Laparoscopic total (Nissen) versus posterior (Toupet) fundoplication for gastroesophageal reflux disease: a propensity score-matched comparison of the perioperative and 1-year follow-up outcome.

INTRODUCTION: The debate continues as to whether laparoscopic total Nissen (LNF) versus partial posterior Toupet fundoplication (LTF) leads to better outcomes in the surgical treatment of axial hiatal hernia with gastroesophageal reflux disease. In the most recent meta-analysis including 13 RCTs with 1564 patients, no significant difference was found between the two procedures in terms of perioperative complications and recurrent reflux rates. Further comparative analyses are urgently needed. METHODS: This retrospective analysis of prospectively recorded data from the Herniamed Registry compared the perioperative and 1-year follow-up outcomes after total Nissen versus partial Toupet fundoplication. Propensity score matching was chosen as the statistical method. Matching was performed for n = 2290 pairs. RESULTS: No systematic discrepancy was found between the Nissen and Toupet fundoplication for any of the outcome parameters (intraoperative complications LNF 2.10% vs LTF 1.48%, general complications 2.27% vs 2.88%, postoperative complications 1.44% vs 1.18%, complication-related reoperation 1.00% vs 0.91%, recurrence on 1-year follow-up 6.55% vs 5.33%, pain on exertion on 1-year follow-up 12.49% vs 9.52%, pain at rest on 1-year follow-up 10.44 vs 9.52% and pain requiring treatment on 1-year follow-up 9.61% vs 8.17%). Also the postoperative dysphagia rate showed with 5.34% after LNF and with 4.64% after LTF no significant difference. CONCLUSION: The findings presented here did not show any significant difference up to 1 year after Nissen or Toupet fundoplication. This is in concordance with the findings of the meta-analyses. However, the perioperative and 1-year follow-up outcomes demonstrate that both operation techniques should be carried out by experienced surgeons.

What is the evidence for the use of biologic or biosynthetic meshes in abdominal wall reconstruction?

INTRODUCTION: Although many surgeons have adopted the use of biologic and biosynthetic meshes in complex abdominal wall hernia repair, others have questioned the use of these products. Criticism is addressed in several review articles on the poor standard of studies reporting on the use of biologic meshes for different abdominal wall repairs. The aim of this consensus review is to conduct an evidence-based analysis of the efficacy of biologic and biosynthetic meshes in predefined clinical situations. METHODS: A European working group, "BioMesh Study Group", composed of invited surgeons with a special interest in surgical meshes, formulated key questions, and forwarded them for processing in subgroups. In January 2016, a workshop was held in Berlin where the findings were presented, discussed, and voted on for consensus. Findings were set out in writing by the subgroups followed by consensus being reached. For the review, 114 studies and background analyses were used. RESULTS: The cumulative data regarding biologic mesh under contaminated conditions do not support the claim that it is better than synthetic mesh. Biologic mesh use should be avoided when bridging is needed. In inguinal hernia repair biologic and biosynthetic meshes do not have a clear advantage over the synthetic meshes. For prevention of incisional or parastomal hernias, there is no evidence to support the use of biologic/biosynthetic meshes. In complex abdominal wall hernia repairs (incarcerated hernia, parastomal hernia, infected mesh, open abdomen, enterocutaneous fistula, and component separation technique), biologic and biosynthetic meshes do not provide a superior alternative to synthetic meshes. CONCLUSION: The routine use of biologic and biosynthetic meshes cannot be recommended.

Benefit of an implanted solid barrier for the feasibility of a sequence of three different hepato-biliary operations in a small animal model.

