Preoperative portal vein or portal and hepatic vein embolization: DRAGON collaborative group analysis.

BACKGROUND: The extent of liver resection for tumours is limited by the expected functional reserve of the future liver remnant (FRL), so hypertrophy may be induced by portal vein embolization (PVE), taking 6 weeks or longer for growth. This study assessed the hypothesis that simultaneous embolization of portal and hepatic veins (PVE/HVE) accelerates hypertrophy and improves resectability. METHODS: All centres of the international DRAGON trials study collaborative were asked to provide data on patients who had PVE/HVE or PVE on 2016-2019 (more than 5 PVE/HVE procedures was a requirement). Liver volumetry was performed using OsiriX MD software. Multivariable analysis was performed for the endpoints of resectability rate, FLR hypertrophy and major complications using receiver operating characteristic (ROC) statistics, regression, and Kaplan-Meier analysis. RESULTS: In total, 39 patients had undergone PVE/HVE and 160 had PVE alone. The PVE/HVE group had better hypertrophy than the PVE group (59 versus 48 per cent respectively; P = 0.020) and resectability (90 versus 68 per cent; P = 0.007). Major complications (26 versus 34 per cent; P = 0.550) and 90-day mortality (3 versus 16 per cent respectively, P = 0.065) were comparable. Multivariable analysis confirmed that these effects were independent of confounders. CONCLUSION: PVE/HVE achieved better FLR hypertrophy and resectability than PVE in this collaborative experience.

R0 resection following chemo (radio)therapy improves survival of primary inoperable pancreatic cancer patients. Interim results of the German randomized CONKO-007± trial.

PURPOSE: Chemotherapy with or without radiotherapy is the standard in patients with initially nonmetastatic unresectable pancreatic cancer. Additional surgery is in discussion. The CONKO-007 multicenter randomized trial examines the value of radiotherapy. Our interim analysis showed a significant effect of surgery, which may be relevant to clinical practice. METHODS: One hundred eighty patients received induction chemotherapy (gemcitabine or FOLFIRINOX). Patients without tumor progression were randomized to either chemotherapy alone or to concurrent chemoradiotherapy. At the end of therapy, a panel of five independent pancreatic surgeons judged the resectability of the tumor. RESULTS: Following induction chemotherapy, 126/180 patients (70.0%) were randomized to further treatment. Following study treatment, 36/126 patients (28.5%) underwent surgery; (R0: 25/126 [19.8%]; R1/R2/Rx [n = 11/126; 6.1%]). Disease-free survival (DFS) and overall survival (OS) were significantly better for patients with R0 resected tumors (median DFS and OS: 16.6 months and 26.5 months, respectively) than for nonoperated patients (median DFS and OS: 11.9 months and 16.5 months, respectively; p = 0.003). In the 25 patients with R0 resected tumors before treatment, only 6/113 (5.3%) of the recommendations of the panel surgeons recommended R0 resectability, compared with 17/48 (35.4%) after treatment (p < 0.001). CONCLUSION: Tumor resectability of pancreatic cancer staged as unresectable at primary diagnosis should be reassessed after neoadjuvant treatment. The patient should undergo surgery if a resectability is reached, as this significantly improves their prognosis.

Consensus on definition and severity grading of lymphatic complications after kidney transplantation.

BACKGROUND: The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy. METHODS: Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres. RESULTS: Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention. CONCLUSION: A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies.

