[Management of lateral abdominal wall hernias]. / Management der lateralen Bauchwandhernien.

Lateral abdominal wall hernias are rare and inconsistently defined, which is why the use of the European Hernia Society classification makes sense, not least for the purpose of comparing the quality of surgical results. A distinction must be made between true fascial defects and denervation atrophy. Based on the available literature, there is generally a low level of evidence with no consensus on the best operative strategy. The proximity to bony structures and the complex anatomy of the three-layer abdominal wall make the technical treatment of lateral hernias difficult. The surgical variations include laparoendoscopic, robotic, minimally invasive, open or hybrid approaches with different mesh positions in relation to the layers of the abdominal wall. The extensive preperitoneal mesh reinforcement open, transabdominal peritoneal (TAPP) laparoscopic repair or total extraperitoneal (TEP) endoscopic repair has met with the greatest approval. The extent of the required medial mesh overlap is determined by the distance between the medial defect boundary and the lateral edge of the straight rectus abdominus muscles. The medially directed preperitoneal and retroperitoneal dissection can be extended into the homolateral retrorectus compartment by laterally incising the posterior rectus sheath or by crossing the midline behind the intact linea alba into the contralateral retrorectus compartment. The intraperitoneal onlay mesh (IPOM) technique is a suitable procedure only for smaller defects with possible defect closure but it is also important as an exit strategy in the case of a defective peritoneum. Individualized prehabilitative and preconditioning measures are just as important as the assessment of preoperative anamnestic and clinical findings and risks with radiographic cross-sectional imaging diagnostics.

Five-year results of a randomized controlled trial comparing high ligation combined with endovenous laser ablation and stripping of the great saphenous vein.

PURPOSE: To report 5-year follow-up data of a randomized study comparing high ligation and stripping (HL + S) with high ligation and endovenous laser ablation (HL + EVLA) of the great saphenous vein (GSV). METHODS: One hundred patients were randomized. After 5 years, patient satisfaction with the overall result, CEAP-C class, VCSS, CIVIQ2 quality of life score, and recurrence rate were assessed (clinical examination and duplex ultrasound). RESULTS: Five-year follow-up rates were 83% HL + S and 68% HL + EVLA. Patient satisfaction with the overall result was rated good or very good by 88% after HL + S and 87% after HL + EVLA. There were significant improvements for both groups in CEAP-C class (HL + S 2.28 vs. 1.19; HL + EVLA 2.3 vs. 1.17), VCSS (HL + S 4.79 vs. 1.81; HL + EVLA 4.13 vs. 1.87), and CIVIQ2 score (HL + S 82 vs. 94; HL + EVLA 75 vs. 93) (p < .001). There was no difference in recurrence rates on clinical examination and duplex ultrasound (HL + S 55% vs. HL + EVLA 40%; p = .217). A reopened or residual incompetent GSV-partial or complete-was found in 24% (HL + S) and 40% (HL + EVLA), respectively (p = .141). CONCLUSION: Varicose vein surgery is followed by favorable clinical results and high patient satisfaction, with no difference between HL + S and HL + EVLA.

Clinical impact of hypogastric artery occlusion in endovascular aneurysm repair.

PURPOSE: To report the long-term results for patients treated with endovascular aneurysm repair and additional embolization and coverage of the hypogastric artery compared with patients treated with simple endovascular aneurysm repair. METHODS: A database of our endovascular aneurysm repair patient cohort was reviewed to find patients with iliac artery aneurysms. The baseline characteristics, the procedural data and the results for patients treated with endovascular aneurysm repair and concomitant hypogastric artery embolization were compared with those for patients treated with simple endovascular aneurysm repair. The results were analyzed for significant differences. RESULTS: Of 106 endovascular aneurysm repair patients treated at our vascular unit from 2001 to 2010, 24 had undergone additional hypogastric artery embolization. The complication rate was significantly increased in this group (12.5% vs. 2.4%; p = 0.041), and the long-term results were significantly poorer. Additional hypogastric artery embolization resulted in late rupture (1.2% vs. 12.5%; p = 0.036), buttock claudication (8.6% vs. 43.8%; p = 0.001) and new onset erectile dysfunction (17.3% vs. 42.9%; p = 0.043). CONCLUSION: Endovascular aneurysm repair with extension of the stent graft to the external iliac artery and embolization of the hypogastric artery was associated with more complications and worse long-term results compared with simple endovascular aneurysm repair.

Surgical quality data and survival after pancreatic cancer resections: a comparison of results for octogenarians and younger patients.