BACKGROUND: Current liver surgery includes complex multi-stage procedures such as portal vein ligation (PVL) followed by extended liver resection, especially in patients with Klatskin tumours. The risk for severe adhesions increases with every procedure. Finally, this complex sequence could fail because of malignant adhesions. Therefore, we proved the hypothesis of reducing malignant adhesions and increasing feasibility of a sequence with three hepato-biliary operations by implantation of a solid barrier. MATERIALS AND METHODS: We operated in male rats (n=40). Our sequence included as 1st operation bile duct ligation mimicking Klatskin III° or IV°, the 2nd operation was a selective portal vein ligation (sPVL) and 3rd procedure was a 70% liver resection. The mechanical barrier (part of a sterile glove) was implanted at the end of the first operation between the upper (median lobe+left lateral lobe [ML+LLL]) and lower (right lobe+caudate lobe [RL+CL]) rat liver lobes. We assessed the degree of adhesions and the feasibility of the 2nd and 3rd operation by using an established adhesion score (Zühlke) and a feasibility score. The severity of the adhesions and the pro-inflammatory cellular response were further evaluated by morphometry of thickness (HE) of the adhesion layer and quantification of infiltrating neutrophils (ASDCL) in the adhesion layer on the liver surface. RESULTS: The planned liver resection as the third procedure was only feasible when a mechanical barrier was placed. Extent of cholestasis or time interval between the operations had no significant impact on adhesions score or feasibility of the whole sequence. CONCLUSION: A sequence of three hepato-biliary operations in a small animal model (rat) is feasible. It should be considered to implant a mechanical barrier in a sequence of more than two surgical interventions in an experimental model in order to assure the feasibility of the final operation.

Effects of methylene-blue staining on the extent of pilonidal sinus excision.

OBJECTIVE: We aimed to examine the effects of methylene-blue staining (MBS) on the volume of specimens after excision of pilonidal sinuses. METHOD: This was a retrospective analysis of 135 excised specimens after pilonidal sinus (PS) surgery. All patients underwent procedures at the Department of Surgery of University Hospital Jena between 2000 and 2010. All specimens were measured in three dimensions. To calculate the volumes of excised specimens, we used a model of a hemi-ellipsoid. Demographic information (age, height, weight, body mass index, smoking status) were also obtained for all patients. RESULTS: Excised specimens with MBS had significantly larger volumes (p<0.001) as reflected in length (p=0.001), width (p=0.001), and depth (p=0.017) of the excised specimen compared with specimens that were not stained with methylene blue (MB). In addition, the volume was larger in subjects with a recurrent PS (p=0.021), which was predominantly the case in female subjects (p=0.025). CONCLUSION: These data suggest that excised specimens with MBS had significantly larger volumes of the excised specimen compared with specimens that were not stained with MB. MBS of a fistula system could enable such a system to be marked sufficiently, thereby facilitating complete resection of a PS.

[Extended Pathohistological Criteria for Assessment of the Long-Term Prognosis of Gastric Cancer]. / Erweiterte pathohistologische Kriterien zur Bewertung der Langzeitprognose des Magenkarzinoms.

BACKGROUND: Gastric cancer is one of the most frequent tumour diseases worldwide. Despite numerous innovations in the diagnostic procedures and treatment the prognosis remains poor as the detection of the disease depends on tumour-associated symptoms which develop rather late in the majority of cases. The treatment outcomes may be improved by a more differentiated and individualised evaluation of the tumour biology. We present a detailed analysis of potentially relevant factors. MATERIAL AND METHODS: From 1995 to 2011, data from 923 patients with gastric cancer have been collected in a prospective tumour database. We performed monovariate and multivariate analyses of factors. For the statistical analyses, SPSS software version 19.0 was used. The literature research was performed with Medline. RESULTS: 748 patients underwent surgical exploration. The resection rate was 87 % with a morbidity and mortality of 27 and 9 % (2004 to 2001: 13 and 5 %), respectively. 36 and 29 % of patients survived 5 years or 10 years, respectively. The 5-year and 10-year survival after curative resection was 58 and 46 %, respectively. TNM-associated criteria, tumour size, histological growth pattern, intestinal metaplasia, location of the tumour and classification according to Lauren were of significant influence in the monovariate analyses. In the multivariate analysis, tumour size, curative resection and lymph node involvement were independent prognostic factors. 90 % of the tumour recurrences developed within five years. The median recurrence-free interval was 16 months. Depending on the type of tumour, different survival times were identified. The 228 patients with node-negative curatively resected gastric cancer had a markedly better long-term prognosis. Diffuse type according to Lauren, tumour size, non-tubular histological growth pattern, female sex and proof of serosa infiltration from the primary tumour were prognostic factors in the monovariate analysis. In the multivariate analysis, tumour size was an independent significant prognostic factor (p = 0.05). CONCLUSION: The data analyses showed that the evaluation of gastric cancer may be extended in a sensitive way by factors that have not been previously established. The benefit of an individualised structured treatment and follow-up on the basis of extended criteria should be investigated in future studies.

