Showing papers in "Langenbeck's Archives of Surgery in 2007"

Reoperative surgery for thyroid disease

Abstract: Background and aims Reoperative surgery for thyroid disease is rare. However, it is sometimes indicated for nodular recurrence after partial surgery for initially benign thyroid disease or for a completion total thyroidectomy when a final diagnosis of well-differentiated thyroid cancer (WDTC) is confirmed on a permanent section of a partially removed thyroid gland. This surgery can expose the patient to postoperative complications such as recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism. The aims of our study were to describe the population subjected to reoperative thyroid surgery and to evaluate postoperative morbidity to find the risk factor.

Angiogenesis in cancer: molecular mechanisms, clinical impact

Abstract: Background Angiogenesis, the formation of new blood vessels from the endothelium of the existing vasculature, is fundamental in tumor growth, progression, and metastasis. Inhibiting tumor angiogenesis is a promising strategy for treatment of cancer and has been successfully transferred from preclinical to clinical application in recent years. Whereas conventional therapeutic approaches, e.g. chemotherapy and radiation, are focussing on tumor cells, antiangiogenic therapy is directed against the tumor supplying blood vessels.

Radiofrequency ablation combined with palliative surgery may prolong survival of patients with advanced cancer of the pancreas

Abstract: The aim of this study is to identify the benefit acquired by the use of radiofrequency ablation in parallel to palliative therapy in patients with advanced cancer of the pancreas. Data on 25 consecutive patients who underwent palliative therapy with or without radiofrequency ablation for unresectable pancreatic cancer were included in this retrospective review. Thirteen patients received palliative therapy alone, whereas 12 patients received palliative therapy plus radiofrequency ablation. Overall mean survival rate in patients receiving paliative therapy alone was 13 months and the maximum survival was 30 months. Where radiofrequency ablation was applied, mean survival was estimated at 33 months (p = 0.0048). Stage III and IV patients treated with palliative therapy alone have a mean survival of 15 and 10 months, respectively. All stage III patients receiving radiofrequency ablation are alive at present and maximum survival has reached 38 months (p = 0.0032), whereas stage IV patients who were treated with radiofrequency ablation have an estimated mean survival period of 14 months (p = 0.1095). Radiofrequency ablation in parallel to palliative therapy seems to provide survival benefit especially for stage III patients with unresectable pancreatic cancer. Further studies should be conducted to determine the usefulness of radiofrequency ablation in the treatment of advanced pancreatic cancer.

Effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction

Abstract: Controversy still exists about the need for pyloric drainage procedures (pyloroplasty or pyloromyotomy) after esophagectomy with esophagogastrostomy and vagotomy. Although pyloric drainage may prevent postoperative delayed gastric emptying, it may also promote bile reflux into the oesophagus. We analysed pyloric drainage methods for their potential effect on gastric outlet obstruction and bile reflux in patients undergoing esophagectomy. One hundred and ninety-eight patients with esophageal carcinoma were treated by transthoracal esophagectomy with gastric conduit reconstruction either with pyloromyotomy (group II, n = 118), pyloroplasty (group III, n = 34) or without pyloric drainage (group I, n = 46) between January 2000 and December 2004. The postoperative gastrointestinal passage by radiological investigation, anastomotic leakage rate, mortality and incidence of gastroesophageal reflux by endoscopy within the first postoperative year were retrospectively analysed. Patient demographics and the types of surgical procedures did not differ between the three groups. There was no difference in hospital mortality, anastomotic leakage rate, gastrointestinal passage and postoperative hospital stay between the three groups. However, more patients with pyloric drainage showed bile reflux (I = 0% vs II+III=14.9%, p = 0.069) and reflux esophagitis (I = 10.3% vs II+III = 34.5%, p < 0.05) compared to patients without pyloric drainage. On the multivariate analysis, pyloric drainage and the anastomotic height were independent and were significant risk factors associated with postoperative reflux esophagitis. Pyloric drainage after esophagectomy with gastric conduit reconstruction should be omitted because it does not improve gastric emptying and may favour biliary reflux esophagitis.

