Pancreatic Fistula and Biochemical Leak after Splenectomy: Incidence and Risk Factors-A Retrospective Single-Center Analysis.

PURPOSE: Postoperative pancreatic fistula (POPF) is a complication discussed in the context of pancreatic surgery, but may also result from splenectomy; a relationship that has not been investigated extensively yet. METHODS: This retrospective single-center study aimed to analyze incidence of and risk factors for POPF after splenectomy. Patient characteristics included demographic data, surgical procedure, and intra- and postoperative complications. POPF was defined according to the International Study Group on Pancreatic Surgery as POPF of grade B and C or biochemical leak (BL). RESULTS: Over ten years, 247 patients were identified, of whom 163 underwent primary (spleen-associated pathologies) and 84 secondary (extrasplenic oncological or technical reasons) splenectomy. Thirty-six patients (14.6%) developed POPF of grade B/C or BL, of which 13 occurred after primary (7.9%) and 23 after secondary splenectomy (27.3%). Of these, 25 (69.4%) were BL, 7 (19.4%) POPF of grade B and 4 (11.1%) POPF of grade C. BL were treated conservatively while three patients with POPF of grade B required interventional procedures and 4 with POPF of grade C required surgery. POPF and BL was noted significantly more often after secondary splenectomy and longer procedures. Multivariate analysis confirmed secondary splenectomy and use of energy-based devices as independent risk factors for development of POPF/BL after splenectomy. CONCLUSION: With an incidence of 4.5%, POPF is a relevant complication after splenectomy. The main risk factor identified was secondary splenectomy. Although POPF and BL can usually be treated conservatively, it should be emphasized when obtaining patients' informed consent and treated at centers with experience in pancreatic surgery.

Pedunculated, well differentiated liposarcoma of the oesophagus mimicking giant fibrovascular polyp.

We present a rare case of a big oesophageal liposarcoma causing dysphagia and weight loss in a 75-year-old patient. Endoscopically, a pedunculated lesion with subtotal obstruction of the oesophageal lumen had been detected and thoracoabdominal oesophageal resection with gastric sleeve reconstruction was performed. Surprisingly, a liposarcoma of the oesophagus was revealed on histopathological analysis, showing MDM2 overexpression. Oncological follow-up has been uneventful and the patient remains in good clinical shape at 15 months after surgery.

[Restorative proctocolectomy for ulcerative colitis : Long-term functional results and quality of life]. / Restaurative Proktokolektomie bei Colitis ulcerosa : Funktionelle Langzeitergebnisse und Lebensqualität.

Restorative proctocolectomy with ileo-pouch-anal anastomosis is the standard procedure for ulcerative colitis. It provides complete removal of the diseased colorectum, avoids permanent ileostomy and allows the preservation of continence. Functional results and quality of life after restorative proctocolectomy are of great importance. Patients usually have 5-6 bowel movements per day, and continence is satisfactory in more than 90% of patients. A good pouch function strongly correlates with high quality of life. Postoperative septic complications are the main risk factor for bad pouch function and pouch failure; therefore nowadays most procedures are performed with a covering ileostomy. Quality of life is usually impaired by active ulcerative colitis, and restorative proctocolectomy improves the quality of life up to the level of a healthy reference population. Taken together, restorative proctocolectomy provides excellent results concerning function and quality of life.

Perineal herniation of an ileal neobladder following radical cystectomy and consecutive rectal resection for recurrent bladder carcinoma.

Secondary perineal herniation of intraperitoneal contents represents a rare complication following procedures such as abdominoperineal rectal resection or cystectomy. We present a case of a perineal hernia formation with prolapse of an ileum neobladder following radical cystectomy and rectal resection for recurrent bladder cancer. Following consecutive resections in the anterior and posterior compartment of the lesser pelvis, the patient developed problems emptying his neobladder. Clinical examination and computed tomography revealed perineal herniation of his neobladder through the pelvic floor. Through a perineal approach, the hernial sac could be repositioned, and via a combination of absorbable and non-absorbable synthetic mesh grafts, the pelvic floor was stabilised. Follow-up review at one year after hernia fixation showed no signs of recurrence and no symptoms. In cases of extensive surgery in the lesser pelvis with associated weakness of the pelvic compartments, meshes should be considered for closure of the pelvic floor. Development of biological meshes with reduced risk of infection might be an interesting treatment option in these cases.

Multifocal sclerosing angiomatoid nodular transformation of the spleen in a patient with simultaneous metachronous liver metastasis after colon cancer surgery: a first case report.