[Living Donor Liver Transplantation - Past and Present]. / Lebertransplantation mit Lebendspende ­ Historie und Gegenwart.

Since the first living donor liver transplantations at the end of the 1980s, this transplantation technique has developed as an established tool within the modern transplantation medicine. Especially in Asia, the majority of liver transplantation is performed through living donation, mainly for religious reasons. Liver grafts for adult recipients are mainly the right liver lobe of the donor, for paediatric recipients mainly the left lateral lobe. In some cases, the living donor liver transplantation is realised from two different donors for one recipient, the so-called "dual graft" transplantation. This article summarises the history of living donor liver transplantation up to the current status of this transplantation procedure worldwide.

[Classic Limberg Flap Procedure for Treatment of a Sacrococcygeal Pilonidal Sinus Disease - Explanation of the Surgical Technique]. / Klassische Rautenplastik nach Limberg zur Behandlung einer sakrokokzygealen Pilonidalsinuserkrankung - Erklärung der OP-Technik.

INTRODUCTION: Sacrococcygeal pilonidal sinus disease is frequently encountered in surgical practice. Besides excision only, the current pilonidal sinus guideline of the Association of the Scientific Medical Societies in Germany (AWMF-S3) also recommends plastic surgical procedures such as the cleft-lift operation described by Bascom, the Karydakis flap procedure and, due to the low recurrence rates, the Limberg flap procedure, for the treatment of this disease. INDICATION: In our case we show the surgical procedure performed on a 23-year-old male patient, who was previously treated for an acute abscess-forming sacrococcygeal pilonidal sinus. METHOD: Our video shows the fasciocutaneous rhombic flap procedure described by Limberg step by step. CONCLUSION: The Limberg flap procedure is a simple operation for the treatment of sacrococcygeal pilonidal sinus disease.

[Assessment of bovine pericardium (tutomesh®) and coated polypropylene (proceed®) in the para-oesophageal position in a pig model]. / Untersuchung von bovinem Perikard (Tutomesh®) und beschichtetem Polypropylen (Proceed®) in paraösophagealer Position im Schweinemodell.

BACKGROUND: Hiatal hernias are nowadays increasingly treated with meshes. Often, biological implants are being used for this application. Oesophageal perforations have been reported as rare but serious complications from the application of synthetic meshes at the oesophageal hiatus. The role of the different mesh types has not been clearly established by experimental research so far. In the present large animal model, we investigated two implant types (Tutomesh® and Proceed®) with respect to their biocompatibility and mechanical stability. MATERIAL AND METHODS: We used 12 domestic pigs aged three months. Tutomesh® and Proceed® were implanted in 6 animals each for bridging at the oesophageal hiatus. After a follow-up of 3 months, the experiment was terminated. We performed endoscopy and intraoperative macroscopic evaluation of the situs. In representative histological sections, established histopathological and immunohistochemical parameters of biocompatibility were investigated and tensile strength testing was performed on standardised tissue samples. RESULTS: One animal of the Proceed® group had grade 2 oesophagitis. None of the animals had an oesophagus arrosion. The analysis of adhesions revealed slightly less adhesions in the Tutomesh® group. There was no significant difference with respect to the investigated inflammation response and immune response between both meshes. The most substantial finding of the mechanical analysis was a loss of tear strength of the Tutomesh®-tissue-complex of 30 % as compared to native tissue and more than 50 % compared to Tutomesh® prior to implantation, respectively. CONCLUSIONS: After 3 months, there was no significant difference between the two implant types with respect to the inflammatory response. The loss of tear strength of the Tutomesh®-tissue-complex at the oesophageal hiatus is probably clinically not relevant and may be explained by the so-called biological remodeling of biological materials. The remodeling depends on the extent of the cross-linking of the respective material. It is expected that biological hernia implants, such as Tutomesh®, may have a marked potential for avoiding complications at the oesophageal hiatus in the long run. This potential cannot be proven after 3 months from our data. Further experimental investigations are necessary to clarify this issue, in particular with respect to the long-term results.

