Showing papers in "Langenbeck's Archives of Surgery in 2016"
TL;DR: Indocyanine green fluorescence angiography (ICG-FA) seems like a promising method to assess perfusion at the site intended for anastomosis, however, there is not enough evidence to determine that the method can reduce the leak rate.
Abstract: Anastomotic leakage following gastrointestinal surgery remains a frequent and serious complication associated with a high morbidity and mortality. Indocyanine green fluorescence angiography (ICG-FA) is a newly developed technique to measure perfusion intraoperatively. The aim of this paper was to systematically review the literature concerning ICG-FA to assess perfusion during the construction of a primary gastrointestinal anastomosis in order to predict anastomotic leakage. The following four databases PubMed, Scopus, Embase, and Cochrane were independently searched by two authors. Studies were included in the review if they assessed anastomotic perfusion intraoperatively with ICG-FA in order to predict anastomotic leakage in humans. Of 790 screened papers 14 studies were included in this review. Ten studies (n = 916) involved patients with colorectal anastomoses and four studies (n = 214) patients with esophageal anastomoses. All the included studies were cohort studies. Intraoperative ICG-FA assessment of colorectal anastomoses was associated with a reduced risk of anastomotic leakage (n = 23/693; 3.3 % (95 % CI 1.97–4.63 %) compared with no ICG-FA assessment (n = 19/223; 8.5 %; 95 % CI 4.8–12.2 %). The anastomotic leakage rate in patients with esophageal anastomoses and intraoperative ICG-FA assessment was 14 % (n = 30/214). None of the studies involving esophageal anastomoses had a control group without ICG-FA assessment. No randomized controlled trials have been published. ICG-FA seems like a promising method to assess perfusion at the site intended for anastomosis. However, we do not have the sufficient evidence to determine that the method can reduce the leak rate.
158 citations
TL;DR: The technique proposed inverts the current ALPPS strategy, minimizing the first stage impact to promote rapid patient recovery and leaving the main surgical procedure for the second stage.
Abstract: The current associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach is represented by an aggressive first surgical procedure followed by a shorter and less aggressive second procedure. This paradigm has been associated with high morbidity and mortality. Inverting the aggressiveness of the surgical stages might be beneficial in order to facilitate patient recovery during interval period. We propose a new technical paradigm for the ALPPS approach. During the first stage, partial parenchymal transection combined with intraoperative portal vein embolization (PVE) was performed. Liver mobilization was kept at minimum while hilar plate or hilum dissection was strictly avoided. The completion surgery by means of the anterior approach was carried out once sufficient future liver remnant (FLR) hypertrophy and function were certified. We applied this technique in four patients (hepatocellular carcinoma in a cirrhotic liver = 1 and colorectal liver metastases = 3). The mean FLR hypertrophy was 62.6 % (range 49–79). All the four patients underwent the completion surgery with R0 margins, and neither one developed liver failure nor major complications. The technique proposed inverts the current ALPPS strategy, minimizing the first stage impact to promote rapid patient recovery and leaving the main surgical procedure for the second stage. The combination of evidence-based facts such as partial parenchymal transection, intraoperative PVE, and “non-touch” oncological rules was feasible and safe, allowing complete tumor resection in highly selected candidates with extensive liver disease.
99 citations
TL;DR: Minimally invasive liver surgery can be performed safely for minor hepatic resections and should be considered whenever possible.
Abstract: Minimally invasive liver surgery is increasing worldwide. The benefit of the robot in this scenario is currently controversially discussed. We compared our robotic cases vs. laparoscopic and open minor hepatic resections and share the experience. From 2011 to 2015, ten patients underwent robotic and 19 patients underwent laparoscopic minor liver resections in the Department of Surgery, University Hospital Erlangen. These patients were compared to a case-matched control group of 53 patients. The perioperative prospectively collected data were analyzed retrospectively. Blood loss was significantly decreased in the robotic (306 ml) and laparoscopic (356 ml) vs. the open (903 ml) surgery group (p = 0.001). Mean tumor size was 4.1–4.8 cm in all groups (p = 0.571). Negative surgical margins were present in 94 % of the open and 100 % of the laparoscopic and robotic group (p = 0.882). Time for surgery was enlarged for robotic (321 min) vs. laparoscopic (242 min) and open (186 min) surgery (p = 0.001). Postoperative hospitalization was decreased after robotic (7 days) and laparoscopic (8 days) vs. open (10 days) surgery (p = 0.004). Total morbidity was 17 % for open, 16 % for laparoscopic, and 1 % for robotic cases (p = 0.345). Postoperative pain medication and elevation of liver enzymes were remarkably lower after minimally invasive vs. open procedures. Minimally invasive liver surgery can be performed safely for minor hepatic resections and should be considered whenever possible. Minor liver resections can be performed by standard laparoscopy equivalent to robotic procedures. Nevertheless, the robot adds a technical upgrade which may have benefits for challenging cases and major liver surgery.
74 citations
TL;DR: The results of the meta-analysis show that 11C-MET PET has an overall good sensitivity and PPV and may be considered a reliable second-line imaging modality to enable minimally invasive parathyroidectomy.
Abstract: Purpose
The great spatial and temporal resolution of positron emission tomography might provide the answer for patients with primary hyperparathyroidism (pHPT) and non-localized parathyroid glands. We performed a systematic review of the evidence regarding all investigated tracers.
73 citations
TL;DR: The aim of the paper is to provide an overview of the current pathogenic and promoting factors of leakage after LSG on the basis of recent literature review and to report the evidence based preventive measures.
