Radiological management of postoperative lymphorrhea.

PURPOSE: Postoperative lymphorrhea can occur after different surgical procedures and may prolong the hospital stay due to the need for specific treatment. In this work, the therapeutic significance of the radiological management of postoperative lymphorrhea was assessed and illustrated. METHOD: A standardized search of the literature was performed in PubMed applying the Medical Subject Headings (MeSH) term "lymphangiography." For the review, the inclusion criterion was "studies with original data on Lipiodol-based Conventional Lymphangiography (CL) with subsequent Percutaneous Lymphatic Intervention (PLI)." Different exclusion criteria were defined (e.g., studies with <15 patients). The collected data comprised of clinical background and indications, procedural aspects and types of PLI, and outcomes. In the form of a pictorial essay, each author illustrated a clinical case with CL and/or PLI. RESULTS: Seven studies (corresponding to evidence level 4 [Oxford Centre for Evidence-Based Medicine]) accounting for 196 patients were included in the synthesis and analysis of data. Preceding surgery resulting in postoperative lymphorrhea included different surgical procedures such as extended oncologic surgery or vascular surgery. Central (e.g., chylothorax) and peripheral (e.g., lymphocele) types of postoperative lymphorrhea with a drainage volume of 100-4000 ml/day underwent CL with subsequent PLI. The intervals between "preceding surgery and CL" and between "CL and PLI" were 2-330 days and 0-5 days, respectively. CL was performed before PLI to visualize the lymphatic pathology (e.g., leakage point or inflow lymph ducts), applying fluoroscopy, radiography, and/or computed tomography (CT). In total, seven different types of PLI were identified: (1) thoracic duct (or thoracic inflow lymph duct) embolization, (2) thoracic duct (or thoracic inflow lymph duct) maceration, (3) leakage point direct embolization, (4) inflow lymph node interstitial embolization, (5) inflow lymph duct (other than thoracic) embolization, (6) inflow lymph duct (other than thoracic) maceration, and (7) transvenous retrograde lymph duct embolization. CL-associated and PLI-associated technical success rates were 97-100% and 89-100%, respectively. The clinical success rate of CL and PLI was 73-95%. CL-associated and PLI-associated major complication rates were 0-3% and 0-5%, respectively. The combined CL- and PLI-associated 30-day mortality rate was 0%, and the overall mortality rate was 3% (corresponding to six patients). In the pictorial essay, the spectrum of CL and/or PLI was illustrated. CONCLUSION: The radiological management of postoperative lymphorrhea is feasible, safe, and effective. Standardized radiological treatments embedded in an interdisciplinary concept are a step towards improving outcomes.

Veno-venous extracorporeal membrane oxygenation (ECMO) support during anaesthesia for oesophagectomy.

The use of extracorporeal membrane oxygenation in adults has increased in popularity and importance for the support of patients with cardiac or pulmonary failure. Although it is now quite commonly used in the intensive care unit, its use has rarely been described as a means of support during anaesthesia and surgery. We report the case of a patient who required curative resection of the oesophagus following previous left pneumonectomy where veno-venous extracorporeal membrane oxygenation was required both during surgery and for the first three days postoperatively. We describe the anaesthetic management of this patient who only had a single lung, review other alternatives and discuss why extracorporeal membrane oxygenation was particularly suited to this case. To the best of our knowledge, the anaesthetic literature to date does not contain a case report of this type.

No relevant difference in quality of life and functional outcome at 12 months' follow-up-a randomised controlled trial comparing robot-assisted versus conventional laparoscopic Nissen fundoplication.

PURPOSE: The present randomised pilot trial was designed to compare robot-assisted (RALF) and conventional laparoscopic fundoplication (CLF) focussing on post-operative quality of life (QOL) and functional outcome. Any long-lasting advantages for patients in this regard could be a justification for the use of RALF for the treatment of gastroesophageal reflux disease (GERD). METHODS: Forty patients with GERD were randomised to either RALF or to CLF. During a follow-up period of 12 months, patients' QOL and functional outcome were investigated using disease-specific questionnaires. RESULTS: There were no significant differences in the mean QOL (1.3 versus 1.1; P = 0.374) and functional outcome (1.27 versus 1.3; P = 0.913) between both groups. Minor side effects such as bloating and persistent diarrhoea were present in four patients of each group. CONCLUSION: The present study did not show any benefit for RALF over CLF regarding QOL and functional outcome at 12 months' follow-up.

