Impact of surgical proficiency levels on postoperative morbidity: a single centre analysis of 558 ileostomy reversals.

PURPOSE: Defunctioning ileostomies reduce the consequences of distal anastomotic leakage following bowel resections. Ileostomy reversal in itself, however, is associated with appreciable morbidity (3-40%) and mortality (0-4%). Despite being a common teaching procedure, there is limited information on the impact of surgical proficiency levels on postoperative outcome. METHODS: Adult patients undergoing closure of a defunctioning ileostomy between September 2008 and January 2017 were identified from a surgical administrative database that was collected prospectively (n = 558). Baseline characteristics (age, ASA score, BMI, health care insurance coverage) and closure techniques were recorded. Operation time, rate of bowel resection, postoperative complications ranked by Clavien-Dindo classification and length of stay were analysed with respect to proficiency levels (residents vs. consultants). RESULTS: Two hundred three ileostomy reversals were performed by residents; 355 ileostomies were closed by consultants. Operation time was considerably shorter in the consultant group (p < 0.001). Major postoperative complication rates however were not different among the groups when adjusted for possible confounders (p = 0.948). The rate of anastomotic leakage was 3% and the overall major morbidity rate was 11%. CONCLUSION: Operation time rather than surgical outcome and overall morbidity were affected by surgical proficiency levels. Therefore, ileostomy reversal can be considered an appropriate teaching operation for young general surgery trainees.

Recurrence after perineal rectosigmoidectomy: when and why?

AIM: Reported recurrence rates after perineal rectosigmoidectomy (Altemeier's procedure) in patients with full-thickness rectal prolapse vary from 0% to 60%. The object of this study was to analyse risk factors for recurrence after this procedure. METHOD: From May 2004 to December 2012, 63 consecutive patients suffering from full-thickness rectal prolapse undergoing perineal rectosigmoidectomy were included. Of these 46 were female and the median age of the whole group was 79 (30-90) years. The median follow-up was 53 (3-99) months. Patient characteristics and operative parameters were compared between patients with and without recurrence. RESULTS: One patient died and another patient needed re-operation. Eight full-thickness recurrences occurred in eight patients after a median of 18 (6-48) months. Stapled compared with handsewn anastomosis (hazard ratio 7.96, 95% confidence interval 1.90-33.47; P = 0.001) and shorter specimen length (hazard ratio 4.06, 95% confidence interval 0.97-16.99; P = 0.03) increased the risk of recurrence in Cox regression analysis. CONCLUSION: The operative technique including stapled anastomosis and length of the resected specimen seems to be associated with a high recurrence rate after perineal rectosigmoidectomy.

[Cost analysis of the fast track concept in elective colonic surgery]. / Kostenanalyse des Fast-Track-Konzeptes bei elektiver Kolonchirurgie.

INTRODUCTION: Fast track (FT) is a modern concept to enhance postoperative recovery after elective surgery. It has been approved during the last years. Beside its medical benefits, fast-track (FT) concepts may provide an economic incentive, although a cost-benefit analysis in the daily clinical routine has not yet been realised. In addition to this an elevated consumption of resources is postulated. PATIENTS AND METHODS: In 2007 we prospectively studied the implementation of the FT concept for elective colonic surgery in the daily clinical routine at the Department of General Surgery of Nuremberg Hospital. In a representative subgroup of patients studied, we performed a cost-cost analysis by comparing these patients to a retrospectively analysed group that had been treated in a conventional traditional manner in 2002. RESULTS: 369  patients were included and treated according to the FT concept. Discharge criteria were met at the 4(th) postoperative day in median (SD 3.9  days, minimum  1, maxiumum 29  days). The rate of general postoperative complications was 24.4 % (16 % minor complications) for all patients and 6.6 % in the group of patients who were discharged within 9 postoperative days or less (n=182). With respect to the main FT items, implementation of the FT concept was considered as effective. Cost-cost analyses showed a cost reduction of 32 % in favour of patients treated with the FT concept. CONCLUSION: This study clearly shows the clinical and economic benefits of the FT concept considering health services research. Therefore further clinical implementation of the FT concept seems beneficial, not only in the view of medical aspects, but also for economic reasons.