BACKGROUND: Although age is no contraindication for pancreatic cancer resections, there are conflicting reports of morbidity and mortality rates and only few data showing direct comparisons of survival for octogenarians and patients younger than 80 years. METHODS: Comparison of complication, reintervention, reoperation, and 30-day in-hospital mortality rates, length of stay, and survival of all octogenarians and patients younger than 80 years undergoing pancreatectomy for ductal adenocarcinoma during the study period from 2001 to 2010 was done. All resectable patients with suspected ductal adenocarcinoma who deemed to be fit for surgery in an interdisciplinary assessment (anesthesiology, gastroenterology, oncology, surgery) were offered pancreatectomy. The only exceptions were Eastern Cooperative Oncology Group (ECOG) performance score 3 and 4 or advanced dementia patients. Resectability was determined according to contrast-enhanced computed tomography scans (pancreas protocol). The database was prospectively maintained. For survival analysis, a first follow-up was made on December 31, 2010, by a query of the national register of residents with retrieval of corresponding International Classification of Diseases (ICD) death diagnoses by the Austrian Institute of Statistics. For surviving octogenarians, a second follow-up was made by telephone interview on August 21, 2013. RESULTS: We identified 9 octogenarians and 99 patients younger than 80 years. Median age in the two groups was 83 and 67 years, respectively. The predominant procedure in both groups was pylorus-preserving pancreaticoduodenectomy (55.6 and 68.7 %, respectively). Complications occurred in 33.3 and 28.3 % of patients, respectively. Reintervention, reoperation, and 30-day in-hospital mortality rates of patients younger than 80 years were 9.1, 6.1, and 5.1 %, respectively. In the octogenarian group, there were no pancreatic fistulas, one transient ischemic attack after stenting of an intraoperatively detected stenosis of the celiac trunk, one infected hematoma that was managed with intravenous antibiotics, and one wound infection. There were no reoperations or postoperative reinterventions. Median length of stay was 18 days, and postoperative 30-day mortality was nil. Median survival was comparable for both age-groups (10.5 vs. 12.1 months, respectively). CONCLUSION: In an interdisciplinary setting, surgical quality data and survival after pancreatic cancer resections are comparable in octogenarians and patients younger than 80 years.

Clinical approach to the patient with a solid pancreatic mass.

Diagnosis and clinical work-up of a solid pancreatic mass is a challenging problem. Patients' history, laboratory parameters, computed tomography magnetic resonance imaging, and endosonography are the cornerstones in diagnosis. Biopsy is indicated in selected patients. The main goal of surgical indication is to select patients with suspected malignancy who are resectable, but avoid unnecessary resections. About 5 % of patients resected due to suspicion of malignancy finally present with a benign histology. Autoimmune pancreatitis is the most frequent cause of such unnecessary resections.

Preparing for prospective clinical trials: a national initiative of an excellence registry for consecutive pancreatic cancer resections.

BACKGROUND: Despite significant improvements in perioperative mortality as well as response rates to multimodality treatment, results after surgical resection of pancreatic adenocarcinoma with respect to long-term outcomes remain disappointing. Patient recruitment for prospective international trials on adjuvant and neoadjuvant regimens is challenging for various reasons. We set out to assess the preconditions and potential to perform perioperative trials for pancreatic cancer within a well-established Austrian nationwide network of surgical and medical oncologists (Austrian Breast & Colorectal Cancer Study Group). METHODS: From 2005 to 2010 five high-volume centers and one medium-volume center completed standardized data entry forms with 33 parameters (history and patient related data, preoperative clinical staging and work-up, surgical details and intraoperative findings, postoperative complications, reinterventions, reoperations, 30-day mortality, histology, and timing of multimodality treatment). Outside of the study group, in Austria pancreatic resections are performed in three "high-volume" centers (>10 pancreatic resections per year), three "medium-volume" centers (5­10 pancreatic resections per year), and the rest in various low-volume centers (<5 pancreatic resections per year) in Austria. Nationwide data for prevalence of and surgical resections for pancreatic adenocarcinoma were contributed by the National Cancer Registry of Statistics of Austria and the Austrian Health Institute. RESULTS: In total, 492 consecutive patients underwent pancreatic resection for ductal adenocarcinoma. All postoperative complications leading to hospital readmission were treated at the primary surgical department and documented in the database. Overall morbidity and pancreatic fistula rate were 45.5 % and 10.1 %, respectively. Within the entire cohort there were 9.8 % radiological reinterventions and 10.4 % reoperations. Length of stay was 16 days in median (0­209); 12 of 492 patients died within 30 days after operation, resulting in a 30-day mortality rate of 2.4 %. Seven of the total 19 deaths (36.8 %) occurred after 30 days, during hospitalization at the surgical department, resulting in a hospital mortality rate of 3.9 % (19/492). With a standardized histopathological protocol, there were 70 % (21/30) R0 resections, 30 % (9/30) R1 resections, and no R2 resections in Vienna and 62.7 % (32/51) R0 resections, 35.3 % (18/51) R1 resections, and 2 % (1/51) R2 resections in Salzburg. Resection margin status with nonstandardized protocols was classified as R0 in 82 % (339/411), R1 in 16 % (16/411), and R2 in 1.2 % (5/411). Perioperative chemotherapy was administered in 81.1 % of patients (8.3 % neoadjuvant; 68.5 % adjuvant; 4.3 % palliative); chemoradiotherapy (1.6 % neoadjuvant; 3 % adjuvant; 0.2 % palliative), in 4.9 % of patients. The six centers that contributed to this registry initiative provided surgical treatment to 40 % of all Austrian patients, resulting in a median annual recruitment of 85 (51­104) patients for the entire ABCSG-group and a median of 11.8 (0­38) surgeries for each individual department. CONCLUSIONS: Surgical quality data of the ABCSG core pancreatic group are in line with international standards. With continuing centralization the essential potential to perform prospective clinical trials for pancreatic adenocarcinoma is given in Austria. Several protocol proposals aiming at surgical and multimodality research questions are currently being discussed

