[CAMIC Recommendations for Surgical Laparoscopy in Non-Obstetric Indications during Pregnancy]. / CAMIC-Empfehlungen zur chirurgischen Laparoskopie aus nicht geburtshilflicher Indikation während der Schwangerschaft.

In the operative surgical primary care, the laparoscopic surgical technique has firmly established itself in recent years. Meanwhile, in the normal population over 90 % of all cholecystectomies and over 80 % of all appendectomies are performed in a minimally invasive manner. The proven benefits of the laparoscopic surgical technique, compared with conventional open surgery, are a comparatively rapid early postoperative recovery with early resumption of the general physical and occupational activity. As these benefits are equally applicable for necessary interventions during pregnancy, in recent years laparoscopy has become the preferred treatment for non-obstetric indications in the gravid patient. Overall, it can be assumed that such interventions have to be performed in approximately 2 % of all pregnant patients. Numerous studies have proven here that the use of laparoscopic techniques, in particular for the expectant mother, is safe and not associated with an increased risk. On the other hand, the current pregnancy makes necessary an adapted approach to the solution of surgical problems to ensure the protection of the unborn child. On the basis of currently available data situation, recommendations are formulated which can be used as a decision-making support for a variety of clinical situations.

[Options and Limitations in Endovascular Therapy for Acute and Chronic Mesenteric Arterial Occlusions]. / Endovaskuläre Möglichkeiten und Grenzen bei akuten und chronischen mesenterialen Verschlussprozessen.

BACKGROUND: The significance of endovascular therapy for mesenteric ischaemia (MI) is being debated. Despite initially lower mortality and morbidity, inconsistent early and late results led to questions concerning indications and technical applications of the procedure. METHODS: 91 patients with MI underwent endovascular treatment in a period of 11 years. In 78 (85.7 %) patients a stent was deployed and in 13 (14.3 %) an angioplasty was performed, principally of the superior mesenteric artery (n = 81/91, 89 %). Follow-up consisted of a clinical and an ultrasound examination in all cases. Mean follow-up was 4.2 years. Our results were compared to those in the literature. RESULTS: Endovascular treatment of the intestinal arteries accounted for 0.6 % of all vascular procedures. Seven of 91 patients (7.7 %) died after an initial PTA/stenting. The overall peri-interventional morbidity was 6.6 % (n = 6/91). Medium- to long-term complications were encountered in 20 patients (22 %), primarily during the first year (85 %). Six of 91 patients developed an in-stent stenosis (6.6 %) and 14/91 patients (15.4 %) stent occlusion. Additionally 2 dislocated stents (2.2 %) and an arterial perforation with bleeding into the mesentery (1.1 %) were seen. Although 3 of these 20 patients were successfully treated with an additional PTA or stenting (15.0 %; n = 3/91, 3.3 %), surgical conversion was necessary in 9 (n = 9/20, 45 %; n = 9/91, 9.9 %). The postoperative mortality was respectively 22.2 % (n = 2/9; n = 2/91, 2.2 %). In the case of acute MI, endovascular procedures are only indicated for patients without peritonitis. In chronic MI, the indication for endovascular treatment depends on the type of occlusion and the vascular anatomy. Despite favourable early results, the outcome of endovascular treatment deteriorates with time reaching a 1-year patency rate of 63 % in a multicentre analysis. This leads to secondary procedures in 30 %. A surgical conversion carries a high mortality. CONCLUSION: The endovascular treatment of intestinal artery disease cannot be considered the treatment of choice, it is rather an alternative method in patients with functional or local contraindications to surgery. Life-long follow-up is necessary to prevent stent complications with fatal consequences. A prospective randomised study concerning the evaluation of the advantages and disadvantages of surgical and endovascular therapy of intestinal artery occlusive disease is required.

[Scope and limitations of minimally invasive resections of the oesophagus and stomach]. / Möglichkeiten und Grenzen der minimalinvasiven Chirurgie bei Resektion des Ösophagus und des Magens.

BACKGROUND: Although minimally invasive surgery is being increasingly performed for the treatment of upper gastrointestinal cancers, the discussion on potential advantages and oncological accuracy is still controversial. MATERIAL AND METHODS: In the framework of a literature survey, current trials on minimally invasive oesophageal resection and laparoscopic abdominal surgery have been analysed. RESULTS: Minimally invasive oesophagectomy and laparoscopic gastric resections for cancer are safe. Minimally invasive resections result in an improved short-term outcome postoperatively in view of less pain, less blood loss and shorter duration of hospital stay. While mortality is equal, morbidity following minimally invasive surgery is reduced. Especially pulmonary complications decrease on the application of minimally invasive oesophagectomy. Minimally invasive operations last longer than open procedures. The oncological results seem to be equal between open and minimally invasive operations. A few studies have shown that laparoscopic gastric resections may result in a reduced number of lymph nodes harvested. The long-term survival between open and laparoscopic resections did not differ in any study. CONCLUSION: Minimally invasive resections for oesophageal and gastric cancer are safe and show several advantages in short-term outcome. Oncological long-term results seem to be comparable. The potential risk of a reduced number of harvested lymph nodes during laparoscopic gastrectomy has to be addressed by an adequate surgical technique.