ANTECEDENTES: La incidencia de complicaciones linfáticas tras el trasplante renal (post-kidney-transplantation lymphatic, PKTL) varía considerablemente en la literatura. Esto se debe en parte a que no se ha establecido una definición universalmente aceptada. Este estudio tuvo como objetivo proponer una definición aceptable para las complicaciones PKTL y un sistema de clasificación de la gravedad basado en la estrategia de tratamiento. MÉTODOS: Se realizó una búsqueda sistemática de la literatura relevante en MEDLINE y Web of Science. Se logró un consenso para la definición y la clasificación de gravedad de las PKTL entre veinte centros de trasplante de alto volumen. RESULTADOS: En 32 de los 87 estudios incluidos se definía la linforrea/linfocele. Sesenta y tres artículos describían como se trataban las PKTL, pero ninguno calificó la gravedad de las mismas. La definición propuesta para la linforrea fue la de un débito diario superior a 50 ml de líquido (no orina, sangre o pus) a través del drenaje o del orificio cutáneo tras su retirada, más allá del 7º día postoperatorio del trasplante renal. La definición propuesta para linfocele fue la de una colección de líquido de tamaño variable adyacente al riñón trasplantado, tras haber descartado un urinoma, hematoma o absceso. Las PKTL de grado A fueron aquellas con escaso impacto o que no requirieron tratamiento invasivo; las PKTL de grado B fueron aquellas que precisaron intervención no quirúrgica y las PKTL de grado C aquellas en que fue necesaria la reintervención quirúrgica. CONCLUSIÓN: Se propone una definición clara y una clasificación de gravedad basada en la estrategia de tratamiento de las PKTLs. La definición propuesta y el sistema de calificación en 3 grados son razonables, sencillos y fáciles de comprender, y servirán para estandarizar los resultados de las PKTL y facilitar las comparaciones entre los diferentes estudios.

[Complication management after bile duct surgery]. / Komplikationsmanagement nach Gallengangschirurgie.

Bile leakage and postoperative bile duct strictures or anastomotic stenosis after bilioenteric anastomosis are complex surgical complications, which are associated with increased morbidity and mortality. Detailed diagnostics and sophisticated decision-making is always requiered. Complex liver surgery (redo procedures, nonanatomic resections, etc.) and surgery involving the liver hilum or exposure of the intraparenchymal Glissonean sheath are risk factors for postoperative bile leakage. Bile leakage is defined as a bilirubin concentration at least three times greater than the serum bilirubin measured in an abdominal drainage on or after the third postoperative day or as the need for radiologic intervention because of biliary collection or relaparotomy for bile peritonitis. Therapeutic strategies for bile leakage comprise conservative watch and wait, interventional procedures (endoscopic or percutaneous biliary drainage) and relaparotomy and are selected based on the postoperative onset, output volume and anatomic localization of the bile leak. Conservative treatment and interventional procedures show a high success rate and should therefore be considered as the treatment of choice in most cases. In contrast to bile leakage, bile duct strictures and anastomotic stenosis are rarely observed after surgery and can usually be treated by interventional procedures. This review article discusses situation-dependent specific treatment of postoperative bile leakage as well as bile duct strictures and anastomotic stenosis in detail.

Systematic review of team performance in minimally invasive abdominal surgery.

Background: Adverse events in the operating theatre related to non-technical skills and teamwork are still an issue. The influence of minimally invasive techniques on team performance and subsequent impact on patient safety remains unclear. The aim of this review was to assess the methodology used to objectify and rate team performance in minimally invasive abdominal surgery. Methods: A systematic literature search was conducted according to the PRISMA guidelines. Studies on assessment of surgical team performance or non-technical skills of the surgical team in the setting of minimally invasive abdominal surgery were included. Study aim, methodology, results and conclusion were extracted for qualitative synthesis. Results: Sixteen studies involving 677 surgical procedures were included. All studies consisted of observational case series that used heterogeneous methodologies to assess team performance and were of low methodological quality. The most commonly used team performance objectification tools were 'construct'- and 'incident'-based tools. Evidence of validity for the assessed outcome was spread widely across objectification tools, ranging from low to high. Diverse and poorly defined outcomes were reported. Conclusion: Team demands for minimally invasive approaches to abdominal procedures remain unclear. The current literature consists of studies with heterogeneous methodology and poorly defined outcomes.

Elastic TPU Mesh as Abdominal Wall Inlay Significantly Reduces Defect Size in a Minipig Model.