Outcome after resection of one hundred gastrointestinal stromal tumors.

AIMS: To evaluate the outcome after surgical resection in patients with gastrointestinal stromal tumors and to determine the factors influencing local tumor recurrence or distant metastatic disease after locally complete tumor resection (R0). METHODS: Outcomes of 100 patients with primary gastrointestinal stromal tumors (GIST) surgically managed between 1997 and 2006 at a single institution were reviewed. Univariate and bivariate analyses were used to determine factors affecting recurrence-free and tumor-free survival. RESULTS: All patients (n = 100) had c-kit-positive GIST. There were 17% (n = 17) very low risk, 41% (n = 41) low risk, 19% (n = 19) intermediate risk and 23% (n = 23) high risk GIST originating from the stomach, small bowel, colon and rectum. The median patient age was 68 years (range 39-92). Seventy-three percent of the patients had symptomatic local disease. Most (94%; n = 94) of them underwent R0 resections of their primary tumor. R0 resection was significantly associated with a lower tumor-related mortality rate (p = 0.0001). The patients with recurrence/metastases had significantly larger tumors (p = 0.0017) and a mitotic index higher than 5/50 HPF (p = 0.0001). Seven of 20 patients from the high-risk group and 2 of 7 patients with metastatic disease developed local recurrence or further metastatatic tumor spread following R0 resection. CONCLUSION: Surgical removal continues to be the mainstay of GIST treatment. R0 resection, tumor size and mitotic index are significant prognostic factors. Overall, more than 30% of the patients with high-risk GIST develop local recurrences and distant metastases despite R0 resection. Additional molecular pathological markers are needed to yield a more accurate tumor profile and to thus achieve a better predictability of the biological behavior of GIST.

[Perioperative handling of anticoagulation]. / Perioperativer Umgang mit Antikoagulation.

A growing number of patients in Germany receive a long-term prophylactic anticoagulation with phenprocoumone or one of the novel direct oral anticoagulants (NOAC), such as dabigatran, rivaroxaban or apixaban. The most common indication for an oral anticoagulant therapy is atrial fibrillation (approximately 75%) where the anticoagulant therapy can reduce the risk for an embolic event, particularly stroke by 60%. Operations carried out during such a therapy can result in major bleeding complications. On the other hand, suspending anticoagulant therapy can lead to an increased risk of thromboembolisms. Thus, the preoperative assessment should address the bleeding risk of the planned operation, the individual risk of thromboembolism, as well as other factors, such as patient age and renal function. If the individual assessment shows a substantial risk of perioperative bleeding when anticoagulant treatment is continued and a substantial risk of thromboembolism if the treatment is suspended, then a perioperative bridging, for example with low molecular weight heparin, is necessary. Perioperative bridging also leads to an increased risk of perioperative bleeding. Thus, undifferentiated bridging for all patients with atrial fibrillation with anticoagulant treatment is not recommended. Instead, the indications for a perioperative bridging should be decided according to individual risk profiles.

[Perioperative handling of immunosuppressive therapy]. / Perioperativer Umgang mit immunsuppressiver Therapie.