Sclerosing angiomatoid nodular transformation of the spleen (SANT) is a benign, extremely rare vascular lesion of the spleen with unknown pathogenesis. SANT is often discovered incidentally, and can sometimes be found in patients with a history of cancer. Based on absent definitive radiological signs and varying growth patterns, distinction from malignant processes such as metastasis can be very difficult. Therefore, surgical resection of the spleen is indicated in most cases of patients with history of cancer. We report a case of a bifocal manifestation of SANT in the spleen in a patient with history of colon cancer and newly-diagnosed metachronous liver metastases.

[Timing of esophagectomy in multimodal therapy of esophageal cancer: Impact of time interval between neoadjuvant therapy and surgery on outcome and response]. / Therapiepause in der multimodalen Behandlung des Ösophaguskarzinoms : Einfluss des Intervalls zwischen neoadjuvanter Therapie und Resektion auf Outcome und Response.

BACKGROUND: Neoadjuvant radiochemotherapy [n(R)CT] has become the standard of care in the multimodal therapy concept for patients with locally advanced esophageal cancer; however, optimal timing of surgery is not clearly defined. OBJECTIVES: The study analyzed whether the length of the interval between completion of n(R)CT and surgery can affect the postoperative outcome, tumor response and long-term survival. MATERIAL AND METHODS: A total of 106 patients with adenocarcinoma and squamous cell carcinoma of the esophagus, treated between 2006 and 2013, were included in this study. On the basis of the median time interval to surgery, patients were divided into two groups [group A ≤ 40 days (n = 54) and group B > 40 days (n = 52)] and compared concerning demographic data, preoperative risk scores, morbidity, outcome, tumor response and long-term survival. RESULTS: The groups were comparable in terms of demographics, preoperative condition of the patients, complications and outcome; however, group A showed a trend towards a higher mortality risk as preoperatively assessed by the physiological and operative severity score for the enumeration of mortality and morbidity in esophagogastric surgery patients (O-POSSUM) (p = 0.064) and group B showed a trend towards a higher rate of complete responders (p = 0.097). CONCLUSION: Concerning perioperative morbidity and mortality, delayed surgery after n(R)CT showed no benefit for the patient's outcome; however, the rate of complete tumor response was higher in patients with a time interval of more than 40 days, although this did not influence long-term survival or recurrence rates.

The OTSC(®) proctology clip system for the closure of refractory anal fistulas.

BACKGROUND: To evaluate the efficacy of the over-the-scope clip (OTSC(®)) proctology set for the closure of refractory anal fistulas. METHODS: This retrospective single-center study included all consecutive patients undergoing an OTSC(®) proctology closure of anal fistulas between October 2012 and June 2014. The OTSC(®) was only used in refractory cases after previous fistula surgery, including patients with Crohn's disease, or multiple previous surgical approaches. RESULTS: There were ten patients (five males and five females) with a median age of 41 years (range 26-69 years). The etiology of the fistula was cryptoglandular in four patients, and perianal Crohn's disease in six patients (including one patient with an anovaginal fistula). The surgical procedure was technically successful in all patients. Permanent fistula closure was achieved in seven out of ten patients (70 %) within a median time of 72 days (range 31-109 days). Median total follow-up time was 230.5 days (range 156-523 days). There were three failures (30 %), including two cryptoglandular and one Crohn's disease-associated fistula. In all three cases, the OTSC(®) was lost spontaneously on days 22, 23, and 40, respectively. In three of the seven patients with successful closure, the OTSC(®) was removed after complete healing of the fistula. CONCLUSIONS: The novel OTSC(®) proctology system is a safe and effective method for the closure of even complex and recurrent fistulas.

[Retroperitoneal emphysema after endoscopic retrograde cholangiopancreatography]. / Retroperitoneales Emphysem nach endoskopischer retrograder Cholangiopankreatikographie.

Retroperitoneal emphysema represents a pathological situation with an abnormal amount of air in the retroperitoneal tissue. The diagnosis is made radiologically.The cause is mostly an iatrogenic complication of different diagnostic or therapeutic procedures. The most common cause is a perforation after endoscopic retrograde cholangiopancreatography (ERCP). In cases of clinically suspected complications after a procedure prompt diagnosis with computed tomography (CT) scan of the abdomen and an interdisciplinary decision on the suitable therapeutic measures is warranted, as immediate therapy reduces morbidity and mortality of patients. For selecting the ideal therapy it is essential to understand the underlying pathophysiological mechanism of retroperitoneal emphysema and to take the clinical situation of the patient into account. Thus periampullary or bile duct lesions facing the retroperitoneum can be treated conservatively in clinically stable patients, whereas in unstable patients with abscess formation, interventional radiological or endoscopic procedures are indicated. In cases of a duodenal lesion an endoscopic closure of the perforation can be performed in stable patients but if the patient shows signs of peritonism or if the clinical situation deteriorates, operative therapy is necessary.

