Impact of tutorial assistance in laparoscopic sigmoidectomy for acute recurrent diverticulitis.

PURPOSE: Adequate training and close supervision by an experienced surgeon are crucial to assure the patient safety during laparoscopic training. This study evaluated the impact of tutorial assistance on the duration of surgery and postoperative complications after laparoscopic sigmoidectomy. METHODS: The data from 235 patients undergoing laparoscopic sigmoidectomy were collected. Operating surgeons were classified as either residents/registrars (group A, tutorial assistance) or consultants operating autonomously (group B). Groups were compared concerning the duration of surgery and in-hospital complications using a multivariable regression model accounting for the most relevant confounders. RESULTS: The median duration of the operation in group A (n = 75) was 221 min, and that in group B (n = 160) 189 min (p < 0.001). The risk of developing any in-hospital complication (Clavien-Dindo classification I-V) was 36.0 % in Group A and 32.5 % in group B (95 % CI -16.6, 9.6 %). The risk of developing moderate to severe surgical complications (Clavien-Dindo classification II-V) was 16.0 % in group A and 12.5 % in group B (95 % CI -13.3, 6.3 %). CONCLUSIONS: We were unable to demonstrate a clear impact of tutorial assistance on the risk of postoperative complications. Although associated with a longer duration of surgery, laparoscopic sigmoidectomy for acute recurrent sigmoid diverticulitis conducted by a junior supervised surgeon appears to be a safe surgical modality.

Surgical treatment of acute recurrent diverticulitis: early elective or late elective surgery. An analysis of 237 patients.

BACKGROUND: The optimal timing of elective surgery in diverticulitis remains unclear. We attempted to investigate early elective versus late elective laparoscopic surgery in acute recurrent diverticulitis in a retrospective study. METHOD: Data of patients undergoing elective laparoscopic surgery for diverticulitis were retrospectively gathered, including Hinchey stages I-II a/b. the primary endpoint was in-hospital complications according to the Clavien-Dindo classification. Secondary endpoints were surgical complications, operative time, conversion rate, and length of hospital stay. RESULTS: Of 237 patients, 81 (34%) underwent early elective operation (group A) and 156 (66%) underwent late elective operation (group B). In-hospital complications developed in 32% in group A and in 34% in group B (risk difference 2%, 95% Confidence Interval (95% CI): -11%, 14%). Higher age (p = 0.048) and borderline higher American Society of Anesthesiologists score (p = 0.056) were risk factors for in-hospital complications. Severe surgical complications occurred in 9% of patients in group A and 10% in group B (risk difference 2%, 95% CI: -6%, 9%). Conversion rate was 9% in group A and 3% in group B (p = 0.070). Severity of disease did not seem to have an impact on complications or length of hospital stay. The median postoperative hospital stay was 8 days in both groups (interquartile range 6-10). Mean operative time was 220 min (SD 64) in group A and 202 min (SD 48) in group B. CONCLUSIONS: This is the first study comparing early versus late elective surgery for diverticulitis in terms of the postoperative outcome using a validated classification. Although the retrospective setting and large confidence intervals don't allow definitive recommendations, these results are of utmost importance for the design of future prospective, randomized controlled trials.

Assessment of intraoperative liver deformation during hepatic resection: prospective clinical study.

BACKGROUND: The implementation of intraoperative navigation in liver surgery is handicapped by intraoperative organ shift, tissue deformation, the absence of external landmarks, and anatomical differences in the vascular tree. To investigate the impact of surgical manipulation on the liver surface and intrahepatic structures, we conducted a prospective clinical trial. METHODS: Eleven consecutive patients [4 female and 7 male, median age = 67 years (range = 54-80)] with malignant liver disease [colorectal metastasis (n = 9) and hepatocellular cancer (n = 2)] underwent hepatic resection. Pre- and intraoperatively, all patients were studied by CT-based 3D imaging and assessed for the potential value of computer-assisted planning. The degree of liver deformation was demonstrated by comparing pre- and intraoperative imaging. RESULTS: Intraoperative CT imaging was successful in all patients. We found significant deformation of the liver. The deformation of the segmental structures is reflected by the observed variation of the displacements. There is no rigid alignment of the pre- and intraoperative organ positions due to overall deflection of the liver. Locally, a rigid alignment of the anatomical structure can be achieved with less than 0.5 cm discrepancy relative to a segmental unit of the liver. Changes in total liver volume range from -13 to +24%, with an average absolute difference of 7%. CONCLUSIONS: These findings are fundamental for further development and optimization of intraoperative navigation in liver surgery. In particular, these data will play an important role in developing automation of intraoperative continuous registration. This automation compensates for liver shift during surgery and permits real-time 3D visualization of navigation imaging.

