Literaturübersicht.

BACKGROUND: Meckel's diverticulum (MD) is the most common diverticulum of the small bowel and an important finding in surgical practice. The aim of this study was to assess the safety of the resection of symptomatic and asymptomatic MD concerning postoperative complications. As MD are relatively rare, an overview of the literature is given. PATIENTS AND METHODS: All patients with MD at the department at general surgery of the Charité - Campus Benjamin Franklin between 1996 and 2010 were assessed. An analysis for symptomatic and incidental MD was performed for incidence, indication, intraoperative findings, histology and postoperative outcome. RESULTS: An MD was intraoperatively found in 71 of 29 682 patients (0.2 %). Of these, a symptomatic MD occurred in 26 patients (37 %). A symptomatic MD was causal in 6 of 7 patients with gastrointestinal bleeding (GIB, p = 0.005). All symptomatic MD and 30 (67 %) asymptomatic MD were resected. Ectopic gastric mucosa was found significantly more frequently in patients with symptomatic MD (p = 0.001). Patients with asymptomatic MD and resection had less complications as a trend (p = 0.057). CONCLUSION: Ectopic mucosa is more frequent in symptomatic MD, especially in bleeding MD. MD should always be considered in GIB of unknown origin. Resection of incidental MD can be recommended in patients without contraindications such as peritonitis, cancer, ascites or immunosuppression.

Suitability of a virtual reality simulator for laparoscopic skills assessment in a surgical training course.

BACKGROUND: Virtual reality simulators (VRS) can acquire specific performance parameters for laparoscopic surgery. The aim of this study was to evaluate the suitability of a VRS for the assessment in a surgical skills course. MATERIALS AND METHODS: One hundred five attendees of a 7-day surgical skills course were tested with a VRS at the beginning (T1) and at the end (T2) of the course. Two standard VRS tasks (lifting and grasping (LG) and fine dissection (FD)) with two scores and 21 individual parameters were used. VRS performance was correlated to laparoscopic experience and experience in playing video games in order to assess the influence of preexisting skills. RESULTS: The participants improved significantly in both scores and in 19/21 VRS parameters between T1 and T2. Laparoscopic experts were significantly better than novices only for the parameter tissue damage on T1 in LG (41.4 %, P < 0.001). Gamers were significantly better than non-gamers in all manual parameters on T1 in LG. Both groups of laparoscopic experience as well as non-gamers improved between T1 and T2 in LG for most parameters, while gamers only improved for tissue damage. CONCLUSIONS: The VRS was able to assess the gain in surgical performance during the course in general. However, laparoscopic experience and video game experience strongly influenced the results. Laparoscopic experience was correlated to the parameter tissue damage, whereas video game experience was correlated to manual parameters. This knowledge can be used to build adequate scoring systems for VRS and to design tasks that target specific course skills.

[How does the surgical society (DGAV) support the continuing medical training in general and visceral surgery?] / Wie unterstützt die Fachgesellschaft (DGAV) die ärztliche Weiterbildung in der Allgemein- und Viszeralchirurgie?

The medical councils (Ärztekammern) develop the contents of the further training regulations with the support of the specialist society. The hospitals with the training supervisors have to implement these contents for the trainees in continuing education and confirm the acquisition of competence for the individual tasks. Surveys of young surgeons in recent years have shown that many participants do not receive structured continuing education, so that there is general dissatisfaction. Therefore, the German Society for General and Visceral Surgery (DGAV) is required to provide assistance to its members to improve continuing education in the departments. For example, the DGAV organizes more than 100 surgical courses annually on all topics of visceral surgery, anatomy, skills courses and revision courses with the Further Education and Advanced Training Quality Center (WeiFoQ). This year a continuing education curriculum was developed over the 6­year continuing education period, so that a structured continuing education is achievable. The contents of the continuing education regulations are included in this continuing education curriculum with explanations, video clips, and graphics, thus providing quick information on each individual surgical clinical picture. A digital surgical catalog provides a quick overview of the status of personal continuing education. It is planned to set up an interface to the eLogbook of the medical councils.

