Sphincter-saving therapy for fistula-in-ano: long-term follow-up after FiLaC®.

BACKGROUND: The treatment of anal fistula remains a challenge between maintaining continence and radical surgery to prevent recurrence. Fistula-tract Laser Closure (FiLaC®) is a sphincter-saving technique using a radial emitting laser fibre to close the fistula tract. The aim of this study was to report long-term outcomes in patients who received FiLaC® therapy for transsphincteric and intersphincteric anal fistula between January 2011 and December 2017. METHODS: A retrospective study was performed on patients who were treated with FiLaC®- for a transsphincteric and intersphincteric anal fistula at our institution between January 2011 and December 2017. In all patients, the FiLaC® procedure was combined with a closure of the internal orifice using a simple 3-0 Z stitch. Patient characteristics, previous proctological history, healing rates, failures and postoperative continence were investigated. RESULTS: The study included 83 patients [mean age 50.01 ± 14.59 years. 64 (77.1%) males] with a mean follow-up period of 41.99 (± 21.59) months (range 4-87 months). Thirteen patients (15.7%) had a recurrent fistula. 65 patients (78.3%) had undergone prior abscess drainage with insertion of a seton. The primary healing rate was 74.7% (62 of 83 patients) overall. Eleven (13.3%) of the 21 patients (25.3%) who failed FiLaC®-therapy underwent a second operation. In eight cases, Re-FiLaC® and in three cases, fistulectomy with closure of the internal orifice was performed. Afterwards 6 (54.5%) of these 11 patients could be considered cured: 3 who had fistulectomy and three who had Re-FiLaC® treatment. The overall healing rate after second FiLaC® was 78.3% (65 of 83 patients) while the overall healing rate for FiLaC® therapy combined with any second procedure was 81.9% (68 of 83 patients). The follow-up period in this group of 11 patients who received re-operation was 38 months (range 13-84 months). Changes in continence occurred in eight patients (9.6%). No patient reported major incontinence postoperatively. CONCLUSIONS: The FiLaC® procedure is associated with good healing rates in long-term follow-up and should be considered as a treatment option for transsphincteric and intersphincteric anal fistulae, especially due to the low complication rate and low risk of sphincter injury.

[Clinical nutrition in surgery. Guidelines of the German Society for Nutritional Medicine]. / Klinische Ernährung in der Chirurgie. S3-Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin e. V.

BACKGROUND: While enhanced recovery after surgery (ERAS) programs are the standard for perioperative management, special nutritional care has to be administered to malnourished patients and those at metabolic risk with special regard to patients with postoperative complications. METHODS: Existing guidelines of the German and European societies of nutritional medicine (DGEM and ESPEN) on enteral and parenteral nutrition in surgery were merged and in accordance with the principles of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, German Association of the Scientific Medical Societies) and Ärztliches Zentrum für Qualität in der Medizin (AeZQ, German Agency for Quality in Medicine) revised and extended. RESULTS AND DISCUSSION: The working group developed 41 consensus-based recommendations for perioperative nutrition. The recommendation strength is: 9x A (recommendation based on significant good quality literature containing at least one randomized controlled trial), 12x B (recommendation based on well-designed trial without randomization), 13x C (recommendation based on expert opinions and/or clinical experience of respected authorities) and 7x CCP (clinical consensus point). CONCLUSION: Even in patients without obvious malnutrition perioperative nutritional support is indicated when oral food intake is not feasible or inadequate for a longer period of time.

Lipid emulsions - Guidelines on Parenteral Nutrition, Chapter 6.