Background: The open abdomen with mesh implantation, followed by early reoperation with fascial closure, is a modern surgical approach in difficult clinical situations such as severe abdominal sepsis. As early fascial closure is not possible in many cases, mesh-mediated fascial traction is helpful for conditioning of a minimized ventral hernia after open abdomen. The aim of this study was to evaluate the clinical utilization of an innovative elastic thermoplastic polyurethane mesh (TPU) as an abdominal wall inlay in a minipig model. Methods: Ten minipigs were divided in two groups, either receiving an elastic TPU mesh or a nonelastic polyvinylidene fluoride (PVDF) mesh in inlay position of the abdominal wall. After 8 weeks, mesh expansion and abdominal wall defect size were measured. Finally, pigs were euthanized and abdominal walls were explanted for histological and immunohistochemical assessment. Results: Eight weeks after abdominal wall replacement, transversal diameter of the fascial defect in the TPU group was significantly smaller than in the PVDF group (4.5 cm vs. 7.4 cm; p = 0.047). Immunhistochemical analysis showed increased Ki67 positive cells (p = 0.003) and a higher number of apoptotic cells (p = 0.047) after abdominal wall replacement with a TPU mesh. Collagen type I/III ratio was increased in the PVDF group (p = 0.011). Conclusion: Implantation of an elastic TPU mesh as abdominal wall inlay is a promising approach to reduce the size of the ventral hernia after open abdomen by mesh-mediated traction. However, this effect was associated with a slightly increased foreign body reaction in comparison to the nonelastic PVDF.

[Intrahepatic cholangiocarcinoma - current perspectives and treatment algorithm]. / Aktueller Therapiealgorithmus des intrahepatischen cholangiozellulären Karzinoms.

Cholangiocarcinoma (CCC) is the second most common primary malignancy of the liver and is typically diagnosed at advanced disease stages. Among curative treatment options for CCC, radical surgical resection with extrahepatic bile duct resection, hepatectomy, and en-bloc lymphadenectomy are considered the mainstay of curative therapy. The assessment of the functional liver reserve by dynamic liver function tests and the estimation of the remaining future liver volume (future liver remnant, FLR) are of paramount importance. The introduction of novel interventional and surgical techniques, such as portal vein embolization, associating liver partition, and portal vein ligation for staged hepatectomy (ALPPS), have enabled clinicians to achieve resectability even in patients previously deemed unresectable. Radiofrequency ablation (RFA) shows acceptable results in small intrahepatic cholangiocarcinoma (IHCC) in liver cirrhosis and should be evaluated if cirrhosis precludes surgical treatment. Transarterial chemoembolization (TACE) or transarterial radioembolization (TARE) alone or in combination with systemic therapy may be applied in cases of surgical irresectability. According to recent results of the British BILCAP trial, adjuvant therapy may be considered after surgical resection in curative intent.

[Oligometastasized colorectal cancer-modern treatment strategies]. / Oligometastasierung beim kolorektalen Karzinom ­ moderne Therapiekonzepte.

BACKGROUND: The prognosis of colorectal cancer in UICC stage IV has been improved in the last decades by improvements in interdisciplinary treatment. MATERIAL AND METHODS: Treatment strategies for oligometastasized colorectal cancer are developing more and more into an individualized treatment. An overview of the current literature of modern treatment concepts in oligometastasized colorectal cancer UICC stage IV is given. RESULTS: Surgery still has the supreme mandate in resectable colorectal liver metastases, as neoadjuvant and adjuvant treatment strategies to not provide any benefits for these patients. In marginal or non-resectable stages systemic treatment is superior in these patients depending on the prognostic parameters. Also in curative settings local treatment options should be considered as a reasonable additive tool. An interesting treatment approach for isolated liver metastases and non-resectable colorectal cancer is liver transplantation. CONCLUSION: Irrespective of new developments in treatment strategies for metastasized colorectal cancer, resection of colorectal liver metastases remains the gold standard whenever possible.

MRI Evaluation of an Elastic TPU Mesh under Pneumoperitoneum in IPOM Position in a Porcine Model.