[Impact of the COVID pandemic on treatment of bariatric patients in Germany-An analysis of the national StuDoQ/MBE register]. / Auswirkungen der COVID-Pandemie auf die Versorgung bariatrischer Patienten in Deutschland ­ eine Analyse des nationalen StuDoQ/MBE-Registers.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic the standard inpatient care of patients was restricted to increase overall and intensive care capacity reserves for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected persons. OBJECTIVE: This article presents the impact of the COVID-19 pandemic on the surgical and postoperative care of bariatric patients in Germany. MATERIAL AND METHODS: A statistical analysis of the national StuDoQ/MBE register data for the period from 1 May 2018 until 31 May 2022 was performed. RESULTS: Throughout the entire study period there was a continuous increase in documented operations, which continued even during the COVID-19 pandemic. A significant intermittent decline in surgery performed was observed only during the imposition of first lockdown in the months of March to May 2020, with a minimum number of 194 cases performed monthly in April 2020. The pandemic had no measurable effect on the surgically treated patient population, the type of surgical procedure, the perioperative and postoperative outcomes and follow-up care. CONCLUSION: Based on the results of the StuDoQ data and the current literature, it can be deduced that bariatric surgery can be carried out with no increased risk during the COVID-19 pandemic and the quality of postoperative care is not impaired.

Reduction of wound infections in laparoscopic-assisted colorectal resections by plastic wound ring drapes (REDWIL)?--A randomized controlled trial.

INTRODUCTION: Surgical site infections (SSIs) are frequent complications in colorectal surgery and may lead to burst abdomen, incisional hernia, and increased perioperative costs. Plastic wound ring drapes (RD) were introduced some decades ago to protect the abdominal wound from bacteria and reduce SSIs. There have been no controlled trials examining the benefit of RD in laparoscopic colorectal surgery. The Reduction of wound infections in laparoscopic assisted colorectal resections by plastic wound ring drapes (REDWIL) trial was thus designed to assess their effectiveness in preventing SSIs after elective laparoscopic colorectal resections. MATERIALS/METHODS: REDWIL is a randomized controlled monocenter trial with two parallel groups (experimental group with RD and control group without RD). Patients undergoing elective laparoscopic colorectal resection were included. The primary endpoint was SSIs. Secondary outcomes were colonization of the abdominal wall with bacteria, reoperations/readmissions, early/late postoperative complications, and cost of hospital stay. The duration of follow-up was 6 months. RESULTS: Between January 2008 and October 2010, 109 patients were randomly assigned to the experimental or control group (with or without RD). Forty-six patients in the RD group and 47 patients in the control group completed follow-up. SSIs developed in ten patients with RD (21.7 %) and six patients without RD (12.8 %) (p = 0.28). An intraoperative swab taken from the abdominal wall was positive in 66.7 % of patients with RD and 57.5 % without RD (p = 0.46). The number of species cultured within one swab was significantly higher in those without RD (p = 0.03). The median total inpatient costs including emergency readmissions were 3,402 ± 4,038 in the RD group and 3,563 ± 1,735 in the control group (p = 0.869). CONCLUSIONS: RD do not reduce the rate of SSIs in laparoscopic colorectal surgery. The inpatient costs are similar with and without RD.

Locally recurrent colorectal cancer: results of surgical therapy.

PURPOSE: Up to 20 % of colorectal cancer patients develop recurrent disease despite standardized surgical techniques and multimodal treatment strategies. Radical resection is the central component of curative therapy in these cases. The aim of this study was to evaluate treatment results in patients with locoregionally recurrent colorectal cancer. METHODS: From January 1995 to December 2007, surgery was performed for recurrent colorectal cancer in 82 patients who had undergone curative (R0) resection of their primary tumor. Assessment included patient, tumor and treatment characteristics, postoperative complications, and time without re-recurrence; recurrence-free and overall survival rates were calculated according to the Kaplan-Meier method. RESULTS: Resection was performed in 60 of the 82 patients (73 %), repeat R0 resection in 52 % (31/60). Patients had a postoperative morbidity of 39 % (31/82), a relaparotomy rate of 13 % (11/82), and a lethality of 7 % (6/82). Forty-eight percent of all surgically-treated patients received a permanent stoma. Re-recurrence was seen in 52 % (16/31). R0 resection was associated with a 5-year survival rate of 35 % (11/31). CONCLUSIONS: Extensive reinterventions often enable repeat R0 resection. Despite relevant morbidity, the lethality appears to be acceptable. Decisive for the prognosis is re-recurrence.

[Simulation training in surgical education - application of virtual reality laparoscopic simulators in a surgical skills course]. / Simulationstraining in der Weiterbildung - Einsatz von virtuellen laparoskopischen Operationssimulatoren in einem chirurgischen Trainingskurs.