The infusion of lipid emulsions allows a high energy supply, facilitates the prevention of high glucose infusion rates and is indispensable for the supply with essential fatty acids. The administration of lipid emulsions is recommended within < or =7 days after starting PN (parenteral nutrition) to avoid deficiency of essential fatty acids. Low-fat PN with a high glucose intake increases the risk of hyperglycaemia. In parenterally fed patients with a tendency to hyperglycaemia, an increase in the lipid-glucose ratio should be considered. In critically ill patients the glucose infusion should not exceed 50% of energy intake. The use of lipid emulsions with a low phospholipid/triglyceride ratio is recommended and should be provided with the usual PN to prevent depletion of essential fatty acids, lower the risk of hyperglycaemia, and prevent hepatic steatosis. Biologically active vitamin E (alpha-tocopherol) should continuously be administered along with lipid emulsions to reduce lipid peroxidation. Parenteral lipids should provide about 25-40% of the parenteral non-protein energy supply. In certain situations (i.e. critically ill, respiratory insufficiency) a lipid intake of up to 50 or 60% of non-protein energy may be reasonable. The recommended daily dose for parenteral lipids in adults is 0.7-1.3 g triglycerides/kg body weight. Serum triglyceride concentrations should be monitored regularly with dosage reduction at levels >400 mg/dl (>4.6 mmol/l) and interruption of lipid infusion at levels >1000 mg/dl (>11.4 mmol/l). There is little evidence at this time that the choice of different available lipid emulsions affects clinical endpoints.

[Elective colon resection in Germany. A survey of the perioperative anesthesiological management]. / Elektive Kolonresektionen in Deutschland. Umfrage zum perioperativen anästhesiologischen Management.

BACKGROUND: Fast-track rehabilitation after elective colon resection is an interdisciplinary multimodal procedure, which combines surgical and anesthesiological aspects. This leads to an improved and accelerated recovery and avoids perioperative complications. This survey focuses on the extent and use of such concepts in Germany. METHODS: In January 2006, a questionnaire was sent to 1270 anesthesiology departments in Germany in which they were asked to describe the standard anesthesia procedures based on a conventional sigmoid resection. RESULTS: The response rate was 385 out of 1270 (30.3%). Preoperative fasting of solid food 12 h before the operation was practiced in 52% and for 6 h in 44% of the clinics. For fluid intake the fasting time was 6 h in 47% and 2 h in 41%. Prophylactic measures for postoperative nausea and vomiting (PONV) were administered in 33% of clinics. Propofol (68%) was the leading narcotic, fentanyl (56%) and sufentanil (48%) were the most commonly used intraoperative analgesics and 75% of clinics used epidural analgesia. CONCLUSION: In Germany the anesthesiological treatment after elective colon surgery adheres broadly to the evidence-based recommendations for fast-track concepts.

[A survey of perioperative therapy for elective colon resection in Germany, 2006]. / Umfrage zur perioperativen Therapie bei elektiven Kolonresektionen in Deutschland 2006.

BACKGROUND: Despite the evidence that fast-track concepts in colon surgery lead to an enhanced recovery rate, there is no information on the prevalence and utilization of such programs in Germany. METHODS: Based on a conventional sigmoid resection, we asked 1,270 surgical departments in Germany to describe their standard surgical procedures in a questionnaire. RESULTS: The response rate was 385 (30.31%). A total of 96% use a bowel preparation, 83% a vertical incision, 10% use a nasogastric decompression for longer then 1 day, 34% avoid intra-abdominal drains, 51% allow clear fluids on the day of surgery, 13% offer solid food on the first day after surgery, 75% use epidural analgesia and 47% discharge the patients by the seventh day after surgery. CONCLUSION: Although there is an evident benefit using fast-track concepts, they are not yet in wide use as a standard procedure. Further efforts have to be made to ensure that the majority of patients will benefit from these concepts.

[Minimally invasive unicondylar knee replacement with computer navigation]. / Minimal-invasive navigiert implantierte unikondyläre Knieendoprothese.

