[show abstract][hide abstract] ABSTRACT: For recurrent disease or primary therapy of advanced ovarian cancer, cytoreductive surgery (CRS) followed by adjuvant chemotherapy is a therapeutic option. The aim of this study was to evaluate the outcome for patients with epithelial ovarian cancer treated with hyperthermic intraoperative chemotherapy (HIPEC) and completeness of cytoreduction (CC).
Data were retrospectively collected from 111 patients with recurrent or primary ovarian cancer operated with the contribution of visceral surgical oncologists between 1991 and 2006 in a tertiary referral hospital.
Ninety patients received CRS and 21 patients CRS plus HIPEC with cisplatin. Patients with complete cytoreduction (CC0) were more likely to receive HIPEC. Overall, 19 of 21 patients (90.5 %) with HIPEC and 33 of 90 patients (36.7 %) with CRS had a complete cytoreduction (P < 0.001). Incomplete cytoreduction was associated with worse survival rates with a hazard ratio (HR) of 4.4 (95%CI: 2.3-8.4) for CC1/2 and 6.0 (95%CI: 2.9-12.3) for CC3 (P < 0.001). In a Cox-regression limited to 52 patients with CC0 a systemic concomitant chemotherapy (HR 0.3, 95%CI: 0.1-0.96, P = 0.046) but not HIPEC (HR 0.98 with 95 % CI 0.32 to 2.97, P = 0.967) improved survival. Two patients (9.5 %) developed severe renal failure after HIPEC with absolute cisplatin dosages of 90 and 95 mg.
Completeness of cytoreduction was proved to be crucial for long-term outcome. HIPEC procedures in ovarian cancer should be performed in clinical trials to compare CRS, HIPEC and systemic chemotherapy against CRS with systemic chemotherapy. Concerning the safety of HIPEC with cisplatin, the risk of persistent renal failure must be considered when dosage is based on body surface.
[show abstract][hide abstract] ABSTRACT: Although widely used, there is a lack of evidence concerning the diagnostic accuracy of C-reactive protein (CRP) and white blood cell counts (WBCs) in the postoperative period. The aim of this study was to evaluate the diagnostic accuracy of CRP and WBCs in predicting postoperative inflammatory complications after open resection of colorectal cancer.
In this retrospective study, clinical data and the CRP and WBCs, routinely measured until postoperative day 5 (POD 5), were available for 1,187 patients who underwent colorectal cancer surgery between 1997 and 2009. Using the receiver-operating characteristic (ROC) methodology, the diagnostic accuracy was evaluated according to the area under the curve (AUC).
Three hundred forty-seven patients (29.2%; 95% CI, 26.7-31.9%) developed various inflammatory complications. Anastomotic leakage occurred in 8.0% (95% CI, 6.1-9.1%) of patients. The CRP level on POD 4 (AUC 0.76; 95% CI, 0.71-0.81) had the highest diagnostic accuracy for the early detection of inflammatory complications. With a cutoff of 123 mg/l, the sensitivity was 0.66 (95% CI, 0.56-0.74), and the specificity was 0.77 (95% CI, 0.71-0.82). The diagnostic accuracy of the WBC was significantly lower compared to CRP.
Measurement of CRP on POD 4 is recommended to screen for inflammatory complications. CRP values above 123 mg/l on POD 4 should raise suspicion of inflammatory complications, although the discriminatory performance was insufficient to provide a single threshold that could be used to correctly predict inflammatory complications in clinical practice. WBC measurement contributes little to the early detection of inflammatory complications.
International Journal of Colorectal Disease 06/2011; 26(11):1405-13. · 2.24 Impact Factor
[show abstract][hide abstract] ABSTRACT: In laparoscopic anterior resection, minilaparotomy still is required. Recently, transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy have been described. Reports on operations that require removal of larger specimens, as in anterior resection, are scarce and limited primarily to small case series and case reports. The current study aimed to evaluate the feasibility and safety of transvaginal rigid-hybrid NOTES anterior resection (tvAR) for symptomatic diverticular disease.