Pancreatic fistula after pancreaticoduodenectomy: the impact of a standardized technique of pancreaticojejunostomy

Abstract: The leading cause for morbidity and mortality after pancreaticoduodenectomy is a pancreatic anastomotic leak and fistula The two most commonly performed anastomoses after pancreaticoduodenectomy are pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) The role of standardization on outcomes after pancreaticoduodenectomy has not been sufficiently addressed The goal is to study the impact of a standardized technique of pancreatic anastomosis (PJ) after pancreaticoduodenectomy in a tertiary referral cancer teaching hospital A single-institution database was analyzed over 15 years The entire data were subdivided into two periods, viz, period A (1992 to 2001), when PG (dunking) was predominantly used, and period B (2003–2007), when a standardized technique of PJ (duct to mucosa) was employed There were 144 pancreaticoduodenectomies performed during period A with a pancreatic fistula rate of 16% During period B, 123 pancreaticoduodenectomies were performed with a pancreatic fistula rate of 32% (p < 00005) It appears that a standardized approach to the pancreatic anastomosis and a consistent practice of a single technique can help to reduce the incidence of complications after pancreaticoduodenectomy

Predictors of morbidity and mortality in the surgical management of hydatid cyst of the liver.

Abstract: Surgery for hydatid cyst of the liver is widely practiced worldwide; this type of management is still associated with high mortality and morbidity. The aim of this study is to find out possible predictors for this high mortality and morbidity. The medical records of 169 patients who underwent surgery for hydatid cyst of the liver were retrospectively reviewed. The mortality and the morbidity rates were assessed as well as the following eight potential predictors of mortality and morbidity: age of the patients, size of the cyst, number of cysts, other organs involved by the disease, the presence of preoperative complications, the type of surgery performed (radical or conservative), whether the disease was new or recurrent, and when surgery was performed in the first period (1973–1986) or in the second period (1987–1999). Cross-tabulation and logistic regression between mortality and morbidity (dependent variable) and the above-mentioned eight potential predictors (independent variables) were carried out. Of the 169 patients, 112 were female subjects and 57 male subjects, the age range was from 5 to 85 years (mean=39.2 years), the mortality rate was 6.5% (n=11), and the overall morbidity rate was 53.8% (n=91), while specific complications of liver hydatid cyst surgery were seen in 32% (n=54). Patients of age >40 years, with a cyst diameter of >10 cm, who presented with pre-operative complications, who had conservative surgery, and who had surgery before 1987 were having a significantly higher mortality and morbidity rate. Age, size of the cyst, the presence of pre-operative complications particularly cyst-biliary communication, and type of surgical procedure performed (conservative or radical) represent as significant predictors of mortality and morbidity of surgery for liver hydatid cyst.

Adrenal involvement in multiple endocrine neoplasia type 1: results of 7 years prospective screening.

Abstract: Adrenal tumors are a common manifestation of the multiple endocrine neoplasia type 1 (MEN-1) syndrome. Prevalence in recent studies varies between 9 and 45%. A genotype–phenotype correlation has been described as well as the development of adrenocortical carcinomas. Long-term prospective data are still lacking. Thirty-eight MEN-1 patients with proven germline mutations have been prospectively observed in a regular screening program in our hospital. Adrenal glands have been screened by biochemical analysis and either by endoscopic ultrasound (EUS) or computed tomography (CT) or both. Median follow-up was 48 months (12–108 months). Age at diagnosis of MEN-1, type of adrenal tumor, genotype, therapy, and clinical characteristics have been analyzed. In 21 (55%) patients, adrenal involvement of the disease was detected. Adrenal lesions were detected in average 6.9 years after the initial diagnosis of MEN-1. Median tumor size was 12 mm (5–40 mm). Tumor size smaller than 10 mm was observed in 11 patients. Twelve patients had unilateral while nine had bilateral adrenal lesions. EUS detected all adrenal tumors, whereas CT failed in seven cases. In three patients, functioning tumors (one pheochromocytoma, one bilateral Cushing adenoma, and one adrenocortical carcinoma) and one nonfunctioning adenoma were diagnosed by histology and biochemical assessment. Two laparoscopic adrenalectomies and one laparoscopic subtotal resection were performed. Nonfunctioning adrenal lesions, not characterized by histology yet, were found in 18 patients. There was no statistical difference with regard to adrenal involvement between patients with germline mutations in exons 2 and 10 (12/21) and those with mutations in exons 3–9 (6/11). MEN-1-associated adrenal tumors are mostly small, benign, and nonfunctioning and much more common than previously reported. EUS was the most sensitive imaging procedure. The genotype–pheotype correlation previously suggested by our group could not be confirmed.

Metastasis to the pancreas—an indication for pancreatic resection?

Abstract: Background and aims Isolated metastatic involvement of the pancreas is very rare. To evaluate the possible benefit of surgery, we retrospectively analyzed patients that underwent pancreatic resection for metastases into the pancreas.

Liver resective surgery: a multivariate analysis of postoperative outcome and complication.