METHODS: From January 2003 to July 2005 a total of 50 St Georg medial knee monosleds with metal-backed tibial components in stably seated form and Uniglide prostheses (Alphanorm/Corin) with mobile bearing onlays were implanted in minimally invasive operations. Postoperatively the alignment-especially of the tibial components-was investigated, to check whether we had achieved the dorsal slope we had been aiming at, i.e. 5-7 degrees , in the region of these knee replacements. RESULTS: Before surgery there were initial malalignments of up to 10 degrees varus and 3 degrees valgus. All leg axes were restored to between -3 degrees and +3 degrees . The desired dorsal slope of 5-7 degrees for the knee monosleds relative to the tibial component was realized, the average slope being 5.3 degrees . The a-p alignment of the tibial component and of the femoral component was correct. CONCLUSIONS: Use of the navigation system leads to more accurate and reproducible results in terms of tibial dorsal slope, which is extremely important when these monosleds are used. Overcorrection of the leg axis is generally avoided. The use of too-high medial onlays is also reliably avoided by the navigation system's monitoring of the level of the cut.

[Pancreatic elastase-1 in the stool for the determination of exocrine pancreas function of postoperative patients with early enteral nutrition -- a pilot study]. / Pankreas-Elastase-1 im Stuhl zur Bestimmung der exokrinen Pankreasfunktion unter frühpostoperativer enteraler Ernährung -- Pilotstudie.

BACKGROUND AND OBJECTIVE: There are only incomplete data about exocrine pancreatic function after major gastrointestinal surgery. Early enteral nutrition with high-molecular diets is increasingly administered to these patients. A knowledge of exocrine secretion of the pancreas is crucial, because pancreatic enzymes are needed for the adsorption of the high-molecular diets. To determine the exocrine pancreatic secretion the fecal elastase-1 is a sensitive method for measuring exocrine pancreatic secretion. PATIENTS AND METHODS: In a prospective study fecal elastase-1 was measured in patients on enteral nutrition (n=12) early after major gastrointestinal operations. They were given a high molecular diet via an intraoperatively placed small-needle catheter jejunostomy, starting 12 hours after operation with a continuous infusion of 20 ml/h (1 kcal/ml),increased to 80 ml/h during the next few days. Samples from the first and second stools after beginning the enteral nutrition were taken for measuring the fecal elastase-1. RESULTS: All patients fed enterally had no relevant feeding-associated complications and no diarrhea. The elastase-1 concentrations were normal in both the first and the second stool samples in all patients (normal stool elastase is > 200 g/g). The average elastase concentration in the first stool sample was 361,4 mg/g (median: 317 mg/g) and 454 mg/g in the second (median: 466,6 mg/g). Thus no exocrine pancreatic insufficiency was detected in any of the patients. CONCLUSION: The results of elastase-1 in stool demonstrate that severe exocrine pancreas dysfunction is not generally present in patients on early enteral nutrition after major gastrointestinal surgery.

Laparoscopic needle catheter jejunostomy: modification of the technique and outcome results.

BACKGROUND: We describe a modification of the technique for laparoscopic jejunostomy in patients with stenosis of the upper gastrointestinal tract and assess the patients outcomes with this enteral access. METHODS: In a retrospective study of 80 patients, we evaluated the outcome of a modified technique for the laparoscopic placement of a jejunostomy catheter into the proximal jejunum. Standard laparoscopy equipment and ready-to-use jejunostomy catheters were used. After the creation of a pneumoperitoneum, the proximal jejunal loop was fixed to the parietal peritoneum. The jejunum was then punctured with a split needle, and the catheter (9F) was pushed into the jejunum. Finally, the catheter was secured with an additional purse-string suture. The external fixation was performed with nonabsorbable sutures. Enteral nutritional support with a polymeric enteral diet was initiated after fluoroscopic control on the first postoperative day at a rate of 20 ml/h. The flow rate was increased progressively until the nutritional goal of 60-80 ml/h was reached on the 3rd or 4th postoperative day. RESULTS: In all patients (n = 80), the placement site of the catheter was correct, and all patients were able to receive enteral nutrition on the 1st postoperative day. There were no intraoperative complications. The mean operating time was 51 min. Two patients developed a localized infection at the catheter site; one patient developed an abscess; and three patients had catheter obstructions. CONCLUSIONS: Patients in need of intermediate or long-term enteral nutrition may benefit from laparoscopic catheter jejunostomy. The technique described is safe, effective, and less invasive than alternative techniques of laparoscopic jejunostomy.