All female patients presenting with symptomatic diverticulitis of the sigmoid colon were candidates for inclusion in the study. The exclusion criteria specified failure to sign informed consent, previous colorectal resection, anesthesiologic contraindication for pneumoperitoneum, liver failure and coagulopathy, severe acute diverticular bleeding, internal fistula with abscess (Hinchey 2b), perforated diverticulitis with peritonitis (Hinchey 3 or 4), gynecologic or urologic contraindications, and absence of preoperative gynecologic examination. A preoperative and 2-week postoperative gynecologic examination was performed. Quality of life and sexual function were assessed preoperatively and 6 weeks postoperatively.
Of 70 patients, 45 (64.3%) were scheduled for tvAR. Five patients were withdrawn at the beginning of laparoscopy with no transvaginal access performed. Of the remaining 40 patients with attempted tvAR, 4 patients underwent conversion to a minilaparotomy (Pfannenstiel incision) and 2 patients were converted to a total median laparotomy. For 34 patients (85%), the operation was completed transvaginally. A total of 2 major complications and 10 minor complications occurred. No serious postoperative gynecologic morbidity was experienced. At 6 weeks postoperatively, sexual function did not differ significantly from preoperative status.
For symptomatic diverticular disease, TvAR is feasible, although the presented technique requires laparoscopic expertise and further refinement.
[show abstract][hide abstract] ABSTRACT: This study was designed to apply modern statistical methods to evaluate risk factors for anastomotic leakage after rectal cancer resection in a retrospective cohort of patients who received a colorectostomy. Whereas a diverting stoma and tumor height are considered proven risk factors for anastomotic leakage, a lack of evidence about additional risk factors persists.
In a single-center study, 527 consecutive patients who received a colorectostomy after rectal cancer resection between 1991 and 2008 were retrospectively assessed. In addition to traditional uni- and multivariate regression, locally weighted scatterplot smoothing (LOWESS) regression and bootstrap analysis were applied to increase internal validity.
Anastomotic leakage occurred in 70 patients (13.3%; 95% confidence interval (CI), 10.5-16.5%) and mortality was 2.5% (95% CI, 1.4-4.2%). Diverting stoma (odds ratio (OR), 0.4; 95% CI, 0.17-0.61) and tumor height (OR, 0.88; 95% CI, 0.8-0.94) were proven to be protective. Neoadjuvant radiotherapy (OR, 2.15; 95% CI, 1.58-4.24) and intraoperative blood loss (OR, 1.05; 95% CI, 1.02-1.09) had a derogatory effect. Bootstrap analysis identified pre-existing vascular disease (95.5%), more advanced UICC stage III or IV tumors (95.7% or 91.5%, respectively), and intraoperative (96.1%) and postoperative (99.4%) blood substitution as harmful. Both intraoperative and postoperative blood substitution caused a dose-dependent increase in risk.
Applying statistical resampling methods identified intraoperative blood loss, blood substitution, vascular disease, and advanced UICC stage as risk factors for anastomotic leakage. Greater distances between the tumor and the anal verge and performance of a diverting stoma were associated with a decreased risk of anastomotic leakage.
Annals of Surgical Oncology 04/2011; 18(10):2772-82. · 4.12 Impact Factor
[show abstract][hide abstract] ABSTRACT: A stereotype of surgeons' personality persists in the general public and among health-care professionals. Only a few studies have attempted to describe this "surgical personality" in detail. The aim of this study was to investigate the personality traits of surgeons compared with internists and to prove the existence of a stereotype among health-care professionals concerning surgeons.
To investigate the existence of a stereotype, nursing staff members in a public tertiary referral 900-bed hospital rated the personality traits of internists and surgeons. Simultaneously, all internists and surgeons in the same hospital were asked to complete the Freiburg Personality Inventory-the most frequently used German self-report form.
