[Patient satisfaction after thyroidectomy - the width of the scar is more important than the length]. / Patientenzufriedenheit nach Thyreoidektomie ­ die Breite der Narbe ist wichtiger als die Länge.

OBJECTIVE: To avoid a scar on the neck, alternative methods of thyroidectomy have been developed. The aim of our study was to determine the significance of the scar and the factors influencing satisfaction after classical thyroidectomy in the long term. MATERIAL AND METHODS: 228 patients who underwent partial or total thyroidectomy for benign thyroid disease between 2001 and 2014 participated in a telephone interview. In addition to patient satisfaction, demographic data, the subjective appearance of the scar, and subjective complaints were recorded. RESULTS: 93.8 % of the patients were satisfied with the treatment. Female and younger patients tended to be more dissatisfied than both male and older patients. The mean scar length was 6.03 ± 2.36 cm and the mean scar width was 2.01 ± 1.46 mm. The length of the scar did not affect satisfaction. In contrast, patients with a wider prominent or conspicuously stained scar were significantly more dissatisfied. Patients who suffered from symptoms such as pressure or difficulty swallowing postoperatively were also significantly more dissatisfied. Cosmetic problems affect satisfaction more than functional problems. CONCLUSIONS: Satisfaction after thyroidectomy is good in the long term. Whether satisfaction can be further improved by using an alternative or minimally invasive procedure is questionable. These procedures may be an alternative for younger and female patients or those who focuses on cosmetics.

Intrahepatic cholangiocarcinoma in a transplant liver--selective internal radiation therapy followed by right hemihepatectomy: report of a case.

Intra- or extrahepatic cholangiocarcinomas are the second most common primary liver malignancies behind hepatocellular carcinoma. Whereas the incidence for intrahepatic cholangiocarcinoma is rising, the occurrence of extrahepatic cholangiocarcinoma is trending downwards. The treatment of choice for intrahepatic cholangiocarcinoma remains liver resection. However, a case of liver resection after selective internal radiation therapy in order to treat a recurrent intrahepatic cholangiocarcinoma in a transplant liver is unknown in the literature so far. Herein, we present a case of a patient undergoing liver transplantation for Wilson's disease with an accidental finding of an intrahepatic cholangiocarcinoma within the explanted liver. Due to a recurrent intrahepatic cholangiocarcinoma after liver transplantation, a selective internal radiation therapy with yttrium-90 microspheres was performed followed by right hemihepatectomy. Four years later, the patient is tumor-free and in a healthy condition.

The role of cryosurgery in the treatment of colorectal liver metastases: a matched-pair analysis of cryotherapy vs. liver resection.

BACKGROUND/AIMS: Although liver resection is the gold standard for patients with colorectal liver metastases (CRLM), only 15-20% of the patients are candidates for surgery. As ablative therapies may extend this low rate of curative option, the aim of the present study was to analyze the impact of cryosurgery (cryo) on survival of patients with CRLM compared to liver resection (Phx). METHODOLOGY: In a matched-pair analysis, patients undergoing Phx or cryo were compared (n = 39 each). Analysis included pre-, peri-and postoperative data and follow-up for tumor-free and overall survival. Survival was estimated by Kaplan-Meier method. RESULTS: Out of 124 patients undergoing 143 cryosurgical procedures, 39 patients could be identified undergoing single liver cryo procedure for CRLM with a curative approach. Matching of these patients with a Phx cohort, patients undergoing Phx revealed better overall (20 vs. 46 months) and tumor-free survival (7.8 vs. 33.6 months) than patients with cryo. CONCLUSIONS: Liver resection is strongly recommended for patients with CRLM compared to cryosurgery.

Evidence for tumor cell spread during local hepatic ablation of colorectal liver metastases.

INTRODUCTION: The aim of the present study was to analyze the impact of cryosurgery (CRYO) on liver metastases compared to other thermoablative techniques. In a rat liver metastases model, evidence for tumor cell spread was analyzed comparing CRYO, radiofrequency ablation (RFA), and laser-induced thermotherapy (LITT). METHODS: In an experimental study, we compared cell spillage in the washout of isolated perfused rat livers undergoing thermal ablation. Within the same model, CC531-GFP rat liver tumors were treated with CRYO, RFA, or LITT and the number of vital tumor cells within the perfusate was measured. Matrix metalloproteinases (MMP-2, MMP-9) were analyzed after in vivo ablation of rat colorectal liver metastases in the third experimental model. RESULTS: Our data showed pronounced washout of cells after CRYO with a higher amount of intravascular cells and cell detritus compared to RFA and LITT. Only the effluent fluid of cryosurgery-treated livers revealed GFP-stained tumor cells. MMP-2 and MMP-9 expression was significantly higher after cryosurgery than after RFA and LITT. CONCLUSION: When using thermoablative techniques, intravascular metastatic cell spillage is highest in CRYO, and increased expression of matrix metalloproteinases may further facilitate tumor cell spread. Therefore, RFA and LITT may be preferable whenever surgical resection of liver tumors is impossible.