BACKGROUND: The frequency of laparoscopic approaches increased in hernia surgery over the past years. After mesh placement in IPOM position, the real extent of the meshes configurational changes after termination of pneumoperitoneum is still largely unknown. To prevent a later mesh folding it might be useful to place the mesh while it is kept under tension. Conventionally used meshes may lose their Effective Porosity under these conditions due to poor elastic properties. The aim of this study was to evaluate a newly developed elastic thermoplastic polyurethane (TPU) containing mesh that retains its Effective Porosity under mechanical strain in IPOM position in a porcine model. It was visualized under pneumoperitoneum using MRI in comparison to polyvinylidenefluoride (PVDF) meshes with similar structure. METHODS: In each of ten minipigs, a mesh (TPU containing or native PVDF, 10 × 20 cm) was randomly placed in IPOM position at the center of the abdominal wall. After 8 weeks, six pigs underwent MRI evaluation with and without pneumoperitoneum to assess the visibility and elasticity of the mesh. Finally, pigs were euthanized and abdominal walls were explanted for histological and immunohistochemical assessment. The degree of adhesion formation was documented. RESULTS: Laparoscopic implantation of elastic TPU meshes in IPOM position was feasible and safe in a minipig model. Mesh position could be precisely visualized and assessed with and without pneumoperitoneum using MRI after 8 weeks. Elastic TPU meshes showed a significantly higher surface increase under pneumoperitoneum in comparison to PVDF. Immunohistochemically, the amount of CD45-positive cells was significantly lower and the Collagen I/III ratio was significantly higher in TPU meshes after 8 weeks. There were no differences regarding adhesion formation between study groups. CONCLUSIONS: The TPU mesh preserves its elastic properties in IPOM position in a porcine model after 8 weeks. Immunohistochemistry indicates superior biocompatibility regarding CD45-positive cells and Collagen I/III ratio in comparison to PVDF meshes with a similar structure.

Surgical treatment options following chemotherapy plus cetuximab or bevacizumab in metastatic colorectal cancer-central evaluation of FIRE-3.

BACKGROUND: The FIRE-3 trial investigated combination chemotherapy plus either cetuximab or bevacizumab in patients with untreated metastatic colorectal cancer (mCRC) not scheduled for upfront surgery. We aimed to determine the number of patients who present with potentially resectable disease during systemic first-line therapy and to compare the findings with study reports concerning resections and outcome. PATIENTS AND METHODS: This evaluation of 448 patients was performed as central review blinded for treatment, other reviewers' evaluations and conducted interventions. Resectability was defined if at least 50% of the reviewers recommended surgical-based intervention. Overall survival was assessed by Kaplan-Meier method. RESULTS: Resectability increased from 22% (97/448) at baseline before treatment to 53% (238/448) at best response (P < 0.001), compared with an actual secondary resection rate for metastases of 16% (72/448). At baseline (23% versus 20%) and best response (53% versus 53%), potential resectability of metastases in this molecular unselected population was similar in cetuximab-treated patients versus bevacizumab-treated patients and not limited to patients with one-organ disease. The actual resection rate of metastases was significantly associated with treatment setting (P = 0.02; university hospital versus hospital/practice). Overall survival was 51.3 months (95% confidence interval [CI] 35.9-66.7) in patients with resectable disease who received surgery, 30.8 months (95% CI 26.6-34.9) in patients with resectable disease without surgery and 18.6 months (95% CI 15.8-21.3) in patients with unresectable disease (P < 0.001). CONCLUSIONS: Our findings illustrate the potential for conversion to resectability in mCRC, certain reluctance towards metastatic resections in clinical practice and the need for pre-planned and continuous evaluation for metastatic resection in high-volume centres. CLINICALTRIALS. GOV-IDENTIFIER: NCT00433927.

Impact of Preoperative Three-Dimensional Computed Tomography Cholangiography on Postoperative Resection Margin Status in Patients Operated due to Hilar Cholangiocarcinoma.

INTRODUCTION: The purpose of this study was to analyse the value of 3-dimensional computed tomography cholangiography (3D-ERC) compared to conventional retrograde cholangiography in the preoperative diagnosis of hilar cholangiocarcinoma (HC) with special regard to the resection margin status (R0/R1). PATIENTS AND METHODS: All hepatic resections performed between January 2011 and November 2013 in patients with HC at the Department of General, Visceral and Transplant Surgery of the RWTH Aachen University Hospital were analysed. All patients underwent an ERC and contrast-enhanced multiphase CT scan or a 3D-ERC. RESULTS: The patient collective was divided into two groups (group ERC: n = 17 and group 3D-ERC: n = 16). There were no statistically significant differences between the two groups with regard to patient characteristics or intraoperative data. Curative liver resection with R0 status was reached in 88% of patients in group ERC and 87% of patients in group 3D-ERC (p = 1.00). We could not observe any differences with regard to postoperative complications, hospital stay, and mortality rate between both groups. CONCLUSION: Based on our findings, preoperative imaging with 3D-ERC has no benefit for operative planning and R0 resection status. It cannot replace the exploration by an experienced surgeon in a centre for hepatobiliary surgery.

Risk factors for morbidity after appendectomy.

