Development of an open prospective observational multicentre cohort study to determine the impact of standardization of laparoscopic intraperitoneal onlay mesh repair (IPOM) for incisional hernia on clinical outcome and quality of life (LIPOM-Trial).

BACKGROUND: Incisional hernias are one of the most frequent complications in abdominal surgery. Laparoscopic repair has been widely used since its first description but has not been standardized. A panel of hernia experts with expertise on the subject "incisional hernia" was established to review existing literature and define a standard approach to laparoscopic IPOM-repair for incisional hernia. All involved surgeons agreed to perform further IPOM-repairs of incisional hernia according to the protocol. METHODS/DESIGN: This article summarizes the development of an open prospective observational multicentre cohort study to analyse the impact of a standardization of laparoscopic IPOM-repair for incisional hernia on clinical outcome and quality of life (health care research study). DISCUSSION: Our literature search found that there is a lack of standardization in the surgical approach to incisional hernia and the use of medical devices. The possibility of different surgical techniques, various meshes and a variety of mesh fixation techniques means that the results on outcome after incisional hernia repair are often not comparable between different studies. We believe there is a need for standardization of the surgical procedure and the use of medical devices in order to make the results more comparable and eliminate confounding factors in interpreting the results of surgical hernia repair. This approach, in our view, will also illustrate the influence of the operative technique on the general quality of surgical treatment of incisional hernias better than a "highly selective" study and will indicate the "reality" of surgical treatment not only in specialist centres. TRIAL REGISTRATION: The LIPOM-trial is registered at www.clinicaltrials.gov, with identifier: NCT02089958.

[Effect of biofeedback and electrostimulation on sphincter function in fecal incontinence]. / Stellenwert von Biofeedback-Training mit kombinierter analer Elektrostimulation bei idiopathischer Stuhlinkontinenz.

UNLABELLED: The following study reports on the effect of biofeedback and transanal electric stimulation as a conservative method in the therapy of idiopathic fecal incontinence. 22 consecutive patients in whom the diagnosis "idiopathic incontinence" was established after endoscopy, endoanal ultrasound and measurement of pudendal nerve terminal motor latency underwent combined sphincter training for 3 months. The results were evaluated prospectively by clinical classification using a modified Kelly-Holschneider-score and anal manometry before and after treatment. Combined biofeedback led to a significant increase of the continence score in 18 of 22 patients (7.7 +/- 3.8 vs. 9.3 +/- 3.0, p = 0.004). Both squeeze (77 +/- 28 mmHg vs. 92 +/- 32 mmHg, p = 0.047) and resting pressures (40 +/- 19 vs. 52 +/- 23 mmHg, p = 0.015) increased significantly during the training period. There were no significant differences in squeeze and resting asymmetry indexes, sensory and urge thresholds and maximal tolerable volumes. The prolongation of biofeedback training from 3 to 6 months in 9 patients did not change clinical or manometric results significantly. CONCLUSIONS: The combination of biofeedback training with anal electrostimulation increases anal squeeze and resting pressures, thus leading to an improvement of clinical incontinence symptoms. Therefore it should be the first choice in the therapy of idiopathic fecal incontinence. A training period of 3 months seems to be sufficient.

Does botulinum type-A toxin affect motor activity after proctocolectomy and ileal pouch-anal anastomosis? An experimental study in dogs.

AIM OF THE STUDY: The use of anticholinergic drugs has provided a useful therapeutic approach to reduce stool frequency in patients with proctocolectomy and ileal pouch-anal anastomosis (IPAA). Botulinum type-A (BTA) toxin has been shown to specifically block acetylcholine release in the intestinal wall. Therefore this study investigated the effect of BTA on small intestinal and J-pouch motility after IPAA. MATERIAL AND METHODS: Proctocolectomy and IPAA were performed in 4 dogs. The motility of the small intestine and the ileal pouch was recorded by serosal electrodes and strain gauge transducers. The intestinal transit time was determined radiologically and pouch compliance was determined manometrically. Multiple measurements were performed before and after endoscopic injection of BTA into the pouch wall. RESULTS: This treatment did not significantly influence stool frequency, intestinal transit time or pouch compliance. Intrinsic pouch motility was characterized by irregular contractions, the amplitudes and frequencies of which remained unchanged after BTA administration. With the exception of lower contraction amplitudes directly proximal to the pouch, there were no significant differences in the characteristics of the migrating myoelectric complex or in the fed pattern of the small intestine and ileal pouch. CONCLUSIONS: BTA does not significantly affect ileal pouch motility. The beneficial effects of anticholinergic drugs therefore seem to be due to their multifactorial mode of action and not to the inhibition of cholinergic neurons in the pouch.

[Fascial healing and wound failure]. / Faszienheilungsmöglichkeiten und Platzbauch.