Normative values in anorectal manometry using microtip technology: a cohort study in 172 subjects.

PURPOSE: The aims of this study were to obtain normative values in resting/squeeze pressure and surface electromyography (s-EMG) in anorectal manometry using microtip technology and to determine the relationship between objective measurable values, gender and age in a cohort with no anorectal disorders. METHODS: One hundred seventy-two white central European subjects (106 males/66 females) were recruited prior to left colonic or upper rectal surgery and studied by anorectal rapid pull-through manometry with a microtip transducer system and endoanal s-EMG using a bipolar plug electrode. s-EMG patterns were determined as plateau, peak and decrease by a blinded co-investigator. Objective measurable sphincter pressures and s-EMG values were correlated with gender, age and s-EMG patterns. RESULTS: Squeeze pressure, voluntary pressure as well as s-EMG amplitude and its area under the curve were significantly lower in women compared to men (p < 0.001 each), whereas resting pressure showed no gender differences. s-EMG patterns were strongly influenced by gender. Male patients showed significantly more plateau pattern whereas peak pattern was significantly more often in women. In both genders, the peak pattern was associated with significant higher squeeze pressures. In all measurements, we found considerable inter-individual variations being higher in elder patients. There was no manometric parameter correlating with age. CONCLUSIONS: Gender is the strongest factor influencing objective measurable manometric data for healthy men and women. There are significant gender differences concerning squeeze patterns. All manometric values should be interpreted in the context of gender and of methodology used. Large prospective cohort studies matched for gender are necessary to clarify the effect of ageing on anal sphincter strength.

Estimate or calculate? How surgeons rate volumes and surfaces.

PURPOSE: Surgeons frequently describe the shape of intraoperative findings using visual judgement and their own sense of proportion or describing these findings in comparison to commonly used or metaphoric subjects. The aim of the study was to analyse the reliability of surgeon's estimations of dimensions. METHODS: The study was performed in two phases. First, physicians had to estimate the metric proportions of four well-known objects. Second, surgeons were asked intraoperatively to estimate the liver resection surface after partial hepatectomy. The exact surface of the resection plane was measured using computed tomography-guided planimetry of the resection specimen. Physician's estimations and the exact measurements of the well-known objects and the liver resection surface were compared. Systematic error was defined by the natural logarithm of estimated/real size. RESULTS: We found a large individual discrepancy in estimating the metric proportions of commonly used objects and a tendency to underestimate both commonly used objects and liver resection surface. Experienced liver surgeons were more accurate in estimating liver resection surface compared with younger staff members. CONCLUSIONS: We found a large bias in estimating the dimension of both commonly used objects and the surface area of liver parenchyma transection. Obviously, estimating errors are more influenced by the individual subject who estimates than by the object itself. In clinical routine, surgeons should rely more on simple measuring devices than on their own sense of proportion. Education in how to estimate more correctly human liver resection surfaces can be achieved by ex vivo studies using porcine livers.

Parenchyma-preserving hepatic resection for colorectal liver metastases.

BACKGROUND: Hepatic resection of colorectal liver metastases is the only curative treatment option. As clinical and experimental data indicate that the extent of liver resection correlates with growth of residual metastases, the present study analyzes the potential benefit of a parenchyma-preserving liver surgery approach. METHODS: Data from a prospectively maintained database of patients undergoing liver resection for colorectal metastases were reviewed. Evaluation of outcome was performed using the Kaplan-Meier method. Correlations were calculated between clinical-pathological variables. RESULTS: One hundred sixty-three patients underwent 198 liver resections for colorectal metastases: 26 major hepatectomies, 65 minor anatomical resections, 78 non-anatomical resections, as well as 29 combinations of minor anatomical and non-anatomical procedures. Overall 1-, 3-, and 5-year survival was 93%, 62%, and 40%, respectively. Patients with repeated liver resections had a 5-year survival of 27%. Interestingly, large dissection areas were associated with a significant reduction of the 5-year survival rate (33%). Five-year survival after major hepatectomy was not significantly reduced. CONCLUSION: For colorectal liver metastases, minor resections offer a prolonged survival compared to major hepatectomies. As patients with stage IV colorectal disease are candidates for repeat resections, preservation of hepatic parenchyma is of increasing importance in the setting of multi-modal and repeated therapy approaches.