Abstract: Notwithstanding technical advances and high experience of liver resection of specialized centers, the rate of complications after surgical resection could be high. In this study, we analyzed causes and foreseeable risk factors linked to postoperative morbidity on the ground of data derived from a single center surgical population. From September 1989 to March 2005, 134 consecutive patients had liver resection for Hcc and 153 consecutive patients with liver metastasis (derived from either colorectal cancer or noncolorectal cancer) at our department. We performed 22 major hepatectomy, 20 left hepatectomy, 14 trisegmentectomy, 77 bisegmentectomy and/or left lobectomy, 74 segmentectomy, and 80 wedge resection. In-hospital mortality rate was 4.5%, about 7% in Hcc cases and 2.6% in liver metastasis. Morbidity rate was 47.7%, caused by the rising of ascites (10%), temporary impairment liver function (19%), biliary fistula (6%), hepatic abscess (25%), hemoperitoneum (10%), and pleural effusion (30%) sometimes combined each other. Some variables, associated with the technical aspects of surgical procedure, are responsible of the rising of complication as: Pringle maneuver length of more than 20 minutes (p=0.001); the type of liver resection procedure [major hepatectomy (p=0.02), left hepatectomy (p=0.04), trisegmentectomy (p=0.04), bisegmentectomy and/or left lobectomy (p=0.04)]; and the request of an amount of blood transfusion of more than 600 cc (p=0.04). Also, both liver dysfunction, in particular Child A vs B and C (p=0.01), and histopathological grading (p=0.01) are associated with a high rate of postsurgical complication in Hcc cases. We make the following recommendations: every liver resection should be planned after intraoperative ultrasonography, anatomical surgical procedure should be preferred instead of wedge resection, and modern devices should be used, like Argon Beam and Ligasure® dissector, to reduce the incidence of both intraoperative and postoperative bleeding and biliary leakage.

Which criterion of intraoperative iPTH assay is the most accurate in prediction of true serum calcium levels after thyroid surgery

Abstract: Intraoperative quick intact parathyroid hormone (iPTH) assay (IOPTH) has become a valuable adjunct in parathyroid surgery reliably predicting cure from hyperparathyroid state. Similarly to parathyroid surgery, the accuracy of the assay in predicting postoperative calcemia after thyroid surgery is related to blood sample timing and the criteria applied with no guidelines widely accepted, so far. This study compares different IOPTH criteria in predicting hypoparathyroidism-related hypocalcemia after thyroid surgery. The study included 200 consecutive patients undergoing total thyroidectomy. Three blood samples for IOPTH were taken in each patient: preoperatively—baseline (BL), at the end of surgery—skin closure (SC), and at 4 h postoperatively (4H). Serum calcium was routinely monitored at 4, 12, 24, 48, and 72 h postoperatively. The incidence and severity of hypocalcemia and related symptoms were matched to IOPTH results. The following criteria were tested: A, greater than 50% drop from BL at SC; B, greater than 70% drop from BL at SC; C, greater than 50% drop from BL at 4H; D, greater than 70% drop from BL at 4H; E, serum iPTH less than 15 pg/ml at SC; F, serum iPTH less than 10 pg/ml at SC; G, serum iPTH less than 15 pg/ml at 4H; H, serum iPTH less than 10 pg/ml at 4H. The accuracy of the tested criteria was calculated in predicting serum calcium level less than 2.0 mmol/l at any point after thyroidectomy. Tested criteria had the following value in predicting serum calcium level less than 2.0 mmol/l after thyroidectomy (sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy, respectively): A (60, 89, 38, 95, and 86%), B (80, 93, 57, 98, and 92%), C (70, 90, 44, 96, and 88%), D (85, 95, 65, 98, and 94%), E (80, 91, 50, 98, and 90%), F (90, 95, 69, 99, and 95%), G (90, 95, 70, 99, and 95%), H (95, 99, 90, 99, and 98%). The criterion of iPTH serum level less than 10 pg/ml at 4 h postoperatively has the highest accuracy in predicting serum calcium level below 2.0 mmol/l after total thyroidectomy when compared with the other criteria.

True smooth muscle neoplasms of the gastrointestinal tract: morphological spectrum and classification in a series of 85 cases from a single institute.

