[Diagnosis and therapy of an acute abdomen]. / Diagnostik und Therapie des akuten Abdomens.

Patients with signs of an acute abdomen continue to be a challenge for both the emergency physician and the intensivist. Clinical symptoms usually result from secondary peritonitis possibly progressing to intraabdominal sepsis. Critically ill patients need rapid diagnostic work-up and an interdisciplinary therapeutic approach. Among patients with secondary peritonitis, those with postoperative peritonitis (e.g., after anastomotic leakage) show a particularly high mortality because of unspecific symptoms. Beyond routine diagnostic procedures, patients with an acute abdomen often require a CT scan which helps to detect the septic focus, thereby often allowing an interventional source control. Therapy consists of three main elements: source control, broad-spectrum antimicrobial therapy, and supportive intensive care medicine.

[Laparoscopic "fast-track" sigmoidectomy for diverticulitis disease in Germany. Results of a prospective quality assurance program]. / Laparoskopische "Fast-track"-Sigmaresektion bei Divertikulitis in Deutschland. Ergebnisse einer prospektiven Qualitätssicherungsmassnahme.

BACKGROUND AND OBJECTIVE: The natural course of sigmoid colon diverticulitis during conservative therapy and the assessment of the perioperative morbidity after sigmoid colon resection are differently evaluated by surgeons and gastroenterologists. The "fast-track" rehabilitation accelerates the reconvalescence and reduces the rate of postoperative general complications after colorectal surgery. The results of the laparoscopic "Fast-track" sigmoidectomy should be examined within a quality assurance program to better evaluate the perioperative risks following surgical management of diverticulitis. PATIENTS AND METHODS: A prospective data collection within the voluntary quality assurance program "fast-track" Kolon II was performed. All participating clinics agreed on a multimodal, evidence-based standard perioperative treatment in terms of a "fast-track" rehabilitation for elective operations for sigmoid diverticulitis. RESULTS: Data from 846 patients undergoing laparoscopic "fast-track" sigmoid colon resection in 23 surgical departments in Germany were collected and evaluated. The mean age of the patients was 63 years (range 23 - 91). 203 patients (24 %) had severe co-morbidities (ASA classification III - IV). A conversion to conventional open surgery was necessary in 51 cases (6 %). Complications occurred in 93 patients (11 %). 76 patients suffered a surgical complication (8.9 %) and 32 patients (3.8 %) a general complication. Two patients died postoperatively due to multi-organ failure following anastomotic leaks. The patients took solid food in median on day 1 after surgery (range, 0 - 5) and passed stool on day 2 (range, 0 - 22). Predefined discharge criteria (free of pain on oral medication, normal oral feeding, stool) were met on day 4 (range, 1 - 58) and the patients were discharged on day 7 (range, 3 - 72). The 30-day re-admission rate was 3.9 %. CONCLUSION: Patients undergoing laparoscopic "fast-track" sigmoidectomy had a low rate of general complications and had a rapid reconvalescence with a short postoperative in-patient treatment as documented in a german quality assurance program.

"Fast-track" rehabilitation for elective colonic surgery in Germany--prospective observational data from a multi-centre quality assurance programme.

BACKGROUND: The results of "Fast-track" colonic surgery in an unselected population outside of specialised units has been unknown yet. MATERIALS AND METHODS: Data from 24 German hospitals performing "Fast-track" rehabilitation as the standard peri-operative care for patients undergoing elective colonic resection were collected in a prospective multi-centre study conducted between April 2005 and September 2006 to evaluate local and general morbidity. RESULTS: One thousand and forty-seven patients undergoing elective "fast-track" colonic resection were included. Compliance to essential parts of "fast-track" rehabilitation was high (epidural analgesia 86,6%, early oral feeding and mobilisation on the day of surgery 85.5 and 85.4%). Surgical morbidity was observed in 148 patients (14.1%) and general morbidity in 95 patients (9.1%), while mortality was 0.8%. Predefined discharge criteria were met within 5 (1-83) days after surgery, but because of economical restraints in the German DRG system, patients were discharged only after 8 (3-83) days. Re-admission rate was 3.9%. CONCLUSION: "Fast-track" rehabilitation for elective colonic resection was safe and feasible in German hospitals of all sizes and yielded a low general morbidity and re-admission rate. Post-operative recovery was enhanced, but discharge from hospital was delayed because of economical reasons.

Deflectable endoscopic instrument system DENIS.

BACKGROUND: The degrees of intraoperative movement with rigid standard instruments during laparo-endoscopic surgery are limited to translation, rotation, and pivoting within the insertion point. Additional distal angulation and rotation of the instrument jaws are a potential improvement. METHODS: Different types of articulated instruments have been developed and tested in phantom and animal experiments. The final prototype was used on 30 patients during laparoscopic surgery following a standardized test protocol. RESULTS: The final design incorporates elastically linked tubular segments, 0-120 degrees variable curvature, and +/- 360 degrees rotation of the jaws element. All functions can be operated with one hand. Testing on phantom and in laparoscopic surgery showed improved handling of organs and tissue with no complications. CONCLUSION: We were able to demonstrate the feasibility of the technical design and the clinical applicability of a deflectable endoscopic instrument system. Although our initial results indicate an improvement in laparoscopic tissue manipulation, the current deflection and jaw rotation require further technical refinement.