Abstract: Background
Leak is the second most common cause of death after bariatric surgery. The leak rate after laparoscopic sleeve gastrectomy (LSG) ranges between 1.1 and 5.3 %. The aim of the paper is to provide an overview of the current pathogenic and promoting factors of leakage after LSG on the basis of recent literature review and to report the evidence based preventive measures.
71 citations
TL;DR: An asymptomatic pilonidal disease does not require treatment andcision followed by a midline wound closure is associated with a considerable recurrence rate and increased incidence of wound complications and should therefore be abandoned.
Abstract: The present national guideline aims to provide recommendations for physicians involved in the treatment of patients with pilonidal disease. It has been published previously as an extended version in German language. This is a systemic literature review. The present guideline was reviewed and accepted by an expert panel in a consensus conference. Some of the present guideline conclusions were based on low- to moderate-quality trials. Therefore, an agreement was necessary in those cases to provide recommendations. However, recommendations regarding the most frequently used surgical procedures were based on numerous prospective randomized trials. An asymptomatic pilonidal disease does not require treatment. A pilonidal abscess should be incised. After regression of the acute inflammation, a definitive treatment method should be applied. An excision is the standard treatment method for the chronic pilonidal disease. Open wound healing is associated with a low postoperative morbidity rate; however, it is complicated by a long healing time. The minimally invasive procedures (e.g., pit picking surgery) represent a potential treatment option for a limited chronic pilonidal disease. However, the recurrence rate is higher compared to open healing. Excision followed by a midline wound closure is associated with a considerable recurrence rate and increased incidence of wound complications and should therefore be abandoned. Off-midline procedures can be adopted as a primary treatment option in chronic pilonidal disease. At present, there is no evidence of any outcome differences between various off-midline procedures. The Limberg flap and the Karydakis flap are most thoroughly analyzed off-midline procedures.
70 citations
TL;DR: The best conservative option to avoid abdominal aortic aneurysm rupture consists in smoking cessation and control of hypertension.
Abstract: Abdominal aortic aneurysm is a common degenerative vascular disorder associated with sudden death due to aortic rupture. This review describes epidemiology, predisposing factors, and biology of ruptured abdominal aortic aneurysms (rAAAs). Based on a selective literature search in Medline (PubMed), original publications, meta-analyses, systematic reviews, and Cochrane reviews were evaluated for rAAA. The hospital admission rate for rAAA is decreasing and is now in the range of approximately 10 per 100,000 population in men. Smoking contributes to about 50 % of population risk for rupture or surgically treated AAA. AAA rupture is a multifaceted biological process involving biochemical, cellular, and proteolytic influences, in addition to biomechanical factors. AAA rupture occurs when the stress (force per unit area) on the aneurysm wall exceeds wall strength. Proteolytic activities of matrix metalloproteinases have been implicated in aneurysm wall weakening and rupture. Aneurysm diameter is the most prominent predisposing factor for aneurysm growth and rupture. Wall stress, aneurysm shape and geometry, intraluminal thrombus, wall thickness, calcification, and metabolic activity influence the rupture risk. The best conservative option to avoid AAA rupture consists in smoking cessation and control of hypertension. Many biological factors influence rupture risk.
61 citations
TL;DR: PG is not superior to PJ in the prevention of POPF and current RCTs have major methodological limitations with significant heterogeneity in regard to surgical techniques, definition of POPf/complications, and perioperative management.
Abstract: To perform an up-to-date meta-analysis of randomized controlled trials (RCTs) comparing pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) in order to determine the safer anastomotic technique. Compared to existing meta-analysis, new RCTs were evaluated and subgroup analyses of different anastomotic techniques were carried out. We conducted a bibliographic research using the National Library of Medicine’s PubMed database from January 1990 to July 2015 of RCTs. Only RCTs, in English, that compared PG versus all types of PJ were selected. Data were independently extracted by two authors. We performed a quantitative systematic review following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A random-effect model was applied. Statistical heterogeneity was assessed using the I
2 and χ
2 tests. Primary outcomes were rate of overall and clinically significant pancreatic fistula (POPF). Ten RCTs were identified including 1629 patients, 826 undergoing PG and 803 undergoing PJ. RCTs showed significant heterogeneity regarding definitions of POPF, perioperative management, and characteristics of pancreatic gland. No significant differences were found in the rate of overall and clinically significant POPF, morbidity, mortality, reoperation, and intra-abdominal sepsis when PG was compared with all types PJ or when subgroup analysis (double-layer PG with or without anterior gastrotomy versus duct to mucosa PJ and single-layer PG versus single-layer end-to-end/end-to-side PJ) were analyzed. PG is not superior to PJ in the prevention of POPF. Current RCTs have major methodological limitations with significant heterogeneity in regard to surgical techniques, definition of POPF/complications, and perioperative management.
53 citations
TL;DR: RPD-SMV/PV is feasible in carefully selected patients and requires longer operative time, had higher median estimated blood loss, and blood transfusions were required more frequently than RPD, but post-pancreatectomy hemorrhage occurred more frequently after this procedure.