Three hundred and thirty-four of 543 (62%) eligible nursing staff members participated; their responses confirmed the existence of a stereotype. A total of 253 of 284 eligible doctors completed the self-report form for a response rate of 89%. Compared with the general population, internists differed in most of 12 personality domains, whereas surgeons differed in 6 of 12 personality traits. The self-assessment revealed a statistically significant excess of achievement orientation (P = .00005) and extraversion (P < .00001) among surgeons and decreased aggressiveness (P = .00012) among internists. No significant difference was found between board-certified surgeons and internists in any of the 12 personality domains.
This study identified a clear discrepancy between the self- and external assessment of personality but only among surgeons. This outcome provides an opportunity for surgeons to reflect on any potential lack of self-awareness and its impact on interdisciplinary patient care.
Surgery 11/2010; 148(5):901-7. · 3.37 Impact Factor
[show abstract][hide abstract] ABSTRACT: Cholecystectomy using a rigid-hybrid transvaginal natural orifice transluminal endoscopic surgery (NOTES) approach (tvNCC) reduces abdominal wall incisions and might decrease surgical trauma by combining endoluminal access and laparoscopic techniques. We assessed the feasibility and safety of rigid-hybrid tvNCC in routine practice for symptomatic cholecystolithiasis or acute cholecystitis in a patient population with low selection.
From September 2008 to July 2009, all female patients with cholecystectomy indications were evaluated for tvNCC. Exclusion criteria were: refusal of tvNCC; inability to give informed consent; gynecological or urological contraindications; lack of preoperative gynecological examinations; need for cholangiography/choledochus revision; anesthesiological contraindications to pneumoperitoneum; liver failure; or coagulopathy. Age, obesity, previous surgery, or degree of gallbladder inflammation were not exclusion criteria. Preoperative and 2-weeks' postoperative gynecological examinations were performed. Sexual function was assessed preoperatively and at 6 weeks postoperatively.
102 of 137 consecutive patients (74.5 %) with symptomatic cholecystolithiasis (n = 74) or cholecystitis (n = 28) were scheduled for rigid-hybrid tvNCC with nine different surgeons. Patient mean age was 52.3 +/- 17.8 years (range 18 - 87) and mean body mass index 27.3 +/- 6.3 kg/m (2) (17.6 - 43.8). Two patients had conversion to conventional laparoscopic cholecystectomy. There were no intraoperative complications. Two major complications occurred: one stroke and one herniation within the transumbilical access. Minor complications were reported in 13 patients (12.7 %) and there were no serious postoperative gynecological findings. At 6 weeks postoperatively, there were fewer dyspareunia symptoms than preoperatively ( P = 0.049).
Rigid-hybrid tvNCC is feasible and safe in routine practice for symptomatic cholecystolithiasis and acute cholecystitis.
[show abstract][hide abstract] ABSTRACT: Clinical studies have demonstrated that stapled transanal rectal resection with Contour Transtar (Transtar procedure) is a safe and effective treatment for patients with obstructive defecation syndrome. The aim of this study was to determine functional outcome and quality of life after the procedure.
Female patients with obstructive defecation syndrome were enrolled prospectively for the Transtar procedure. Intussusception and anterior rectocele were confirmed by clinical investigation and by magnetic resonance defecography. Functional outcome was measured by obstructed defecation syndrome score, severity of symptoms score, and Wexner score preoperatively and postoperatively. Quality of life was assessed by the Cleveland Clinic constipation score, the fecal incontinence quality of life scale, and the SF-36v2 health survey.
Between January 2007 and November 2008, 52 consecutive patients (median age: 64 years) were included in the study. Before the surgery, 12 patients experienced fecal incontinence. Functional scores improved significantly: 6 weeks after surgery, the obstructed defecation syndrome score decreased from a median of 16 (range, 9-22) to 5 (range, 2-10) and the severity of symptoms score, from 16 (range, 9-21) to 4 (range, 0-9) (each P < .0001). After 6 weeks, 10 patients had fecal incontinence and 12 patients experienced fecal urgency. At 3 months, 6 patients were still incontinent, 3 of whom were treated successfully with sacral neuromodulation. Fecal urgency resolved in all cases after 6 months. Quality of life improved, particularly in the mental components.