Abstract: True smooth-muscle neoplasms of the GI tract have been only rarely studied in the KIT era. Their incidence among other GI mesenchymal tumours and their clinicopathological spectrum have not been sufficiently analysed. We reviewed all GI mesenchymal lesions at the Pathology Institute of the Nuremberg Clinic Centre from 1994 through 2005. Among 262 lesions, there were 142 GISTs (54%) and 85 true smooth muscle neoplasms (32%). Smooth muscle neoplasms comprised 72 polypoid leiomyomas (78%, 5 oesophageal and 67 colorectal), 10 intramural leiomyomas (11%, 5 oesophageal, 4 gastric and one ileal), two intramural leiomyosarcomas in the sigmoid colon and ileum (2%) and one polypoid leiomyosarcoma involving the stomach, descending colon and the retroperitoneum concurrently. None of the leiomyomas with available follow-up have recurred or metastasised. Smooth muscle neoplasms are the second most common mesenchymal neoplasms in the GI tract after GISTs. They may arise either from the muscularis mucosae or proper muscle layer forming polypoid and intramural lesions, respectively. Polypoid leiomyomas are more common in the rectosigmoid, while intramural ones mainly arise in the vicinity of the oesophagogastric junction. Polypoid leiomyomas are sufficiently treated by endoscopic resection, and local surgical excision is the treatment of choice for intramural leiomyomas. Intramural leiomyosarcomas are rare high-grade sarcomas that commonly have infiltrated into the surrounding tissue or metastasised by the time of diagnosis.

The use of vacuum assisted closure (VAC™) in soft tissue injuries after high energy pelvic trauma

Abstract: Application of vacuum-assisted closure (VAC™) in soft tissue defects after high-energy pelvic trauma is described as a retrospective study in a level one trauma center. Between 2002 and 2004, 13 patients were treated for severe soft tissue injuries in the pelvic region. All musculoskeletal injuries were treated with multiple irrigation and debridement procedures and broad-spectrum antibiotics. VAC™ was applied as a temporary coverage for defects and wound conditioning. The injuries included three patients with traumatic hemipelvectomies. Seven patients had pelvic ring fractures with five Morel–Lavallee lesions and two open pelviperineal trauma. One patient suffered from an open iliac crest fracture and a Morel–Lavallee lesion. Two patients sustained near complete pertrochanteric amputations of the lower limb. The average injury severity score was 34.1 ± 1.4. The application of VAC™ started in average 3.8 ± 0.4 days after trauma and was used for 15.5 ± 1.8 days. The dressing changes were performed in average every 3 days. One patient (8%) with a traumatic hemipelvectomy died in the course of treatment due to septic complications. High-energy trauma causing severe soft tissues injuries requires multiple operative debridements to prevent high morbidity and mortality rates. The application of VAC™ as temporary coverage of large tissue defects in pelvic regions supports wound conditioning and facilitates the definitive wound closure.

Microscopic regional lymph node status in papillary thyroid carcinoma with and without lymphadenopathy and its relation to outcomes

Abstract: Aim The aim of this study was to evaluate microscopic nodal status in papillary thyroid carcinoma (PTC) with and without lymphadenopathy and its relation to outcomes.

Incidental papillary microcarcinoma of the thyroid--factors affecting lymph node metastasis.

Abstract: Despite the overall excellent prognosis for patients with thyroid papillary microcarcinoma (PMC), these tumors are associated with lymph node metastasis. The aim of this study is to identify the rate of lymph node metastasis and evaluate the clinical and pathological factors affecting metastasis in thyroid PMC. Among 475 patients with papillary thyroid carcinoma treated between 1990 and 2003, 81 patients (17%) were diagnosed as PMC and the records of these patients were evaluated retrospectively. Clinicopathologic features were evaluated by univariate and multivariate analyses. According to age, metastases, extent, and size risk definition, all patients were in low-risk group. Lymph node metastases were determined in 12.3% of patients. Mean follow-up was 7 years (range from 28 to 192 months). Ten-year disease-free and overall survival rates were 97 and 100%, respectively. Both multifocality and thyroid capsular invasion were found to be independent risk factors for lymph node metastasis by multivariate analysis. Patients with thyroid PMC in low-risk group with multifocal tumors and with capsule invasion may have increased risk of lymph node metastasis, and must be considered in follow-up of the patients who have these factors.

VEGF(165) and bFGF protein-based therapy in a slow release system to improve angiogenesis in a bioartificial dermal substitute in vitro and in vivo.

Abstract: Background Angiogenesis can be enhanced by several growth factors, like vascular endothelial growth factor-165 (VEGF165) and basic fibroblast growth factor (bFGF). Delayed release of such growth factors could be provided by incorporation of growth factors in fibrin matrices. In this study, we present a slow release system for VEGF165 and bFGF in fibrin sealant.