Unplanned reoperation and reintervention after pancreatic resections: an analysis of risk factors.

BACKGROUND: The purpose of the study was to determine the incidence of any unplanned reoperation or reintervention procedure after pancreatic resection and to identify the underlying risk factors. METHODS: A total of 189 consecutive pancreatic resections performed from 2001-2008 were searched for any unplanned reoperation, percutaneous drainage, or angiographic reintervention. A retrospective analysis of a prospectively maintained database, including patient characteristics, comorbidities, details of surgery, specific complications, incidence of reoperation/reintervention, and mortality was performed. RESULTS: Overall rates of reoperation, reintervention, and mortality were 6.3% (12/189), 7.9% (15/189), and 1.6% (3/189), respectively. Four patients underwent reintervention and reoperation, so the combined reoperation/reintervention rate was 12.2% (23/189). Reoperation (P < 0.001) and reintervention (P = 0.002) correlated with mortality. Hemorrhage (relative risk [RR], 58; P = 0.0017) and the combination of hemorrhage and pancreatic fistula (RR, 117; P < 0.0001) were identified as risk factors for unplanned reoperation, hemorrhage (RR, 82; P = 0.005), pancreatic fistula (RR, 42; P < 0.001), and the combination of both complications (RR, 246; P < 0.001) for reoperation and/or reintervention. Other patient- or procedure-related factors did not influence the reoperation and/or reintervention rates significantly. CONCLUSIONS: Pancreatic fistula and hemorrhage are the predominant factors that afford unplanned reoperation/reintervention. Although reporting the incidence of unplanned reoperation will include the most severe postoperative complications, a considerable number of reinterventions are missed. Therefore, in outcome analyses of pancreatic surgery, not only reoperations but also any interventional therapies should be included.

Single incision laparoscopic cholecystectomy (SILC) versus laparoscopic cholecystectomy (LC)-a matched pair analysis.

INTRODUCTION: The aim of our study was to compare single incision laparoscopic cholecystectomy (SILC) and laparoscopic cholecystectomy (LC) with respect to complications, operating time, postoperative pain, use of analgesics, length of stay, return to work, rate of incisional hernia, and cosmetic outcome. METHODS: Sixty-seven patients underwent SILC. Of a cohort of 163 LC operated in the same time period, 67 patients were chosen for a matched pair analysis. Pairs were matched for age, gender, ASA, BMI, acuity, and previous abdominal surgery. In the SILC group, patient characteristics (gender, age, BMI, comorbidities, ASA, previous abdominal surgery, symptomatic cholecystolithiasis, cholecystitis) and perioperative data (surgeon, operation time, conversion rate and cause, intraoperative complications, postoperative complications, reoperation rate, VAS at 24 h, VAS at 48 h, use of analgesics according to WHO class, and length of stay) were collected prospectively. RESULTS: Follow-up in the SILC and LC group was completed with a minimum of 17 and a maximum of 26 months; data acquired were recovery time the patients needed until they were able to get back into the working process, long-term incidence of postoperative hernias, and satisfaction with cosmetic outcome. Operating time was longer for SILC (median 75 min, range 39-168 vs. 63, range 23-164, p = 0.039). There were no significant differences for SILC and LC with regard to postoperative pain measured by VAS at 24 h (median 3, range 0-8 vs. 2, range 0-8, p = 0.224), at 48 h (median 2, range 0-6 vs. 2, range 0-8, p = 0.571), use of analgesics, and length of stay (median 2 days, range 1-9 vs. 2, range 1-11, p = 0.098). There was no major complication in either group. The completion rate of SILC was 85.1% (57 of 67). Although there was a trend towards an earlier return to the working process in patients of the SILC group, this was not significant. The rate of incisional hernias was 1.9% (1/53) in the SILC and 2.1% (1/48) in the LC group indicating no significant difference. Self-assessment of satisfaction with the cosmetic outcome was not judged different by patients in both groups. CONCLUSION: SILC is associated with longer operating time, but equals LC with respect to safety, postoperative pain, use of analgesics, length of stay, return to work, rate of incisional hernia, and cosmetic outcome.