[Sequential intervention with primary excision and Limberg plastic surgery procedure for treatment of sacrococcygeal pilonidal sinus : Results of a pilot study]. / Zweizeitiges Verfahren mit primärer Exzision und Limberg-Plastik zur Therapie eines sakrokokzygealen Pilonidalsinus : Ergebnisse einer Pilotstudie.

BACKGROUND: The current German S3 guidelines recommend radical excision for pilonidal sinus disease. Furthermore, the Karydakis operation and the plastic surgery procedure according to Limberg are also recommended. Contrary to the S2 guidelines of 2008, these two plastic surgery procedures for coverage are recommended for the treatment of the first-time manifestation of this disease. Most studies on the classical Limberg plastic surgical procedure are comparative in nature and describe a simultaneous intervention from which patients with an abscess are excluded. AIM: The aim of this present study was to analyze the results of a sequential procedure including primary excision followed by a Limberg plastic surgery procedure for the treatment of acute abscesses and chronic pilonidal sinus disease. MATERIAL AND METHODS: From July 2010 to June 2013 a total of 50 patients with pilonidal sinus disease were treated at the University Hospital Jena with an initial radical excision. In accordance with the Association of the Scientific Medical Societies in Germany (AWMF) guidelines which were valid during that time, patients were offered plastic surgery coverage for recurrence prophylaxis and in cases of recurrence a Limberg plastic surgery procedure was recommended. RESULTS: Of the 50 patients 22 opted for a Limberg plastic surgery procedure during the interval. The mean follow-up after the Limberg plastic surgery procedure was 20.1 months (range 2-36 months). During the follow-up period, there were no recurrences (0 %) but four major complications (18.2 %) and one minor complication (4.5 %) were observed. CONCLUSION: This concept can be applied in cases of acute abscess formation and in chronic pilonidal sinus disease. The patient's decision with respect to a Limberg plastic surgery procedure for recurrence prophylaxis does not have to be made immediately. In addition, the Limberg plastic surgery procedure is performed in an infection-free stage. The second inpatient stay, second surgical procedure and prolonged time off work are a disadvantage.

[Minimal access surgery: A survey among surgeons in Central Germany]. / "Minimal access surgery" : Ein Meinungsbild bei Chirurgen in Mitteldeutschland.