Scandinavian Quality Register for Thyroid and Parathyroid Surgery: audit of surgery for primary hyperparathyroidism.

Abstract: Background and aim Scandinavian Quality Register for Thyroid and Parathyroid Surgery is an on-line web-based database with the aim to improve the quality of thyroid and parathyroid surgery. Preliminary data from surgery for primary hyperparathyroidism are reported here.

Islet cell transplantation today

Abstract: Long-term studies strongly suggest that tight control of blood glucose can prevent the development and retard the progression of chronic complications of type 1 diabetes mellitus. In contrast to conventional insulin treatment, replacement of a patient’s islets of Langerhans either by pancreas organ transplantation or by isolated islet transplantation is the only treatment to achieve a constant normoglycemic state and avoiding hypoglycemic episodes, a typical adverse event of multiple daily insulin injections. However, the cost of this benefit is still the need for immunosuppressive treatment of the recipient with all its potential risks. Islet cell transplantation offers the advantage of being performed as a minimally invasive procedure in which islets can be perfused percutaneously into the liver via the portal vein. Between January 1990 and December 2004, 458 pancreatic islet transplants worldwide have been reported to the International Islet Transplant Registry (ITR) at our Third Medical Department, University of Giessen/Germany. Data analysis of islet cell transplants performed in the last 5 years (1999–2004) shows at 1 year after adult islet transplantation a patient survival rate of 97%, a functioning islet graft in 82% of the cases, whereas insulin independence was meanwhile achieved in 43% of the cases. However, using a novel protocol established by the Edmonton Center/Canada, the insulin independence rates have improved significantly reaching meanwhile a 50–80% level. Finally, the concept of islet cell or stem cell transplantation is most attractive, as it offers many perspectives: islet cell availability could become unlimited and islet or stem cells my be transplanted without life-long immunosuppressive treatment of the recipient, just to mention two of them.

Sirolimus impairs wound healing.

Abstract: Background and aims Clinically, the immunosuppressive drug sirolimus, used in organ transplantation, appears to impair wound healing. Little is known about the mechanisms of action. We investigated the effect of sirolimus on wound healing, and we analyzed the expression of stimulating mediators of angiogenesis (VEGF, vascular endothelial growth factor) and collagen synthesis (nitric oxide) in wounds.

Improved collagen type I/III ratio at the interface of gentamicin-supplemented polyvinylidenfluoride mesh materials.

Abstract: Formation of recurrent inguinal and incisional hernia shows an underlying defect in the wound-healing process with an insufficient quality of scar formation. Even after mesh repair an altered collagen formation and insufficient mesh integration has been found as main reason for recurrences. Therefore, the development of bioactive mesh materials to achieve a local modification of the scar formation to improve patients outcome is advisable. A polyvinylidenfluoride mesh material (PVDF) was constructed and surface modified by plasma-induced graft polymerization of acrylic acid (PVDF + PAAc). Surface supplementation was sought by binding of gentamicin to the provided active sites of the grafted mesh surfaces (PVDF+PAAc+Gentamicin). In vivo modulation of collagen formation was evaluated in a standardized animal model where an abdominal wall replacement was performed in 45 Sprague–Dawley rats. Seven, 21, and 90 days after mesh implantation, collagen/protein ratio and the collagen type I/III ratio as well as the expression of type I alpha 1 collagen mRNA (SYBR Green real-time RT-PCR) were analyzed at the perifilamentary region. Additionally, expression of matrix metalloproteinases (MMP-8/-13) has been investigated immunohistochemically. Implantation of the PVDF + PAAc + Gentamicin mesh induced a significantly decreased expression of MMP-8 and MMP-13 at the interface 21 and 90 days after implantation compared to the other groups. Whereas no significant effect was observed comparing the overall collagen/protein ratio, the quality of collagen formation expressed by the collagen type I/III ratio showed significantly higher ratios around the PVDF + PAAc + Gentamicin mesh 21 and 90 days after implantation. Correspondingly, an up to 5.3-fold expression of type I alpha 1 collagen mRNA was found. The present data confirm that a surface modification of PVDF mesh samples using plasma-induced graft polymerization of acrylic acid and supplementation of gentamicin is able to improve scar quality and mesh integration.