Evaluation of type 1 diabetics for simultaneous pancreas-kidney transplantation with regard to cardiovascular risk.

The main cause of death for diabetic patients and patients on dialysis is coronary artery disease (CAD). The most common cause of graft loss following simultaneous pancreas and kidney transplantation (SPK) is death with a functioning graft due to CAD. Therefore, careful pretransplantation evaluation of CAD is mandatory. In our series, every patient undergoes a noninvasive cardiac function test like dobutamine stress echocardiography (DSE) or myocardial thallium scintigraphy using adenosine to induce medical stress. Thirty patients were evaluated for SPK: 15 patients with myocardial scintigraphy and 8 with DSE. Seven investigations showed pathological findings and we performed coronary angiograms, none of which showed coronary artery stenosis. Seven primary coronary angiograms were performed: four due to a history of CAD and three as a primary diagnostic. Following SPK one patient died at 21 days after transplantation due to myocardial infarction. He had a history of CAD with angioplasty and stent implantation. Noninvasive cardiac function tests like DSE or myocardial scintigraphy are reliable methods to evaluate CAD in patients with diabetic nephropathy awaiting SPK. In case of a suspicious finding or a history of CAD, a coronary angiogram should be performed to assess the need for revascularization. Following this algorithm we may further reduce the mortality of SPK.

Influence of methicillin-resistant Staphylococcus aureus carrier status in liver transplant recipients.

The prevalence of methicillin-resistant Staphylococus aureus (MRSA) has increased worldwide and MRSA has emerged as an important cause of sepsis in cirrhotic patients and liver transplant recipients. In this retrospective study, the prevalence of MRSA colonization and its influence on infections following orthotopic liver transplantation (OLT) was investigated. From August, 2002 until November, 2004, 66 primary cadaver OLT were performed for adult recipients. Antibody induction used Daclizumab (n = 49) or ATG (n = 14). Maintenance immunosuppression consisted of tacrolimus and steroids, with 30 patients receiving mycophenolate mofetil and 4, rapamune. For perioperative anti-infectious prophylaxis cefotaxime, metronidazole, and tobramycin were administered for 48 hours. The preoperatively performed routine swabs revealed MRSA colonization in 12 of 66 (18.2%) patients. The stage of cirrhosis was equivalent for MRSA(-) patients according to Child score. The mean MELD score was significantly higher for MRSA(+) patients (24.3 versus 18.7, P = .036). More MRSA(+) patients were hospitalized at the time of transplantation (14/54 versus 8/12, P = .018). The incidence of posttransplant infections was not significantly different among the two groups. Within the first year 7 of 66 (10.6%) patients died: 3 of 12 (25%) MRSA(+) and 4 of 54 (7.4%) MRSA(-). The 1-year survival was lower in the MRSA(+) group (74.1% versus 94.1%). In conclusion, this study did not show that an MRSA-positive carrier status implies an increased risk for septic complications following OLT. Mortality was increased for MRSA(+), but failed to show a significant difference. A significantly higher MELD score and pretransplant hospitalization for MRSA(+) patients may contribute to the higher mortality and reflect sicker patients.

Does the liver ever age? Results of liver transplantation with donors above 80 years of age.

INTRODUCTION: Facing an increasing shortage of donor organs, donor criteria become more extended and so-called marginal organs are accepted for transplantation. For liver donation donor age above 70 years is accepted as a risk factor concerning primary dysfunction or nonfunction. Therefore, the aim of this study was to compare the early outcome of grafts older versus younger than 80 years of age. PATIENTS AND METHOD: Between August 2002 and February 2004, 40 adult liver transplants were performed using triple immunosuppression with tacrolimus, MMF, and low-dose corticosteroids. Recipients with HCC received low-dose rapamycin after postoperative day 14. The outcome of grafts from donors under 80 years of age (n=35) was compared with those from donors 80 years old or more (n=5). For statistical analysis Mann-Whitney-U-Test and Fisher's Exact Test were used with P < .05 considered statistically significant. RESULTS: The average donor age of our population was 54.4 +/- 17.3 years with five donors older than 80 years (80-83 years). These donors all had additional risk factors. The recipients of the latter grafts suffered from HCC and liver cirrhosis Child A (n=2) or from viral hepatitis (n=3). One recipient had advanced cirrhosis with severe complications. The outcomes of both groups were comparable concerning intraoperative and postoperative courses. All recipients of old liver grafts left the hospital with stable graft function. CONCLUSION: Liver grafts over 80 years can be transplanted with good results, especially if given to recipients with malignancy and otherwise stable liver function.