Negative Pressure Wound Therapy vs Conventional Wound Treatment in Subcutaneous Abdominal Wound Healing Impairment: The SAWHI Randomized Clinical Trial.

Importance: Negative pressure wound therapy (NPWT) is an established treatment option, but there is no evidence of benefit for subcutaneous abdominal wound healing impairment (SAWHI). Objective: To evaluate the effectiveness and safety of NPWT for SAWHI after surgery in clinical practice. Design, Setting, and Participants: The multicenter, multinational, observer-blinded, randomized clinical SAWHI study enrolled patients between August 2, 2011, and January 31, 2018. The last follow-up date was June 11, 2018. The trial included 34 abdominal surgical departments of hospitals in Germany, Belgium, and the Netherlands, and 539 consecutive, compliant adult patients with SAWHI after surgery without fascia dehiscence were randomly assigned to the treatment arms in a 1:1 ratio stratified by study site and wound size using a centralized web-based tool. A total of 507 study participants (NPWT, 256; CWT, 251) were assessed for the primary end point in the modified intention-to-treat (ITT) population. Interventions: Negative pressure wound therapy and conventional wound treatment (CWT). Main Outcomes and Measures: The primary outcome was time until wound closure (delayed primary closure or by secondary intention) within 42 days. Safety analysis comprised the adverse events (AEs). Secondary outcomes included wound closure rate, quality of life (SF-36), pain, and patient satisfaction. Results: Of the 507 study participants included in the modified ITT population, 287 were men (56.6%) (NPWT, 155 [60.5%] and CWT, 132 [52.6%]) and 220 were women (43.4%) (NPWT, 101 [39.5%] and CWT 119 [47.4%]). The median (IQR) age of the participants was 66 (18) years in the NPWT arm and 66 (20) years in the CWT arm. Mean time to wound closure was significantly shorter in the NPWT arm (36.1 days) than in the CWT arm (39.1 days) (difference, 3.0 days; 95% CI 1.6-4.4; P < .001). Wound closure rate within 42 days was significantly higher with NPWT (35.9%) than with CWT (21.5%) (difference, 14.4%; 95% CI, 6.6%-22.2%; P < .001). In the therapy-compliant population, excluding study participants with unauthorized treatment changes (NPWT, 22; CWT, 50), the risk for wound-related AEs was higher in the NPWT arm (risk ratio, 1.51; 95% CI, 0.99-2.35). Conclusions and Relevance: Negative pressure wound therapy is an effective treatment option for SAWHI after surgery; however, it causes more wound-related AEs. Trial Registration: ClinicalTrials.gov Identifier: NCT01528033.

Impact of concomitant thyroid pathology on preoperative workup for primary hyperparathyroidism.

BACKGROUND: The former standard surgical treatment in patients with primary hyperparathyroidism (pHPT) has been bilateral cervical exploration. New localization techniques and the possibility of intraoperative measurement of intact parathormone (iPTH) permit a focused, minimally invasive parathyroidectomy (MIP). The introduction of MIP without complete neck exploration leads to the potential risk of missing thyroid pathology. The aim of the present study is to evaluate the value of MIP in respect to coexisting thyroid findings and their impact on preoperative workup for primary hyperparathyroidism. METHODS: This is a prospective study including 30 consecutive patients with pHPT (median age 65 years; 17 females, 13 males). In all patients preoperative localization was performed by ultrasonography and 99m Tc-MIBI scintigraphy- Intraoperative iPTH monitoring was routinely done. RESULTS: Ten patients (33%) had a concurrent thyroid finding requiring additional thyroid surgery, and two patients (7%) with negative localization results underwent bilateral neck exploration. Therefore, MIP was attempted in 18 (60%) patients. The conversion rate to a four gland exploration was 6% (1/18). The sensitivities of 99m Tc-MIBI scanning and ultrasonography were 83.3% and 76.6%, respectively. The respective accuracy rates were 83.3% and 76.6%. Of note, the combination of the two modalities did not improve the sensitivity and accuracy in our patient population. During a median follow-up of 40 months, none of the patients developed persistent or recurrent hypocalcaemia, resulting in a 100% cure rate. CONCLUSION: Coexisting thyroid pathology is relatively frequent in patients with pHPT in our region. Among patients having pHPT without any thyroid pathology, the adenoma localization is correct with either ultrasonography or 99m Tc-MIBI scintigraphy in the majority of cases. MIP with iPTH monitoring are highly successful in this group of patients and this operative technique should be the method of choice.