Abstract: This study aims to define the current status of robotic pancreatoduodenectomy (RPD) with resection and reconstruction of the superior mesenteric/portal vein (RPD-SMV/PV). Our experience on RPD, including RPD-SMV/PV, is presented along with a description of the surgical technique and a systematic review of the literature on RPD-SMV/PV. We have performed 116 RPD and 14 RPD-SMV/PV. Seven additional cases of RPD-SMV/PV were identified in the literature. In our experience, RPD and RPD-SMV/PV were similar in all baseline variables, but lower mean body mass and higher prevalence of pancreatic cancer in RPD-SMV/PV. Regarding the type of vein resection, there were one type 2 (7.1 %), five type 3 (35.7 %) and eight type 4 (57.2 %) resections. As compared to RPD, RPD-SMV/PV required longer operative time, had higher median estimated blood loss, and blood transfusions were required more frequently. Incidence and severity of post-operative complications were not increased in RPD-SMV/PV, but post-pancreatectomy hemorrhage occurred more frequently after this procedure. In pancreatic cancer, RPD-SMV/PV was associated with a higher mean number of examined lymph nodes (60.0 ± 13.9 vs 44.6 ± 11.0; p = 0.02) and with the same rate of microscopic margin positivity (25.0 % vs 26.1 %). Mean length or resected vein was 23.1 ± 8.08 mm. Actual tumour infiltration was discovered in ten patients (71.4 %), reaching the adventitia in four patients (40.0 %), the media in two patients (20.0 %), and the intima in four patients (40.0 %). Literature review identified seven additional cases, all reported to have successful outcome. RPD-SMV/PV is feasible in carefully selected patients. The generalization of these results remains to be demonstrated.
49 citations
TL;DR: With increasing accuracy of the system, image guidance was progressively used for atypical resections and combined microwave ablation and resection instead of formal liver resection.
Abstract: Image-guided systems have recently been introduced for their application in liver surgery. We aimed to identify and propose suitable indications for image-guided navigation systems in the domain of open oncologic liver surgery and, more specifically, in the setting of liver resection with and without microwave ablation. Retrospective analysis was conducted in patients undergoing liver resection with and without microwave ablation using an intraoperative image-guided stereotactic system during three stages of technological development (accuracy: 8.4 ± 4.4 mm in phase I and 8.4 ± 6.5 mm in phase II versus 4.5 ± 3.6 mm in phase III). It was evaluated, in which indications image-guided surgery was used according to the different stages of technical development. Between 2009 and 2013, 65 patients underwent image-guided surgical treatment, resection alone (n = 38), ablation alone (n = 11), or a combination thereof (n = 16). With increasing accuracy of the system, image guidance was progressively used for atypical resections and combined microwave ablation and resection instead of formal liver resection (p < 0.0001). Clinical application of image guidance is feasible, while its efficacy is subject to accuracy. The concept of image guidance has been shown to be increasingly efficient for selected indications in liver surgery. While accuracy of available technology is increasing pertaining to technological advancements, more and more previously untreatable scenarios such as multiple small, bilobar lesions and so-called vanishing lesions come within reach.
45 citations
TL;DR: PG should be an alternative to TG, even in locally advanced proximal gastric cancers treated by NACT, provided that the tumor size and location permit preservation of adequate remnant of stomach without compromising oncological resection margins.
Abstract: The appropriate extent of gastric resection for patients with proximal third gastric cancer is controversial. This study addresses whether the choice of surgical strategy (proximal gastrectomy [PG] versus total gastrectomy [TG]) influences the outcomes for proximal third gastric adenocarcinoma. Review of prospective database at Tata Memorial Hospital from January 2010 to December 2012 identified 343 patients diagnosed and treated for gastric cancer. Of these, 75 underwent curative resections with D2 lymphadenectomy for proximal third gastric adenocarcinoma, which entailed proximal gastrectomy in 43 and total gastrectomy in 32 patients, depending on the epicenter of the primary and its relation with the mid-body of the stomach. Morbidity, lymph node yield, resection margins, patterns of recurrence, and survival were compared between these two groups. 41/75 tumors were pT3 (23 cases [53.4 %] in the PG and 18 cases [56.3 %] in the TG group). Thirty-six patients [83.7 %] in PG and 29 patients [90.6 %] in TG group received neoadjuvant chemotherapy (NACT). There were no significant differences with regard to median blood loss, general complication rates and length of hospitalization between the two groups. The lymph node yield was comparable between the two procedures [PG = 14; TG = 15]. Positive proximal resection margin rates were comparable between the two groups [PG = 4.7 %; TG = 9.4 %], and there was no statistical difference observed in the distal resection margin positivity rates [PG = 4.7 %; TG = 3.1 %]. Regarding the patterns of recurrence, local recurrence in PG was 4.7 % and there was no local recurrence in the TG group (p = 0.08). Distant recurrence rates was dominant in TG [PG = 30.2 % versus TG = 53.1 %]. The overall 2-year survival following PG and TG was 73.8 and 49.9 %, respectively, and not statistically different (p = 0.10). The extent of resection for proximal third gastric cancer does not influence the clinical outcome. PG and TG have similar survival rates. Both procedures can be accomplished safely. Therefore, PG should be an alternative to TG, even in locally advanced proximal gastric cancers treated by NACT, provided that the tumor size and location permit preservation of adequate remnant of stomach without compromising oncological resection margins. Future QOL studies would further lend credence to the concept of PG for proximal third gastric cancer.
TL;DR: A novel modified classification of EAF is presented and the current state of the art in its prevention and management including nutritional issues and feeding strategies are reviewed, highlighting several surgical techniques for dealing with EAF that have been reported in the literature throughout the years.
Abstract: Entero-atmospheric fistula (EAF) is an enteric fistula occurring in the setting of an open abdomen, thus creating a communication between the GI tract and the external atmosphere. Management and nursing of patients suffering EAF carries several challenges, and prevention of EAF should be the first and best treatment option. Here, we present a novel modified classification of EAF and review the current state of the art in its prevention and management including nutritional issues and feeding strategies. We also provide an overview on surgical management principles, highlighting several surgical techniques for dealing with EAF that have been reported in the literature throughout the years. The treatment strategy for EAF should be multidisciplinary and multifaceted. Surgical treatment is most often multistep and should be tailored to the single patient, based on the type and characteristics of the EAF, following its correct identification and classification. The specific experience of surgeons and nursing staff in the management of EAF could be enhanced, applying distinct simulation-based ex vivo training models.