Evaluation of the combined laparoscopic and mediastinoscopic esophagectomy technique.

BACKGROUND: Laparoscopic esophagectomy is technically difficult especially during dissection in the upper mediastinum. This limitation may be surpassed with the help of mediastinoscopy or of the recently introduced robotic surgical systems. The aim of the present study was to evaluate in an experimental porcine model the feasibility of the combined laparoscopic and mediastinoscopic transhiatal esophagectomy technique and to compare it with the robotic-assisted transhiatal and conventional approaches. MATERIALS AND METHODS: Transhiatal esophagectomy was performed in Landrace pigs under general anesthesia using three different techniques: Group A (n = 9): combined laparoscopic and mediastinoscopic, group B (n = 4): robotic-assisted and group C (n = 8): conventional "open". The feasibility, difficulty and accuracy of the procedure along with operative time, blood loss, intraoperative incidents and overall satisfaction of the surgical team were assessed for each technique. RESULTS: Operations in group A were feasible and reproducible. Although the procedure was technically difficult, the constant view on the operative field was highly appreciated by the operative team and facilitated an accurate and safe dissection. The main intraoperative complications were related to the side-effects of tension pneumothorax accompanying pleural injuries. In group B the features of the robotic system reduced the difficulty of dissection and obviated the need for mediastinoscopy. Operations in group C were quick and almost incident-free, facilitated also by the particularities of the animal model that could not reproduce identically the clinical situation. CONCLUSIONS: The combined laparoscopic and mediastinoscopic esophagectomy technique is feasible and offers certain advantages over the open approach while the robotic-assisted approach is an emerging less difficult alternative. Further studies are required to establish whether the advantages of minimally-invasive approach compensate for the increased technical difficulty and prolonged operative time.

Development of a navigation system for minimally invasive esophagectomy.

BACKGROUND: A major challenge of minimally invasive esophagectomy is the uncertainty about the exact location of the tumor and associated lymph nodes. This study aimed to develop a navigation system for visualizing surgical instruments in relation to the tumor and anatomic structures in the chest. METHODS: An immobilization device consisting of a vacuum mattress fixed to a stretcher was built to decrease patient movement and organ deformation. Computer tomography (CT) markers were embedded in the stretcher at a defined distance to a detachable plate with optical markers on the side of the stretcher. A second plate of optical markers was fixed to the operating instrument. These two optical marker plates were tracked with an optical tracking system. Their positions were then registered in a preoperative CT data set using the authors' navigation software. This allowed a real-time visualization of the instrument and target structures. To assess the accuracy of the system, the authors designed a phantom consisting of a box containing small spheres in a specific three-dimensional layout. The positions of the spheres were first measured with the navigation system and then compared with the known real positions to determine the accuracy of the system. RESULTS: In the accuracy assessment, the navigation system showed a precision of 0.95 +/- 0.78 mm. In a test data set, the instrument could be successfully navigated to the tumor and target structures. CONCLUSION: The described navigation system provided real-time information about the position and orientation of the working instrument in relation to the tumor in an experimental setup. Consequently, it might improve minimally invasive esophagectomy and allow for surgical dissection in an adequate distance to the tumor margin and ease the location of affected lymph nodes.

Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled trial.