[Non-occlusive Mesenteric Ischemia caused by Diabetic Ketoacidosis - Pneumatosis intestinalis and Portal Venous Gas as an Indication of Mesenteric Ischemia]. / Nicht-okklusive Mesenterialischämie bei diabetischem Koma.

HISTORY: A 67-year-old woman was found lying naked on the bathroom floor for at least the last 12 hours. She had a medical history of insulin-dependent diabetes mellitus type 2 and a resection of the cecal pole. EXAMINATIONS: The patient was hypotonic (60/40 mmHg), hypothermic (29 °C) and hyperglycemic. The bowel sounds were sparse. There was a severe metabolic acidosis (pH 6.7). A Urinalysis showed a high concentration of ketone bodies. An abdominal ultrasonography revealed air reflexes in the liver parenchyma. A computer tomography was used to diagnose an acute mesenteric ischemia (AMI) with pneumatosis intestinalis and portal venous gas. TREATMENT: In an exploratory laparotomy the finding of necrotic bowl made it necessary to resect 160 cm of the small intestine as well as the remaining ileum and right hemikolon during a second surgery on the following day. Histopathologically there was no evidence for an occlusive genesis in the resected specimen. CONCLUSION: The clinic of the AMI is manifold - with fatal consequences in case of delayed diagnosis. Serum parameters are often overestimated. In this case report a diabetic coma was responsible for the AMI. The diagnosis was based on sonographic imaging followed by computed tomography, so that the life-saving operation could be performed. Therefore, sonography should be considered as a mandatory examination of critically ill patients.

Do antibacterial skin sutures reduce surgical site infections after elective open abdominal surgery? - Study protocol of a prospective, randomized controlled single center trial.

BACKGROUND: Surgical site infections (SSI) remain one of the most common complications in conventional abdominal surgery with an incidence between 4% and 19% (Sandini et al., Medicine (Baltimore) 95:e4057, 2016) in the literature. It is unclear whether the use of coated suture material for skin closure reduces the risk of SSI. In line with in-vitro results, we hypothesize that the use of antibacterial skin sutures (triclosan-coated poliglecaprone 25) reduces the rate of SSI after open abdominal surgery. METHODS/DESIGN: To prevent SSI, triclosan-coated poliglecaprone 25 sutures will be tested against un-coated suture material for skin closure after elective open abdominal surgery of 364 patients. The study is planned as a single-center, prospective randomized controlled trial. Patients will be followed for 30 days after surgery to detect and document wound complications. The rate of SSI after 30 days will be analyzed in both groups. DISCUSSION: If we can confirm the proposed hypothesis in our study, this could be a promising and feasible approach to lower SSI after open abdominal surgery. By lowering the rate of SSI this might offer a cost-saving and morbidity-reducing procedure. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00010047 . Registered on 05.01.2017.

Th1- and Th2-type cytokines in plasma after major trauma.