[Is There an Age Limit for Surgical Interventions?]. / Gibt es ein Alterslimit für chirurgische Maßnahmen?

The demographic development leads to an increase of elderly patients (> 70 years) who require surgical interventions. Nowadays, even complex surgical interventions are performed with good results in very old patients. In view of an increasing life expectancy, radical oncological surgery makes sense even in high age. High age itself is not a risk factor for perioperative morbidity and mortality, and therefore there is no age limit for surgical interventions. However, comorbidities are more frequent in old patients, and these can massively increase the risk of surgery. Thus, for the individual patient, pros and cons of surgical interventions have to be weighed up. A specialised geriatric assessment and an optimal perioperative management of the old patient can improve the results of surgical therapy.

Antibiotic prophylaxis at urinary catheter removal prevents urinary tract infection after kidney transplantation.

BACKGROUND: Urinary tract infections (UTI) are common nosocomial infections in kidney transplant recipients, with limited evidence to guide antibiotic prophylaxis at urinary catheter removal. The aim of our study was to evaluate the effect of short-term antibiotic therapy at the moment of catheter removal after kidney transplantation. METHODS: Twenty kidney transplant recipients received 250 mg of ciprofloxacin orally twice daily 1 day before and at the day of the removal of the urinary catheter and were compared with 20 kidney transplant recipients without prophylaxis. UTI was diagnosed by use of urine culture and clinical signs. RESULTS: All patients were comparable in sex, age, etiology of end-stage renal failure, immunosuppression, donor type, and initial function. After catheter removal at the 6th postoperative day, a rapid rise of UTI in kidney transplant recipients without prophylaxis (n = 12, 60%) was observed, whereas in patients with antibiotic prophylaxis the rate of UTI could be significantly reduced to 20%. Escherichia coli was the most isolated pathogen in the patients with UTI and was detected at the catheter tip in more than 50% of cases. In 2 patients (10%) after antibiotic prophylaxis, a ciprofloxacin-resistant E coli strain was detected. CONCLUSIONS: The use of antibiotic prophylaxis during urinary catheter removal is recommended to prevent UTI in kidney transplant recipients.

[Advances, limitations and prospects of oncological liver surgery]. / Fortschritt, Limitationen und Zukunft der onkologischen Leberchirurgie.

Modern oncological liver surgery continues to push the limits of resectability by incorporating an array of new developments in the fields of surgery, anaesthesia and intensive care, oncology, radiology and transplantation medicine. New criteria for determining the resectability of primary and secondary liver tumours have been developed and introduced into national consensus guidelines. Modern tools for improving oncological outcome include the rapid induction of liver hypertrophy prior to major liver resection, downstaging of tumours with advanced chemotherapy protocols, minimally invasive local therapies like radiofrequency ablation and chemo- or radioembolisation, and liver transplantation for non-resectable hepatocellular carcinoma.

[Anastomotic techniques for the gastrointestinal tract]. / Anastomosentechniken am GastrointestinaItrakt.

The correct suture technique for anastomoses of the gastrointestinal (GI) tract is a major task in the daily practice of surgery and a basic requirement for a successful operation. This article provides an overview of the surgical principles and techniques involved in the creation of intestinal anastomoses, including the differentiated use of various suturing aids in the GI tract. Hand sewn and stapled anastomotic techniques are illustrated and discussed. The ongoing discussion and question as to which technique is best for GI anastomoses remains unanswered as there is no obligatory standard, even though the requirements are well defined. An ideal anastomosis should fulfil the following criteria: it must be well vascularized, safe, tension-free and spillage from the operation field should be avoided.

Renal graft outcome in combined heart-kidney transplantation compared to kidney transplantation alone: a single-center, matched-control study.

BACKGROUND: Renal allograft outcome in heart-kidney transplantation (HKTx) might be affected by hemodynamic instability and high levels of calcineurin inhibitor-dependent immunosuppression. METHODS: From November 1999 to March 2008, 13 patients who received HKTx were compared with a matched control group of 13 kidney transplantation (KTx) recipients with similar cardiovascular risk factors. Graft function, rejection periods, and patient survival were analyzed. RESULTS: Renal allograft rejection was noted in three patients (23%) after HKTx and in four patients (31%) after KTx. Serum creatinine levels were comparable at 1 week, 1 month, 1, 2, and 3 years after transplantation. Patient survival rates at 1, 2, and 3 years were 100% for HKTx recipients and 100, 92, and 92% for isolated KTx patients. Graft survival was 92% at 1, 2, and 3 years after HKTx and 100% at 1 year and 92% at 2 and 3 years after isolated KTx. CONCLUSIONS: Our results with excellent long-term graft function and survival after combined HKTx indicate that this procedure is a valuable option for a growing number of patients suffering from coexistent cardiac and renal failure.