Popular belief meets surgical reality: impact of lunar phases, Friday the 13th and zodiac signs on emergency operations and intraoperative blood loss.

BACKGROUND: The influence of superstition, moon calendars, and popular belief on evidence-based medicine is stunning. More than 40% of medical staff is convinced that lunar phases can affect human behavior. The idea that Friday the 13th is associated with adverse events and bad luck is deep-rooted in the population of Western industrial countries. The aim of the present study was to test the hypothesis that these myths are transferable to real-life surgery. METHODS: We analyzed the extent to which moon phases, zodiac signs, and Friday the 13th influence blood loss, emergency frequency, and intestinal perforations by evaluating the operation records of all 27,914 consecutive patients of our institution undergoing general, visceral, or vascular surgery between August 2001 and August 2010. Dates of surgery were allocated to lunar phases and to zodiac signs, as well as to Friday the 13th. RESULTS: A total of 111 lunar cycles and 15 Fridays the 13th occurred within the 3,281-day observation period. Patients' characteristics did not differ in lunar phases, zodiac signs, or Fridays the 13th. Full moon phases, the presence of Friday the 13th, and zodiac signs influenced neither intraoperative blood loss nor emergency frequency. No statistical peaks regarding perforated aortic aneurysms and gastrointestinal perforations were found on full moon or Friday the 13th. CONCLUSIONS: Scientific analysis of our data does not support the belief that moon phases, zodiac signs, or Friday 13th influence surgical blood loss and emergency frequency. Our data indicate that such beliefs are myths far beyond reality.

Contribution of final-year medical students to operation room performance--economical and educational implications.

PURPOSE: The so-called "practical year" is the last part of medical students' education in Germany. Without being paid, final-year medical students have to work for 1 year under supervision in academic teaching hospitals. It is mandatory for every student to rotate to a surgical department for 4 months. The aim of the present study was to assess the working time contribution of final-year medical students on operation room performance at the surgical department of a university hospital. METHODS: Over an 8-year period, purely surgical times of 24,214 operations in 2,792 days were analyzed with special regard to final-year medical students' participation rate. Students' cumulative workload in the operating room was compared to that of surgical residents. RESULTS: Mean participation rate of final-year medical students was 47.8%, being higher in elective surgery than in emergency surgery (53.9% vs. 24.7%; p < 0.001). When students participated in operations, mean daily cumulative working time of student's cohort was 10.3 ± 0.12 h. Daily cumulative workload of medical students in the operating room strongly correlated with both medical doctors' cumulative workload (r (2) = 0.573) and daily workload of the team (r (2) = 0.740, p < 0.001 each). Final-year medical students assisted significantly more often in time-consuming operations. CONCLUSION: Final-year medical students contribute significantly to surgical operation room performance, similarly but less intensively than residents. Employment of students may counterbalance staff shortage in operating rooms. Therefore, it is likely that the German health care system relies on unpaid medical students to minimize the total cost of surgery. According to the extent of workload accomplished by final-year medical students, a remuneration of the "practical year" seems reasonable.

Triclosan-coated sutures reduce wound infections after hepatobiliary surgery--a prospective non-randomized clinical pathway driven study.

OBJECTIVES: Wound infections after abdominal surgery are still frequent types of nosocomial infections. Suture materials might serve as a vehicle for mechanical transport of bacteria into the surgical wound. To reduce bacterial adherence to surgical sutures, triclosan-coated polyglactin 910 suture materials with antiseptic activity (Vicryl plus®) were developed. The aim of this prospective non-randomized clinical pathway driven study was to ascertain if the use of Vicryl plus® reduced the number of wound infections after transverse laparotomy. PATIENTS AND METHODS: Between October 2003 and October 2007, 839 operations were performed using a transverse abdominal incision. In the first time period, a PDSII® loop suture was used for abdominal wall closure. In the second time period, we used Vicryl plus®. Risk factors were collected prospectively to compare the two groups. RESULTS: Using a PDSII® loop suture for abdominal wall closure in the first time period, 9.2% of the patients developed wound infections. In the second time period, using Vicryl plus®, the number of wound infections decreased to 4.3% (p < 0,005). Both groups were comparable regarding risk factors despite no other changes in protocols of patient care. CONCLUSION: Antiseptic-coated loop Vicryl suture for abdominal wall closure can be superior to PDSII sutures in respect to the development of wound infections after a two-layered closure of transverse laparotomy.

Torquated giant appendix epiploica mimicking intraperitoneal liposarcoma: report of a case.