TL;DR: Surgical treatment is the only curative management option for patients with ITPN of the pancreas and to determine the best management strategy for this tumor and improve accuracy of prognosis for patients, collected and analyzed published data on ITPNs.
Abstract: Background and aims
Intraductal tubulopapillary neoplasms (ITPNs) of the pancreas are rare. The purpose of this study was to collate and analyze published data on ITPNs of the pancreas to determine the clinicopathological features of the tumors and the surgical outcomes of patients.
TL;DR: Lower age, female sex, and hepatic malignancy are significant risk factors for requiring repeat abdominal surgery and one in four patients will require repeat surgery within 4 years after elective abdominal surgery.
Abstract: Today, 40 to 66 % of elective procedures in abdominal surgery are reoperations. Reoperations show increased operative time and risk for intraoperative and postoperative complications, mainly due to the need to perform adhesiolysis. It is important to understand which patients will require repeat surgery for optimal utilization and implementation of anti-adhesive strategies. Our aim is to assess the incidence and identify risk factors for repeat abdominal surgery. This is the long-term follow-up of a prospective cohort study (Laparotomy or Laparoscopy and Adhesions (LAPAD) study; clinicaltrials.gov NCT01236625). Patients undergoing elective abdominal surgery were included. Primary outcome was future repeat abdominal surgery and was defined as any operation where the peritoneal cavity is reopened. Multivariable logistic regression analysis was used to identify risk factors. Six hundred four (88 %) out of 715 patients were included; median duration of follow-up was 46 months. One hundred sixty (27 %) patients required repeat abdominal surgery and underwent a total of 234 operations. The indication for repeat surgery was malignant disease recurrence in 49 (21 %), incisional hernia in 41 (18 %), and indications unrelated to the index surgery in 58 (25 %) operations. Older age (OR 0.98; p 0.002) and esophageal malignancy (OR 0.21; p 0.034) significantly reduced the risk of undergoing repeat abdominal surgery. Female sex (OR 1.53; p 0.046) and hepatic malignancy as indication for surgery (OR 2.08; p 0.049) significantly increased the risk of requiring repeat abdominal surgery. One in four patients will require repeat surgery within 4 years after elective abdominal surgery. Lower age, female sex, and hepatic malignancy are significant risk factors for requiring repeat abdominal surgery.
TL;DR: RFA is an option for treatment, with minimal invasiveness and a low complication rate, and it is effective primarily in cases with benign nodules and nodular goiter, and in Cases with good compliance, the likelihood of success is greater.
Abstract: The activity of the application of single-session ultrasonography (US)-guided percutaneous radio frequency ablation (RFA) in benign thyroid nodules was investigated in this prospective clinical study. RFA treatment was applied to 100 nodules in 100 patients (78 women, 22 men; average age 44.5 years old; age range 18–71) who had euthyroid condition, nodule size larger than 1 cm in the ultrasonography, proven to be benign by fine needle aspiration cytology. The nodules were separated into three groups according to the content: solid, cystic and mixed. In first 73 cases, the process performed under local anesthesia and the other 27 cases were performed under general anesthesia. RFA process was standardized to 70 W in all of the patients, and a moving shot technique was used. The results acquired in the third and sixth months of the controls were evaluated, and the volume of the nodules was screened. No differences between the thyroid function tests performed before and after RFA were detected (p > 0.05). The mean volume of the nodules before the process, in the third month after the process, and in the sixth month were 16.8, 4.8, and 2.6 ml, respectively (p < 0.001). The decrease in cystic nodules was greater than solid and mixed structures. Temporary hoarseness occurred in one case and skin edema was detected in a patient at the isthmus. RFA is an option for treatment, with minimal invasiveness and a low complication rate, and it is effective primarily in cases with benign nodules and nodular goiter. In cases with good compliance, the likelihood of success is greater. General anesthesia can be a good option for anxious cases to gather better results.
TL;DR: This study showed a significant relationship between postoperative complications and geriatric frailty using sarcopenia in patients with gastric cancer after TG with D2 lymphadenectomy.
Abstract: Purpose
This study was performed to determine the association of frailty and nutritional status with postoperative complications after total gastrectomy (TG) with D2 lymphadenectomy in patients with gastric cancer.
TL;DR: Subtotal parathyroidectomy is a safe and efficacious treatment for patients with rHPT and Utilization of intraoperative iPTH assay can guide surgical exploration and improve the cure rate.
Abstract: The aim of this study was to evaluate the outcomes of surgery for patients with secondary renal hyperparathyroidism (rHPT). This is a retrospective cohort study. Our institutional database was searched for eligible patients treated in 1995–2014. The inclusion criterion was initial parathyroidectomy for rHPT. Clinical and follow-up data were analyzed to estimate the cure rate (primary outcome), and morbidity (secondary outcome). The study group comprised 297 patients (154 females, age 44.5 ± 13.7 years, follow-up 24.6 ± 10.5 months), including 268 (90.2 %) patients who had underwent subtotal parathyroidectomy, and 29 (9.8 %) who had had incomplete parathyroidectomy. Intraoperative iPTH assay was utilized in 207 (69.7 %) explorations. Persistent rHPT occurred in 12/268 (4.5 %) patients after subtotal parathyroidectomy and 5/29 (17.2 %) subjects after incomplete parathyroidectomy (p = 0.005). The patients operated on with intraoperative iPTH assay had a higher cure rate than non-monitored individuals, 201/207 (97.1 %) vs. 79/90 (87.8 %), respectively (p = 0.001). In-hospital mortality occurred in 1/297 (0.3 %) patient. The hungry bone syndrome occurred in 84/268 (31.3 %) patients after subtotal parathyroidectomy and 2/29 (6.9 %) subjects after incomplete parathyroidectomy (p = 0.006). Transient recurrent laryngeal nerve paresis occurred in 14/594 (2.4 %) and permanent in 5/594 (0.8 %) nerves at risk. Subtotal parathyroidectomy is a safe and efficacious treatment for patients with rHPT. Utilization of intraoperative iPTH assay can guide surgical exploration and improve the cure rate.