BACKGROUND: Major trauma induces a dysregulation of immune response supported in parts by lymphocyte dysfunction. Controversial data about a shift within the T-helper cell subsets Th1/Th2 are reported. METHODS: To prove whether Th1/Th2-type cytokine plasma levels reflect the postulated Th2 shift after trauma, we investigated in a retrospective study 195 severely injured patients (47 women, 148 men; mean age 39.7 +/- 15.8 years; Injury Severity Score 32.0 +/- 11.3 points; overall 1,887 samples) during their ICU stay posttrauma. Mortality rate was 19%. Th1-type cytokines interleukin 2 (IL-2), interferon gamma, IL-12 (p70), and IL-18 and Th2-type cytokines IL-4, IL-10, and IL-11 were determined using the enzyme-linked immunosorbant assay technique in patients and in healthy controls. RESULTS: IL-2 and interferon gamma were seldom detectable. All other mediators were significantly increased matched to controls (p < 0.05). All cytokines were elevated most prominent during weeks 1 and 2 posttrauma and declined thereafter. A trend toward lower levels in nonsurvivors was seen for both groups of cytokines. However, significant differences were only seen for Injury Severity Score, age, white blood cells, and C-reactive protein. All mediators correlated positively with each other (p < 0.01), a Th2-type shift was not observed. Two groups of patients were identified: one group with generally high plasma levels of all cytokines investigated and a second group of nonresponders who presented with low or diminished plasma levels in which most nonsurvivors were found. CONCLUSION: We conclude that in plasma no Th1/Th2 shift can be observed after major trauma.

Ischemic preconditioning improves postoperative outcome after liver resections: a randomized controlled study.

BACKGROUND: Clamping of the portal triad (Pringle maneuver) prevents blood loss during liver resection, but leads to liver injury upon reperfusion. Ischemic preconditioning (IP) has been shown to protect the liver against prolonged ischemic injury in animal models. However, the clinical value of this procedure has not yet been established. METHODS: 61 Patients undergoing hepatic resection under inflow occlusion were randomized to either to receive (Group-A n = 30) or not to receive (Group-B n = 31) an IP (10 minutes of ischemia followed 10 minutes of reperfusion). RESULTS: Mean (+/- SD)/ Group-A vs. Group-B. Pringle time of 34 +/- 14 and 33 +/- 12 minutes and the extent of resected liver tissue (2.7 +/- 1.3 vs. 2.7 +/- 1.1 segments) were comparable in both groups. Complications, including death, severe liver dysfunction and biliary leakage occurred in 6 patients of Group-A vs. 14 patients of Group-B (p<0.05). Intraoperative blood loss was significantly lower in Group-A (1.28 +/- 0.91 l vs. 1.94 +/- 0.76 l; p<0.001) with 5 vs. 15 patients requiring transfusions (p<0.01). In a multivariate analysis the duration of the Pringle maneuver (p<0.05) and the absence of preconditioning (p<0.05) were independent predictors for the occurrence of postoperative complications. CONCLUSIONS: IP protects against reperfusion injury, reduces the incidence of complications after hepatic resection under inflow occlusion and is simple to use in clinical practice.

[Solitary Fibrous Tumor: a Rare Cause of Recurrent Severe Hypoglycemia]. / Solitär fibröser Tumor: eine seltene Ursache rezidivierender schwerer Hypoglykämien.

HISTORY AND CLINICAL FINDINGS: A 73-year-old woman was admitted to hospital early in the morning by an emergency doctor in initially unclear comatose conditions with a blood glucose of 24 mg/dl. There were no important previous diseases requiring any medication. She was in good physical state. EXAMINATIONS: Except for a lowered breath sound on the right side of the chest the physical findings were normal. Endocrinologic tests, diagnostic imaging (Chest-x-ray, ultrasonography of abdomen and pleura, abdominal and thoracic CT) and fine needle biopsy suggested a non-islet-cell-tumor on the right side of the pleura as cause of hypoglycemia. TREATMENT: Resection of the tumor resulted in normoglycemia and the pathologic examination of the tumor specimen revealed a solid fibrous tumor. CONCLUSION: A solid fibrous tumor is a relatively common cause of the rare syndrome of non-islet-cell-tumor hypoglycemia. It shows typical endocrinologic findings, which immediately help to clarify the differential diagnosis with other causes of severe hypoglycemia. Early thorough endocrinologic testing is therefore paramount for the recognition of this distinct hypoglycemic disease which is related to the release of IGF-2, respectively Big-IGF-2, from the tumor cells.

