Incisional hernia rate 3 years after midline laparotomy.

BACKGROUND: Incisional hernia is the most frequent long-term complication after visceral surgery, with an incidence of between 9 and 20 per cent 1 year after operation. Most controlled studies provide only short-term follow-up, and the actual incidence remains unclear. This study evaluated the incidence of incisional hernia up to 3 years after midline laparotomy in two prospective trials. METHODS: Three-year follow-up data from the ISSAAC (prospective, multicentre, historically controlled) and INSECT (randomized, controlled, multicentre) trials focused on the rate of incisional hernia 1 and 3 years after surgery. Differences between the two groups were compared using t tests for continuous data and the χ2 test for categorical data. RESULTS: Analysis of 775 patients included in the two trials suggested that the incisional hernia rate increased significantly from 12.6 per cent at 1 year to 22.4 per cent 3 years after surgery (P < 0.001), a relative increase of more than 60 per cent. CONCLUSION: This follow-up of two trials demonstrated that 1 year of clinical follow-up for detection of incisional hernia is not sufficient; follow-up for at least 3 years should be mandatory in any study evaluating the rate of postoperative incisional hernia after midline laparotomy.

[Damage to implants due to high-frequency electrocautery : analysis of four fractured hip endoprostheses shafts]. / Implantatschädigung durch Einsatz eines Hochfrequenzmessers : Analyse von vier Hüftendoprothesenschaftbrüchen.

In revision surgery of joints, high-frequency electrocauterization instruments are used for homeostasis and dissection of soft tissue. If there is contact of these instruments with the metal implants, flashover can occur. This can lead to thermal microstructural changes in the material and as a consequence may reduce the fatigue strength of the implant. Four cases of hip revision surgeries were analysed. In all cases flashovers occurred and secondarily, the titanium hip endoprosthesis stem broke in the neck section of the prosthesis. The conducted investigations showed that contact between the high-frequency instrument and the anterolateral aspect of the endoprosthesis neck had occurred. Electrothermal implant damage was found in the broken area. If in hip revision surgery the stem is not to be replaced, contact between high-frequency instruments and the metal implant should be avoided.

Evaluation of the International Study Group of Pancreatic Surgery definition of delayed gastric emptying after pancreatoduodenectomy in a high-volume centre.

BACKGROUND: Delayed gastric emptying (DGE) is a common complication after pancreatoduodenectomy. The International Study Group of Pancreatic Surgery (ISGPS) definition of DGE has not been evaluated and validated in a high-volume centre. METHODS: Complete data sets including assessment of gastric emptying were identified from a database of patients undergoing pancreatoduodenectomy between 2001 and 2008. Factors associated with DGE (grades A, B and C) were assessed by univariable and multivariable analyses. RESULTS: DGE occurred in 340 (44.5 per cent) of 764 patients. Median hospital stay was significantly prolonged in patients with DGE: 13, 21 and 40 days for grades A, B and C respectively versus 11 days for patients without DGE. DGE was associated with prolonged intensive care unit (ICU) admission (at least 2 days): 20.6, 28.6 and 61.8 per cent of those with grades A, B and C respectively versus 9.4 per cent of patients without DGE. Factors independently influencing DGE grade A were female sex, preoperative heart failure and major complications (grade III-V). Validation of the DGE definition revealed that DGE grades A and B were associated with interventional treatment in 20.1 and 44.4 per cent of patients. CONCLUSION: The ISGPS DGE definition is feasible and applicable in patients with an uneventful postoperative course. Major postoperative complications and ICU treatment, however, might limit its usefulness. The identified risk factors for DGE are not amenable to perioperative improvement.

Endoscopic retroperitoneal neurectomy for chronic pain after groin surgery.

BACKGROUND: Chronic postoperative pain after inguinal surgery remains a difficult problem. The role of minimally invasive surgery in this complex setting is still unexplored. METHODS: Between January 1997 and January 2007, 34 men and five women with a mean(s.d.) age of 47(16) years underwent endoscopic retroperitoneal neurectomy (ERN) for chronic neuropathic groin pain due to genitofemoral nerve with or without ilioinguinal nerve entrapment. Follow-up data were obtained 1 and 12 months after surgery. RESULTS: At both timepoints after ERN, the severity of chronic postoperative groin pain at rest and during daily activities, and the rate of occupational disability, were significantly decreased in 27 of the 39 patients compared with preoperative values (all P < 0.001). CONCLUSION: ERN for chronic postoperative genitofemoral nerve entrapment neuropathy was successful in the majority of patients selected for the procedure. This minimally invasive approach allows simultaneous neurectomy of genitofemoral and ilioinguinal nerves.