A 49-year-old woman presented with acute abdominal pain in the right iliac fossa in our emergency department. Pain was abrupt in onset and severely colicky in nature. Abnormal laboratory values included a C-reactive protein of 75 mg/L and a CA-125 of 70.3 U/mL. White blood cell count was normal. Abdominal computed tomography (CT) scan revealed an inhomogeneous mass of 9.5 x 3.5 x 5.5 cm in diameter close to the appendix vermiformis and the sigmoid colon. Because of the clinical symptoms of an acute abdomen an explorative laparotomy was performed. Intraoperatively a pedunculated tumor beginning at the serosa of the sigmoid colon was found. The appendix was unremarkable. The macroscopic aspect as well as the backtable incision of the tumor was suspicious of an intraperitoneal liposarcoma. Rapid section and histopathologic examination revealed necrotic fat tissue without any malignancy. The patient was discharged from the hospital 7 days after the operation with normal laboratory parameters and without further complication. When epiploic appendagitis is evident as a big tumor mass in addition to clinical symptoms of an acute abdomen and elevated tumor markers, surgical exploration is mandatory.

A Biologic Surgical Implant in Complex Abdominal Wall Repair: 3-Year Follow-Up Results of a Multicentric Prospective Study.

PURPOSE: Despite the advancements in the reinforcement and closure techniques available, complex abdominal wall reconstruction (CAWR) remains a challenging surgical undertaking with considerable risk of postoperative complications. Biological meshes were developed that may help to complement standard closure techniques and offer an alternative to synthetic meshes, which carry significant risks with their use in complex cases. PATIENTS AND METHODS: A total of 114 patients underwent surgical treatment for CAWR with a Permacol™ (a biologic surgical implant). The study objective was to evaluate the short-term (6 months), mid-term (12-24 months), and long-term (36 months) clinical outcomes (through 36 months) associated with the use of a biologic surgical implant in these cases. RESULTS: The cumulative hernia recurrence rate was 18.7% (17/91) at 24 months and 22.4% (19/85) at 36 months. Twelve (14.1%) subjects required reoperation for hernia repair within 36 months for repair of recurrent hernias. Between 6- and 36-months post-surgery, patients reported improvement in their Carolina comfort scale (CSS) measures of severity of pain, sensation of mesh, and movement limitations. CONCLUSION: A biologic surgical implant can provide long-term benefit to complex abdominal wall repairs in patients staged grade III according to the Ventral Hernia Working Group (VHWG).

Cholecystocolonic fistula prevents upper intestinal obstruction by a large gallstone after perforation into the duodenum.

BACKGROUND: Bilioenteric fistulas are rare complications of cholecystolithiasis that are associated with high morbidity and mortality and mainly appear in elderly patients. CASE PRESENTATION: This is the report of a patient suffering from cholecystoduodenal fistula with additional cholecystocolonic fistula. DISCUSSION: This cholecystocolonic fistula provoked a short bowel syndrome with symptomatic diarrhea and prevented an upper gastrointestinal ileus caused by the large perforated gallstone into the duodenum. This interesting constellation has not been described in literature yet.

Retroperitoneal abscess with consecutive acute renal failure caused by a lost gallstone 2 years after laparoscopic cholecystectomy.

A 70-year-old male patient presented with abdominal pain, acute renal failure, and fever 2 years after laparoscopic cholecystectomy. During the surgical drainage of the abscess formation on the patient's right flank, a huge gallstone was found in the retroperitoneum. The patient was dismissed from the hospital 11 days after admission with normal lab panel and restored renal function.

Staged lavage versus single high-volume lavage in the treatment of feculent/purulent peritonitis: a matched pair analysis.

BACKGROUND: Spontaneous and iatrogenic secondary peritonitis remain to have a mortality of 10-30% and significant socioeconomic impact in survivors and especially non-survivors. Data on the most cost-effective treatment are lacking. We therefore studied outcome and resource utilization in a homogeneous cohort of patients with secondary fecal or purulent peritonitis undergoing surgery with source control and two different types of abdominal lavage. METHODS: Thirty-one consecutive patients with secondary feculent or purulent peritonitis of the lower gastrointestinal tract underwent a single high-volume lavage. That cohort was matched with 31 patients with the same source, extent, and quality of peritonitis treated by source control and staged lavage (intermittent lavage). RESULTS: Patients in both groups were comparable in gender distribution, age, comorbidity, source, extent, and severity of peritonitis with the history of intestinal perforation in the single high-volume lavage group being significantly higher than in the intermittent lavage group (2.0 +/- 1.7 vs. 1.1 +/- 0.8d; p = 0.008). Patients in the single high-volume lavage group had significantly less operations, thus requiring significantly less operation time (OR-time), intensive care unit (ICU)-requirement, ventilatory support, and inotropic support. CONCLUSION: Patients with secondary fecal or purulent peritonitis in at least two quadrants, undergoing a one step surgical repair including source control, primary anastomosis, and single high-volume lavage with more than 25 l have a comparable outcome to patients treated by staged lavage at significantly lower OR and ICU-utilization.