BACKGROUND: Training and simulation are gaining importance in surgical education. Today, virtual reality surgery simulators provide sophisticated laparoscopic training scenarios and offer detailed assessment methods. This also makes simulators interesting for the application in surgical skills courses. The aim of the current study was to assess the suitability of a virtual surgery simulator for training and assessment in an established surgical training course. MATERIALS AND METHODS: The study was conducted during the annual "Practical Course for Visceral Surgery" (Warnemuende, Germany). 36 of 108 course participants were assigned at random for the study. Training was conducted in 15 sessions over 5 days with 4 identical virtual surgery simulators (LapSim) and 2 standardised training tasks. The simulator measured 16 individual parameters and calculated 2 scores. Questionnaires were used to assess the test persons' laparoscopic experience, their training situation and the acceptance of the simulator training. Data were analysed with non-parametric tests. A subgroup analysis for laparoscopic experience was conducted in order to assess the simulator's construct validity and assessment capabilities. RESULTS: Median age was 32 (27 - 41) years; median professional experience was 3 (1 - 11) years. Typical laparoscopic learning curves with initial significant improvements and a subsequent plateau phase were measured over 5 days. The individual training sessions exhibited a rhythmic variability in the training results. A shorter night's sleep led to a marked drop in performance. The participants' different experience levels could clearly be discriminated ( ≤ 20 vs. > 20 laparoscopic operations; p ≤ 0.001). The questionnaire showed that the majority of the participants had limited training opportunities in their hospitals. The simulator training was very well accepted. However, the participants severely misjudged the real costs of the simulators that were used. CONCLUSIONS: The learning curve on the simulator was successfully mastered during the course. Construct validity could be demonstrated within the course setting. The simulator's assessment system can be of value for the assessment of laparoscopic training performance within surgical skills courses. Acceptance of the simulator training is high. However, simulators are currently too expensive to be used within a large training course.

Structure and stability of the negative hydrogen molecular ion.

We present the results of a Coulomb explosion experiment that allows for the imaging of the rovibrational wave function of the metastable H2- ion. Our measurements confirm the predicted large internuclear separation of 6 a.u., and they show that the ion decays by autodetachment rather than by spontaneous dissociation. Imaging of the resulting H2 products reveals a large angular momentum of J = 25 ± 2, quantifying the rotation that leads to the metastability of this most fundamental molecular anion.

Management and results of complications after anterior resection with colonic pouch reconstruction for rectal cancer.

AIM: Colonic J-pouch reconstruction is widely carried out during low anterior resection. The aim of this observational study was to describe the complications and evaluate the results of adverse event management. METHOD: A total of 128 patients underwent an elective anterior resection with colorectal or coloanal J-pouch reconstruction for primary rectal cancer between January 1997 and December 2008. RESULTS: The overall mortality was 1.6%. Three (2.3%) patients developed pouch necrosis, one of whom died. The rate of anastomotic leakage was 11.7%. Other major complications included intra-abdominal abscess (3.1%), haemorrhage (0.8%) and abdominal dihiscence (0.8%). In all cases of anastomotic leakage, the pouch was salvaged, with 80% of patients undergoing surgical revision with relaparotomy and transanal suture. Patients with pouch necrosis underwent relaparotomy with removal of the pouch and a terminal colostomy. In all cases of intra-abdominal abscess without anastomotic leakage, radiologically controlled percutaneous drainage was carried out. CONCLUSION: Anal function can usually be saved after anastomotic leakage by salvage surgery without increase in mortality.

[Statement of the surgical working group upper gastrointestinal tract (CAOGI) and the quality committee of the German Society for General and Visceral Surgery (DGAV) on the modified minimum caseload requirements for esophagus resection]. / Stellungnahme der Chirurgischen Arbeitsgemeinschaft oberer Gastrointestinaltrakt (CAOGI) sowie der Qualitätskommission der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) zu der geänderten Mindestmenge für die Ösophagusresektion.

A positive association between the number of operations and postoperative hospital mortality, the so-called caseload-treatment result relation, has been confirmed many times in the literature; however, the definition of the underlying volumes is not uniform. The number of 26 resections/year/institution, which has now been established by the Federal Joint Committee as the future minimum caseload requirement, is discussed in this statement of the surgical working group upper gastrointestinal tract (CAOGI) and the quality committee of the German Society for General and Visceral Surgery (DGAV), taking the treatment situation in Germany and the current data situation into account.

Predictors of permanent ileostomy after restorative proctocolectomy.

