A randomised, multi-centre, prospective, observer and patient blind study to evaluate a non-absorbable polypropylene mesh vs. a partly absorbable mesh in incisional hernia repair.

BACKGROUND: The implantation of a polymer mesh is considered as the standard treatment for incisional hernia. It leads to lower recurrence rates compared to suture techniques without mesh implantation; however, there are also some drawbacks to mesh repair. The operation is more complex and peri-operative infectious complications are increased. Yet it is not clear to what extent a mesh implantation influences quality of life or leads to chronic pain or discomfort. The influence of the material, textile structure and size of the mesh remain unclear. The aim of this study was to evaluate if a non-absorbable, large pore-sized, lightweight polypropylene (PP) mesh leads to a better health outcome compared to a partly absorbable mesh. METHODS/DESIGN: In this randomised, double-blinded study, 80 patients with incisional hernia after a median laparotomy received in sublay technique either a non-absorbable mesh (Optilene® Mesh Elastic) or a partly absorbable mesh (Ultrapro® Mesh). Primary endpoint was the physical health score from the SF-36 questionnaire 21 days post-operatively. Secondary variables were patients' daily activity score, pain score, wound assessment and post-surgical complications until 6 months post-operatively. RESULTS: SF-36, daily activity and pain scores were similar in both groups after 21 days and 6 months, respectively. No hernia recurrence was observed during the observation period. Post-operative complication rates also showed no difference between the groups. CONCLUSION: The implantation of a non-absorbable, large pore-sized, lightweight PP mesh for incisional hernia leads to similar patient-related outcome parameters, recurrence and complication rates as a partly absorbable mesh.

[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.

Multimodal perioperative rehabilitation for colonic surgery in the elderly.

BACKGROUND: Traditional perioperative care for colonic surgery in elderly patients is associated with increased morbidity and mortality compared to that of younger patients. Although multimodal perioperative rehabilitation has evolved as a valid concept to improve postoperative outcome, its use has not yet been established for colonic surgery in the elderly. METHODS: Data from 24 German hospitals performing multimodal perioperative rehabilitation as the standard perioperative care for elderly patients who have undergone elective colonic resection was assessed in a prospective multicenter study between April 2005 and April 2007. RESULTS: A total of 742 patients aged > or = 70 were examined. Overall compliance with the multimodal care protocol decreased with increasing age. Although laparoscopic colonic surgery was performed in 39.1% of the septuagenarians, the number decreased to 25.1% in the very old patients. The overall complication rate was 22.9% in the septuagenarians (18.1% surgical and 11.6% general complications) and increased in the very old patients to 38.4% (28.0% and 23.6%, respectively) The overall mortality rate was 1.0% and showed no age-specific variations. CONCLUSIONS: Although the overall morbidity did increase with age, it was still less when compared to that of historical groups with traditional care. Therefore, multimodal perioperative rehabilitation should be recommended for the elderly.

"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.

[Interdisciplinary clinical pathway for colorectal cancer]. / Interdisziplinärer Behandlungspfad bei kolorektalem Karzinom.

Limited financial resources in public health care have led to the introduction of clinical pathways as a means to a better effectivity and efficacy. Colorectal cancer met the requirements for establishing such a pathway in a distinguished way: high patient volume, high costs, interdisciplinary multi-modal treatment concepts in a relevant frequency, and existing evidence based guidelines. This article gives an example of a clinical pathway for colorectal cancer as established in our hospital. The potential of such pathways to save costs as well as their implications on treatment results and patients' satisfaction will have to be critically analyzed in the future before their value can be definitely estimated.

IgM-enriched immunoglobulin (pentaglobin) positively influences the course of post-surgical intra-abdominal infections.

BACKGROUND: Polyvalent IgM-enriched intravenous human immunoglobulin (IVIG) preparations are discussed to be beneficial regarding sepsis outcome. MATERIALS AND METHODS: Sixty-four patients with abdominal infection were treated with Pentaglobin or Albumin. Serum levels of endotoxin and chemokines were determined. RESULTS: Incidence of fever was 19/28 in the pentaglobin and 18/26 in the albumin group, the percentage of days with fever was 34 +/- 26 for pentaglobin and 43 +/- 25 for albumin (mean +/-SD). Procalcitonin levels of the pentaglobin treated patients fell under the upper limit of normal on day six whereas levels of albumin patients remained elevated. CONCLUSION: Pentaglobin has a positive influence on the course of post-surgery intra-abdominal infection.

[Pancreatic tail tumor as an unusual first manifestation of Wegener's disease]. / Pankreasschwanztumor als ungewöhnliche Erstmanifestation eines M. Wegener.

A fifty-year-old, previously healthy woman presented with abdominal pain and weight loss. Diagnostic work-up revealed a mass in the tail of the pancreas with the appearance of a pancreatic carcinoma. Partial pancreatectomy was performed. Postoperatively, the patient's kidney function deteriorated. Pathohistological examination of the resected tissue showed a granulomatous vasculitis but no maligant tumor. Renal biopsy revealed a rapid progressive glomerulonephritis. Positive C-ANCA screening confirmed the diagnosis of Wegener's disease and an immunosuppressive therapy was established. This case demonstrates the difficult management of a potentially benign pancreatic mass, as reliable discrimination from pancreatic adenocarcinoma is not always possible.

Success in treatment of complicated diverticular disease is stage related.