Structure and organisation of 47 nutrition support teams in Germany: a prospective investigation in 2000 German hospitals in 1999.

OBJECTIVE: Evaluation. Contrary to the Anglo-American region, very little is known in Germany on the structure and organisation of nutrition support teams (NST). DESIGN: Prospective investigation of the structure and organisation of German NST, using standardised interview questionnaires. SETTINGS: Hospitals with more than 250 beds in Germany. SUBJECTS: German NST (n=47). INTERVENTIONS: Face-to-face interview in 1999, using a standardised questionnaire. RESULTS: From a total of 2000 German hospitals, NST have been established at 47 hospitals (2.3%). Most NST are affiliated to a large university hospital or an academic teaching hospital. In general, the NST are not independently operating units but are affiliated to a special discipline, and were in operation for an average of 8 y. The NST cared for a median of 65 outpatients annually. At the university hospitals in average, 477 in-patients were treated per year, at the teaching hospitals 400 and at all other hospitals 179. The work of the NST centred on enteral nutrition. A total of 47% of the physicians, 19% of the nurses and 19% of the dietitians in the NST held a nutrition-specific additional qualification. A total of 2% of the physicians, 68% of the nurses and 77% of the dietitians are exclusively responsible for the NST. More than 70% of the financing of the personnel was secured through third-party funds. CONCLUSION: In Germany, neither uniform nor comprehensive patient care by NST existed in 1999. More than 50% of all NST members do not hold a nutrition-specific additional qualification. Frequently, besides their tasks in the team, the NST staff also carries out other clinical functions. Contrary to the American NST, the German NST are not interdisciplinary operating units but are primarily financed through third-party funds of the industry.

Impact of omega-3 fatty acid enriched TPN on leukotriene synthesis by leukocytes after major surgery.

Major surgery leads to post-traumatic immune dysregulation which is driven by the activation of potent proinflammatory mediators including the leukotrienes (LTs). The LTs of the four-series derive from arachidonic acid (an omega-6 fatty acid). In contrast, LTs of the five-series are metabolic products of eicosapentaenoic acid (an omega-3 fatty acid) and exert less biological activities. Therapeutical strategies to attenuate proinflammatory signals include the provision of omega-3 fatty acids. Thirty patients with major elective abdominal surgery and an indication for total parenteral nutrition (TPN) were compared in a prospective, double blind, randomized study of two parallel groups. Group 1 (n=14) received an omega-3 fatty acid enriched 20% lipid emulsion (MCT:LCT:fish oil = 5:4:1, MLF541; Lipoplus) for 5 days postoperatively. Group 2 (n=16) received a standard 20% fat emulsion (LCT; Intralipid). The LT release from whole blood leukocytes stimulated with Ca-ionophore was analyzed preoperatively and on postoperative days 1, 6 and 8 by HPLC. There was a significant increase in the generation of LTB(5) (P=0.0035) and in the ratio of LTB(5)/LTB(4) (P=0.0017) the omega-3 group, but not in the reference group after 5 days infusion of the lipid emulsions. The omega-6/omega-3 fatty acid ratio 3:1 of the newly developed MLF541 lipid emulsion is appropriate to increase the synthesis of the biologically less active leukotrienes of the five-series. Nutritive enrichment with omega-3 fatty acids in a balanced ratio with omega-6 fatty acids is an important step to avoid hyperinflammatory situations in patients after major surgery.

[Preoperative fasting. An update]. / Präoperative Nahrungskarenz. Ein update.

In Germany the predominant standard of preoperative care for elective surgery is fasting after midnight, with the aim of reducing the risk of pulmonary aspiration. However, for the past several years the scientific evidence supporting such a practice has been challenged. Experimental and clinical studies prove a reliable gastric emptying within 2 h suggesting that, particularly for limited intake of clear fluids up to 2 h preoperatively, there would be no increased risk for the patient. In addition, the general incidence of pulmonary aspiration during general anaesthesia (before induction, during surgery and during recovery) is extremely low, has a good prognosis and is more a consequence of insufficient airway protection and/or inadequate anaesthetic depth rather than due to the patient's fasting state. Therefore, primarily to decrease perioperative discomfort for patients, several national anaesthesia societies have changed their guidelines for preoperative fasting. They recommend a more liberal policy regarding per os intake of both liquid and solid food, with consideration of certain conditions and contraindications. The following article reviews the literature and gives an overview of the scientific background on which the national guidelines are based. The intention of this review is to propose recommendations for preoperative fasting regarding clear fluids for Germany as well.