BACKGROUND: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a surgical approach for ulcerative colitis and familial adenomatous polyposis. This study evaluated predictors of the need for a permanent ileostomy to identify patients at high risk of IPAA failure. METHODS: This was a retrospective analysis of patients who underwent proctocolectomy and IPAA between 1997 and 2008. A logistic regression model was used for multivariable analysis of potential risk factors. RESULTS: Proctocolectomy was combined with IPAA in 185 patients, of whom 169 had a loop ileostomy formed. IPAA and ileostomy closure were successful in 162 patients (87.6 per cent). Reasons for not closing the ileostomy included pouch failure (16 patients), patient choice (5) and death (2). Thus one in eight patients had a permanent ileostomy after planned IPAA. Age was the major predictor of the need for a permanent ileostomy in multivariable analysis (P = 0.002) with a probability of more than 25 per cent in patients aged over 60 years. However, advancing age was associated with colitis, co-morbidity, obesity and corticosteroid use. CONCLUSION: The probability of the need for a permanent ileostomy after IPAA increases with age.

Hot water molecules from dissociative recombination of D3O+ with cold electrons.

Individual product channels in the dissociative recombination of deuterated hydronium ions and cold electrons are studied in an ion storage ring by velocity imaging using spatial and mass-sensitive detection of the neutral reaction fragments. Initial and final molecular excitation are analyzed, finding the outgoing water molecules to carry internal excitation of more than 3 eV in 90% of the recombination events. Initial rotation is found to be substantial and in three-body breakup strongly asymmetric energy repartition among the deuterium products is enhanced for hot parent ions.

Ultraviolet and visible light photodissociation of H3+ in an ion storage ring.

Ultraviolet and visible photodissociation of a vibrationally excited H(3)(+) ion beam, as produced by standard ion sources, was successfully implemented in an ion storage ring with the aim of investigating the decay of the excited molecular levels. A collinear beams configuration was used to measure the photodissociation of H(3)(+) into H(2)(+) + H fragments by transitions into the first excited singlet state with 266 and 532 nm laser beams. A clear signal could be observed up to 5 ms of storage, indicating that enough highly excited rovibrational states survive on the millisecond time scale of the experiment. The decay into H(2)(+) + H shows an effective time constant between about 1 and 1.5 ms. The initial photodissociating states are estimated to lie roughly 1 eV below the dissociation limit of 4.4 eV. The expected low population of these levels gives rise to an effective cross section of several 10(-20) cm(2) for ultraviolet and some 10(-21) cm(2) for visible light. For using multistep resonant dissociation schemes to monitor rotational populations of cold H(3)(+) in low-density environments, these measurements open promising perspectives.

The vasculitis in IBD is associated with the degree of inflammation.

The role of vasculitis in the pathogenesis of IBD remains unclear. The aim of this study was to evaluate the detection rate of vasculitis in patients with IBD, its location in the intestinal wall layers and whether it occurs dependent of the degree of inflammation. Immunohistological staining with the endothelial cell marker CD31 and the pan-T cell marker CD3 was performed in 56 colonic specimens of Crohn's disease, in 43 of ulcerative colitis, and in 5 of colon cancer. Quantification of the degree of inflammation was done using a histological colitis score. There was no sign of vasculitis in the healthy intestinal wall layers. In Crohn's disease, specimens with minor inflammatory activity (score 0-2) disclosed no vasculitis. Vasculitis was observed in 82% of the specimens with an inflammatory degree of 3 and in 100% with an inflammatory degree of 4. Vasculitis was detected in all intestinal wall layers altered by inflammation. A direct association between vasculitis and granulomas was observed in only 5% of the specimens with an inflammatory degree of 4. All ulcerative colitis specimens evidenced an inflammatory degree between 2 and 4. No vasculitis was found in specimens with an inflammatory degree of 2, but in 57% with an inflammatory degree of 3 and in 100% with an inflammatory degree of 4. Vasculitis is only detectable in the mucous membrane changed by inflammation. Thus, the vasculitis in IBD is exclusively observed in the intestinal wall layers altered by inflammation. The extent of vasculitis depends on the degree of inflammation. An association between vasculitis and granuloma in Crohn's disease is seen in 5% of the cases.

Abdominal resection rectopexy with an absorbable polyglactin mesh: prospective evaluation of morphological and functional changes with consecutive improvement of patient's symptoms.

