TEP versus TAPP: comparison of the perioperative outcome in 17,587 patients with a primary unilateral inguinal hernia.

INTRODUCTION: More than 20 years since the introduction of TAPP and TEP into clinical routine, there is a lack of clarity due to conflicting comparative data. Therefore, more results from registries are needed. PATIENTS AND METHODS: A total of 17,587 patients were enrolled prospectively between September 1, 2009, and April 15, 2013, in the Herniamed registry. Of these patients, 10,887 (61.9%) had a TAPP and 6700 (38.1%) a TEP repair. The dependent variables were intra- and postoperative complication rates, number of reoperations as well as absolute and relative frequencies. The results of unadjusted analyses were verified via multivariable analyses. RESULTS: Multivariable analysis verified the results of unadjusted analysis, indicating that the surgical technique did not have any significant impact, also while taking account of other factors, on occurrence of intraoperative [p = 0.1648; OR = 1.214 (0.923; 1.596)] and general postoperative complications [p = 0.0738; OR = 1.315 (0.974; 1.775)]. Postoperative surgical complications [OR = 2.323 (1.882; 2.866); p < 0.0001] were noted more often after TAPP. Furthermore, the hernia defect size [p < 0.0001; I vs III: OR = 0.439 (0.313; 0.615), II vs III: OR = 0.712 (0.582; 0.872)] or scrotal [p < 0.0001; OR = 2.170 (1.501; 3.137)] hernia and age [p = 0.0002; 10-year OR = 1.135 (1.062; 1.213)] had a significant impact on the occurrence of postoperative complications. Complications were observed more commonly for larger hernia defects and a scrotal hernia. However, the difference in the postoperative complication rate between TEP and TAPP did not result in any difference in the reoperation rate (TEP 0.82% vs TAPP 0.90%; p = 0.6165). CONCLUSION: The intraoperative and general postoperative complication rates as well as the reoperation rate for complications show no significant difference between TEP and TAPP. The higher postoperative complication rate for TAPP, which could be managed conservatively, is partly explained by larger defect sizes, more scrotal hernias and older age.

Perioperative outcome of unilateral versus bilateral inguinal hernia repairs in TAPP technique: analysis of 15,176 cases from the Herniamed Registry.

INTRODUCTION: Following repair of a unilateral inguinal hernia, there is a risk of 1% per year of onset of an inguinal hernia on the other side. Comparison of bilateral with unilateral TAPP operation in a high-volume center found that morbidity and reoperation rates were only marginally higher for bilateral TAPP operation. Some authors are calling for prophylactic operation of the contralateral side. METHODS: Between September 2009 and April 2013, data were entered into the Herniamed Registry on 15,176 patients who had undergone TAPP operation. Of these patients, 10,887 had been operated on because of a unilateral (71.7%) and 4289 because of a bilateral (28.3%) inguinal hernia. RESULTS: A significant difference was noted in the rate of postoperative complications occurring within 30 days, which was 4.9% for bilateral compared with 3.9% for unilateral inguinal hernia (p = 0.009). The postoperative complications necessitated reoperation in 0.9% of patients after unilateral and in 1.9% of patients after bilateral inguinal hernia repair, thus attesting to the significantly higher risk presented by bilateral inguinal hernia repair (p = <0.001).Multivariate analysis confirmed the highly significant influence of bilateral TAPP on increased reoperation rates due to complications (p > 0.0001). The odds ratio was 2.13 (95% CI 1.58-2.86). Comparison of the results from a high-volume center with those from the Herniamed Registry showed that perioperative complication rates were markedly higher. CONCLUSION: Perioperative outcome of bilateral TAPP operation demonstrates significantly worse postoperative complication and reoperation rates compared with unilateral TAPP. Likewise, the results were markedly unfavorable compared with those of a high-volume center. If a bilateral hernia repair should be attempted in those patients with only a unilateral hernia, these data give the surgeon more information on how to better prepare a patient and obtain consent preoperatively.