BACKGROUND: Robotic technology represents the latest development in minimally-invasive surgery. Nevertheless, robotic-assisted surgery seems to have specific disadvantages such as an increase in costs and prolongation of operative time. A general clinical implementation of the technique would only be justified if a relevant improvement in outcome could be demonstrated. This is also true for laparoscopic fundoplication. The present study was designed to compare robotic-assisted (RALF) and conventional laparoscopic fundoplication (CLF) with the focus on operative time, costs und perioperative outcome. METHODS: Forty patients with gastro-esophageal reflux disease were randomized to either RALF by use of the daVinci Surgical System or CLF. Nissen fundoplication was the standard anti-reflux procedure. Peri-operative data such as length of operative procedure, intra-and postoperative complications, length of hospital stay, overall costs and symptomatic short-term outcome were compared. RESULTS: The total operative time was shorter for RALF compared to CLF (88 vs. 102 min; p = 0.033) consisting of a longer set-up (23 vs. 20 min; p = 0.050) but a shorter effective operative time (65 vs. 82 min; p = 0.006). Intraoperative complications included one pneumothorax and two technical problems in the RALF group and two bleedings in the CLF group. There were no conversions to an open approach. Mean length of hospital stay (2.8 vs. 3.3 days; p = 0.086) and symptomatic outcome thirty days postoperatively (10% vs. 15% with ongoing PPI therapy; p = 1.0 and 25% vs. 20% with persisting mild dysphagia; p = 1.0) was similar in both groups. Costs were higher for RALF than for CLF (3244 euros vs. 2743 euros, p = 0.003). CONCLUSION: In comparison with CLF, operative time can be shorter for RALF if performed by an experienced team. However, costs are higher and short-term outcome is similar. Thus, RALF can not be favoured over CLF regarding perioperative outcome.

[Project "Partnership"--university surgical departments and hospitals for basic and regular medical care. Directing cooperation for the future]. / Projekt Partnerschaft--Universitätsklinik und Krankenhaus der Grund- und Regelversorgung. Wegweisende Kooperation in die Zukunft.

Over the last 20 years, urgently needed changes in the German health care system have forced hospitals to make a flexible adjustment to rising costs and the single handed, almost unmanageable dynamics of technical innovation in medicine. The partnership between the Salem Hospital and the Heidelberg University Hospital represents a pioneering management concept for the future. The alliance between a university surgical department with a basic peripheral hospital provides large advantages to patients, staff, hospitals and cost carriers.

The ECM proteoglycan decorin links desmoplasia and inflammation in chronic pancreatitis.

BACKGROUND: Recurrent inflammation in chronic pancreatitis (CP) is not well understood. AIMS: To investigate whether decorin, an extracellular matrix (ECM) proteoglycan with macrophage modulating activity, is a pathogenic factor allowing diseased pancreatic stroma to sustain inflammation by affecting the cytokine profile of accumulating inflammatory cells. METHODS: Decorin was examined in 18 donors and 32 patients with CP by quantitative reverse transcription polymerase chain reaction (QRT-PCR), western blotting, and immunohistochemistry of pancreatic specimens. QRT-PCR was used to assess cytokine expression in donor peripheral blood mononuclear cells (PBMC), exposed or not to decorin in vitro, and to compare it with the cytokine profile of circulating and resident mononuclear cells (MNC) of patients with CP. RESULTS: In CP, desmoplasia is associated with overexpression of decorin in the growing ECM and enlarged pancreatic nerves. In culture, exposure of MNC to decorin stimulated expression of the MNC recruiting chemokine MCP-1. In biopsies, MNC infiltrates in decorin rich CP tissue showed a 300-fold upregulation of MCP-1 compared with decorin free peripheral blood, whereas no difference was found in basal MCP-1 expression in PBMC of patients versus donors. This effect was specific for MCP1-other inflammatory cytokines, such as interleukin 1beta and tumour necrosis factor alpha, were not affected. CONCLUSION: Decorin is a molecular marker of desmoplasia in CP, and excessive decorin may allow fibrotic masses to nourish and protract inflammation by deregulating the process of MNC accumulation and activation. These data provide a molecular basis for surgical resection of diseased tissue as a treatment option in CP.

[Postoperative ileus. Pathophysiology and prevention]. / Postoperativer Ileus. Pathophysiologie und Prävention.

Continuous improvements in surgical technique and anaesthesia for ileus have resulted in a significant reduction of perioperative complications. Postoperative outcome of surgical patients is increasingly dependent on the severity of postoperative ileus, which often determines morbidity and length of hospital stay. In the present article we discuss possible variables influencing this disease. Furthermore, means of prevention and therapeutic strategies for postoperative ileus are briefly presented.

Evacuation of neorectal reservoirs after TME.