[Long-term results of benign bile duct strictures after treatment with pedicled jejunal patches]. / Langzeitergebnisse nach Behandlung benigner Gallengangsstrikturen mit gestieltem Jejunumstreifen.

Benign strictures of the common bile duct after surgery or due to gallstones may lead to obstruction and derangement of bile drainage in the extrahepatic biliary system. Although the treatment of choice in these situations is the endoscopic dilatation, in some cases with stenosis of a long segment of the bile duct a partial replacement with a vascularised jejunal patch may be possible and useful. To our knowledge, there are no reports on long-term results of the procedure. We describe the course, the surgical technique and long-term results of four patients with a jejunal patch reconstruction of the common bile duct. Ten years after surgery there were no radiologic or laboratory signs of a restenosis of the common bile duct.

[Requirement for the structure and function of a nutritional support team]. / Anforderungen an Struktur und Funktion eines Ernährungsteams. Projektgruppe KlinischerErnährung (PROKER).

Procedures in clinical nutrition have gained both invasiveness as well as the complexity. Thus improved education of professionals and their alliance in hospital based nutritional support teams (NST) is demanding. Two forms of collaboration, the "interdisciplinary nutritional committee" and the "department for nutritional therapy", are discussed. It is the goal of this contribution to present structure and tasks of an independently working department for nutritional support therapy. The pertinent areas of activity are composed as followed: clinical nutritional therapy, home nutrition, education, research, and quality management. The team members include the physician, the dietitian, the nurse, the nutritionist, and the pharmacist. The individual tasks as well as the areas of responsibility are presented. We discuss, whether nutritional support teams might be suitable to achieve cost reduction, provided adequate working conditions are available. Issues like "performance related reimbursement" and "NST certification" by health care organizations are discussed. We also elude to the option to merge services with other health care providers in order to built up an inter-disciplinary organization system. We conclude that nutritional support teams have to be prepared to meet hospital needs. Costs/benefit balances have to be assessable and must be documented. Although the effectiveness of selected nutritional support teams was clearly shown, it is the challenge of each individual team to produce proof of effectiveness for itself. Acceptable working conditions, however, should be provided as they have to be considered indispensable to achieve high quality performance.

[Post-traumatic intrahepatic arterioportal fistula]. / Die posttraumatische intrahepatische arterioportale Fistel.

Traumatic arterioportal fistulas (APF) are very rare. The most common reasons are liver biopsy and liver injuries. They are also caused by liver tumours and vessel anomalies. This is a case-report of a patient who developed an APF after blunt abdominal trauma. The fistula bearing part of the liver was resected in two sessions. In cases of large APFs with a flow from multiple collaterals the therapy of choice is the embolization. If not possible a selective excision of the fistulous sac or the resection of the fistula containing liver segment are recommended.

Outcome and cost-effectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal tract surgery: a prospective randomized study.