TL;DR: The anatomy of the RLN is highly variable, and ELB is likely to have been underreported in intraoperative studies, and the possibility of ELB needs to be assessed in patients to prevent iatrogenic injury and long-term postoperative complications.
Abstract: The recurrent laryngeal nerves (RLN) are branches of the vagus nerve that go on to innervate most of the intrinsic muscles of the larynx. Historically, the RLN has been considered to branch after it enters the larynx, but numerous studies have demonstrated that it often branches before. The wide variability of this extralaryngeal branching (ELB) has significant implications for the risk of iatrogenic injury. We aimed to assess the anatomical characteristics of ELB comprehensively. Articles on the ELB of the RLN were identified by a comprehensive database search. Relevant data were extracted and pooled into a meta-analysis of the prevalence of branching, branching pattern, distance of ELB point from the larynx, and presence of positive motor signals in anterior and posterior ELB branches. A total of 69 articles (n = 28,387 nerves) from both intraoperative and cadaveric modalities were included in the meta-analysis. The overall pooled prevalence of ELB was 60.0 % (95 % CI 52.0–67.7). Cadaveric and intraoperative subgroups differed with prevalence rates of 73.3 % (95 % CI 61.0–84.0) and 39.2 % (95 % CI 29.0–49.9), respectively. Cadavers most often presented with a ELB pattern of bifurcation, with a prevalence of 61.1 %, followed by no branching at 23.4 %. Branching of the RLN occurred most often at a distance of 1–2 cm (74.8 % of cases) prior to entering the larynx. A positive motor signal was most often noted in anterior RLN branches (99.9 %) but only in 1.5 % of posterior branches. The anatomy of the RLN is highly variable, and ELB is likely to have been underreported in intraoperative studies. Because of its high likelihood, the possibility of ELB needs to be assessed in patients to prevent iatrogenic injury and long-term postoperative complications.
TL;DR: In the present study, SEQ was faster than SIM at the beginning of the learning curve and did not reduce the total training time needed to reach an ambitious proficiency level; thus, laparoscopic experience can be gained to a certain extent with a simple shoebox.
Abstract: Learning curves for minimally invasive surgery are prolonged since psychomotor skills and visuospatial orientation differ from open surgery and must be learned. This study explored potential advantages of sequential learning of psychomotor and visuospatial skills for laparoscopic suturing and knot tying compared to simultaneous learning. Laparoscopy-naive medical students were randomized into a sequential learning group (SEQ) or a simultaneous learning group (SIM). SEQ (n = 28) trained on a shoebox with direct 3D view before proceeding on a box trainer with 2D laparoscopic view. SIM (n = 25) trained solely on a box trainer with 2D laparoscopic view. Training time and number of attempts needed were recorded until a clearly defined proficiency level was reached. Groups were not different in total training time (SEQ 5868.7 ± 2857.2 s; SIM 5647.1 ± 2244.8 s; p = 0.754) and number of attempts to achieve proficiency in their training (SEQ 44.0 ± 17.7; SIM 36.8 ± 15.6; p = 0.123). SEQ needed less training time on the box trainer with 2D laparoscopic view than did SIM (SEQ 4170.9 ± 2350.8 s; SIM 5647.1 ± 2244.8 s; p = 0.024), while the number of attempts here was not different (SEQ 29.9 ± 14.1; SIM 36.8 ± 15.6; p = 0.097). SEQ was faster in the first attempts on the shoebox (281.9 ± 113.1 s) and box trainer (270.4 ± 133.1 s) compared to the first attempt of SIM on the box trainer (579.4 ± 323.8 s) (p < 0.001). In the present study, SEQ was faster than SIM at the beginning of the learning curve. SEQ did not reduce the total training time needed to reach an ambitious proficiency level. However, SEQ needed less training on the box trainer; thus, laparoscopic experience can be gained to a certain extent with a simple shoebox.
TL;DR: The aim of this manuscript is to outline the current diagnostic and therapeutic options for intraabdominal hypertension and abdominal compartment syndrome and suggest new diagnostic markers could play an important role in the future.
Abstract: If untreated, the abdominal compartment syndrome (ACS) has a mortality of nearly 100 %. Thus, its early recognition is of major importance for daily rounds on surgical intensive care units. Intraabdominal hypertension (IAH) is a poorly recognized entity, which occurs if intraabdominal pressure arises >12 mmHg. Measurement of the intravesical pressure is the gold standard to diagnose IAH, which can be detected in about one fourth of surgical intensive care patients. The aim of this manuscript is to outline the current diagnostic and therapeutic options for IAH and ACS. While diagnosis of IAH and ACS strongly depends on clinical experience, new diagnostic markers could play an important role in the future. Therapy of IAH/ACS consists of five treatment “columns”: intraluminal evacuation, intraabdominal evacuation, improvement of abdominal wall compliance, fluid management, and improved organ perfusion. If conservative therapy fails, emergency laparotomy is the most effective therapeutic approach to achieve abdominal decompression. Thereafter, patients with an open abdomen require intensive care and are permanently threatened by the quadrangle of fluid loss, muscle proteolysis, heat loss, and an impaired immune function. As a consequence, complication rate dramatically increases after 8 days of open abdomen therapy. Despite many efforts, the mortality of patients with ACS remains unacceptably high. Permanent clinical education and surgical trials will be necessary to improve the outcome of our critically ill surgical patients.