Therapeutic strategies for the management of delayed gastric emptying after pancreatic resection

Abstract: Delayed gastric emptying (DGE) is one of the most troublesome postoperative complications following pancreatic resection. Not only does it contribute considerably to prolonged hospitalization, but it is also associated with increased postoperative morbidity and mortality. We performed an electronic and manual search of the international literature for studies dealing with the treatment of DGE following pancreatic resection using the Medline database. The search items used were “delayed gastric emptying,” “pancreaticoduodenectomy,” “Whipple procedure,” “pylorus-preserving pancreaticoduodenectomy,” and “complications following pancreatic resection” in various combinations. A number of studies were identified regarding possible therapeutic alternatives for the treatment of DGE. From the class of prokinetic regimens, most studies seem to support the use of erythromycin. However, its use has not gained wide acceptance. Regarding the operative technique, both standard Whipple and pylorus-preserving pancreatic resection carry similar rates of DGE. Billroth II type-like gastrointestinal reconstruction is the most widely accepted method and is associated with lower rates of DGE. Reoperations for managing severe DGE were very rarely reported. The incidence of DGE in high-volume centers specialized in pancreatic surgery is well below 20%, thus following the improved rates that have been reported in the last decade regarding mortality and length of hospital stay after pancreatic surgery. DGE mandates a uniform definition and method of evaluation to achieve homogeneity among studies. Standardization of the operative technique, as well as “centralizing” pancreatic resections in high-volume centers, should aid to improve the occurrence of this bothersome postoperative complication.

Systemic immune dysfunction in pancreatic cancer patients.

Abstract: Background and aims We investigated the immune status in 32 pancreatic cancer patients (PC) in comparison with healthy controls (HC).

Current concepts and perspectives of immunosuppression in organ transplantation.

Abstract: Background While early surgical success made organ transplantation possible in the 1950s and 1960s, the breakthrough in clinical organ transplantation was achieved through the discovery and invention of modern immunosuppressive agents in the early/mid-1980s. Especially during the 1990s, a large array of immunosuppressants has expanded the armamentarium used to prevent and treat allograft rejection, resulting in an excellent short-term and an acceptable long-term outcome. However, these drugs have potent but still non-specific immunosuppressive properties and frequently show severe acute and chronic side effects, sometimes questioning the overall success.

Five-year follow-up of a prospective non-randomised study comparing duodenum-preserving pancreatic head resection with classic Whipple procedure in the treatment of chronic pancreatitis.

Abstract: Background Three prospective randomised studies were conducted to compare pancreatoduodenectomy (PD) with duodenum-preserving pancreatic head resection (DPPHR) in patients suffering from chronic pancreatitis (cP). In these three series, the superiority of the duodenum-preserving technique with regard to quality of life (QOL) and pain relief has been demonstrated. Long-term follow-up investigations have not been published so far. The present paper reports on a 5-year follow-up study of a prospective, non-randomised trial comparing classic Whipple procedure (PD) with Beger DPPHR.

Risk factor stratification after simultaneous liver and colorectal resection for synchronous colorectal metastasis

Abstract: This study was conducted to devise a prognostic model for patients undergoing simultaneous liver and colorectal resection. A retrospective analysis was performed on 138 colorectal patients who underwent simultaneous liver and colorectal resection between September 1994 and September 2005. The primary endpoint of the study was overall survival. Three patients with positive liver resection margin were excluded from the analysis. At multivariate level, poor prognostic factors were liver resection margin ≤5 mm (P = 0.047; relative risk, 1.684; 95% CI = 1.010–2.809), CEA greater than 5 ng/ml (P = 1 (P = <0.042; relative risk, 1.687; 95% CI = 1.020–2.789), and lymph node ≥ 4 (P = <0.012; relative risk, 1.968; 95% CI = 1.158–3.347). The risk stratification grouping of the 135 patients was performed according to the following criteria: low risk group, 0–1 factor; intermediate risk group, 2 factors; high-risk group, 3–4 factors. Of 135 patients, 86 patients (63.0%) were categorized as low-risk group, 36 patients (26.6%) as intermediate risk group, and 14 patients (10.4%) as high-risk group. Median survival times for low, intermediate, high-risk groups were 68.0, 43.6 (95% CI, 24.7–62.4), and 23.5 months (95% CI, 9.4–31.5), respectively. The high-risk group demonstrated an approximately threefold (relative risk, 3.1; 95% CI, 1.6–6.0) increased risk of death. A simple risk factor stratification system was proposed to evaluate the chances of cure of patients after simultaneous resection of liver metastases and primary colorectal carcinoma. The risk factor stratification showed three groups with distinct survival. The risk stratification may help to predict patient survival after simultaneous liver and colorectal resection. This system needs further prospective validation.