Every year 16 million operations are performed in Germany. Many patients have an autoimmune disorder, for example rheumatoid arthritis, psoriasis or chronic inflammatory bowel disease, which requires treatment. Immunosuppressants are widely applied. Physicians must make a risk-adapted decision whether the immunosuppressant medication can be continued perioperatively or if certain drugs must be paused and if so, with what risks. The handling of immunosuppressants during the perioperative period is very relevant as many patients, for example with rheumatoid arthritis are in need of a hip or knee replacement or patients with inflammatory bowel disease need an operation due to the chronic illness. The interruption of an immunosuppressant therapy should be discussed in an interdisciplinary board according to the underlying disease, because the continuation of immunosuppressants perioperatively can lead to an increased rate of complications, especially wound healing disorders. If a patient is on a glucocorticoid therapy the following must be considered: during the perioperative period the body has an increased demand for glucocorticoids due to the stress reaction. If glucocorticoids are administered in a dosage of more than 7.5 mg/day equivalent of prednisolone this stress reaction is inhibited. Thus, in these cases a perioperative substitution with hydrocortisone is recommended.

[Perioperative handling of antidiabetic drugs]. / Perioperativer Umgang mit Antidiabetika.

Diabetes mellitus is the most frequent metabolic disorder in the western world with a prevalence of 3% in adults under 65 years of age and 14.3% in adults over 65 years of age. Due to the increasing age of our population, the number of patients taking oral antidiabetic drugs has increased. Thus, operating physicians must make a risk-adapted decision whether the medication can be continued perioperatively or if certain drugs must be paused, and if so, with what risks. Operative interventions can lead to a number of metabolic shifts, which change the normal glucose metabolism. Hyperglycemia in the perioperative period is a risk factor for postoperative sepsis, dysfunction of the endothelium, cerebral ischemia and poor wound healing. Due to perioperative fasting oral antidiabetic medication can lead to severe hypoglycemia if taken during this period. This leads to an increased morbidity and mortality in the perioperative period and extends the duration of stay in the intensive care unit (ICU) as well as the overall hospital stay. Oral antidiabetic medication should be paused on the day of the operation and restarted in line with the gradual postoperative return to solid food. Especially metformin, the most commonly used medication in the treatment of type 2 diabetes, should be paused perioperatively due to the severe side effect of lactate acidosis.

[The use of tumor therapeutics in the perioperative period]. / Perioperativer Umgang mit antitumoralen Medikamenten.

In 2010 Germany had 447,300 new cases of cancer. From 2000 to 2010 the incidence of cancer increased by 21% in men and by 14% in women. The change in the age structure with an aging population is the crucial influencing factor. Various cancer types can now be treated by oral antitumor agents used as a chronic medication. Physicians must decide whether the oral antitumor agents can be continued perioperatively or if certain drugs must be paused and if so, with what risks. Oral antitumor agents are a very heterogeneous group of medication. The use of oral antitumor agents during the perioperative period has not been thoroughly examined, but most often a perioperative interruption is recommended. In general, poor wound healing is a frequent complication of this group of medication. The handling of oral antitumor agents in the perioperative period should be based on an individual decision with consideration of the desired therapy goal as well as the individual prognosis. In general, all oral antitumor agents are chronic medication and are continued until a loss of efficacy or intolerable side effects occur. A potentially curative therapy should be paused for the shortest possible time in order not to jeopardize the remission already achieved. Furthermore, generally accepted recommendations concerning the interval between chemotherapy and a planned operation have not yet been established. A rough rule of thumb could be to plan the operation after the regeneration of the blood count or at the same point in time of the next planned chemotherapy.

[The use of platelet aggregation inhibitors in the perioperative period]. / Perioperativer Umgang mit Thrombozytenaggregationshemmern.