TL;DR: The results indicate a discrepancy between ERAS targets and actual practice in comorbid patients undergoing major visceral surgery, need for a prompt redefinition of ERAS mobilization targets,need for the improvement of counseling, and need for the implementation of ERas principles.
Abstract: Enhanced recovery after surgery (ERAS) programs have been introduced increasingly into major visceral surgery. Key elements target on early drain removal and mobilization of the patients; however, reporting of adherence to ERAS protocols has often been insufficiently assessed. The present study aims to prospectively evaluate ERAS compliance after major visceral surgery. A prospective pilot study was designed, and 34 patients scheduled for major hepatopancreatic or gastric surgery were followed postoperatively until postoperative day (POD) 10. Analgesia and drain management, diet, mobilization, willingness to exercise, and the use of discharge criteria were accurately assessed within an established ERAS protocol scenario. Thirty-one cases were analyzed that consisted of 54.8 % major pancreatic, 29.0 % hepatic, and 16.1 % gastric resections. The median hospital stay was 12.5 days, and 83.9 % of the patients met the objective criteria before discharge. By POD 4, wound, epidural, and urinary catheters were still in place in 70, 60, and 40 % of the patients, respectively. Fifty percent of the patients ambulated out of bed until POD 2. The cumulative duration of postoperative mobilization per day ranged from 15 to 155 min, and only 40 % of the patients felt comfortable with additional mobilization or physical exercise. Adherence to ERAS protocols is poorly reported. The results indicate a discrepancy between ERAS targets and actual practice in comorbid patients undergoing major visceral surgery, need for a prompt redefinition of ERAS mobilization targets, need for the improvement of counseling, and need for the implementation of ERAS principles.
TL;DR: When the extra-capsular technique was adopted during total thyroidectomy, identifying fewer PGs in their orthotopic positions not only lowered risk of temporary and protractedhypoparathyroidism but also shortened recovery from protracted hypoparathiroidism.
Abstract: It remains uncertain whether the number of parathyroid glands (PGs) seen during extra-capsular dissection impacts short- and long-term hypoparathyroidism. Our study aimed to address this by analyzing patients who underwent total thyroidectomy for benign disease. Consecutive patients undergoing total thyroidectomy were analyzed. The extra-capsular dissection technique was performed throughout the study period. The number of PGs identified, auto-transplanted and found on excised specimen was recorded prospectively. The number of PGs in situ was equaled to four minus the number of PGs auto-transplanted and PGs found on specimen. Temporary hypoparathyroidism was defined as serum adjusted calcium 6-week oral supplements. Permanent hypoparathyroidism was defined as need for oral supplements for ≥1 year. Five-hundred and sixty-nine patients were eligible for analysis. After adjusting for other significant parameters, greater number of PGs identified was an independent risk factor for temporary (p < 0.001) and protracted hypoparathyroidism (p = 0.007). Mean recovery time from protracted hypoparathyroidism for identifying ≤three PGs was significantly shorter than identifying all four PGs (2.8 vs. 7.8 months, p < 0.001). Chance of having all four PGs in situ decreased with greater number of PGs identified (p < 0.001). When the extra-capsular technique was adopted during total thyroidectomy, identifying fewer PGs in their orthotopic positions not only lowered risk of temporary and protracted hypoparathyroidism but also shortened recovery from protracted hypoparathyroidism.
TL;DR: The application of Tachosil® to the pancreatic stump after distal pancreatectomy is a safe procedure but provides no relevant benefit in terms of POPF, mortality, reoperation rate, blood loss or length of hospital stay.
Abstract: Postoperative pancreatic fistula (POPF) is a frequent and clinically relevant problem after distal pancreatectomy. A variety of methods have been tested in the attempt to prevent POPF, most of them without convincing results. A systematic literature search was conducted in PubMed, Embase and the Cochrane Library to identify clinical studies comparing pancreatic stump closure with the addition of Tachosil® to conventional stump closure. The identified studies were critically appraised, and meta-analyses were performed using a random-effects model. Dichotomous data were pooled using odds ratios, and weighted mean differences were calculated for continuous outcomes, together with the corresponding 95 % confidence intervals. Four studies (two randomised controlled trials and two retrospective clinical studies) reporting data from 738 patients were included in the meta-analysis. Overall POPF, clinically-relevant POPF, mortality, reoperations, intraoperative blood loss and length of hospital stay did not differ significantly between conventional closure and additional covering of the pancreatic stump with Tachosil®. A sensitivity analysis of only randomised controlled trials confirmed the results. The application of Tachosil® to the pancreatic stump after distal pancreatectomy is a safe procedure but provides no relevant benefit in terms of POPF, mortality, reoperation rate, blood loss or length of hospital stay. Future research should concentrate on novel methods of pancreatic stump closure to prevent POPF after distal pancreatectomy.
TL;DR: The findings indicate that the G8 score, based on patients’ nutritional assessments, is a useful screening method for older HCC patients who qualify for elective liver resection.