Technology and principles of tomographic image-guided interventions and surgery.

Image guidance of instruments can be performed by fluoroscopy, ultrasound imaging, computed tomography (CT), magnetic resonance imaging (MRI), and by stereotactic navigation. During the last year, there has been significant progress in MRI instrument guidance in the field of interventional radiology. Our first 168 clinical cases of MRI-guided interventional procedures, e.g., aspiration biopsy of neoplasms and tomographic microtherapy with local interstitial chemo-ablation, confirm the feasibility of MRI guidance. An expansion of MRI guidance during surgical endoscopic procedures is currently under evaluation and the initial results of this development are presented. Tomographic-guided surgery and the implementation of MRI or CT scanning within the environment of an operating room (OR) entail specific technological requirements and OR design considerations. Fast sequences, interventional protocols, in-room monitor, as well as MR-compatible probes, cannulae, catheters, instruments, endoscopes, and auxiliary equipment that are necessary for this combined surgical image-guided approach are described.

Ports, Trocars/Cannulae, and Access Techniques.

One of the keys to safe laparo-endoscopic surgery is an expeditious, reliable, and safe access to the operative field. Aside from appropriate surgical technique, the technology of trocars, cannulae, and other endoscopically guided insertion techniques plays a decisive role for safe identification of and access to the peritoneal cavity. This report takes a close look at critical features of trocar and cannula design for blind insertion with the focus on the biomechanical principles involved in traversing the abdominal wall. Particular attention has been paid to techniques minimizing the risk of accidental injury to major vessels, intestine, and other important structures. The principle of controlled visualized access led to several developments in the field of trocars, cannulae, and puncture techniques. Aside from blind and open access with the Veress needle, conventional trocars and cannulae, a selected variety of endoscopically assisted ports such as the optical Veress needle, optical trocars and optical scalpel, and a vacuum-supported access system are described in detail.

[Special problems of primary hyperparathyroidism in pregnancy]. / Zur besonderen Problematik des primären Hyperparathyreoidismus in der Schwangerschaft.

In cases of premature, persistent nausea and vomiting, or if these conditions continue past the 14th week of pregnancy, the possibility of primary hyperparathyroidism should be considered and the condition eradicated in order to avoid serious complications for mother and child. Judging from our experience and according to current literature, starting in the 12th week of pregnancy the effects of primary hyperparathyroidism on both mother and child can be prevented through surgery.

[Intraoperative cardiopulmonary disorders during esophagectomy in relation to the surgical technique]. / Intraoperative kardio-pulmonale Störungen bei Osophagusresektion in Abhängigkeit von der Operationstechnik.

Twenty-one healthy female sheep were anaesthetised in a standard technique with ketamine, dehydrobenzperidol and etomidate. In seven sheep an endoscopic esophagectomy was made (group 1), in seven a blunt esophagectomy (group 2) and in a further seven a thoraco-abdominal esophagectomy (group 3). ECG monitoring, invasive blood pressure measurement, measurement of the central venous pressure and the pulmonary artery pressure with estimation of cardiac output, arterial and mixed venous blood gas analyses were made. The measurement times were: ZDM 1 = preoperative, ZDM 2 = after laparotomy, ZDM 3 = after cervical esophagus preparation or thoracotomy, ZDM 4 = after esophagectomy, ZDM 5 = after inflation of the lungs and ZDM 6 = after a second exploration of the esophagus bed (only groups 1 and 2). Finally the sheep in groups 1 and 2 were thoracotomised on the right side. In group 1 the measurement parameters remained largely unchanged during the entire experiment. In group 2 significant and by the end of the operation irreversible pathological changes occurred immediately after the blunt esophagus resection (ZDM 4): decrease of MAP, paO2 and CO, increase of AaDO2 and PVR. In group 3 similar changes were observed, they began, however, during ZDM 3. The measurement results can be explained in accordance with the operative anatomical findings. How far postoperative pulmonary complications can be avoided in patients with the endoscopic technique must be demonstrated in clinical use.

[Preoperative assessment of depth of infiltration of rectal tumors by staging, endosonography and magnetic resonance tomography. A prospective study]. / Die präoperative Beurteilung der Infiltrationstiefe von Rectumtumoren durch Staging, Endosonographie und Magnetresonanztomographie. Eine prospektive Untersuchung.

The choice of individual therapy for rectal tumours requires the pretherapeutic assessment of the depth of infiltration of the tumour. Fourty-four patients with rectal tumour were evaluated preoperatively by digital examination, endosonography and magnetic resonance imaging (MRI). Test results were compared with the postoperative histological examination. In digitally accessible tumours clinical staging had an accuracy rate of 85%. The sensitivity of endosonography was 83%, compared with 54% for MRI. Our findings suggest that endosonography may be more accurate as MRI, especially for rectal adenomas and early carcinomas.