INTRODUCTION: A survey about perceptions concerning natural orifice transluminal endoscopic surgery (NOTES) and single port operations (SPO) was conducted among medical professionals at hospitals in Central Germany. The identity of the participants remained anonymous. The focus was on the subjective perception of medical colleagues and included a statement of preferred methods if the medical professional would need to undergo surgery. METHODS: Within a radius of 120 km of the city of Erfurt, all 150 surgical departments were approached and asked to complete a series of questionnaires containing general and personal questions. The analysis was performed according to the professional rank, age and sex of the participants. The questionnaires contained questions on patient preferences, cosmetic aspects and other factors, such as marketing, industry-driven, playful approach of the surgeon and appeal of a new procedure. RESULTS: In total 83 surgical departments participated in the survey resulting in 432 eligible questionnaires. Of the participants 29 % were female, the average age was 44 years, 20 % were heads of departments, 37 % senior surgeons, 20 % specialist surgeons and 23 % residents. The proportion of conventional minimally invasive surgical procedures was on average 30 % of all surgical interventions. Two hospitals offered transvaginal hybrid NOTES (cholecystectomy), 45 % performed SPOs, 36 % of the participants agreed strongly or moderately with the concept of SPO and 34 % rejected NOTES. The factors industry-driven, promotion/marketing and appeal of a new procedure were evaluated as very important or relatively important by the majority of the participants (> 70 %). When evaluating the factor playful approach of the surgeon, the proportion was 55 %. The factor patient preferences was evaluated as very high or high by 25% of the participants while it had no impact on 8 % or only a minor impact on 36 %. In case of undergoing surgery themselves, conventional laparoscopy would be preferred and NOTES was rated last among all options. CONCLUSION: The soft factors that were analyzed (i.e. marketing, industry-driven, playful approach of the surgeon and appeal of something new) were evaluated as much more important in the surgeons' opinion compared to patient criteria (i.e. patient preferences and cosmetic results). The soft factors are, however, not to be judged as generally negative as they are to a certain extent necessary (marketing), useful (impulses from industry) or are part of the surgical creativity (playfulness). The discrepancies in the medical professional evaluation of the different factors shows that the reasoning and the motivation of the actions are not necessarily identical.

[Preparation and in-vitro analysis of a polyethylenimine coating on hernia meshes]. / Herstellung und In-vitro-Analyse einer Polyethylenimin-Beschichtung auf Herniennetzen.

BACKGROUND: Certain coatings such as titanium may improve the biocompatibility of hernia meshes. The coating with biopolymers such as polyethylenimine (PEI) can also improve the material characteristics of implants. This approach has, however, not yet been explored. Thus, it was the aim of the present work to clarify if and how hernia meshes with their three-dimensional structure can be successfully coated with PEI and with which technique this coating can be best analysed. METHODS: Commercially available meshes made from polypropylene, polyester and ePTFE have been coated with PEI. The coating was analysed via cell proliferation test (mouse fibroblasts), electron microscopy, X-ray photoelectron spectroscopy (XPS) and fluorescence microscopy. Cell viability and cytotoxicity were tested by the MTT test. RESULTS: With the PEI surface modification, mouse fibroblasts grow faster and in greater numbers on the mesh surface. XPS as well as fluorescence microscopy show weaknesses in their applicability and meaningfulness because of the three-dimensional mesh structure while XPS showed overall better results. Optical proof in the electron microscope after cell fixation was not unambiguously accomplished with the techniques used here. In the MTT test, no cellular damage from the PEI coating was detected after 24 hours. CONCLUSION: The present results show for the first time that PEI coating of hernia meshes is possible and effective. The PEI coating can be achieved in a fast and cost-efficient way. Further investigations are necessary with respect to coating quality and cytotoxicity before such a coating may be used in the clinical routine. In conclusion, PEI is a promising polymer that warrants further research as a coating for medical implants.

[Assessment of resectability of colorectal liver metastases and extended resection]. / Beurteilung der Resektabilität kolorektaler Lebermetastasen und erweiterte Resektionen.

Most patients with colorectal liver metastases are treated within a multimodal therapy regime whereby liver resection is a key point in the curative treatment concept. The achievement of an R0 situation is of vital importance for long-term survival. Besides general operability and the assessment of comorbidities, resection depends on the quality of liver parenchyma (functional resectability) and the anatomical position of the tumor (oncological resectability). The improvement of operation techniques and perioperative medicine nowadays allow complex surgical procedures for metastasis surgery. This article presents the methods for the assessment of resectability and modern strategies of preoperative conditioning as well as approaches for extended liver resection.

Post-operative internal hernia through an orifice underneath the right common iliac artery after Dargent's operation.

We report the case of a 39-year-old woman with ileus resulting from a small bowel incarceration underneath the right common iliac artery. The patient had a history of a radical trachelectomy with laparoscopic pelvic lymphadenectomy ("Dargent's operation") for cervical carcinoma. After dissection of the iliac vessels, a small bowel loop could slide underneath the common iliac artery. The hernia was closed by gluing a collagen patch over the right common iliac artery onto the retroperitoneal cavity. To our knowledge, such a case has not previously been reported in the medical literature.

