[Laparoscopic rectal resection technique]. / Technik der laparoskopischen Rektumresektion.

The quality of radical oncological operations for patients with rectal cancer determines the rate of local recurrence and long-term survival. Neoadjuvant chemoradiotherapy for locally advanced tumors, a standardized surgical procedure for rectal tumors less than 12 cm from the anus with total mesorectal excision (TME) and preservation of the autonomous nerve system for sexual and bladder function have significantly improved the oncological results and quality of life of patients. The TME procedure for rectal resection has been performed laparoscopically in Germany for almost 20 years; however, no reliable data are available on the frequency of laparoscopic procedures in rectal cancer patients in Germany. The rate of minimally invasive procedures is estimated to be less than 20 %. A prerequisite for using the laparoscopic approach is implicit adherence to the described standards of open surgery. Available data from prospective randomized trials, systematic reviews and meta-analyses indicate that in the early postoperative phase the generally well-known positive effects of the minimally invasive approach to the benefit of patients can be realized without any long-term negative impact on the oncological results; however, the results of many of these studies are difficult to interpret because it could not be confirmed whether the hospitals and surgeons involved had successfully completed the learning curve. In this article we would like to present our technique, which we have developed over the past 17 years in more than 1000 patients. Based on our experiences the laparoscopic approach can be highly recommended as a suitable alternative to the open procedure.

[Report of 12 years experience in the surgical treatment of 286 paraesophageal hernias]. / Erfahrungen aus 12 Jahren chirurgischer Versorgung von 286 paraösophagealen Hernien.

BACKGROUND: In contrast to axial hiatus hernias, paraesophageal hernias are rare but can lead to chronic iron deficiency anemia and severe acute complications. Treatment is manifold and consistent standards are lacking. OBJECTIVES: The aim of this study was to describe our experiences of 286 patients with paraesophageal hernias, who underwent surgery from 2003 to 2014 at a tertiary referral center. The study was particularly concerned with morbidity, mortality, quality of life and recurrence rates. MATERIAL AND METHODS: In 12 years a total of 286 paraesophageal hernias were surgically treated, 255 with a minimally invasive procedure and 31 with an open approach. In 138 patients (48 %) the suture-based hiatoplasty was reinforced by means of a lightweight mesh, which was fixed with fibrin glue in 90 cases. Abdominal fixation of the stomach consisted of a gastropexy and anterior (n = 244) or posterior (n = 42) fundoplication. RESULTS: Complications arose in 8.4 % of the patients. The mean hospital stay was 5.3 (± 2.8) days for elective surgery and 24.7 (± 17.8) days for emergency operations. The gastrointestinal quality of life index according to Eypasch significantly increased from mean preoperative values of 92.8 (± 22.5) to 109.6 (± 20.2) in the postoperative course (p < 0.001). Of the patients 20 (7 %) suffered a recurrence requiring surgery, including 7 early and 13 late recurrences. During the immediate postoperative period radiographically detected recurrences were promptly revised. The strategy of late recurrences in the long-term course was based on patient symptoms and asymptomatic hernias were treated conservatively while symptomatic hernias were surgically treated. Symptomatic late recurrences developed in 4.6 % of the patients, including 7.4 % (11 out of 148) without and 1.4 % (2 out of 138) with primary mesh repair. CONCLUSION: The repair of paraesophageal hernias in 286 patients provided excellent patient satisfaction and symptom improvement with low perioperative morbidity and mortality. Mesh reinforcement reduced the recurrence rate. The quality of life index is a suitable clinical course parameter for evaluation of paraesophageal hernias.

[Inguinal and femoral hernia repair]. / Chirurgie der Leisten- und Schenkelhernien.

With an incidence of 200,000 new cases per year in Germany, inguinal hernia has a significant socioeconomic impact. The 2009 guidelines from the European Hernia Society established treatment recommendations. Hernia repair is based on reinforcing the posterior wall of the inguinal canal by suture or mesh repair by an anterior or posterior approach. Lightweight mesh reduces recurrence rates and is the treatment of choice even in primary hernias. Laparoscopic hernia repair is associated with specific risks but is superior in postoperative pain and earlier return to work.

[Quality management during postoperative pain therapy]. / Qualitätsmanagement der postoperativen Schmerztherapie.

BACKGROUND: A main target of surgical treatment is to minimize postoperative pain. The aim of this study was to evaluate the benefit of quality management on postoperative pain and to improve pain therapy. METHODS: In a prospective study, postoperative pain was recorded in a total of 700 patients in a general and visceral surgical ward in 2000, 2001, and 2002. Pain was measured on a ten-point visual analogue scale (0 no pain, 10 most severe pain). RESULTS: Applying the principles of quality management (plan, do, check, act), we analyzed the reasons for high pain scores in detail. After study of the results in 2000, additional recommendations and guidelines for perioperative pain therapy were provided to all the physicians, and the mean visual analogue pain scores decreased by 15% in 2001 and more than 30% in 2002. At baseline, 12% of patients had pain above the threshold of 3 at rest and 5 in motion. These scores could be reduced to 6% and 3% in the two successive years, respectively. CONCLUSION: A simple pain management system in a general surgical ward led to considerable improvement in postoperative pain scores as assessed by visual analogue scale.