[Prerequisites for endoscopic esophagectomy]. / Voraussetzungen zur endoskopischen Osophagektomie.

Blunt dissection of the esophagus is considered the least invasive technique in the treatment of either benign or malignant disease of the esophagus. Its disadvantage is that it has to be carried out blindly. In order to reduce the degree of invasiveness of the surgical procedure, a new endoscopic microsurgical technique for dissection of the esophagus has been developed and tried out in animals. Our new endoscopic microsurgical technique obviates a thoracotomy, while direct endoscopic vision results in improved dissection. The endoscopic view permits selective exposure of blood vessels and prevents injury to the adjacent organs.

[Endoscopic microsurgical dissection of the esophagus: a contribution to the reduction of pulmonary complications following esophageal resection? A comparative animal experiment study]. / Die endoskopisch-mikrochirurgische Dissektion der Speiseröhre: ein Beitrag zur Reduzierung pulmonaler Komplikationen nach Oesophagusresektion? Eine vergleichende tierexperimentelle Studie.

A new endoscopic microsurgical technique for dissection of the esophagus has been developed and tried out in animals. With this technique the esophagus is dissected and removed via a cervical approach by means of a new operating endoscope. In a randomized animal study we compared endoscopic versus blunt dissection and versus abdominothoracic resection. During endoscopic dissection we saw significantly lower bleeding and no laceration of the pleural cavity or damage to the recurrent laryngeal or to the vagus nerve. Significant changes of hemodynamics or gas exchange were observed in the blunt dissection group: increase of heart frequency, decrease of arterial pressure and decrease of paO2. In contrast these parameters did not change in the endoscopic group.

Endoscopic microsurgical dissection of the esophagus. Results in an animal model.

Blunt dissection of the esophagus is considered the least invasive technique in the treatment of either benign or malignant diseases of the esophagus. Its disadvantage is that it has to be carried out blindly. The results may be uncontrollable hemorrhage, unrecognized injuries to the trachea, and damage to the recurrent laryngeal nerve. In order to reduce the degree of invasiveness a new endoscopic microsurgical technique for the dissection of the esophagus has been developed and tried out in animals. This paper presents the operative technique. Our new endoscopic microsurgical technique obviates a thoracotomy, while direct endoscopic vision results in improved dissection. The magnified endoscopic view permits selective exposure of blood vessels and prevents injury to the adjacent organs.

Training program for transanal endoscopic microsurgery.

Televised endoscopy and the concept of the "assisted" endoscopic operation is of great help in teaching surgical endoscopic techniques. The use of training dummies provides a new method of training manual dexterity and surgical skills in special courses or in surgical skill laboratories. We have developed a training system for transanal endoscopic microsurgery. Operations with our technique were performed on 116 patients. Like other microsurgical techniques, our method requires a special introduction and intensive training. This paper presents our multistage, video-supported training course for teaching transanal endoscopic microsurgery. The one-day training session is divided into four steps: (1) becoming acquainted with the technology; (2) training on cloth phantom; (3) training on opened bowel; (4) training on closed bovine bowel distended by gas insufflation. Each step is introduced by a short videotape didactically demonstrating the particular aspects of the method.

Clinical results of transanal endoscopic microsurgery.

Using the "transanal endoscopic microsurgery" technique, 140 patients were treated at the Department of Surgery in Cologne and Mainz. Of the patients with adenomas, 68.2% had typical symptoms preoperatively. The postoperative hospital attendance was 8.7 days, with an average resection size of 14.4 cm2. The postoperative complication rate was 5%, and there were no deaths related to the technique. In a prospective controlled trial, 2.2% of the patients with adenomas treated endoscopically in Mainz showed recidivation, requiring reoperation. The follow-up rate was 100%. In 30 cases, microscopic examination revealed carcinoma. Radical reoperation in 8 pT1 tumours showed neither remaining tumour nor lymph node metastases. Twelve patients with pT1 carcinoma treated by local surgery alone were recurrence-free with an average follow-up period of 12.3 months. So far, there have been no late results.

Technique of transanal endoscopic microsurgery.

Sessile adenomas are predominantly localized in the rectum and lower sigma. Surgical removal is indicated but often implies an invasive surgical procedure. Using conventional transanal surgical techniques, only the lower rectum can be reached and there are high rates of recurrence. The new technique combines an endoscopic view of the rectum under gas insufflation via a stereoscopic telescope with conventional surgical preparation and suturing. Adenomas can be excised using the mucosectomy technique or full-thickness-excision, whereas carcinomas should be excised using full-thickness excision with a sufficient border of healthy mucosa. In carcinomas of the sacral cavity, we remove the retrorectal fat up to the fascia of Waldeyer, including the regional lymph nodes. Transanal endoscopic microsurgery is the most economical and tissue-saving surgical technique for the removal of rectal adenomas and early rectal carcinomas.