New kid on the block: perineal stapled prolapse resection (PSP) is it worthwhile in the long-term?

PURPOSE: Perineal stapled prolapse resection (PSP) has been described as a new surgical treatment for external rectal prolapse in 2008. Short-term and midterm results acknowledged PSP as a safe, fast and simple procedure for high-risk patients. This study aims to assess long-term results after PSP. METHODS: All patients who underwent PSP from 2007 to 2015 were analyzed retrospectively. Data was gathered from medical records and operative reports and by interviews with the general practitioner or the patient. RESULTS: Indication for PSP was provided in 64 cases. One procedure had to be changed to an Altemeier's and another to a laparoscopic rectopexy. The median age was 79.9 years (range 25.9-97.5). Spinal anaesthesia was used in 19 patients. The median operation time was 32.5 min (range 25-51.2). There was no mortality. One patient had to be reoperated. All other complications were minor. The median hospital stay was 6.0 days (range 2-23). Median follow-up of patients alive was 6.0 years (range 0.2-8.4). The 5-year recurrence-free survival rate for primary prolapse was 70.1 % compared to 34.3 % for recurrent prolapses (p = 0.048). Further positive prognostic factors were specimen length over 8 cm and lack of preoperative obstructed defecation syndrome. Faecal incontinence was remedied in 18, and new onset was recorded in 6 patients (significant incontinence rate reduction (p = 0.025)). CONCLUSION: Due to low morbidity and the possibility of spinal anaesthesia, PSP is suitable for frail patients. The recurrence rate for primary prolapse is similar to alternative perineal procedures like Delorme's and Altemeier's, but inferior to the laparoscopic techniques.

Monitoring c-reactive protein after laparoscopic colorectal surgery excludes infectious complications and allows for safe and early discharge.

BACKGROUND: Early detection of infectious complications is urgently needed in the era of DRG-based compensation. This work assessed the diagnostic accuracy of c-reactive protein (CRP) level in the detection of infectious complications after laparoscopic colorectal resection. METHODS: Laparoscopic colorectal resections were identified from a prospective database. Complications were graded according to the Dindo-Clavien classification. Surgical site infections were defined according to the Centers of Disease Control. CRP level was routinely measured until postoperative day (POD) 7. Uni- and multivariate analysis were performed. Diagnostic accuracy was evaluated using receiver operating curves. RESULTS: 355 patients were operated for diverticulosis (88.7%), neoplasia (6.8%), and other causes (4.5%). Mean age and body mass index were 59.8 ± 13.7 years and 26.5 ± 15 kg/m(2). Left, right, and total laparoscopic colectomies were performed in 316, 33, and 6 patients. Complications occurred in 85 patients and 16 patients (4.5%) were reoperated. Fifty-one patients (14.4%) suffered from infectious complications at a median of 6 POD, while 9 anastomoses leaked (2.7%). In multivariate analysis, presence of an abscess at surgery was predictive of an infectious complication (OR 2.5, 95% CI 1.1-5.3), as were a body mass index >30 kg/m(2) and operative time >160 min in a bootstrap analysis. Overall, CRP peaked on POD 2 and declined thereafter. Most infectious complications were apparent starting on POD 6. A CRP <56 mg/l on POD 4 had a negative predictive value of 100% (95% CI 94.9-100%) to rule out infectious complications. Above 56 mg/l, sensitivity was 100% (95% CI 0.8-1) and specificity 49% (95% CI 0.4-0.6) for the development of infectious complications in the absence of clinical signs. This translated into a remarkable diagnostic accuracy of 78% (95% CI 0.7-0.9). CONCLUSION: Monitoring CRP level in laparoscopic colorectal surgery demonstrated a high diagnostic accuracy for infectious complications, thus allowing for safe and early discharge.

IPMN: surgical treatment.

PURPOSE: Cystic pancreatic tumors are being detected more frequently, and particularly, intraductal papillary mucinous neoplasia (IPMN) has recently attracted increased attention. The detection rate of IPMN has increased over the last decade; however, management of this neoplasm remains controversial. METHODS: Based on a review of the relevant literature and the international guidelines, we discuss the diagnostic evaluation of IPMN, its treatment, and prognosis. RESULTS: While IPMN represents only a distinct minority of all pancreatic cancers, they appear to be a relatively frequent neoplastic form of pancreatic cystic neoplasm. It may not be possible to differentiate main duct disease from branch duct disease (MD-IPMN vs. BD-IPMN) prior to surgery. This distinction has not only an impact on treatment but also on prognosis, as MD-IPMN is more often malignant. IPMN has updated consensus guideline indications for conservative and surgical resection. CONCLUSIONS: Since patients with IPMN of the pancreas are at risk of developing recurrent IPMN and pancreatic ductal adenocarcinoma in the remnant pancreas and extrapancreatic malignancies, early recognition, treatment, and systemic surveillance are of great importance. No conclusions can be drawn from the available evidence with respect to the efficacy of surveillance and follow-up treatment programs. A better understanding of the natural course of IPMN and the biology of pancreatic cancer is mandatory to enable further diagnostic and treatment improvements.