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.

Expression of the CXCR6 on polymorphonuclear neutrophils in pancreatic carcinoma and in acute, localized bacterial infections.

The chemokine receptor CXCR6 has been described on lymphoid cells and is thought to participate in the homing of activated T-cells to non-lymphoid tissue. We now provide evidence that the chemokine receptor CXCR6 is also expressed by activated polymorphonuclear neutrophils (PMN) in vivo: Examination of biopsies derived from patients with pancreatic carcinoma by confocal laser scan microscopy revealed a massive infiltration of PMN that expressed CXCR6, while PMN of the peripheral blood of these patients did not. To answer the question whether CXCR6 expression is a property of infiltrated and activated PMN, leucocytes were collected from patients with localized soft tissue infections in the course of the wound debridement. By cytofluorometry, the majority of these cells were identified as PMN. Up to 50% of these PMN were also positive for CXCR6. Again, PMN from the peripheral blood of these patients were nearly negative for CXCR6, as were PMN of healthy donors. In a series of in vitro experiments, up-regulation of CXCR6 on PMN of healthy donors by a variety of cytokines was tested. So far, a minor, although reproducible, effect of tumour necrosis factor (TNFalpha) was seen: brief exposure with low-dose TNFalpha induced expression of CXCR6 on the surface of PMN. Furthermore, we could show an increased migration of PMN induced by the axis CXCL16 and CXCR6. In summary, our data provide evidence that CXCR6 is not constitutively expressed on PMN, but is up-regulated under inflammatory conditions and mediates migration of CXCR6-positive PMN.

Systematic review and meta-analysis of the effect of portal triad clamping on outcome after hepatic resection.

BACKGROUND: The effect of portal triad clamping (PTC) on outcome after hepatic resection is uncertain. METHODS: A systematic literature search was conducted to detect randomized controlled trials (RCTs) assessing the effectiveness and safety of PTC alone and of PTC with ischaemic preconditioning (IPC) of the liver. Studies on clamping of the inferior vena cava or hepatic veins were excluded. Endpoints included postoperative overall morbidity and mortality, cardiopulmonary and hepatic morbidity, blood loss, transfusion rates and alanine aminotransferase (ALT) levels. Meta-analyses were performed using a random-effects model. RESULTS: Eight RCTs published between 1997 and 2006 containing a total of 558 patients were eligible for final analysis. The design of the identified studies varied considerably. Analyses of endpoints revealed no difference between intermittent PTC and no PTC. Meta-analyses of PTC with and without previous IPC revealed no differences, but postoperative ALT levels were significantly lower with IPC. CONCLUSION: On currently available evidence, the routine use of PTC does not offer any benefit in perioperative outcome after liver resection. It cannot be recommended as a standard procedure.

[Multicentric randomised controlled trials in Germany: overview and interim analysis 1 year after inclusion of in the rubric "Clinical Trials"]. / Rekrutierende multizentrische chirurgische Studien in Deutschland : Zwischenbilanz ein Jahr nach Einführung der Rubrik.

BACKGROUND: For 1 year now, German surgical multicentric randomised controlled trials (MRCT) in Germany may be included under the heading "Clinical Trials" in our monthly updated trial list. MATERIAL AND METHODS: Quantitative and qualitative analysis of MRCT presented in the trial list was performed to give an overview and interim statement 1 year after implementation of the journal heading "Clinical Trials". RESULTS: In 1 year, the study list increased from four to eleven MRCT and the numbers of randomized patients from 396 to 1511. The MRCT show distinct differences regarding funding sources and reimbursement for participating centres per patient included. The study protocols of four of 11 MRCT were published in scientific journals. CONCLUSION: The new regular heading gives important details about ongoing surgical trials in Germany. The steady growth of trials and recruited patients demonstrates the practicability of randomized controlled trials in surgery.

[Gastrointestinal stromal tumors (GIST). Surgical therapy]. / Gastrointestinale Stromatumoren (GIST). Chirurgische Therapie.

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasms of the gastrointestinal tract. GIST occur predominantly in the stomach and less frequently in the extraduodenal small bowel, the colon, and the rectum; rarely, GIST can be found in the esophagus and the duodenum. Due to their biological behavior, the primary treatment goal for localized primary GIST is complete resection, without the need for lymphadenectomy or wide resection margins. Thus, gastric wedge resections and segmental resections of the small bowel are the most common surgical procedures for treating primary GIST. Surgical therapy of extensive primary tumors or of metastatic or recurrent GIST should be integrated into a multimodal therapeutic concept that includes targeted therapy with tyrosine kinase inhibitors, such as imatinib.