Acceptance criteria of pancreas grafts: how do surgeons decide in Europe?

OBJECTIVES: Some donor factors, such as age, cause of death, and obesity, affect the outcomes of pancreas transplantation. Donors with a high-risk profile are usually not declined for pancreas donation. The purpose of our study was to investigate differences between accepted and refused pancreata after being procured and offered. METHODS: In a retrospective study we analyzed all offered pancreata (n = 1360) in the "Eurotransplant Area" between May 25, 2002 and September 18, 2003. Included in this study were 525 pancreata transplanted (38.6%) and 608 pancreata refused for medical reasons (44.7%). A total of 227 pancreata (16.7%) refused for other than medical reasons were excluded from this analysis. RESULTS: The significant differences in the donor profiles between transplanted and refused pancreata were cause of death (P < .001), donor age (P < .001), body mass index (BMI, P < .001), serum lipase and amylase (P < .05) at the time of procurement, and a history of smoking (P = .001) or alcohol abuse (P < .001). No differences were found for serum sodium (P = .188), blood leukocytes (P = .349), serum glucose at the time of procurement (P = .155), amylase and lipase at the time of admission (P = .34; P = .758), and vasopressor use at the time of admission or at the procedure (P = .802; P = .982). CONCLUSION: Even after procuring and offering potentially good pancreata, nearly half the organs are refused for medical reasons. Acceptance criteria in the Eurotransplant region reveal a conservative attitude toward pancreas acceptance.

Simultaneous pancreas-kidney transplantation in patients with antiphospholipid syndrome.

BACKGROUND: Graft thrombosis is one of the main reasons of graft loss following simultaneous pancreas-kidney transplantation (SPK). Although antiphospholipid syndrome (APLS) is known as a high risk for graft thrombosis in kidney transplants alone, little is known about APLS in SPK. METHODS: Between September 2000 and December 2001, 45 SPK were performed. The treatment and clinical course of 2 patients with APLS is presented. RESULTS: In one patient, APLS was known before transplantation. After SPK, she was treated by systemic heparin followed by coumarin. Both grafts are doing well 5 months posttransplant. The second patient underwent SPK without knowledge of APLS. The patient developed a deep vein thrombosis 5 weeks posttransplant. Hypercoagulability screening revealed APLS. Treatment consisted of systemic anticoagulation. Grafts were not affected. CONCLUSION: SPK can successfully be performed in APLS patients if anticoagulation is performed consistently. To reduce the risk of graft thrombosis, a pretransplant screening for APLS would probably be of benefit.

High levels of C-reactive protein after simultaneous pancreas-kidney transplantation predict pancreas graft-related complications and graft survival.

BACKGROUND: Although pancreas graft-related complications are frequent after simultaneous pancreas-kidney transplantation (SPK), there are no parameters predicting the risk for these complications. METHOD: A two-center retrospective study was performed in 97 patients who underwent SPK to investigate the peak serum value of c-reactive protein (CRP) during the first 72 hr after SPK in view of graft-related complications and graft survival. RESULTS: Mean peak CRP was 115.6 +/- 71.5 mg/L. Mean peak CRP was higher in patients needing relaparotomy (n=31) (136.4 vs. 105.8 mg/L, P=0.048), especially when postoperative bleeding was excluded (P=0.015); in patients with graft pancreatitis (P=0.03); and in patients with graft loss (n=19; P<0.001) compared with patients without these complications. With a cut-off of peak CRP at the level of mean plus 1 SD (187.05 mg/L), there was a significantly higher incidence of relaparotomies (P=0.01; bleedings excluded: P=0.003), graft pancreatitis (P=0.03), and pancreas graft loss (P<0.0001) in patients with high peak CRP compared with patients with low peak CRP. No differences were noticed with regard to rejection rate, mortality, and kidney graft loss. CONCLUSION: Our findings suggest that peak CRP is a helpful parameter in predicting pancreas graft-related complications and pancreas graft survival after SPK. Our results also stress the importance of early graft damage in pancreas transplantation.

Do complications related to laparoscopic cholecystectomy influence the prognosis of gallbladder cancer?