Biomechanical properties of (semi-) synthetic glues for mesh fixation in endoscopic inguinal hernia repair.

PURPOSE: In endoscopic inguinal hernia repair, the use of fibrin glues for mesh fixation instead of staples and sutures can demonstrably reduce postoperative morbidity without increasing the recurrence rate. Various fibrin glues differ in terms of their mesh fixation strength. As an alternative to fibrin glue, there is an increasing trend toward using synthetic glues for mesh fixation in both open and endoscopic inguinal hernia surgery. To date, no studies have been conducted comparing the fixation strength of (semi-) synthetic glues with that of fibrin glues. Here, using a biomechanical model, we compared the adhesive strength of two glues (BioGlue and Glubran) used in surgery with a fibrin glue. METHODS: We used light-weight polypropylene meshes (TiMesh light). In each case, the biomechanical stability of five meshes in each group was tested with 2 ml fibrin glue (Evicel), 2 ml BioGlue or 2 ml Glubran (cyanoacrylate). The defect in the muscle tissue used was 4.5 cm in diameter for a mesh size of 10 × 15 cm. Measurements were taken using a standardized stamp penetration test while aiming not to remain under a minimum fixation strength of 32 N. RESULTS: Using Evicel for mesh fixation, an adhesive strength of 64.3 N was achieved. This was significantly greater than that obtained in the absence of fixation (2.9 N, p < 0.001) and higher than the requisite value of 32 N. Using Glubran, it was possible once again to significantly improve the adhesive strength (105.4 N, p = 0.008). The use of BioGlue improved the adhesive strength to 131.7 N, but not significantly so compared with Glubran (p = 0.110). CONCLUSIONS: In terms of adhesive strength, (semi-) synthetic glues can be used for mesh fixation instead of fibrin glue and even achieve significantly better adhesive strength than fibrin glue. However, further clinical studies are needed to identify the role of (semi-) synthetic glues compared with fibrin glues in endoscopic inguinal hernia surgery.

[Typical intraoperative complications in laparoscopic surgery]. / Typische intraoperative Komplikationen in der laparoskopischen Chirurgie.

For all common laparoscopic procedures (e. g. cholecystectomy, appendectomy, inguinal hernia repair, fundoplication and colorectal resection) it has been possible to demonstrate in systematic reviews and meta-analyses that they produce better results in terms of perioperative outcome than open surgery. Accordingly, there are very few publications that report on intraoperative complications and their management. In this respect a distinction must be made between positioning complications, access complications and complications related to the pneumoperitoneum, which can manifest in all laparoscopic procedures, as well as the specific complications associated with individual procedures.The main focus of any consideration of intraoperative complications must of course be on strategies to prevent the occurrence. If intraoperative complications have occurred, the most important aspect is the diagnosis and control with prime importance accorded to which complications can still be controlled using a laparoscopic approach and when an open procedure must be used. In general a switch to open surgery should be made in the event of serious complications. Only a highly experienced laparoscopic surgeon will be able to safely manage complications once they have occurred without putting the patient at further risk. In doubtful situations the approach that poses least risk is open surgery for complications that have already occurred.

Herniamed: an internet-based registry for outcome research in hernia surgery.

PURPOSE: Despite the high frequency of hernia surgery procedures and continuous improvements, thanks to new hernia meshes and fixation techniques, in Germany, for example, the recurrence rate and rate of chronic inguinal pain after inguinal surgery are more than 10% far too high. Introduction of a hernia register in Denmark led to a significant reduction in the recurrence rate. METHODS: The aim of a hernia registry as an application-oriented outcome research tool is to monitor and evaluate (concomitant research) how the knowledge gleaned from evidence-based science is implemented in the everyday clinical setting and, ultimately, investigate its effectiveness (outcome research). RESULTS: The new Internet-based English- and German-language registry for the entire spectrum of inpatient and outpatient hernia surgery is designed to improve the quality of patient care and provide valid data on outcome research. Via the Internet, all relevant patient data (comorbidities, previous operations, staging, specific surgical technique, medical devices used, perioperative complications and follow-up data) can be entered into the registry database. The participating hospitals and surgeons can at any time view their own data by means of an evaluation statistics tool. The outcome research project Herniamed focuses on inguinal hernias, umbilical hernias, incisional hernias, epigastric hernias, parastomal hernias and hiatus hernias. The online-based outcome research registry meets the most stringent data protection criteria. CONCLUSION: With the Internet-based English- and German-language hernia register, a new instrument is now available for outcome research in hernia surgery.