BACKGROUND: The pathophysiology of rectal prolapse and intussusception has not yet been clarified. This is reflected in the multiplicity of surgical procedures. The aim of this prospective study was to measure morphological and functional changes of the pelvic floor and the rectum before and after resection rectopexy. METHODS: A total of 21 patients (mean age 60 years; 2 men, 19 women) with manifest rectal prolapse and rectoanal intussusception underwent sigmoidectomy and rectopexy with an absorbable polyglactin mesh graft. The following analyses were performed preoperatively and, on average, 15 months (range 6-21 month) postoperatively: radiologic defecography, rectal volumetry, sphincter manometry, and evaluation of clinical symptoms. RESULTS: Postoperatively there was no patient with rectal prolapse, and only one with an intussusception. Rectal compliance increased from 6.4 to 10.2 ml/mmHg. Rectal volumetry showed a decrease of the thresholds for the sensation of "desire to defecate" and "maximal tolerated volume" (100-75 ml, 175-150 ml). Postoperatively, there was a higher level of the pelvic floor during contraction. The anorectal angle, vector volume, radial asymmetry, sphincter length, and resting and squeezing pressures were unchanged. Surgery improved rectal evacuation (p = 0.03), continence (p = 0.01), stool consistency (p = 0.03), and warning period (p = 0.01). Patients' personal assessment showed an improved overall satisfaction. CONCLUSIONS: Resection rectopexy is a reliable method for treating rectal prolapse and rectoanal intussusception with clear improvement of the patient's clinical symptoms. The restored anorectal function can be attributed to improved rectal compliance, a lower sensory threshold, an elevation of the pelvic floor during squeezing, and an improved rectal evacuation.

[Advanced training of general and visceral surgeons in life-saving emergency surgery : Results of a survey among participants of a surgery course]. / Fortbildung von Allgemein- und Viszeralchirurgen in der lebensrettenden Notfallchirurgie : Ergebnisse einer Umfrage unter Operationskursteilnehmern.

BACKGROUND: Due to a decreasing number of emergency procedures for body cavity injuries, surgical training is inadequate and current educational concepts must be reconsidered. The German Society for General and Visceral Surgery has set up a surgical training course in 2014 to overcome this shortage. In order to assess the eligibility, needs, benefits and success of such a training format, participants were asked to evaluate the program. MATERIAL AND METHODS: All participants evaluated the course during participation and were later asked to answer an online survey regarding their age, gender, level of surgical education, surgical discipline, level of care of the hospital, emergency surgical experience and frequency of performing emergency surgery, participation in other programs, experiences after participating in the course, rating of the current training curriculum and funding of such courses. RESULTS: Out of 142 participants 83 replied to the online survey. Over 90% reported a lasting positive influence of the course on emergency surgical skills. More than half of the responders remembered a clinical situation which they successfully managed due to the skills they gained during the course. Surgeons experienced in emergency treatment felt significantly more benefit than less experienced colleagues. A consultancy position, the level of care of the hospital, age and sex of the participants did not influence the overall benefits reported. The majority of responding surgeons were in favor of including such a training course in surgical education and stipulated public financial support. CONCLUSION: Course formats that mediate emergency surgery strategies and skills are established and well accepted. Training of surgeons in life-saving emergency surgery is in the public interest and is also partly the responsibility of society.

Ex situ quantification of the cooling effect of liver vessels on radiofrequency ablation.

PURPOSE: To quantify the cooling effect of hepatic vessels on liver radiofrequency (RF) ablation ex situ. METHODS: Bipolar RF applicators (diameter = 1.8 mm, electrode length = 30 mm) were inserted parallel to perfused glass tubes (diameter = 5 and 10 mm; flow = 250-1,800 ml/min) at distances of 5 and 10 mm in porcine livers ex vivo. RF ablation was performed at 30 W/15 kJ. RF lesions were analyzed by measuring the maximum (r (max)) and minimum radius (r (min)) and the lesion area. RESULTS: Glass tubes without flow showed no influence on RF lesions, whereas perfused glass tubes had a significant cooling effect on lesions. r (min) was reduced to 50% at 5 mm applicator-to-vessel distance and the lesion area was reduced from 407 to 321 mm(2) (p < 0.001). There was no significant influence of glass tube diameter or flow volume on any of the analyzed parameters. CONCLUSIONS: Cooling effects of intrahepatic vessels could be simulated in an ex situ model. Cooling effects should be taken into account in RF ablation within 10 mm distance to major liver vessels regardless of blood flow volume or vessel diameter. Surgical RF ablation with temporary blood flow occlusion should be considered in such constellations.