Severe acute lower gastrointestinal bleeding: risk factors for morbidity and mortality

Abstract: Many factors can cause morbidity and mortality in patients with severe acute lower gastrointestinal bleeding (LGIB). The objectives of this study are to analyze three aspects related to severe acute LGIB: (1) indications and prognostic factors for urgent surgery, (2) risk factors for morbidity and mortality, and (3) relapse rates. A retrospective cohort was collected between 1985 and 2002 in a tertiary referral center. One hundred seventy-one patients with severe acute LGIB were reviewed (LGIB is defined as frank rectal bleeding either with a hematocrit decrease ≥10 points or when a transfusion of at least three units of concentrated red blood cells is needed). The main outcome measures are: (1) indications for urgent surgery and results, (2) morbidity and mortality, and (3) relapse. There were 158 (92%) stable patients, and in 61% of these, the bleeding was identified via colonoscopy. Bleeding was identified using urgent colonoscopy in a higher percentage of patients compared to delayed colonoscopy (68% versus 14%; p < 0.001). Urgent surgery was indicated in 24 (14%) patients, and the approach was peri-anal in 5 (21%) patients and abdominal in the rest. Local intestinal resection was performed on the 15 patients in which bleeding was identified, whereas a subtotal colectomy was performed on the remaining 4 patients. The presence of hypotension (p = 0.001; 35 versus 10%) and etiology of LGIB (p < 0.001) are prognostic factors of urgent surgery. Morbidity was 6.4%, and mortality was 4.7%. The only morbidity or mortality risk factors detected were the presence of associated comorbidities (p = 0.008) and the need for urgent surgery (p = 0.002). The most frequent etiology was diverticulosis (25%). After a mean follow-up of 132 ± 75 months, bleeding relapsed in 30% of patients. It is difficult to predict which patients are going to need urgent surgery in severe acute LGIB; only the presence of hypotension on arrival at the emergency ward would lead us to suspect a negative outcome for the hemorrhage. In severe acute LGIB, morbidity and mortality is high, and this is mainly due to the high level of associated comorbidity and the need for urgent surgery. It is necessary for strict hemodynamic monitoring of the patients at risk if we want to improve outcomes. The bleeding relapse rate is high in LGIB, although generally, it is not severe.

Surgery for right-sided colonic diverticulitis: results of a 10-year-observation period

Abstract: In contrast to sigmoid diverticular disease, right colonic diverticulitis is a rare disease in Western countries. The clinical presentation is often similar to acute appendicitis. The aim of this study was to analyze surgical challenge in right-sided diverticulitis. All patients who underwent resection for both right-sided and sigmoid diverticular disease were registered prospectively in a database (observation period, 1996–2005). A retrospective analysis of all patients who underwent resection for right-sided colonic diverticulitis (ileocolic resection, right colectomy) was performed. Special focus was set on incidence, clinical symptoms, indication, procedure, clinical outcome, and histopathologic findings including immunohistochemistry. From a total of 593 patients treated surgically for recurring or acute complicated diverticular disease, the majority (97.8%) suffered from sigmoid diverticulitis (n = 580), whereas 2.2% (n = 16) underwent surgery for right-sided diverticulitis (including three patients with combined sigmoid and cecal diverticulitis). Related to the total number of appendectomies (n = 1167), this represented an incidence of 1.4%. In five of 16 patients, acute appendicitis was presumed preoperatively. Most common diagnostic was ultrasonography. In the group of patients with right-sided diverticulitis, the most common procedure was right hemicolectomy (n = 10), followed by ileocolic resection (n = 3) and combined right colonic resection with sigmoid resection (n = 3). Histopathological investigation confirmed complicated diverticulitis of the cecum with local perforation or abscess in 75% of the patients (12/16). Hypoganglionosis or aganglionosis was diagnosed in seven of the 16 resected specimens. As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis may be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis. As most cases will remain clinically unimminent, surgery is only indicated in complicated right-sided cases. Resection of the inflamed colonic segment with primary anastomosis is safe and can be performed laparoscopically. It can only be speculated whether hypoganglionosis or aganglionosis is a causative factor in the etiology of right-sided diverticulitis.

Incisional hernia: challenge of re-operations after mesh repair.