Relationship between bite-to-hospital time and morbidity in victims of carpet viper bite in North-Central Nigeria.

BACKGROUND: Envenomation from snake bites is a public health hazard in tropical countries. The observed mortality among in-hospital patients bitten by carpet viper (Echis ocellatus) in northern Nigeria has drastically reduced, related to the use of a mono-specific ovine Fab anti-snake venom. However, many victims survive with temporary or permanent physical or psychological sequelae. OBJECTIVE: Our aim was to find the relationship between bite-to-hospital time and morbidity in patients bitten by carpet viper. METHODS: A prospective study was conducted in North-Central Nigeria. The signs of morbidity scored were oedema, tenderness, prolonged whole blood clotting time, blister, ulcer, need for blood transfusion, coma, hypotension, convulsion, length of hospital stay, need for disarticulation, and need for skin graft. A score of 1 was given to each objective and verifiable sign. Bite-to-hospital time of 233 subjects was obtained. RESULTS: Most of the subjects, 150(64%) came to the hospital within six hours of snake bite, out of whom two(1%) came within one hour. The median bite-to-hospital time was five hours with a range of 0.5-216 hours. Major morbidities were oedema accounting for 212 (91.0%; 95% CI =86.6-94.3%). incoagulable blood was seen in 205(88%; 95% CI = 83.1-91.9%) and tenderness in 201(86.3%; 95% CI = 81.2-90.4%). The mean morbidity score was 8 ± 4. For every unit increase in log bite-to-hospital time, the morbidity score increased by 1.85 (p < 0.001). CONCLUSION: Morbidity caused by carpet viper bite is high in Nigeria and worsens with increasing bite-to-hospital time.

[Single-port transumbilical endoscopic cholecystectomy: a new standard?]. / Single-Port-Cholezystektomie: Der neue Standard?

BACKGROUND AND OBJECTIVE: Single-port transumbilical laparoscopic cholecystectomy (SPTLC) may become a standard procedure in the surgical treatment of acute and chronic gallbladder diseases. The initial experience with this new technique is reported. METHODS: 186 patients underwent laparoscopic single-port laparoscopic cholecystectomy between September 2008 and February 2010 at the Vivantes Klinikum Am Urban, Berlin, Germany. All these operations were performed with conventional straight laparascopic instruments using a single-port system. RESULTS: Conversion to a three-port technique or open procedure became necessary in four patients after failure to perform the single-port method. The average age of the 120 women (64%) and 66 men (36%) was 45 (range 15-88 years) years. The ASA grade (American Society of Anesthesiologists) averaged 2 (range, 1-3) and the BMI 28.5 (range 17-49). Mean operative time was 63 min (range, 28-17 min). 48 patients (26%) had histopathological evidence of acute cholecystitis. During a mean follow-up period of 39 weeks (range 1-78 weeks), 11 patients (6%) developed complications related to the surgery, five of these patients (3%) requiring a subsequent re-operation. CONCLUSIONS: Single-port transumbilical laparoscopic cholecystectomy for acute and chronic gallbladder disease is a feasible approach for routine cholecystectomy. After a short learning curve the operation time and rate of complications are comparable to standard multi-port laparoscopic cholecystectomy. A limitation of the procedure are very obese patients and multiple previously performed abdominal operations.

[Extra-articular recurrent bleeding from the medial retinaculum]. / Extraartikuläre rezidivierende Blutungaus dem medialen Retinaculumbereich.