The clinical stage of disease is one of the many factors affecting outcome after treatment for complicated diverticular disease. We retrospectively assessed surgical results during the period 1994-1999 in 406 patients with complicated diverticular disease, according to the stage of disease, surgical technique, postoperative complications, and mortality. Single-stage resection and primary anastomosis were performed safely in most patients with stage I or II disease. Severe complications were rare in stage I but increased in incidence with higher stages. Patients with stage III are a high-risk group. This stage often requires a two-stage procedure (primary anastomosis and protective ileostoma or the Hartmann procedure). Despite these measures, many severe complications occurred in stage III.

Overview on compression anastomoses: biofragmentable anastomosis ring multicenter prospective trial of 1666 anastomoses.

This study represents a European prospective clinical multicenter trial and was undertaken to evaluate the applicability of the biofragmentable anastomosis ring (BAR) as a routine anastomotic tool in teaching hospitals. The trial results analyzed consisted of 1666 BAR anastomoses performed in 1360 patients from March 1989 to May 1996 in the upper (1042 anastomoses) and lower (624 anastomoses) gastrointestinal (GI) tract. Only patients selected for elective procedures and having previously undergone orthograde bowel cleansing were entered into the trial. In the upper GI tract six anastomoses (0.58%) developed clinically relevant and radiologically detectable leaks with indications for reoperation. In the lower GI tract 42 (6.73%) anastomoses showed a radiologically detectable leak with clinical manifestations in 28 cases (4.48%). Reoperation was performed in 18 cases (2.80%). The overall leakage rate with clinical relevance was 2.04%. Three gastrojejunostomy episodes of bleeding were observed (0.18%) at the BAR anastomotic site. During the early postoperative course there was no ileus due to obstruction of a BAR anastomosis. Reintroduction of diet after the operation was not delayed. In two centers a follow-up evaluation reported no BAR-related late anastomotic stenoses. There were no intraoperative deaths, but 54 patients died postoperatively. Peritonitis following anastomotic leakage was responsible for postoperative deaths in four cases; three of them were related to BAR anastomoses. In conclusion, the BAR anastomotic procedure is an established, rapid, simple to learn, highly standardized, safe technique with the advantage of no persistent foreign material in the anastomotic region and therefore no induction of stenosis. At present, the application of anastomoses in various segments of the GI tract, from the stomach to the middle third of the rectum, can be recommended.

Reconstruction of the food passage after total gastrectomy: randomized trial.

Controversial results have been reported regarding the importance of the duodenal food passage after total gastrectomy. There are a number of experimental and clinical studies showing an advantage for the jejunal interposition between esophagus and duodenum. Others favor the Roux-en-Y reconstruction, as it is technically less demanding. The purpose of this study was the randomized comparison between two major reconstruction principles after total gastrectomy for gastric cancer (i.e., jejunal interposition with pouch versus Roux-en-Y pouch reconstruction). A group of 120 patients with gastric cancer were randomized and operated on during a 5-year period according to standardized operative protocols, using either a jejunal interposition with pouch (JIP) or the Roux-en-Y reconstruction with pouch (RYP). Endpoints of this study were operation time, intra- and postoperative problems and complications, patients' body weight, functional assessment, and quality of life. Of the 120 patients, 14 had to be withdrawn during the operation because only the Roux-en-Y reconstruction was technically possible. Finally, 53 patients with JIP were compared with 53 patients with RYP for the perioperative course. There were no significant differences between the two procedures (RYP and JIP) regarding complications (24.5% and 26.4%, respectively), mortality (3.8% and 1.9%, respectively), and operation time (4.35 hours and 4.40 hours, respectively). For long-term functional comparison 46 (RYP, n = 26; JIP, n = 20) patients were without recurrence after 3 years of survival. Comparison of body weight, Visick scoring, and the Spitzer Index also did not reveal any significant difference between the two operation methods.(ABSTRACT TRUNCATED AT 250 WORDS)

[Combined liver-islet transplantation after epigastric exenteration in carcinoma of Vater's ampulla]. / Kombinierte Leber-Insel-Transplantation nach Oberbauchexenteration bei Papillencarcinom.

A 44 year old female underwent an upper abdominal exenteration because of an adenocarcinoma of the pancreas with liver metastases (T1 N1 M1). Reconstruction was performed by orthotopic liver transplantation and intraportal islet transplantation. Due to initial non function of the first liver graft, a second liver transplantation was performed. Thereafter, the patient received 375,000 islet equivalents of the primary liver donor in addition to 295,400 islet equivalents of another donor. Six months postoperatively, the patient is off insulin except irregular injections of 4-6 units of insulin to protect her from hyperglycemia after lunch. CT scans of the liver do not show any signs of tumor recurrence. Upper abdominal exenteration with consecutive islet transplantation offers a good method of reconstruction after radical surgery in the upper abdomen. The oncological aspects of the procedure have to be further investigated.

[The functionally inactive endocrine pancreas tumor]. / Der funktionell inaktive endokrine Pankreastumor.

Endocrine tumors of the pancreas are extremely rare (1-3%). We present two cases with functional inactive tumors--one benign and one malignant--, which were immunohistologically secreting glucagon without having clinical symptoms. Differential diagnosis, operative strategy and therapy of endocrine tumors of the pancreas are discussed.

[Pelvic pouches]. / Pouches im kleinen Becken.

Since Nissen performed his first ileo-anal anastomosis for a benign large bowl disease in 1933, restorative proctocolectomy has undergone substantial developments, thus especially in the last two decades. Different pouch designs (J-, S-, W- and H-pouch) obtain normal defecation in patients treated with proctocolectomy. Many groups prefer the J-Pouch for it's technical simplicity and good results.