HYPOTHESIS: Perioperatively administered enteral immunonutrition will improve early postoperative morbidity and cost-effectiveness after gastrointestinal tract surgery. DESIGN: A prospective, randomized, double-blind, multicenter clinical trial. SETTING: Surgical departments in German university and teaching hospitals. PATIENTS: One hundred fifty-four patients with upper gastrointestinal tract malignant neoplasms who were eligible for analysis. INTERVENTION: Preoperatively, patients received 5 days of oral immunonutrition (an arginine-, RNA-, and omega3 fatty acid-supplemented diet) or an isoenergetic control diet (1 L/d). Early postoperative enteral feeding with immunonutrition or an isoenergetic, isonitrogenous control diet using a catheter jejunostomy was performed for 10 days. MAIN OUTCOME MEASURES: Postoperative infectious complications, their treatment costs, and cost-effectiveness of immunonutrition were analyzed. Plasma levels of the fatty acids eicosapentaenoic acid and docosahexaenoic acid were measured. RESULTS: In the immunonutrition group, significantly fewer infectious complication events occurred (14 vs 27; P = .05). The number of patients with complications was significantly lower in the supplemented diet group after postoperative day 3 (7 vs 16; P = .04). The treatment costs of complications in the supplemented diet group were suggestively lower than in the control diet group (DM 75172 vs DM 204273). Cost-effectiveness was DM 1503 in the experimental group vs DM 3587 in the control group, where DM denotes deutsche mark (German currency). CONCLUSION: The perioperative administration of an enteral immunonutrition significantly (P = .05) decreased the early occurrence of postoperative infections and reduced substantially the treatment costs of the complications after major upper gastrointestinal tract surgery.

[10 years results after repair of recurrent problem inguinal hernia with prolene mesh]. / Zehn-Jahres-Ergebnisse nach Reparation der Problemrezidivleistenhernie mit Prolenenetz.

The repair of multiple recurrences of inguinal hernias remains a surgical challenge. In 38 patients with a problematic recurrent inguinal hernia we implanted a polypropylene mesh (Prolene) in order to reinforce the transversalis fascia and to repair the inguinal hernia. 20 of these were medial and 14 lateral hernias; 4 patients had a combination of both types. All patients were prospectively included into this study and were seen in median follow-up periods of 3 and 6 months, as well as 4 and 9 years. As early complications hematoma of the wound (n = 3), scrotal edema (n = 1), temporary pain at the wound site (n = 12) and paresthesia (n = 13) occurred. Two patients (n = 2) developed a femoral hernia and one patient suffered from a persisting nerve injury of the ilioinguinal nerve. Due to the low complication and recurrency rate the tension free repair with polypropylene mesh is a effective method for treatment of problematic recurrent hernias.

[Lipoma: a rare differential gastrointestinal tumor diagnosis]. / Lipom: seltene Differentialdiagnose gastrointestinaler Tumore.

This is a case report of a female patient who during a routine follow-up after a gastrectomy showed a tumor of the ileo-cecal valve, which--according to all radiologic diagnostic procedures--was highly suspected to be a malignant tumor. However, the histologic diagnosis was benign lipoma. The incidence and the characteristics of gastrointestinal lipomas in the actual literature will be reviewed.

[Laparoscopic fine needle catheter jejunostomy]. / Laparoskopische Feinnadelkatheterjejunostomie.

Gastrostomy or jejunostomy allow a safe and effective long-term enteral nutritional support. In patients with stenosis of the upper gastrointestinal tract the percutaneous endoscopic route is frequently not feasible. In these cases a laparoscopic approach is proposed. In 18 patients (n = 18) mostly with recurrent tumors of the upper gastrointestinal tract a laparoscopic catheter was placed into the jejunum without complications. Enteral feeding was started on the first day after catheter placement. One patient experienced a cathetersite infection. We describe a modified technique of laparoscopic jejunostomy the placement which is easy, effective and less invasive.

[Relevance of preoperative nutritional therapy for postoperative outcome]. / Relevanz präoperativer Ernährungstherapie für postoperative Ergebnisse.

Several studies on preoperative artificial nutrition have shown beneficial effects only in severely malnourished patients (weight loss > 15% within short time, serum albumin < 2.8 g/dl). In this group of patients undergoing major gastrointestinal surgery, the postoperative complication rate was reduced to 40-60%. The medical care costs saved per complication avoided were 11,000-14,000 US dollars. A 5-day period of preoperative oral application of immunonutrition containing omega 3-fatty acids, arginine and nucleotides at home may prevent the risks of preoperative hospitalization and may lead to immunomodulating effects, which in addition to the improvement of nutritional status, will be able to decrease postoperative complication rates by a further 50-60%.