The difficulties of acute or delayed failure of fascial healing after laparotomies are of great socioeconomic relevance. Despite a plurality of publications in the last decades, the incidence of burst abdomen (1-3%) and incisional hernia (10-15%) remained unchanged. The generally accepted cause is a multifactorial event with a large number of influencing factors. Therefore, only interdisciplinary cooperations are a match for the scientific complexity of this topic. A still underestimated problem is the description of wound healing factors influencing the microclimate in fascial healing. New aspects of pharmacotherapy and better understanding of collagen synthesis and dynamics of closure tension might improve the clinical situation in the future.

Hepatoid thymic carcinoma: report of a case.

We describe the clinicopathologic findings in a so far unrecognized thymic tumor. The tumor occurred in a 70-year-old woman with respiratory distress but neither myasthenia gravis nor other symptoms. Metastases or another primary tumor were absent. The well-circumscribed neoplasm was located in the thymic region, measured 18 x 12 x 8 cm, and showed a homogeneous, tan-colored, soft cut surface. By histology, the tumor lacked a true capsule and a lobular growth pattern, was almost devoid of stroma, and infiltrated among remnant thymus lobules. The polygonal tumor cells formed solid sheets, trabeculae, or occurred as single cells that resembled hepatocytes. Proliferative activity was low. Portal structures, sinuses, and bile were absent as were areas of conventional thymoma, adenocarcinoma, or germ cell tumor. The tumor expressed cytokeratins 7 and 19, alpha1-antitrypsin, alpha1-antichymotrypsin, and hep-Par-1. Alpha-fetoprotein (AFP), human beta-chorionic gonadotropin (beta-HCG), placental alkaline phosphatase, CD5, CD30, CD31, CD34, CD45, CD68, CD99, S-100, HMB45, desmin, actin, or neuroendocrine markers were not expressed, and intratumorous CD1a+ or TdT+ immature T cells were absent. AFP was repeatedly undetectable in the blood. Mediastinal tumor recurrence was detected 6 months after surgery. Following radiochemotherapy, the patient has remained free of disease for 26 months. We conclude that this tumor is a thymic carcinoma (WHO type C thymoma). A diagnosis of hepatoid yolk sack tumor appears unlikely considering absence of a bona fide germ cell component, lack of AFP expression, and the patient's female gender. Because of its morphologic and immunohistochemical features, we propose the term "hepatoid thymic carcinoma" for this new type of thymic carcinoma.

Defecation mechanisms after proctocolectomy and ileal pouch--anal anastomosis in dogs.

BACKGROUND AND AIMS: The role of intrinsic pouch motility after ileal pouch-anal anastomosis (IPAA) during defecation is still speculative. MATERIALS AND METHODS: IPAA was performed in 12 dogs. Defecation mechanisms were evaluated by motility recordings during spontaneous defecation and during expulsion of an endoluminal balloon and by radiography with sequential sector-related gray scale analysis. RESULTS: Spontaneous defecations appeared without significant changes in electrical or mechanical activity of the pouch. Sequential filling of the pouch led to defecation in only seven dogs while the others did not succeed in emptying their pouch even with maximal balloon inflation. Neither strain gauge measurements nor electromyography demonstrated peristaltic contractions of the pouch during defecation while sector-related gray scale analysis revealed strong contractions of the abdominal wall during pouch emptying. CONCLUSION: Pouch emptying is independent of intrinsic pouch motility. The ileoanal pouch acts as a functionally passive reservoir, and its evacuation is initiated by a rise of the intra-abdominal pressure.

[Sugar tumor. Rare differential diagnosis of pulmonary clear cell tumor after renal carcinoma]. / Sugar-Tumor. Seltene Differentialdiagnose eines klarzelligen Lungentumors nach Nierenzellkarzinom.

Pulmonary clear cell or sugar tumor is a rare entity of unknown etiology and histogenesis. As primary extrapulmonal sugar tumor (PEST) this neoplasia can also be found in the trachea, vulva, rectum, pancreas or atrial-septal region. So far about 40 case reports have been published in english literatur. We present the case report of a patient with a pulmonal sugar tumor, who previously underwent nephrectomy because of clear cell renal carcinoma. Clinical aspects, differential diagnosis, therapy and histogenetic aspects are discussed.

[Functional results and quality of life after proctocolectomy and ileal J-pouch-anal anastomosis for ulcerative colitis]. / Funktionelle Langzeitergebnisse und Lebensqualität nach Proktokolektomie und Ileumpouch-analer Anastomose bei Colitis ulcerosa.