[Portal vein embolisation prior to extended liver resection - current and future aspects]. / Pfortaderembolisation zur Konditionierung erweiterter Leberresektionen - aktueller Stand und Ausblick.

Extended liver resections are associated with the risk of postoperative liver dysfunction up to liver failure. For this reason, prior to extended liver resections patients are conditioned in multi-modal therapy regimes. Portal vein embolisation is an essential part of such a multi-modal therapy. The aim of this intervention is an induction of hypertrophy of the future remnant liver volume. Thereby, the risk of postoperative liver failure is decreased. This article summarises the actual aspects of portal vein embolisation prior to extended liver resections.

Supporting liver transplantation by clinical pathway intelligence.

A reproducible and transparent quality of clinical treatments plays an important role in the performance of a hospital. In liver transplantation (LT), this is particularly important for patient safety, resource planning, documentation, and quality management. Thus, the clinical pathway for LT was documented in an electronic format within our research project PIGE. Data from clinical information systems were linked to this pathway, which allows for process monitoring (the assessment of the current state for every patient in the LT process) and a retrospective analysis of all treatments in addition to all data pertaining to the treatment, for example, cost, time, number of personnel, etc.

[Liver transplantation with living donor : current aspects, perspectives and significance in Germany]. / Lebertransplantation mit Lebendspende : Aktuelles, Perspektiven und Stellenwert in Deutschland.

More than 20 years ago living donor liver transplantation was introduced into clinical practice. Specifics of this method were developed initially for children and later on for adults particularly in regions where a liver transplantation program using deceased donors was not readily available. The most sensitive aspect of living donation, namely the danger to a healthy relative in order to perform the transplantation is immanent in the system and, thus, it is definitively a secondary option as compared to deceased organ donation. Following worldwide initial euphoria the numbers have markedly decreased in the western world since the start of the new millennium. In Asian countries in particular, much work has been done to optimize the procedure so that the donor safety and the outcome quality for the recipient have been impressively demonstrated in large patient populations. There is still a severe donor organ shortage and the option to allocate an optimal (partial) organ on an individual basis by living donation has given new impact to the discussion about a further rise in the profile of living donations here as well. The new version of the German transplantation legislation implemented in summer 2012 requires a number of conditions with respect to insurance for living donors. The current state and perspectives are presented here.

[Liver transplantation - current aspects of allocation, indication and donor pool expansion]. / Lebertransplantation - aktuelle Aspekte der Allokation, Indikation und Strategien zur Erweiterung des Spenderpools.

Liver transplantation is nowadays an established treatment option for end-stage liver disease and the associated complications. In this article, we summarise the actual aspects of allocation, indication for transplantation as well as approaches for donor pool expansion in the field of liver transplantation in Germany. Beside the maintenance of long-term survival and quality of life, the actual donor organ shortage is the most important issue worldwide. While trying to control this shortage, there is a lot of discussion about the transplantation for malignant liver disease. In our opinion, the focus in this topic should be the utilisation and expansion of the donor pool. There are many logistic and medical aspects which could be optimised. Furthermore, there are open questions in public and political discussions (up to the revision of the transplantation law) which should be improved for the purpose of the waiting list patients.

[The latissimus dorsi myocutaneous free flap--a salvage option for abdominal wall reconstruction in complex incisional hernias]. / Die M. latissimus dorsi-Lappenplastik--Salvage-Option bei der komplizierten Rezidiv-Narbenhernie.

Complex incisional hernias are a serious burden for the patient and a challenge for the surgeon. The main problem is the covering of the defect after the resection of large proportions of low-grade tissue. In this work, we describe 2 patients who underwent complex reconstruction of recurrent incisional hernias using a bovine pericardium mesh (Tutomesh®) and a latissimus dorsi myocutaneous free flap.