Every year 16 million operations are performed in Germany. Many patients take platelet aggregation inhibitors as a primary or secondary prevention to reduce the risk of cardiovascular events. Especially during the perioperative period, this risk reduction is relevant due to an increased risk for cardiac events (in approximately 6.2% of operations). As a result of a presumed increased risk of bleeding, platelet aggregation inhibitors are often paused perioperatively. Thus, doctors must decide on a risk-adapted basis whether the medication can be continued perioperatively and, if so, with what risks. If acetylsalicylic acid (ASA) treatment is solely used as primary prevention it can be paused during the perioperative period, whereas ASA treatment for secondary prevention should only be paused for operations within narrow confines. When pausing ASA, a sufficient time interval should be maintained before the operation. Furthermore, the ASA withdrawal syndrome with an increased predisposition for clotting is an important phenomenon to be considered. Additionally, the perioperative handling of dual platelet aggregation inhibition needed after coronary stent implantation should be addressed. Due to an increased risk for in-stent thrombosis, dual platelet aggregation inhibition is only reluctantly paused. Emergency surgery must, if not otherwise possible, be carried out even if the dual platelet aggregation inhibition is not paused; however, if the risk for intraoperative bleeding is too high and the risk of an in-stent thrombosis is lower in comparison, P2Y12 inhibitors (e.g. clopidogrel) should be paused and the operation carried out solely with ASA therapy.

Proximal jejunal stoma as ultima ratio in case of traumatic distal duodenal perforation facilitating successful EndoVAC® treatment: A case report.

INTRODUCTION: During damage control surgery for blunt abdominal traumata simultaneous duodenal perforations can be missed making secondary sufficient surgical treatment challenging. Endoluminal vacuum (EndoVAC™) therapy has been shown to be a revolutionary option but has anatomical and technical limits. PRESENTATION OF THE CASE: A 59-year old man with hemorrhagic shock due to rupture of the mesenteric root after blunt abdominal trauma received damage control treatment. Within a scheduled second-look, perforation of the posterior duodenal wall was identified. Due to local and systemic conditions, further surgical treatment was limited. Decision for endoscopic treatment was made but proved to be difficult due to the distal location. Finally, double-barreled jejunal stoma was created for transstomal EndoVAC™ treatment. Complete leakage healing was achieved and jejunostomy reversal followed subsequently. DISCUSSION: During damage control surgery simultaneous bowel injuries can be missed leading to life-threatening complications with limited surgical options. EndoVAC™ treatment is an option for gastrointestinal perforations but has anatomical limitations that can be sufficiently shifted by a transstomal approach for intestinal leakage. CONCLUSION: In trauma related laparotomy complete mobilization of the duodenum is crucial. As ultima ratio, transstomal EndoVAC™ is a safe and feasible option and can be considered for similar cases.

"Rendezvous technique" for intraluminal vacuum therapy of anastomotic leakage of the jejunum.

BACKGROUND: Anastomotic leakage (AL) is one of the most common and serious complications following visceral surgery. In recent years, endoluminal vacuum therapy has dramatically changed therapeutic options for AL, but its use has been limited to areas easily accessible by endoscope. CASE PRESENTATION: We describe the first use of endoluminal vacuum therapy in the small intestine employing a combined surgical and endoscopic "rendezvous technique" in which the surgeon assists the endoscopic placement of an endoluminal vacuum therapy sponge in the jejunum by means of a pullback string. This technique led to a completely closed AL after 27 days and 7 changes of the endosponge. CONCLUSION: The combined surgical and endoscopic rendezvous technique can be useful in cases of otherwise difficult endosponge placement.

[Laparoscopic single port surgery : Is structured training necessary?]. / Laparoskopische Single-Port-Chirurgie : Ist eine strukturierte Ausbildung notwendig?

As essentially all operations performed with open laparotomy can be completed with minimal access, surgeons and industry continue to push the boundaries of minimally invasive surgery. New and controversial approaches, such as natural orifice translumenal endoscopic surgery (NOTES) and single incision or single port surgery are being explored with the goal of reduced surgical morbidity. The fundamental idea of single port surgery is therefore to minimize the number of abdominal wall incisions and allow access for all laparoscopic instruments through one skin incision. Several techniques in use require specialized equipment with multiple ports through one umbilical incision or one multichannel port. For single port surgery to be widely adopted surgeons must demonstrate safety, efficacy and reproducibility of the technique across a wide range of patients and clinical scenarios. In order to meet these requirements concerns about well-founded surgical training and quality monitoring must be addressed as with any major technical advance.