A young woman had subcutaneous bleeding at the retinaculum of the left knee after minor trauma. A small vein was attached to the scar and repeatedly ruptured after several other small traumas. Conservative therapy had no impact on the genesis of the bleeding. Having gone through severe bleeding situations with massive swelling of the knee five times in a row, the patient underwent surgical exploration.The source of recurrent bleeding, a small vein, could be identified and excised. After that no further bleeding episodes took place.

[Liver transplantation for primary biliary cirrhosis: retrospective analysis of results at a single center]. / Lebertransplantation bei primär biliärer Zirrhose: Retrospektive Analyse eines Zentrums.

BACKGROUND AND OBJECTIVE: Currently liver transplantation (LTx) is the only effective curative therapy of end-stage primary biliary cirrhosis (PBC). Recent data have shown a recurrence rate of up to 32%. However, many studies are based on only a small number of patients with a marginal follow-up below 10 years. It was the aim of this study to analyse survival and complication rates after LTx among 100 patients in a long-term follow-up of up to 17 years. PATIENTS AND METHODS: Between 1989 and 2006 data of 115 patients receiving LTx for PBC at the Charité Campus Virchow were retrospectively analysed. The median age of 89 women (84%) and 17 men (16%) was 54 years (25-67). RESULTS: Actuarial patient survival rate after 10 and 17 years was 88% and 83%. 13 patients (12%) died after a median survival time of 42 months (0.5-136). Two of these patients developed organ dysfunction due to recurrence of PBC. In addition, histological recurrence was found in 17 patients (16%) after a median time of 61 months (36-158). Survival analysis of hospital stay, preoperative Child-Pugh score, rejection episodes, PBC recurrence and retransplantation showed no significant results. CONCLUSION: Long-term follow-up of up to 17 years after liver transplantation for primary biliary cirrhosis showed excellent survival rates. Both the amount and severity of postoperative complications and the preoperative Child-Pugh score did not affect the long-time survival rate significantly.

Liver transplantation for primary biliary cirrhosis: influence of primary immunosuppression on survival.

INTRODUCTION: Liver transplantation is the only established curative therapy for end-stage primary biliary cirrhosis (PBC). However, the influence of primary immunosuppression on long-term patient and graft survival is still controversial. PATIENTS AND METHODS: Among 1372 patients who underwent liver transplantation from April 1989 to January 2001, 95 (6.9%) suffered from PBC. The primary immunosuppression consisted of cyclosporine (CyA; n = 56) and tacrolimus (FK; n = 39). RESULTS: The median survival of all PBC patients at 5 years was 92% and at 10 years, 90%. There was no difference between the two primary immunosuppression agents. Seven patients died, including five in the cyclosporine group (median = 25 months) and two in the tacrolimus cohort (median = 37 months). One CyA patient group died due to PBC recurrence. Seven patients underwent retransplantation without any difference in primary immunosuppression (CyA 7%; FK 10%). Fifty patients developed an acute rejection episode (CyA 57%; FK 46%); 2 patients, chronic rejection (CyA 2%; FK 4%). Fifty-five patients developed AMA titers after liver transplantation (CyA 66%; FK 46%). Patients presented cyclosporine-based regimens showed significantly (P = .001) more side effects. CONCLUSION: Long-term follow-up after liver transplantation for PBC shows excellent organ and patient survival. The choice of the primary immunsuppressant had no significant influence on patient survival, PBC-related graft loss, or development of acute or chronic rejection episodes.

Coumestrol antagonizes neuroendocrine actions of estrogen via the estrogen receptor alpha.