INTRODUCTION: The aim of the present study was to evaluate the risk factors for postoperative complications after an appendectomy with special regard to both the time period from hospital admission to operation and night time surgery. PATIENTS AND METHODS: Patients who underwent an appendectomy due to acute appendicitis and were admitted to the University Hospital Aachen between January 2003 and January 2014 were included in this retrospective analysis. Regarding the occurrence of postoperative complications, patients were divided into the following two groups: the group with complications (group 1) and the group without complications (group 2). RESULTS: Of the 2136 patients who were included in this study, 165 patients (group 1) exhibited complications, and in 1971 patients (group 2), no complications appeared. After a univariate logistic regression analysis, six predictors for postoperative complications were found and are described as follows: (1) complicated appendicitis (odds ratio (OR) 4.8 (3.46-6.66), p < 0.001), (2) operation at night (OR 1.62 (1.17-2.24), p = 0.004), (3) conversion from laparoscopic to open access (OR 37.08 (12.95-106.17), p < 0.001), (4) an age > 70 years (OR 6.00 (3.64-9.89), p < 0.001), (5) elevated CRP (OR 1.01 (1.01-1.01), p < 0.001) and (6) increased WBC count (OR 1.04 (1.01-1.07), p = 0.003). After multivariate logistic regression analysis, a significant association was demonstrated for complicated appendicitis (1.88 (1.06-3.32), p < 0.031), conversion to open access (OR 16.33 (4.52-58.98), p < 0.001), elevated CRP (OR 1.00 (1.00-1.01), p = 0.017) and an age > 70 years (OR 3.91 (2.12-7.21), p < 0.001). The time interval between hospital admission and operation was not associated with postoperative complications in the univariate and multivariate logistic regression analyses, respectively. However, the interaction between complicated appendicitis and the time interval to operation was significant (OR 1.024 (1.00-1.05), p = 0.028). CONCLUSION: Based on our findings, surgical delay in the case of appendicitis and operation at night did not increase the risk for postoperative complications. However, the mean waiting time was less than 12 h and patients aged 70 years or older were at a higher risk for postoperative complications. Furthermore, for the subgroup of patients with complicated appendicitis, the time interval to surgery had a significant influence on the occurrence of postoperative complications. Therefore, the contemporary operation depending on the clinical symptoms and patient age remains our recommendation.

Rectal foreign body insertion as a rare cause of persistent lumbosacral plexus injury.

Rectal foreign body insertion is a common condition in emergency surgery, which often requires surgical intervention. Here we report a clinical case of rectal foreign body insertion as a rare cause of persistent lumbosacral plexus injury. A 72-year-old man presented to the emergency department complaining of acute bilateral paraplegia with loss of sensation in both legs, as well as total urinary retention. The patient underwent abdominal computed tomography, which showed a rectal foreign body measuring 13 × 11.5 × 10 cm in the lower abdomen and pelvis. Extraluminal assistance through a median laparotomy was required after unsuccessful attempts at transanal recovery alone. After removal of the foreign body, the rectal wall and anorectal sphincter were massively dilated, with severe bruising of the rectal mucosa on proctoscopy. A protective loop-ileostomy was performed. The sacral plexus is located posteriorly in the pelvis. Physiologically, the nerves are well protected by surrounding anatomical structures. Post-traumatic lumbosacral plexus injuries with paraplegia, urinary retention and anorectal sphincter insufficiency occur quite frequently after heavy traffic accidents. Lumbosacral plexus injury as a result of rectal foreign body insertion is rare. Severe neurological deficits through rectal foreign body insertion are rare but known medical conditions. To the best of our knowledge, this is the first reported case of severe and persistent post-traumatic lumbosacral plexus injury through a rectal foreign body.

Surgical sutures: coincidence or experience?