Colon pouch reconstruction after deep rectal resection is functionally superior to straight colorectal/anal anastomosis. However, stool evacuation difficulties could jeopardize the functional benefit of neorectal reservoirs. Beside the well proven colon J-pouch, the transverse coloplasty pouch may represent a viable alternative. We examined evacuation and functional outcome after total mesorectal excision and transverse coloplasty pouch reconstruction. Thirty consecutive patients with cancer of the middle and distal third of rectum underwent a total mesorectal excision. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin enema postoperatively. Eight months after surgery, video defecography, anal manometry and pouch volumetry were performed and the patients were interviewed according to a standardized continence questionnaire. Rectal resection and reconstruction with transverse coloplasty pouch anastomosis could be performed in all patients. No insufficiency of the pouch occurred. In the follow-up, no patient had difficulties to evacuate the pouch, none of these patients needed enemas or suppositories to facilitate defecation. All patients were continent for solid stools. Twenty-five of 27 patients had up to three bowel movements per day. Patients with reduced pelvic floor movement in the defecography proved more likely to suffer from urgency, fragmented evacuation and incontinence. Transverse coloplasty pouch reconstruction after total mesorectal excision is not associated with stool evacuation problems. Urgency and incontinence, which are rarely seen after this type of reconstruction, correlate with impaired pelvic floor movement rather than with pouch size or anal sphincter tonus.

[Technique of pancreas-preserving duodenectomy]. / Die Technik der pankreaserhaltenden Duodenektomie.

Even in pancreatic surgery, as in other organs, there is a tendency towards subtle organ-preserving techniques. Benign duodenal tumors which cannot be resected transduodenally or multiple dysplastic duodenal adenomas in patients with familial adenomatous polyposis (FAP) usually require partial pancreaticoduodenectomy. However, pancreas-preserving duodenectomy may represent a viable alternative. This technique allows for the resection of the entire duodenum without resection of the pancreatic head. Large duodenal adenomas, multiple adenomas with dysplasia in patients with FAP, and based on the literature extended duodenal injury after trauma may represent indications for this surgical technique. Compared with duodenopancreatectomy, this intervention can be performed with a comparably low morbidity and leads to good functional results. Beside the preservation of pancreatic parenchyma and the reduction of the number of anastomoses, this technique offers the advantage of uncomplicated endoscopic follow-up. In this article we describe the surgical technique of pancreas-preserving duodenectomy and our experience with this intervention.

[Pancreatic resection in the elderly : Is the risk justified?]. / Pankreasresektionen im Alter : Ist das Risiko vertretbar?

BACKGROUND: Due to demographic changes and improved diagnostic and therapeutic options surgery in the elderly is an essential field of discussion in medicine. Working groups are becoming increasingly more concerned with the question whether old age is a risk factor for complex surgical procedures. OBJECTIVE: This study was carried out to help assess and evaluate the risk of pancreatic resection in the elderly. MATERIAL AND METHODS: In a retrospective analysis of a prospectively maintained database of pancreatic resections, data from a 4-year period were evaluated and analyzed. A division into two age groups was defined according to the literature with the age of 75 years being the dividing line. RESULTS: During the 4 years of the study 209 pancreatic resections were performed in 146 patients under the age of 75 years and 63 patients over the age of 75 years. A pancreatic head resection was performed in 133 patients, distal pancreatectomy in 57, pancreatectomy in 16 and segmental resection in 3 patients. The overall mortality rate was 2.4 %, only patients over the age of 75 years were affected and was not directly related to surgery in any of the cases. The risk of patients dying perioperatively was significantly increased over the age of 75 years as was the comorbidity rate. Regarding surgically related complications there were no differences between the two groups. CONCLUSION: Pancreatic resection in elderly patients > 75 years is justified because of the very low surgical morbidity and mortality which can now be achieved in experienced centers if comorbidities of patients are taken into account in the decision-making process. The age per se does not constitute a contraindication.

[Natural orifice transluminal endoscopic surgery in Germany: Data from the German NOTES registry]. / "Natural orifice transluminal endoscopic surgery" in Deutschland : Daten aus dem deutschen NOTES-Register.