BACKGROUND: Laparoscopy is thought to worsen the prognosis of gallbladder cancer (GBC) discovered unexpectedly at laparoscopic cholecystectomy (LC). However, laproscopy has never been shown to have an influence on patient survival in clinical series. METHODS: We Performed a two-center retrospective analysis of 28 patients with GBC (11 previously known, 17 unexpectedly discovered by LC) to determine whether laparoscopy and complications related to LC had any influence on the prognosis of GBC. Resectability for cure after LC, survival, and recurrence related to both the procedure itself and complications associated with LC were analyzed. RESULTS: Of the 17 patients with unexpected GBC, 16 were considered resectable for cure at the time of LC. Advanced disease was detected in eight patients by re staging (n = 5) or exploration (n = 3). Seven patients (43.8%) underwent reoperation for cure. Mean survival of patients with unexpected GBC was 26.5 months. Mean survival was shorter when complications (bile spillage, injury of common bile duct, or tumor violation) occurred during LC (10.2 vs 33 months, p = 0.016). If bile spillage was the only complication at LC, there was also a trend to shorter survival (12 vs 33 months, p = 0.061). CONCLUSION: Complications during LC significantly worsen the prognosis of GBC. Therefore, bile spillage and excessive manipulation of the gallbladder should be avoided.

[Acute pancreatitis]. / Akute Pankreatitis.

Acute pancreatitis is an acute inflammatory process of the pancreas mainly due to biliary obstruction or alcohol consumption. Most episodes of acute pancreatitis are mild and resolve under conservative treatment. Severe forms of acute pancreatitis, especially the necrotising form, still have a high mortality rate and can be difficult to treat. The problem today is to identify the few cases that should be treated operatively. Infected necroses are well accepted as an indication for operative treatment. Surgery consists of débridement and necrosectomy followed by closed or open lavage. In biliary pancreatitis, ERCP is performed early in cases of biliary obstruction, with or without cholangitis. In these patients cholecystectomy should be performed electively after clinical recovery.

[Transplantation and outcome quality]. / Transplantation und Ergebnisqualität.

Organ transplants are procedures which require intensive personal and material resources. The results of organ transplants have continuously improved during recent decades. International data bases (registries) have documented the continuous evolution of organ transplantation. On the basis of the German Transplant Law guidelines for "Requirements regarding quality control for procedures related to organ procurement and transplantation" have been formulated by the German Medical Chamber. Thus, monitoring of outcome quality will become a requirement for all German transplant centers. In this paper, the guidelines for the different organ transplants (kidney, pancreas, liver, heart, lung) are discussed as well as quality control for living donor transplantation. Studies from the USA and Europe demonstrated volume-outcome relationships in organ transplantation. In addition, in kidney transplantation a centre-effect could be demonstrated which influences outcome more than the immunological match between donor and recipient. The introduction of required quality control may have far reaching consequences for the future structure of organ transplantation in Germany.

[Pyoderma gangrenosum after TAPP hernioplasty. A rare differential necrotizing wound infection diagnosis]. / Pyoderma gangraenosum nach TAPP-Hernioplastik. Eine seltene Differentialdiagnose nekrotisierender Wundinfektionen.

Pyoderma gangrenosum is an aseptic skin disease that occasionally complicates operative incisions and mimics postoperative necrotising wound infection. So far there are only a few case reports about bacterial necrotising infections following laparoscopy; no report exists about postoperative pyoderma gangrenosum after minimally invasive surgery. Differential diagnosis of both these diseases with potentially high morbidity and mortality is, however, essential, as they require opposite therapeutic regimens. Here we present the case of a patient who developed pyoderma gangrenosum after laparoscopic hernioplasty. Pathophysiological, clinical and therapeutic aspects of the disease are discussed.

[Morbidity following simultaneous pancreas/kidney transplantation]. / Morbidität der kombinierten Pankreas-/Nierentransplantation.

BACKGROUND: Simultaneous pancreas-kidney transplantation (SPK) is still associated with the highest rate of morbidity among solid organ transplantations. Although improved long-term survival following SPK has been proven in IDDM patients, a further decrease in morbidity would be desirable. METHODS: A retrospective, single-center study was performed to investigate the morbidity following SPK and to compare the results to kidney transplantation alone (KTA). Parameters included the rates of relaparotomies, septic complications (urinary tract infection, wound infection, pneumonia), and graft function. RESULTS: Between September 2000 and August 2001, 99 patients underwent transplantation (34 SPK, 63 KTA, 2 pancreas transplants alone). Relaparotomies were performed in six SPK patients (17.6%), mostly due to complications related to the pancreatic graft (n=5). Three reoperations (4.8%) were necessary in KTA patients (p=0.085). Septic complications occurred more often in SPK than in KTA patients (55.9% vs 30.2%, p<0.05). This difference resulted from the high rate of wound infections in SPK patients (35.3%). No intra-abdominal infection or sepsis occurred in any patient. There was one hospital death in SPK and KTA patients, respectively. The rejection rate was similar in SPK (17.6%) and KTA (12.7%, p=0.72). At discharge 91.2% of SPK patients were insulin free and 97.1% free of dialysis. At discharge 96.8% of KTA patients were free of dialysis. CONCLUSION: SPK is still associated with a higher morbidity (relaparotomies, septic complications) than KTA, although life-threatening complications were rare. There was no increased mortality following SPK.