BACKGROUND: Knotting sutures by hand is still important in daily surgical routine, especially laparotomy closure. The expectation is that hand suturing relies on the experience and subjective estimation of the surgeon. The aim of this study was to investigate whether hand suturing tension is reproducible and if surgical experience influences reproducibility. METHODS: At the annual Congress of the German Association of Surgery, 118 surgeons performed repetitive sutures on a standardized and certified measuring device simulating the final knot of a fascial closure. Each surgeon was asked to perform five identical single knots in a row using the suture tension that each considered ideal. Tension during knotting was measured in Newtons. The surgeons were divided into five subgroups based on surgical experience: group 1, <1 year; group 2, 2-5 years; group 3, 6-10 years; group 4, 11-20 years; and group 5, >30 years. RESULTS: The tension measured at the end of knotting ranged from 0.19 to 10 N. The mean suture tension at endpoint was 3.88 N for group 1 and slightly higher in the other groups, but not significantly different. The overall mean suture tension was 5.43 N and did not correlate with surgical experience. Suture tension was not reproducible. CONCLUSION: Sequential suture tension varied, even among experienced surgeons. The ideal tissue-dependent suture tension has not been defined. Measured values appear to be intuitive, relying on individual feeling rather than the level of experience.

Randomized clinical trial of open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery programme (ORANGE II study).

BACKGROUND: Laparoscopic left lateral sectionectomy (LLLS) has been associated with shorter hospital stay and reduced overall morbidity compared with open left lateral sectionectomy (OLLS). Strong evidence has not, however, been provided. METHODS: In this multicentre double-blind RCT, patients (aged 18-80 years with a BMI of 18-35 kg/m2 and ASA fitness grade of III or below) requiring left lateral sectionectomy (LLS) were assigned randomly to OLLS or LLLS within an enhanced recovery after surgery (ERAS) programme. All randomized patients, ward physicians and nurses were blinded to the procedure undertaken. A parallel prospective registry (open non-randomized (ONR) versus laparoscopic non-randomized (LNR)) was used to monitor patients who were not enrolled for randomization because of doctor or patient preference. The primary endpoint was time to functional recovery. Secondary endpoints were length of hospital stay (LOS), readmission rate, overall morbidity, composite endpoint of liver surgery-specific morbidity, mortality, and reasons for delay in discharge after functional recovery. RESULTS: Between January 2010 and July 2014, patients were recruited at ten centres. Of these, 24 patients were randomized at eight centres, and 67 patients from eight centres were included in the prospective registry. Owing to slow accrual, the trial was stopped on the advice of an independent Data and Safety Monitoring Board in the Netherlands. No significant difference in median (i.q.r.) time to functional recovery was observed between laparoscopic and open surgery in the randomized or non-randomized groups: 3 (3-5) days for OLLS versus 3 (3-3) days for LLLS; and 3 (3-3) days for ONR versus 3 (3-4) days for LNR. There were no significant differences with regard to LOS, morbidity, reoperation, readmission and mortality rates. CONCLUSION: This RCT comparing open and laparoscopic LLS in an ERAS setting was not able to reach a conclusion on time to functional recovery, because it was stopped prematurely owing to slow accrual. Registration number: NCT00874224 ( https://www.clinicaltrials.gov).

Effect of Age on Liver Function in Patients Undergoing Partial Hepatectomy.

BACKGROUND: Postresectional liver failure is the most frequent cause of fatal outcome following liver surgery. Diminished preoperative liver function in the elderly might contribute to this. Therefore, the aim of the present study was to evaluate preoperative liver function in patients <60 or >70 years of age scheduled for liver resection. METHODS: All consecutive patients aged <60 or >70 years who are about to undergo elective liver surgery between 2011 and 2013 and underwent the methacetin breath liver function test (LiMAx) preoperatively were included. Histologic assessment of the resected liver gave insight into background liver disease. Correlation between age and liver function was calculated with Pearson's test. RESULTS: Fifty-nine patients were included, 31 were aged <60 and 28 were aged >70 years. General patient characteristics and liver function LiMAx values (340 (137-594) vs. 349 (191-530) µg/kg/h, p = 0.699) were not significantly different between patients aged <60 and >70 years. Moreover, no correlation between age and preoperative liver function LiMAx values was found (R = 0.04, p = 0.810). CONCLUSION: Liver function did not seem to differ between younger and older patients.

[Rectal perforation : A rare complication following radiotherapy]. / Rektumperforation : Eine seltene Komplikation nach Strahlentherapie.