BACKGROUND: Ileal pouch-anal anastomosis is the surgical standard in the therapy of ulcerative colitis. It was the aim of the present study to evaluate functional long-term results and correlate them with quality of life. PATIENTS AND METHODS: 37 patients with a follow-up of more than 5 years were included. Functional results and quality of life were assessed by standardised questionnaires (modified Kelly-Hohlschneider-Score, EORTC QLQ-C30). RESULTS: 24 of 37 patients could be evaluated. Median follow-up was 8 (5-13) years. Postoperative stool- frequency was 5.5 +/- 1.7/d. When compared with the preoperative situation, patients suffered less from urgency. Stool-frequency and -consistency, soiling and sensibility remained unchanged. 83 % of patients had a subjective increase of life quality with the ileoanal pouch. The quality of life index was almost normal with 83 (28-100) %. Patients with postoperative complications had a significant decrease of life quality when compared to patients with uneventful course. There was no statistically significant correlation of life quality with age, gender or stool continence. CONCLUSIONS: Ileal pouch-anal anastomosis leads to a long-term increase of stool frequency with partially impaired stool continence. Patients with uneventful course have a significantly better life quality.

Mesh reconstruction preventing sacral herniation.

Sacral hernias are uncommon defects developing through the pelvic floor after partial or total sacrectomy. We report on a 29-year-old woman, who has been under our care with a cystic formation after perineosacral resection of a rhabdomyosarcoma and partial sacrectomy. The cystic tumor was resected and a mesh repair performed to prevent sacral herniation. The current literature is summarized; etiology and management recommendations of this rare complication are discussed.

[Sugar tumor of the lung--case report and review of the literature]. / Sugar-Tumor der Lunge. Kasuistik und Literaturübersicht.

Clear cell tumors of the lung are commonly primary, clear-cell, bronchial carcinomas or metastasis of a renal cell carcinoma. Compared to this, pulmonary sugar tumor is a rare entity. A large intracellular content of glycogen and immunohistochemical procedures lead to diagnosis. The demonstration of the premelanosomal protein HMB-45 is considered as proof, but this is not airtight. We present a case of metachronic, benign, and HMB-45-negative sugar tumor of the lung after hypernephroma and give a review of the literature.

Repair of intercostal pulmonary herniation.

Intercostal pulmonary herniation occurring years after blunt thoracic trauma is a rare phenomenon. We report on the case of a 66-year-old patient who developed a pulmonary herniation 2 years after a seat-belt injury. Thoracotomy was performed, and the thoracic wall defect was closed with approximating periostal absorbable sutures. The postoperative course was uneventful. Different surgical approaches and the use of prosthetic patches are discussed. Periostal fixation of the adjacent ribs with absorbable sutures is usually sufficient for herniation repair. In cases in which prosthetic meshes are needed, the application of PTFE might produce the best results with the least complications.

Temporary closure of the abdominal wall (laparostomy).

The definitive closure of the abdominal wall, i.e., a closure of the fascial layer and skin may not be favorable in the treatment of numerous surgical conditions, e.g., peritonitis, trauma, or mesenteric ischemia. In these cases, the abdominal wall is temporarily closed, and a laparostomy is created to facilitate re-exploration or to prevent abdominal compartment syndrome. Regarding the technique and material used for the temporary closure, no prospective randomized data exists, but mesh materials are commonly used. They provide drainage of infectious material, permit visual control of the underlying viscera, facilitate access to the abdominal wall, preserve the fascial margin, enable healing by secondary intention, and allow mobilization of the patient. In the case of decreasing intra-abdominal pressure, meshes can be trimmed to centralize the rectus muscle and to facilitate definitive closure. Non-absorbable meshes have been frequently reported to cause enteric fistulae and persistent infection necessitating mesh explantation. While these infectious complications appear to occur less frequently with the use of absorbable materials, these meshes will finally lead to an incisional hernia, requiring repair with non-absorbable mesh after a period of 6-12 months. Nevertheless, in the complex situation requiring a temporary abdominal wall closure, use of absorbable mesh material is common and represents the state of the art.

[Structural anomalies in lung apices after pneumothorax operation]. / Strukturanomalien im Lungenspitzenbereich nach Pneumothoraxoperation.

INTRODUCTION: Fifty-eight patients (mean age 27 years, range 17-44) with primary spontaneous pneumothorax (PSP) underwent resection of apical bullae and partial apical pleurectomy via mini-thoracotomy or thoracoscopy, in 12 cases bilaterally, between 1982 and 1999. METHOD: After a mean follow-up period of 111 (16-212) months, 26 patients with 31 operated lungs were reassessed by high-resolution CT (HRCT) to demonstrate postoperative morphological changes. RESULTS: Neither relevant clinical symptoms nor recurrence of a pneumothorax were found. However, HRCT revealed new apical bleb formations in 22 (71%) of 31 lungs. Neither the surgical approach, the technique of resection nor giving up smoking could be correlated to the tissue alterations. Surgical excision of the apex of the lung does not stop bleb formation. CONCLUSION: This study confirms earlier results from a different institution, when blebs recurred in 50% of the cases. The presence of these new apical formations neither influenced the clinical outcome nor predisposed to recurrence of PSP. Parietal (partial) pleurectomy seems mandatory to prevent PSP in the long-term.