BACKGROUND: The German NOTES registry (GNR) was initiated by the German Society for General and Visceral Surgery (DGAV) as a treatment and outcome database for natural orifice transluminal endoscopic surgery (NOTES). AIM: The aim of this study was the descriptive analysis of all GNR data collected over a 5-year period since its start in 2008 with more than 3000 interventions. MATERIAL AND METHODS: The GNR is an online database with voluntary participation available to all German-speaking clinics. Demographic data, therapy details, complications and data on the postoperative course of patients are recorded. All cases in the GNR between March 2008 and November 2013 were included in the analysis. RESULTS: From a total of 3150 data sets 2992 (95 %) were valid and suited for the analysis. Hybrid transvaginal cholecystectomy was the most frequently used procedure (88.7 %), followed by hybrid transvaginal/transgastric appendectomy (6.1 %) and hybrid transvaginal/transrectal colon procedures (5.1 %). Intraoperative complications occurred in 1.6 %, postoperative complications in 3.7 % and conversions were reported in 1.5 %. Intraoperative bladder injuries and postoperative urinary tract infections were identified as method-specific complications of transvaginal procedures. Bowel injuries occurred as a rare (0.2 %) but potentially serious complication of transvaginal operations. CONCLUSION: The German surgical community ensures a safe and responsible introduction of the new NOTES operation techniques with its active participation in the GNR. Despite an overall low complication rate, the high number of procedures in the GNR permitted the identification of method-specific complications. This knowledge can be used to further increase the safety of NOTES in practice.

[Management of inguinal hernia--a comparison of current methods]. / Leistenhernienversorgung--ein Vergleich gängiger Verfahren.

Between July 1995 and June 1996, 280 patients were operated on for inguinal hernia within the scope of a prospective, randomized study. The aim of the study was to compare the Shouldice technique with tension-free hernioplasty (Lichtenstein, TAPP). The operation time was comparable in all three groups. There was less need for analgesics and postoperative morbidity was less after the tension-free technique. No severe complications such as deep wound infection or infection of the implant were seen in any of the groups. After a follow-up period of 18 months, we found two recurrences after the Shouldice operation and one recurrence in each of the tension-free groups. Treatment satisfaction after tension-free hernioplasty was high. One year after the Shouldice operation, about 10% of the patients were dissatisfied because of persistent discomfort and pain. Because of lower morbidity, less pain, and low recurrence rates after tension-free hernioplasty, we find the tension-free techniques to be superior to conventional hernioplasty.

[Duodenum-preserving pancreas head resection-an operative technique for retaining the organ in the treatment of chronic pancreatitis]. / Die duodenumerhaltende Pankreaskopfresektion. Organerhaltendes Operationsverfahren in der Behandlung der chronischen Pankreatitis.

Chronic pancreatitis is an inflammatory disease characterized by the progressive conversion of pancreatic parenchyma to fibrous tissue. The most frequent causes are alcohol overconsumption and anatomic variants such as pancreas divisum, cholelithiasis, and individual genetic predisposition. The process of fibrosis with consecutive loss of pancreatic parenchyma leads to exocrine insufficiency and maldigestion and, in advanced stages of the disease, to diabetes mellitus. Beside exocrine and endocrine malfunction, mechanical complications occur such as the formation of pancreatic pseudocysts and duodenal and common bile duct obstruction. About 50% of patients with chronic pancreatitis need surgical intervention due to untreatable chronic pain. As recent investigations suggest that the head of the pancreas triggers the chronic inflammatory process, resection of this inflammatory mass must be regarded as pivotal in any surgical intervention. Radical techniques such as the Whipple procedure are undoubtedly successful regarding pain reduction but, even in its pylorus-preserving variant, associated with high postoperative morbidity due to a large loss of pancreatic parenchyma and the absence of duodenal passage. Thirty years ago, H.G. Beger described for the first time the technique of duodenum-preserving pancreatectomy, which better combines resection of the pancreatic head with low morbidity. Over the years, different variations of the original Beger technique (Frey, Izbicky, Berne modification) have been developed, and the excellent results obtained with these methods underline that organ-sparing techniques should be preferred in the surgical treatment of chronic pancreatitis.