The phytoestrogen coumestrol has estrogenic actions on peripheral reproductive tissues. Yet in the brain this compound has both estrogenic and anti-estrogenic effects. We used estrogen receptor alpha knockout mice (ERalphaKO) to determine whether coumestrol has estrogenic actions in mice and also if these effects are mediated by the classic ERalpha. Female wild-type (WT) and ERalphaKO mice were ovariectomized and treated with estradiol (E2), dietary coumestrol, both, or neither compound. Ten days later the animals were sacrificed, blood was collected, and brain tissues were perfused. Fixed brains were sectioned and immunocytochemistry was employed to quantify progesterone receptors (PR) in the medial preoptic (POA) and ventromedial nucleus of the hypothalamus (VMN). Plasma was assayed for luteinizing hormone (LH). Estrogen treatment induced PR immunoreactivity in both regions in brains of WT females. In ERalphaKO mice, lower levels of PR were induced. The stimulatory effects of E2 on PR were attenuated in the POA by cotreatment with coumestrol, and the same trend was noted in the VMN. WT ovariectomized females treated with E2 had low levels of LH, while LH was high in untreated females and even higher in ovariectomized females treated with coumestrol. ERalphaKO females in all treatment groups had high levels of LH. Taken together, the results show that coumestrol has anti-estrogenic actions in the brain and pituitary and that ERalpha mediates these effects.

Family members' experiences with decision making for incompetent patients in the ICU: a qualitative study.

BACKGROUND: Understanding the challenges faced by family members involved in decisions about the use of life-sustaining treatment for incompetent patients in the ICU is necessary for developing empirically based supportive interventions. OBJECTIVES: To describe and explain the experiences of family members who were involved in decisions on behalf of their loved ones in order to promote understanding of such experiences and to suggest areas for effective, supportive intervention. METHODS: The grounded-theory method of qualitative research was used. Data collection involved semistructured interviews of 17 persons who had been involved in decisions about the use of life-sustaining treatment for a family member in the ICU. RESULTS: Family members discussed the need to arrive at a judgment of the patient's condition and to work with caregivers to have the family member's decision about life-sustaining treatment enacted. Data analysis suggests that clinicians can best support family members by helping the members arrive at a judgment about the patient's condition and treatment desires and by connecting with the family members to ensure that treatment goals are mutual. Supporting family members in this way helps them accept and go on in a positive way after the experience. CONCLUSIONS: Family members of patients in the ICU are willing and able to take responsibility for decisions about the use of life-sustaining treatment for their loved ones. The long-term acceptance of the experience and the decisions made depends greatly on the interactions between the family member who makes the decision and nurses and physicians in the clinical setting.

A novel immunohistochemical technique for demonstration of specific binding of human monoclonal antibodies to human cryostat tissue sections.

We describe a novel immunohistochemical technique which permits the detection of specific binding of human monoclonal antibodies (MAb) to cryostat sections of human tissues. The technique overcomes the problem of background staining caused by the presence of endogenous immunoglobulins in tissue sections. This is achieved by the formation of a molecular complex of the primary antibody (a human MAb), horseradish peroxidase-conjugated goat anti-human immunoglobulin, and normal human serum. This complex is then incubated with cryostat sections of human tissue, and binding of the complex is demonstrated using diaminobenzidine/hydrogen peroxide. The method is suitable for immunohistochemical screening of small samples of tissue culture supernatant for the presence of human MAb of potential interest, and for determining the pattern of binding of such MAb to a wide range of normal and pathological human tissues.

Immunodetection of human tumour-associated cell-bound antigens by human monoclonal antibodies.

A novel cellular enzyme-linked immunoassay has been developed to detect specific binding of human monoclonal antibodies to target tumour cells obtained by enzymatic disaggregation of surgically resected human colorectal carcinomas. Cell preparations derived from human tissues contain endogenous immunoglobulin. The method described is designed to detect specific binding of a human monoclonal antibody while minimising extraneous background signals caused by the presence of endogenous immunoglobulins in the preparation. This is achieved by first generating immune complexes, which are then incubated with the target cells. The assay is well suited for rapid screening of large numbers of tissue culture supernatants and could be adapted for cells of other tumours. Small quantities of target cells and supernatant are used and the assay can be completed within 5 h.