Abstract: The widespread use of meshes for the repair of incisional hernia is currently followed by an increasing number of re-operations. The incidence of incisional hernia recurrence after mesh repair varies between 3 and 32%. The problem of mesh failure and options for another surgical intervention seem rather unattended. We present our experience of 77 re-operations after previous mesh repair that were performed between 1995 and 2004 out of a total of 1,070 operations for incisional hernia. The retrospective analysis focused on recurrence in relation to location, material of the previous mesh repair and the surgical procedure to resolve the problem. The locations of the preceding meshes were epifascial as onlays (n=23), retromuscular as sublays (n=46), within the defect as inlays (n=6) or intraperitoneally (n=2). The direction of the incision was vertical medial (n=41) or horizontal crossing the linea semilunaris (n=36). Recurrences after median incisional hernia mesh repair mainly occurred at the cranial border of the mesh subxiphoidal. Except for two patients, all recurrences manifested at the margin of the enclosed mesh. Re-operation after previous mesh repair is a surgical challenge. The type of revision procedure has to consider the position and material of the previous mesh. In our clinic recurrences, heavyweight polypropylene meshes were mostly treated with mesh exchange and lightweight polypropylene meshes could be treated by extension with a second mesh. In contrast to suture techniques, deficient mesh repairs are more evidently related to technical problems.

Organ dysfunction and long term outcome in secondary peritonitis.

Abstract: Secondary peritonitis is still associated with high mortality, especially when multiorgan dysfunction complicates the disease. Good prognostic tools to predict long term outcome in individual patients are lacking and therefore require further study. 163 consecutive patients with secondary peritonitis were included, except those with postoperative or traumatic peritonitis. In 58 patients treated in the intensive care unit (ICU), organ dysfunction was quantified using Sequential Organ Failure Assessment (SOFA) score in the first 4 days. Predictive factors for poor outcome were evaluated in all patients. Hospital and 1-year mortality was assessed. Hospital mortality was 19% and 1-year mortality 23%. Acute physiology and chronic health evaluation II (APACHE II), previous functional status, and sepsis category were predictive of fatal outcome in the total cohort (p = 0.034, p < 0.001, and p < 0.001). In patients treated in the ICU, advanced age and admission SOFA score were independent predictors of death (p = 0.014, p < 0.0001). The SOFA score showed the best discriminative ability for poor outcome (AuROC 0.78). Degree of organ dysfunction measured using SOFA score was the best predictor of hospital mortality in patients suffering from secondary peritonitis.

Qualitative and quantitative evaluation of total and types I and III collagens in patients with ventral hernias

Abstract: The purpose of this study was to evaluate the amount of total and types I and III collagens of samples from the linea alba in patients with hernias (epigastric, umbilical, and incisional) on the anterior wall of the abdomen, comparing them to findings obtained from a cadaver control group without hernias. Samples of the linea alba aponeurosis from 26 patients with hernias on the anterior abdominal wall and from 32 cadavers without hernias were analyzed and compared for qualitative and quantitative evaluation of the total and the types I and III collagens. Sirius-red staining was used to evaluate the total collagen, and for types I and III collagens, immunohistochemistry was used with monoclonal antibody anticollagen types I and III, respectively. The amount of total collagen was 18.05% smaller in patients with hernias than in cadavers (p<0.05). Type I collagen was 20.50% smaller in patients than in cadavers (p<0.05). There was no significant difference in the amount of type III collagen between cases and controls (p=0.383). The results of this study indicate a relationship between hernias of the anterior abdominal wall and smaller amounts of total and type I collagens.

Clinicopathological profile and long-term outcome in young adults with gastric cancer: multicenter evaluation of 214 patients.

Abstract: Gastric cancer (GC) is usually diagnosed in the sixth and seventh decade of life, although it may also be found in younger patients. The aim of this study was to analyse the potential differences in demographic and clinicopathological factors between the younger (40 years of age and less) and older (above 40 years) population of GC. An electronic database covering all gastric cancer patients treated between 1977 and 1998 at eight university surgical centres was reviewed. Of 3,431 patients treated, 214 (6.2%) were 40 years of age or younger. No differences in tumour staging or location could be identified, but the diffuse type lesions were more common in the younger patients (52.6 vs 29.8%). No differences were found in morbidity and mortality rates, except a higher incidence of cardiopulmonary complications in older patients undergoing stomach resection (6.6 vs 12.3%). Median survival of patients after gastrectomy was 24.7 months (95% confidence interval [CI] 22.7–26.6) and was insignificantly longer in younger (30.8 months, 95%CI 21.0–40.5) than older (24.1 months, 95%CI 22.1–26.1) patients (P = 0.056). Median survival for unresectable cases was 5.4 months (95%CI 5.1–5.7) and was comparable in the younger (median 5.5 months, 95%CI 5.2–5.8) and older (median 4.4 months, 95%CI 3.7–5.1) groups. GC in young adults demonstrates only minor deviations from the general population with a similar long-term outcome.