Abstract: Older patients are considered to have increased risk for complications after major surgery, but age alone is not a reliable predictor of postoperative complications. However, no universal screening test adequately predicts postoperative complications in older patients. This prospective study recorded pertinent baseline geriatric assessment variables to identify risk factors for postoperative complications in hepatocellular carcinoma (HCC) for patients aged ≥70 years who undergo hepatectomy. We retrospectively analyzed 71 consecutive patients ≥70 years of age. Patients had geriatric assessments of baseline and later cognition, nutritional and functional status, and burden of comorbidities, completed preoperatively and at 1, 3, and 6 months postoperatively. Postoperative morbidities were recorded. Postoperative morbidities developed in 18 patients (25 %). Univariate analysis identified serum albumin, operating time and blood loss, cirrhosis, geriatric 8 (G8), and Mini Nutritional Assessment as possible risk factors for postoperative complications, but only G8 < 14 survived multivariate analysis as an independent predictor of complications. Our findings indicate that the G8 score, based on patients’ nutritional assessments, is a useful screening method for older HCC patients who qualify for elective liver resection. Preoperative G8 scores can help forecast postoperative complications in older HCC patients. Future studies with larger numbers of patients, limited to HCC and liver resections, are needed to verify our results.
TL;DR: Application of the institutional ERAS pathway could be maintained in the first 4 years after implementation leading to sustained improved functional recovery and clinical outcome.
Abstract: Enhanced recovery after surgery (ERAS) implementation has proven to reduce complication rate and length of hospital stay. Little is known about the sustainability of these results over time. The study aim was to assess the application of ERAS pathway over the first 4 years after initial implementation. This retrospective study analyzed data collected prospectively from 482 consecutive elective colorectal patients operated in 2011 during the ERAS implementation process (n = 66), and after initial implementation in 2012 (n = 136), 2013 (n = 152), and 2014 (n = 128). Auditing ERAS was appraised from different perspectives: adherence with the ERAS protocol, clinical outcomes, and functional recovery. Patients were compared by year. The groups were similar in terms of demographics and surgical strategies. Length of stay remained stable at 7 days without significant variation over time (p = 0.741). The 30-day complications and readmission rates were not statistically different (respectively p = 0.068 and p = 0.639). There was also no difference in functional recovery, more particularly, first flatus occurred at day 2 (p = 0.177), pain was adequately controlled with oral analgesics at day 2 (p = 0.111), and patients were mobilized more than 4 h the first postoperative day in more than 60 % of cases (p = 0.343). Overall adherence with the ERAS pathway was 73 % during implementation and, respectively, 73 and 77 % for 2012 and 2013 after initial implementation (p = 0.614). A significant decrease between 2013 (77 %) and 2014 (73 %) was observed (p = 0.032). Application of the institutional ERAS pathway could be maintained in the first 4 years after implementation leading to sustained improved functional recovery and clinical outcome.
TL;DR: DGE is a substantial complication not only after pancreatoduodenectomy, but it also occurs frequently after DPR, and prevention of pancreatic fistula might reduce its incidence, especially in patients with malign pathology.
Abstract: Delayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy and other types of upper gastrointestinal surgery with published incidences as high as 60 %. The present study examines the incidence of DGE following distal pancreatic resection (DPR). Between 2002 and 2014, 100 patients underwent conventional DPR at our department. DGE was classified according to the 2007 International Study Group of Pancreatic Surgery definition. Patients were analyzed regarding severity of DGE, morbidity and mortality, length of hospital stay, and demographic factors. Overall incidence of DGE was 24 %. No difference in age, gender, or other demographic factors was observed in patients with DGE. Perioperative characteristics (splenectomy rate, closure technique of the pancreatic remnant, operation time, blood loss and transfusion, ICU, ASA score) were comparable. Major complications were associated with DGE (11/24 patients (46 %) vs. 19/76 patients (25 %) without DGE) and the rate of pancreatic fistula was significantly higher in the group of patients with DGE (14/24 patients (58 %) vs. 27/76 patients (36 %), P = 0.047). In multivariate analysis, a periampullary malignancy was shown to be a significant factor for DGE development. DGE significantly prolonged hospital stay (14 vs. 22 days). DGE is a substantial complication not only after pancreatoduodenectomy, but it also occurs frequently after DPR. Prevention of pancreatic fistula might reduce its incidence, especially in patients with malign pathology.
TL;DR: The intrathoracic stapled side-to-side anastomosis technique seems to be feasible, safe, and easy to perform, associated with a limited postsurgical complication rate and a good functional outcome.
Abstract: Minimally invasive esophagectomy (MIE) has been met with increased interest for the surgical treatment of esophageal cancer. One critical obstacle for the implementation of MIE has been the intrathoracic anastomosis. In this study, we describe a technique of thoracoscopic intrathoracic anastomosis using a linear stapler in prone position and present the short-term outcomes of this procedure. This prospective pilot study included 46 consecutive patients with a cancer either of the gastroesophageal junction (GEJ) or the distal esophagus who underwent either total MIE or thoracoscopic-assisted esophagectomy followed by intrathoracic stapled side-to-side anastomosis. The short-term outcomes including postoperative complications were recorded and analyzed. This pilot study included 41 males (89 %) and 5 females (11 %) with a mean age of 65.7 years. The majority had adenocarcinoma (93 %). Before surgery, 4 patients (8.7 %) had an incomplete endoscopic submucosal resection, 5 patients (11 %) received chemotherapy alone, and 33 patients (71 %) had chemoradiotherapy. Mean operation time was 408 minutes. Postoperative complications classified as Clavien-Dindo Grade IIIa or more severe occurred in 7 patients (15 %), of whom 4 patients (8.7 %) developed anastomotic leakages without any need for intensive care. Another 2 patients (4.3 %) required intensive care due to aspiration pneumonia and acute renal failure. No in-hospital mortality was registered. Only one patient (2.2 %) with anastomotic leakage developed postoperative anastomotic stenosis requiring balloon dilatation. The intrathoracic stapled side-to-side anastomosis technique seems to be feasible, safe, and easy to perform, associated with a limited postsurgical complication rate and a good functional outcome.