ELR+ CXC chemokine expression in benign and malignant colorectal conditions.

BACKGROUND: CXCR2 chemokine ligands CXCL1, CXCL5 and CXCL6 were shown to be involved in chemoattraction, inflammatory responses, tumor growth and angiogenesis. Here, we comparatively analyzed their expression profile in resection specimens from patients with colorectal adenoma (CRA) (n = 30) as well as colorectal carcinoma (CRC) (n = 48) and corresponding colorectal liver metastases (CRLM) (n = 16). METHODS: Chemokine expression was assessed by microdissection, quantitative real-time PCR (Q-RT-PCR), the enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry (IHC). RESULTS: In contrast to CXCL6, we demonstrated CXCL1 and CXCL5 mRNA and protein expression to be significantly up-regulated in CRC and CRLM tissue specimens in relation to their matched tumor neighbor tissues. Moreover, both chemokine ligands were demonstrated to be significantly higher expressed in CRC tissues than in CRA tissues thus indicating a progressive increase in the transition from the premalignant condition to the development of the malignant status. Although a comparative analysis of the CXCL1/CXCL5 protein expression profiles in CRC patients revealed that the absolute expression level of CXCL1 was significantly higher in comparison to CXCL5, mRNA- and protein overexpression of CXCL5 in CRC and CRLM tissues was much more pronounced (80- and 60- fold in CRC tissues, respectively) in comparison to CXCL1 (5- and 3.5- fold in CRC tissues, respectively). CONCLUSION: Our results demonstrate a significant association between CXCL1 and CXCL5 expression with CRC and CRLM suggesting for both chemokine ligands a potential role in the progression from CRA to CRC and thus, in the initiation of CRC.

Acute Cholecystitis.

BACKGROUND: The treatment of acute cholecystitis has been controversially discussed in the literature as there are no high-evidence-level data yet for determining the optimal point in time for surgical intervention. So far, the laparoscopic removal of the gallbladder within 72 h has been the most preferred approach in acute cholecystitis. METHODS: We conducted a systematic review by including randomized trials of early laparoscopic cholecystectomy for acute cholecystitis. RESULTS: Based on a few prospective studies and two meta-analyses, there was consent to prefer an early laparoscopic cholecystectomy for patients suffering from acute calculous cholecystitis while the term 'early' has not been consistently defined yet. So far, there is new level 1b evidence brought forth by the so-called 'ACDC' study which has convincingly shown in a prospective randomized setting that immediate laparoscopic cholecystectomy - within a time frame of 24 h after hospital admission - is the smartest approach in ASA I-III patients suffering from acute calculous cholecystitis compared to a more conservative approach with a delayed laparoscopic cholecystectomy after an initial antibiotic treatment in terms of morbidity, length of hospital stay, and overall treatment costs. Concerning critically ill patients suffering from acute calculous or acalculous cholecystitis, there is no consensus in treatment due to missing data in the literature. CONCLUSION: Laparoscopic cholecystectomy for acute cholecystitis within 24 h after hospital admission is a safe procedure and should be the preferred treatment for ASA I-III patients. In critically ill patients, the intervention should be determined by a narrow interdisciplinary consent based on the patient's individual comorbidities.

Liver resections of isolated liver metastasis in breast cancer: results and possible prognostic factors.

Background. Breast cancer liver metastasis is a hematogenous spread of the primary tumour. It can, however, be the expression of an isolated recurrence. Surgical resection is often possible but controversial. Methods. We report on 29 female patients treated operatively due to isolated breast cancer liver metastasis over a period of six years. Prior to surgery all metastases appeared resectable. Liver metastasis had been diagnosed 55 (median, range 1-177) months after primary surgery. Results. Complete resection of the metastases was performed in 21 cases. The intraoperative staging did not confirm the preoperative radiological findings in 14 cases, which did not generally lead to inoperability. One-year survival rate was 86% in resected patients and 37.5% in nonresected patients. Significant prognostic factors were R0 resection, low T- and N-stages as well as a low-grade histopathology of the primary tumour, lower number of liver metastases, and a longer time interval between primary surgery and the occurrence of liver metastasis. Conclusions. Complete resection of metastases was possible in three-quarters of the patients. Some of the studied factors showed a prognostic value and therefore might influence indication for resection in the future.