[Radio-guided parathyroidectomy: successful intraoperative parathyroid localization diagnosis with 99mTc-sestamibi in primary and recurrent hyperparathyroidism]. / Radio-guided Parathyreoidektomie: Erfolgreiche intraoperative Lokalisationsdiagnostik bei primärem und rezidivierendem Hyperparathyreoidismus mit 99mTc-MIBI.

INTRODUCTION: In addition to ultrasonography, CT scan, MRI and venous sampling, 99mTc-MIBI scintigraphy has gained increasing acceptance in preoperative localization of abnormal parathyroid tissue. The sensitivity of this radionuclide method is 87% in primary (p), 58% in secondary (s), and 75% in recurrent hyperparathyroidism (HPT). This study evaluated the use of intraoperative nuclear mapping in patients with HPT. METHODS: Retrospective analysis was performed in 24 patients with HPT (18 p, 4 s, 2 recurrent) undergoing a technetium-sestamibi-guided neck exploration during an 18-months period. Abnormal parathyroid tissue was localized using an intraoperative gamma probe detector 2 h after application of 700 MBq 99mTc-sestamibi and verified by pathology. RESULTS: Intraoperative nuclear mapping identified 15 of 18 adenomas in patients with pHPT. The target-to-background ratio was 1.3 to 4.1 in these patients compared to 1.0 to 1.2 in undetected adenomas. In 67% of these patients we performed a minimally invasive open parathyroidectomy. In two cases of recurrent HPT the scan-guided detection of ectopic parathyroid tissue was efficient. In contrast, the method was less helpful in four patients with multiglandular disease. CONCLUSION: The intraoperative use of a gamma probe detector is highly effective in identifying parathyroid adenomas in pHPT and recurrent HPT and supports minimally invasive techniques.

Extensive sterile abscess in an invasive fibrous thyroiditis (Riedel's thyroiditis) caused by an occlusive vasculitis.

Riedel's thyroiditis is a rare disease determined by an invasive fibrosclerotic transformation of the thyroid gland. It may be one manifestation of multifocal fibrosis with still unknown etiology. Because it mimics carcinoma, a biopsy must be performed to get the correct diagnosis. The condition is self-limiting when confined to the neck. Prognosis depends on the extent of extracervical fibrosclerosis. We present a patient with a huge cervical and mediastinal, unilateral thyroid mass expanding to the aortic curve, which led to tracheal deviation and compression with symptoms of stridor and dyspnea. These symptoms continued under a course of high-dose steroids; thus an operation was necessary to relieve the airway obstruction and limit inflammation. Intraoperative and pathological findings showed an inflammatory infiltration of the adjacent neck muscles and a sterile abscess caused by an occlusive vasculitis. Therefore, hemithyroidectomy had to be performed instead of a local limited resection.

[Dislocation of clips of the cystic duct stump]. / Dislokation von Clips am Cystikusstumpf.

The security of six different laparoscopic clips was investigated using 60 kryopreserved specimens of human cystic ducts. After fixation of the cystic duct the cross placed clips were distracted in axial direction and the maximum forces to remove the clip were registered. The mean dislocation-force was 4.6 Newton for titanium clips and 9.3 Newton for absorbable clips with a highly significant difference (p < 0.001, Wilcoxon-test). Additional to the advantage of complete biodegradibility these data favour the use of absorbable clips, because of a better hold force compared to titannium clips.

Dialysis neutropenia: the role of the cytoskeleton.

Dialysis neutropenia is the result of pulmonary sequestration of neutrophils after complement activation by the dialyzer membrane. Increased expression of neutrophil adhesion receptors, such as CD11b/CD18, suggests that neutrophil adhesion to the capillary endothelium is a possible mechanism. An alternative hypothesis is that the complement fragment C5a modulates neutrophil mechanical properties via the cytoskeleton-largely filamentous actin (F-actin)-stiffening them and thereby slowing their passage through the pulmonary capillaries. To investigate this hypothesis, we developed an assay to measure the F-actin content of neutrophils in whole blood using flow cytometry and the stain NBD-phallacidin. We measured neutrophil F-actin content during hemodialysis of patients with polysulfone (N = 6), Hemophan (N = 6), and Cuprophan membranes sterilized with either ethylene oxide (N = 5) or steam (N = 6). Cell counts, neutrophil and monocyte CD11b expression and plasma C5a concentrations were also measured. The results confirm the strong relationship between the degree of neutropenia, increases in CD11b expression and plasma C5a levels reported by previous researchers. Modulation of the F-actin content of neutrophils was also strongly related to C5a levels, indicating that the neutrophil cytoskeleton is active during dialysis. Modeling of cell counts suggests that with Cuprophan a substantial fraction of neutrophils and monocytes are sequestered before they even pass through the dialyzer, suggesting some form of systemic activation of these cells. Evidence for systemic activation was also seen in measurements of F-actin content, but not CD11b expression, a finding that strengthens the case for the involvement of the cytoskeleton in dialysis neutropenia.