TL;DR: Transplanted stem cells and MSCs transfected with VEGF significantly accelerated many parameters of the healing process following major hepatic resection, and support liver function, regeneration, and liver volume/weight.
Abstract: The study aims to determine the effects of mesenchymal stem cell (MSC) therapy and a combination therapy of MSCs transfected with vascular endothelial growth factor (VEGF) for liver regeneration after major resection. Thirty-eight rats were divided into four groups: group 1: control (sham operation); group 2: control (70 % hepatic resection); group 3: 70 % hepatic resection + systemically transplanted MSCs; and group 4: 70 % hepatic resection + systemically transplanted MSCs transfected with the VEGF gene. MSCs were injected via the portal vein route in study groups 3 and 4. Expression levels of VEGF, fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), epidermal growth factor (EGF), transforming growth factor (TGF), hepatocyte growth factor (HGF), and augmenter of liver regeneration (ALR) were analyzed in the remnant liver tissue. We investigated the levels of angiogenic factors, VEGF-receptor, angiopoietin-1 (Angpt1) and Angpt2. Biochemical parameters of liver function in blood samples were measured and a histologic assessment of the livers was performed. The postoperative liver weight and volume of each rat were measured 14 days after surgery. The expression levels of all measured growth factors were significantly increased in groups 3 and 4 compared to the control groups. The levels of Angpt1 and Angpt2 correlated with levels of VEGF and thus were also significantly higher in the study groups. There were significant differences between the estimated liver weights and volumes of group 4 and the resected controls in group 2. With the exception of portal inflammation, levels of all histological parameters were observed to be higher in MSC-treated groups when compared with the resected controls in group 2. Transplanted stem cells and MSCs transfected with VEGF significantly accelerated many parameters of the healing process following major hepatic resection. After the injection of MSCs and VEGF-transfected MSCs into the portal vein following liver resection, they were engrafted in the liver. They increased bile duct and liver hepatocyte proliferation, and secreted many growth factors including HGF, TGFβ, VEGF, PDGF, EGF, and FGF via paracrine effects. These effects support liver function, regeneration, and liver volume/weight.
TL;DR: In a cohort of patients that underwent partial or total thyroidectomy, the Thunderbeat appeared to be at least as good as the Harmonic Focus in terms of duration of surgery, blood loss, and length of hospital stay.
Abstract: An effective method for controlling haemostasis during open thyroidectomy procedures is crucial because of the high risks of haemorrhage and neck haematoma. This study aimed to demonstrate the efficacy of the integrated ultrasonic/bipolar Thunderbeat™ for this procedure. This retrospective non-inferiority study compared the Thunderbeat™ and the ultrasonic Harmonic Focus® devices in 761 consecutive patients receiving a partial or total open thyroidectomy (with or without neck dissection). The main outcomes were duration of surgery, blood loss, and length of hospitalisation. Secondary outcomes were occurrence of hypocalcaemia, recurrent nerve paralysis, or other post-operative complications. A non-inferiority logistic regression approach was used to evaluate primary outcomes, adjusting for age, gender, body mass index, type of surgery, anaesthesiology score, and indication (benign or malign). The data demonstrated that the Thunderbeat was non-inferior to the Focus in terms of duration of surgery, blood loss, and length of hospital stay. Furthermore, subgroup analyses showed non-inferiority of the Thunderbeat for partial thyroidectomy (all three outcomes), total thyroidectomy (duration of surgery and length of hospitalisation), and total thyroidectomy with neck dissection (length of hospitalisation). In terms of recurrent nerve paralysis and post-operative complications, the Thunderbeat performed at least as well as the Focus; however, no conclusions could be drawn regarding the occurrence of post-operative hypocalcaemia. In a cohort of patients that underwent partial or total thyroidectomy, the Thunderbeat appeared to be at least as good as the Harmonic Focus.
TL;DR: In this population-based study, CT scan was the only radiological modality that significantly reduced the rate of negative appendectomy, and should be more frequently used if clinical findings are unconclusive.
Abstract: Negative appendectomies are costly and are embedded with unnecessary risks for the patients. A careful indication for surgery seems mandatory even more so, since conservative therapy emerges as a potential alternative to surgery. The aims of this population-based study were to analyze whether radiological examinations for suspected appendicitis decreased the rate of negative appendectomies without increasing the rate of perforation or worsening postoperative outcomes. This study is a retrospective analysis of a prospective population-based database. The data collection included preoperative investigations and intraoperative and postoperative outcomes. Based on 2559 patients, the rate of negative appendectomies decreased significantly with the use of CT scan as compared to clinical evaluation only (9.3 vs 5 %, p = 0.019), whereas ultrasonography alone was not able to decrease this rate (9.3 vs 6.2 %, p = 0.074). Delaying surgery for radiological investigation did not increase the rate of perforation (18.1 vs 19.2 %; adjusted odds ratio (OR) 1.01; 0.8–1.3; p = 0.899). Postoperative complications (surgical reintervention, postoperative wound infection, postoperative hematoma, postoperative intra-abdominal abscess, postoperative ileus) were all comparable. In this population-based study, CT scan was the only radiological modality that significantly reduced the rate of negative appendectomy. The delay induced by such additional imaging did not increase perforation nor complication rates. Abdominal CT scans for suspected appendicitis should therefore be more frequently used if clinical findings are unconclusive.