BACKGROUND: Radiotherapy in the treatment of prostate cancer is well established. Intestinal complications following radiotherapy are divided into acute and chronic toxicity. Chronic complications like perforation and fistula formation to the rectum are rare and difficult to treat. MATERIALS AND METHODS: In case of chronic radiotherapy complications and particularly chronic fistula formation to the rectum, evidence is low. Therefore, an overview of the available literature of surgical therapy strategies is given. RESULTS: Options for the treatment of acute intestinal toxicity are established and therapy algorithms exist. Therapy of acute rectal perforation covers primary suture repair with or without diversion stoma as well as primary rectal resection with or without primary restoring bowel continuity. In chronic rectal lesions and particularly in fistula formation to the rectum, abdominal treatment strategies are preferred with additional interposition of an omental flap or vascularized muscle flap. CONCLUSION: Although evidence for surgical therapy strategies of the rare chronic rectourethral and rectovesical fistula is low, treatment is a real interdisciplinary challenge and should be provided in a specialized center.

[Video-assisted retroperitoneal debridement : Minimally invasive treatment and long-term results for necrotizing pancreatitis]. / Videoassistiertes retroperitoneales Débridement : Minimalinvasive Therapie und Langzeitverlauf bei nekrotisierender Pankreatitis.

BACKGROUND: Among patients with necrotizing pancreatitis 15-20% develop infected necrosis, which entails mortality rates of up to 20%. Particularly driven by the results of the Dutch Pancreatitis Study Group there has been a paradigm change from open necrosectomy to step-up treatment with initial percutaneous and/or endoscopic drainage followed, if necessary, by minimally invasive retroperitoneal debridement. AIM OF THE STUDY: Description of case series in which patients underwent video-assisted retroperitoneal debridement (VARD) including follow-up focused on quality of life. METHODS: Systematic cohort study including all patients who underwent a VARD procedure at the Department of General, Visceral and Transplantation Surgery at Aachen University Hospital from 2011 to 2015. Quality of life was recorded using the EORTC QLQ-C 30 questionnaire and compared to a representative sample of the German general population. RESULTS: The VARD procedure was performed in 9 cases, although in 1 case conversion to an open approach due to an acute bleeding was necessary. There was no 30-day and 60-day mortality following VARD. During the postoperative stay no patient required specific treatment for surgical complications. In particular, no enterocutaneous fistula or organ perforation was observed. Regarding the quality of life score there was no significant difference concerning the global health status, compared to the sample from the general population. DISCUSSION: Our data reinforce that a step-up approach in patients with necrotizing pancreatitis is a feasible and safe treatment procedure. For the first time, we could demonstrate satisfactory results in a long-term follow-up including QOL.

Port-site incisional hernia - A case series of 54 patients.

BACKGROUND: The increased use of laparoscopy has resulted in certain complications specifically associated with the laparoscopic approach, such as port-site incisional hernia (PIH). Until today, it is not finally clarified if port-site closure should be performed by fascia suture or not. Furthermore, the optimal treatment strategy in PIH (suture vs. mesh) is still widely unclear. The aim of this study was to present our experience with PIH in two independent departments and to derive possible treatment strategies from these results. METHODS: Between 2003 and 2013, 54 patients were operated due to port-site incisional hernia in two surgical centres. Their data were collected and retrospectively analyzed depending on surgical technique of port-site hernia repair (Mesh repair group, n = 13 vs. Suture only group, n = 41). RESULTS: Port site incisional hernia occurred in 96% (52 patients) after the use of trocars with 10 mm or larger diameter. Patients treated with mesh repair had significantly higher body mass index (BMI) (32 ± 9 vs. 27 ± 4; p = 0.023) and significantly higher rates of cardiac diseases (77% vs. 39%; p = 0.026) than patients in the suture only group. Mean fascial defect size was significantly larger in the Mesh repair group than in the Suture only group (31 ± 24 mm vs. 24 ± 32 mm; p = 0.007) and mean time of operation was significantly longer in patients operated with mesh repair (83 ± 47 min vs. 40 ± 28 min; p < 0.001). There were no significant differences in mean hospital stay (3 ± 4 days; p = 0.057) and hernia recurrence rates (9%; p = 0.653) between study groups. Mean time of follow up was 32 ± 35 months. CONCLUSIONS: In Port sites of 10 mm and larger diameter fascia should be closed by suture, whereas the risk of hernia development in 5 mm trocar placements seems to be a rare complication. Port-site incisional hernia should be treated by suture or mesh repair depending on fascial defect size and the patients' risk factors regarding preexisting deseases and body mass index.