Small bowel obstruction caused by an incarcerated hernia after iliac crest bone harvest.

The iliac crest has become an often used site for autogenous bone graft, because of the easy access it affords. One of the less common complications that can occur after removal is a graft-site hernia. It was first reported in 1945 (see the work by Oldfield, 1945). We report a case of iliac crest bone hernia in a 53-year-old male who was admitted for elective resection of a pseudarthrosis and reconstruction of the left femur with iliac crest bone from the right side. One and a half months after initial surgery, the patient presented with increasing abdominal pain and signs of bowel obstruction. A CT scan of the abdominal cavity showed an obstruction of the small bowel caused by the bone defect of the right iliac crest. A laparoscopy showed a herniation of the small bowel. Due to collateral vessels of the peritoneum caused by portal hypertension, an IPOM (intraperitoneal onlay-mesh) occlusion could not be performed. We performed a conventional ventral hernia repair with an onlay mesh. The recovery was uneventful.

Annular pancreas associated with duodenal carcinoma.

Annular pancreas (AP) is a rare congenital anomaly. Coexisting malignancy has been reported only in a few cases. We report what is, to the best of our knowledge, the first case in the English literature of duodenal adenocarcinoma in a patient with AP. In a 55-year old woman with duodenal outlet stenosis magnetic resonance cholangiopancreatography showed an aberrant pancreatic duct encircling the duodenum. Duodenojejunostomy was performed. Eight weeks later she presented with painless jaundice. Duodenopancreatectomy revealed a duodenal adenocarcinoma, surrounded by an incomplete AP. Thus, co-existent malignancy with AP can be present without obstructive jaundice and without being visible through preoperative diagnostics.

Ischemic preconditioning-induced hyperperfusion correlates with hepatoprotection after liver resection.

AIM: To characterize the impact of the Pringle maneuver (PM) and ischemic preconditioning (IP) on total blood supply to the liver following hepatectomies. METHODS: Sixty one consecutive patients who underwent hepatic resection under inflow occlusion were randomized either to receive PM alone (n = 31) or IP (10 min of ischemia followed by 10 min of reperfusion) prior to PM (n = 30). Quantification of liver perfusion was measured by Doppler probes at the hepatic artery and portal vein at various time points after reperfusion of remnant livers. RESULTS: Occlusion times of 33 +/- 12 min (mean +/- SD) and 34 +/- 14 min and the extent of resected liver tissue (2.7 segments) were similar in both groups. In controls (PM), on reperfusion of liver remnants for 15 min, portal perfusion markedly decreased by 29% while there was a slight increase of 8% in the arterial blood flow. In contrast, following IP + PM the portal vein flow remained unchanged during reperfusion and a significantly increased arterial blood flow (+56% vs baseline) was observed. In accordance with a better postischemic blood supply of the liver, hepatocellular injury, as measured by alanine aminotransferase (ALT) levels on day 1 was considerably lower in group B compared to group A (247 +/- 210 U/I vs 550 +/- 650 U/I, P < 0.05). Additionally, ALT levels were significantly correlated to the hepatic artery inflow. CONCLUSION: IP prevents postischemic flow reduction of the portal vein and simultaneously increases arterial perfusion, suggesting that improved hepatic macrocirculation is a protective mechanism following hepatectomy.

Blunt injury to the thyroid gland: proposed classification and treatment algorithm.

BACKGROUND: Traumatic hemorrhage of the thyroid gland is a rare injury with few published case reports. Surgical and nonsurgical management have been advocated but there is no consensus of opinion. METHODS: This study is a retrospective review of published case reports including two own cases. A classification and an algorithm for diagnosis and treatment of thyroid gland injuries is proposed. RESULTS: A literature review reveals 16 case reports. Of these, 11 patients underwent neck exploration for control of hemorrhage and resection of the associated thyroid abnormality while 5 patients were conservatively managed. Of note is the fact that 10 of the 16 patients (63%) had pre-existing thyroid disease. These 10 patients constituted (91%) of the group requiring surgical treatment. CONCLUSION: Our proposed classification and algorithm offers management guidelines for this rather rare injury. Conservative treatment may be successful in selected patients with lower grade injuries and without concomitant thyroid disease.