[Laparoscopically placed clips on the human cystic duct--an experimental comparison of dislocation between resorbable and titanium clips]. / Laparoskopisch applizierte Clips am humanen Ductus cysticus--Ein experimenteller Dislokationsvergleich zwischen resorbierbaren und Titan-Clips.

Kryopreserved specimens of cystic ducts were used for displacement tests to investigate the security of different laparoscopic clips. The cystic duct was fixed, and the transverse placed clips were distracted in axial direction and the forces registered. The median values of the six investigated clips ranged between 4.1 N and 11.2 N with a highly significant difference (P < 0.001, Kruskal-Wallis ANOVA). In detail, both resorbable clips (polydioxanone, polyglyconate/polyglycol acetate) were superior to the four titanium clips (P < 0.005, Wilcoxon test). In addition to the advantage of complete biodegradibility, these data favour the use of absorbable clips because holding force is better than that of titanium clips.

[Angiosarcoma of the spleen. Case report and review of the literature]. / Angiosarkom der Milz. Fallbericht und Literaturübersicht.

Angiosarcoma of the spleen is a very rare but highly malignant vascular neoplasm. So far only 140 cases have been reported. A 42-year-old patient is presented in which the radiologic imaging misled to the diagnosis of infiltrating echinococcosis. After splenectomy histological and immunohistochemical staining gave proof of metastatic angiosarcoma. The patient died three months later as a consequence of multiple organ dysfunction syndrome. The literature is reviewed in regard to clinical features, diagnosis and therapy.

In vitro and ex vivo effects of aspirin in patients on a low-dose aspirin therapy.

In 19 patients on a low-dose aspirin therapy with 100 mg/d, an insufficient effect of aspirin was observed in five patients (aggregations induced by arachidonic acid and collagen, thromboxane B2-formation in serum and after collagen). Aspirin added in vitro increased the inhibition to a degree comparable to that seen in the other 14 patients, i.e. the insufficient effect could be due to a lack of compliance or to a reduced availability of the drug. In another 20 patients there was a good inhibitory effect of aspirin; additional aspirin did not increase the inhibition of arachidonic acid-induced aggregation and serum-thromboxane B2, but slightly increased collagen-induced aggregation and thromboxane B2 formation. The effect was the same, whether the aspirin was given in vivo or added in vitro.

[Joint surfaces of the carpometacarpal articulation of the thumb in man]. / Die Gelenkflächen der Articulatio carpometacarpea pollicis des Menschen.

With respect of height and width of the proximal joint surface of the macerated 1st metacarpal bone as well as of height of the left trapezium results significant minor values compared with bones of right extremities. The measurement datas of height and width of both joint surfaces at the left macerated specimens are less significant than at left humid preparations. With respect of height of the proximal articular surfaces of the right 1st metacarpal bone, there are greater values than at the cartilageneous preparations by statistical significance. At macerated and humid preparated articulation surfaces of the saddle moint of the thumb there are 3 typical profiles in the 2 main planes: a spiral curve (vaulted in the dorsal or ulnar direction), a circular curve, and a s-shaped curve. The radius of the curve will be determined with adaptation of defined curve patterns. At the distal joint surface of the macerated trapezium, the circularly and spirally curved profiles are significantly much more crooked in the dorso-palmar direction than at the cartilageneous articulation surface on the contrary. The humid preparated distal joint surface of the trapezium in the radio-ulnar direction is clearly much more curved. The spiral form is found in 52,6% of all macerated and in 41,6% of all humid preparated specimens. The s-shaped profile is very rarely found at macerated joints (8%), whereas it appears in 26% at humid preparated surfaces. Corresponding cartilageneous saddle joints of the thumb are even similarly curved in 47% of the radio-ulnar and 40,5% of the dorso-palmar joints slices. The clear majority of the opposite carpometacarpal joint surfaces of the thumb show an individually variabel, partly an incongruent curving attitude. If different profiles at corresponding humid preparated joint surfaces assemble the following curvatures prevail: a) In the radio-ulnar cutting direction the combination: circular curve of the distal joint surface of the trapezium and spiral curve of the proximal surface of the 1st metacarpal bone, b) in the dorso-palmar direction: the combination spiral curve of the distal surface of the trapezium and circular curve of the 1st metacarpal bone.