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.

[Multicenter surgical studies recruiting in Germany. A new regular heading in the German surgical journal "Der Chirurg"]. / Rekrutierende multizentrische chirurgische Studien in Deutschland. Eine neue Rubrik in der Zeitschrift "Der Chirurg".

BACKGROUND: Information about multicenter randomized controlled trials (mRCT) comparing surgical procedures that are open for patient recruitment is hardly available for potentially interested surgeons. On the other hand many mRCT fail because of poor recruitment of participating surgeons, not just of patients. MATERIAL AND METHOD: The available items in the International Clinical Trials Registry Platform (ICTRP) of the World Health Organisation were analyzed for their relevance to surgeons, and a basic data set was extracted by two surgeons in a consensus procedure. RESULTS: Of 20 items in the ICTRP, seven were identified as relevant to the surgeon in practice: study acronym with register number, principal investigator, patients, surgical procedures, status of the study (randomized patients and sample size), financing and case money, and contact information. DISCUSSION: In a new column introduced into the German surgical journal"Der Chirurg", a regularly updated list of recruiting mRCT will be printed. The trials must be registered internationally and provide basic information for interested surgeons. CONCLUSION: Through this new heading, improvements are expected in communication between surgeons performing trial studies, patient recruitment, and in planning, conducting, and analyzing mRCT.

Molecular characterisation of pancreatic ductal adenocarcinoma in patients under 40.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) rarely affects people under 40. OBJECTIVES: To determine whether the clinical, pathomorphological and genetic features of PDAC occurring in young patients (

[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.

[Surgical clinical studies and their practical realization]. / Chirurgisch-klinische Studien in der praktischen Durchführung.

The employment of the optimal therapeutic option according to the best current knowledge is called evidence-based medicine (EBM). Moreover, considering the cost explosion in public health systems, EBM should contribute towards economical and targeted use of the restricted resources and towards quality assurance in medicine. Obviously, this is applicable to the operative specialties and can be termed as evidence-based surgery. Surgeons have to do their "homework" about this subject and to perform randomized controlled trials (the gold standard with the greatest evidence) on a large scale, in order to come up to this expectation in future. Evidence-based therapy is essential for the preservation and especially for the further development and evolution of high-quality surgery with, at the same time, quality assurance in the new millenium. This article presents the definition of EBM and its implication in the operative fields. Fundamental principles for the practical conduct of clinical randomized controlled trials are defined and the specific problems in surgery are discussed.

[Surgeons learn how to learn. Study of 76,499 herniorrhaphies performed between 1993 and 1997 registered by the chamber of physicians in Westfalia-Lippe]. / Chirurgen lernen Lernen Eine. Untersuchung von 76.499 Leistenhernienreparationen der Jahre 1993-1997 der Arztekammer Westfalen-Lippe.

INTRODUCTION: New techniques require "new" surgeons who are able to apply them safely. The bushfire-like employment of laparoscopic cholecystectomy confronted a community of surgeons totally inexperienced in that technique. Thus, the collective learning curve was paralleled by a temporary increase of postoperative complications. The aim of the following study was to analyze the learning curve for laparoscopic herniorrhaphy with regard to the complication rates during that period. METHODS: A total of 76,499 questionnaires from the external quality assurance of the Westfalia-Lippe physicians board registered between 1993 and 1997 were analyzed retrospectively. The parameters (duration of the operation and hospitalization, ASA classification, rate of obese patients, intra- and postoperative complications) were analyzed and plotted as a synchronized learning curve of the whole group of surgeons. RESULTS: As for laparoscopic cholecystectomy, a learning curve was found for laparoscopic herniorrhaphy, which could be attributed to a decreasing duration of the procedures and increasing ASA classification and rate of morbid obese patients while complication rates were kept constantly low. After 9 months of application laparoscopic hernia repair seemed to have been introduced to a new collective of surgeons while learning parameters showed inverse trends for a short period of time. The complication rate of laparoscopic hernia repair was constantly lower than in routine open inguinal hernia repair. CONCLUSION: Since laparoscopic inguinal hernia repair is a demanding method, surgeons apparently did not forget the lessons learned from the introduction of laparoscopic cholecystectomy as they were able to avoid increasing intra- and postoperative complication rates during their learning curve. Surgeons are learning to learn.