Long-term results of a randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs.

INTRODUCTION: There is an ongoing debate about the preferred technique for inguinal hernia repair. In this randomized study the long-term results of Shouldice, Lichtenstein and transabdominal preperitoneal (TAPP) hernia repair were compared. METHODS: Some 280 men with a primary hernia were randomized prospectively to undergo Shouldice, tension-free Lichtenstein or laparoscopic TAPP repair. Patients were examined after 52 months to assess hernia recurrence, nerve damage, testicular atrophy and patient satisfaction. RESULTS: Hernia recurrence occurred in six patients after Shouldice repair, and in one patient each after Lichtenstein and TAPP repairs. All recurrences after tension-free repairs were diagnosed within the first year after surgery. Nerve injuries were significantly more frequent after open Shouldice and Lichtenstein repairs. Patient satisfaction was greatest after laparoscopic TAPP repair. CONCLUSION: Tension-free repair was superior to the non-mesh Shouldice technique. The open anterior approach to the groin was associated with demonstrable nerve injury, and laparoscopic TAPP repair was the most effective approach in the hands of an experienced surgeon.

[Heparin-associated thrombocytopenia caused by low-molecular-weight heparin]. / Heparin-assoziierte Thrombozytopenie durch niedermolekulare Heparine.

Recent studies have shown that low-molecular-weight heparins (LMWH) are not suitable for treating patients with heparin-associated thrombopenia (HAT) type 2, as they can cause the same complications as unfractionated heparin UFH. The case described ist that of concerns as female patient who died after developing HAT type 2 following LMWH given perioperatively to prevent thromboembolism. This case indicates again that LMWH can trigger HAT type 2 even if administered only once a day. For HAT to be successfully treated it is essential that the condition is diagnosed early enough by means of routine regular laboratory checks of the number of thrombocytes during any heparin treatment in order to detect the disease before clinical symptoms become apparent.

[Juxtapapillary intraduodenal lipoma as a rare cause of jaundice and acute pancreatitis]. / Juxtapapilläres intraduodenales Lipom als seltene Ursache von Ikterus und akuter Pankreatitis.

A 52-year-old man was admitted to hospital with acute pancreatitis and jaundice. The patient's medical history showed a case of hospitalization due to acute pancreatitis about three years before. Diagnostic examinations (abdomen sonography, CT, contrast medium radiography of the small intestine, ERCP) revealed a juxtapapillary lipoma, approximately 1 by 6 cm, obstructing the papilla Vateri. After the examinations had been completed and the pancreatitis had largely eased off, the lipoma was removed by transduodenal surgery. There were no postoperative complications.

Duodenum preserving pancreatic head resection in the treatment of chronic pancreatitis.

Chronic pancreatitis is an inflammatory disease which is characterized by a progressive conversion of pancreatic parenchyma into fibrous tissue. Most frequent causes are alcohol over-consumption, beside anatomic variants such as pancreas divisum, cholelithiasis or individual genetic predisposition. The process of fibrotic transformation with consecutive loss of pancreatic parenchyma leads to exocrine insufficiency and maldigestion, and in advanced stage of the disease to diabetes mellitus. In addition to exocrine and endocrine malfunction, mechanical complications such as formation of pancreatic pseudocysts, duodenal and common bile duct obstruction occur. About 50% of the patients with chronic pancreatitis will need surgical intervention due to intractable chronic pain. Recent investigations suggest that the head of the pancreas triggers the chronic inflammatory process. Therefore, resection of this inflammatory mass must be regarded as the pivotal part of any surgical intervention. Radical techniques such as Whipple-procedure are undoubtedly successful regarding pain reduction. However, even in its pylorus preserving variant this technique is associated with a high postoperative morbidity due to large loss of pancreatic parenchyma and the loss of the duodenal passage. 30 years ago, H. G. Beger described for the first time the technique of duodenum preserving pancreatic head resection that better combines resection of the pancreatic head with low morbidity. Over the years different variations of the original Beger technique (Frey, Izbicky, Berne modification) have been developed, and the excellent results obtained with these techniques underline, that organ sparing procedures should be preferred in the surgical treatment of chronic pancreatitis.