[Education in laparoscopic surgery: national survey on current strategies and relevance of simulation training]. / Ausbildung in der laparoskopischen Chirurgie: Umfrage zu vorhandenen Konzepten und der Bedeutung von Simulationseinheiten.

BACKGROUND: Laparoscopic surgery demands from the surgeon specific operative skills. Learning -curves have been described for many procedures in this technique. In order to evaluate the avail-able laparoscopic teaching resources and meth-ods in Germany an opinion survey was per-formed. MATERIALS AND METHODS: Directors of 284 surgical departments were polled using a questionnaire regarding department and operation statistics, -laparoscopic education and availability of simulation facilities ("Skills Labs" SL). RESULTS: The response rate was 54 %. 88 % of the department directors considered laparoscopic -simulation an efficient teaching method and 91 % felt that simulation improves operating room performance. A SL was available in 27 % of these -departments. The training modules most commonly offered were basic laparoscopic skills such as coordination exercises (100 %) and suturing techniques (89 %). The actual median acquisition costs amounted to 20 000 € in our evaluation, with annual running costs of a median of 1000 €. CONCLUSION: Although most of the questioned surgeons acknowledged the value of SL, this method of education is not widely available in Germany. Therefore we feel that simulation training in Germany still requires stronger support.

[Stoma prolapse and stoma retraction]. / Stomaprolaps und Stomaretraktion.

Prolapse and retraction of an intestinal stoma are postoperative complications which severely decrease the quality of life of patients and in some cases lead to an operative revision. Both entities should be treated with sophisticated care by specialized stoma therapists in the early phase in order to prevent secondary problems such as dermal ulceration. However, in case of additional problems, such as ileus, bleeding, incarceration or impossibility of adequate stoma care, an operative revision is indicated. It remains an individual decision whether a local or a transabdominal revision of the stoma is necessary.At present the level of information and the number of well designed studies dealing with prolapse or retraction of a stoma are unsatisfactory and there are merely studies which report on prolapse and retraction as an incidental finding rather than primarily focusing on these problems. In addition there is a lack of clear cut definitions for both entities which would allow a comparison of data obtained in different studies.There is clearly a demand for a structured scientific clarification as the occurrence of stomal retraction or prolapse may present psychological and medical problems for the patients and therefore needs to be treated, conservatively and/or operatively, by both stoma specialists and surgeons.

Timing of conversion to mammalian target of rapamycin inhibitors is crucial in liver transplant recipients with impaired renal function at transplantation.

BACKGROUND: Renal dysfunction, primarily related to long-term use of calcineurin inhibitor-based immunosuppression, is the most common complication after liver transplantation. OBJECTIVE: To evaluate whether liver transplant recipients with impaired kidney function at transplantation can benefit from early conversion to mammalian target of rapamycin inhibitor therapy (mTORi) compared with patients with late induction of mTORi-based therapy. MATERIALS AND METHODS: Between 2003 and 2008, therapy was changed to an mTORi-based regimen in 57 patients. Patients were divided into 4 groups: group 1, early conversion (≤3 months after orthotopic liver transplantation) to mTORi therapy, and with impaired perioperative renal function; group 2, early conversion to mTORi therapy, and with normal perioperative renal function; group 3, late conversion to mTORi therapy, and with impaired perioperative renal function; and group 4, late conversion to mTORi therapy, and with normal perioperative renal function. RESULTS: One month after conversion, the mean (SD) increase in calculated glomerular filtration rate in groups 1 (early conversion) and 3 (late conversion) was comparable: 8 (9) mL/min vs 7 (10) mL/min. At month 3, the increase in calculated glomerular filtration rate between groups 1 and 3 was significant (15 [11] mL/min vs 9 [15] mL/min; P = .04), an effect that persisted at month 6 (16 [12] mL/min vs 10 [12] mL/min; P = .05) and month 12 (22 [14] mL/min vs 12 [15] mL/min; P = .04). CONCLUSION: In liver transplant recipients with perioperatively impaired renal function, early conversion to mTORi therapy should be performed because this approach seems to be more effective in improving long-term renal function.