Despite the described postoperative symptoms, most of which can be treated conservatively, the Transtar procedure is an effective treatment for patients with obstructive defecation syndrome and improves quality of life significantly.
Diseases of the Colon & Rectum 06/2010; 53(6):881-8. · 3.34 Impact Factor
[show abstract][hide abstract] ABSTRACT: Modern sphincter-preserving surgery for ultralow rectal carcinoma has a comparable oncological radicality to abdomino-perineal extirpation (APE). The aim of this study was to assess the long-term morbidity of ultralow anterior resection (ULAR) and its impact on quality of life (QoL) METHODS: The medical records of 142 consecutive patients who underwent surgery for ultralow rectal carcinoma from January 1991 to December 2004 were reviewed retrospectively. The rate of rehospitalisation and rate of non-reversed temporary stomas ("failure" stoma) were analysed. Generic and cancer-specific quality of life questionnaires were used to assess quality of life.
There were a total of 82 ULAR and 60 APE. After ULAR, 25 (30.5%) of the patients were readmitted, stenosis and anastomotic leakage being the main reasons. After APE, only 2 (3.3%) of the patients were readmitted (P < 0.001). The rate of patients with a permanent stoma after sphincter-saving surgery was 22.0%. The failure rate was higher for older patients (P = 0.005) and for coloanal pull-through anastomosis (P = 0.001). The exploratory analysis revealed a negative impact of a "failure" stoma on QoL.
Severe long-term morbidity and high failure rate of stoma reversal have a significantly worse impact on QoL after ULAR; therefore, APE is a valid alternative to ULAR, especially in elder patients with planned coloanal pull-through anastomosis.
International Journal of Colorectal Disease 04/2010; 25(4):425-32. · 2.24 Impact Factor
[show abstract][hide abstract] ABSTRACT: To date, transgastric access in humans for natural orifice transluminal endoscopic surgery (NOTES) has been poorly evaluated.
To compare endoscopic visualization of the transgastric access point with the laparoscopically defined ideal entrance to the peritoneal cavity.
Prospective pilot study in humans.
Single tertiary-care center.
This study involved 31 patients referred for laparoscopic cholecystectomy.
Access points were marked by endoscopy alone, endoscopy combined with diaphanoscopy, and endoscopy after pneumoperitoneum. Points were correlated with a laparoscopically visualized, previously defined ideal access area.
To choose the appropriate access point within the laparoscopically defined ideal access area to the peritoneal cavity away from major vessels and adjacent organs, by using endoscopy and to establish landmarks for the endoscopist, look for a learning curve, and identify potential problems.
The percentage of access points within the laparoscopically defined ideal area was 35.5% with endoscopy alone, 13.8% using the diaphanoscopy method, and 45.2% after transcutaneous pneumoperitoneum. A safe access point (> or = 3 cm from major gastric vessels) could be achieved with the 3 techniques in 83.9%, 65.5%, and 87.1% of patients, respectively. A positive learning curve for endoscopic localization was identified before (P = .008) and after (P = .014) pneumoperitoneum. Virtual complications were greater in obese patients.
This was a small pilot study with hypothetical complications and problems, because actual transgastric access was not performed. The criteria for an ideal access area were very strict.
Endoscopy, especially with the use of pneumoperitoneum, can reliably locate a safe transgastric entrance point. However, the endoscopically chosen site correlates poorly with the ideal laparoscopically determined site for transgastric access.
[show abstract][hide abstract] ABSTRACT: A new surgical technique, the Perineal Stapled Prolapse resection (PSP) for external rectal prolapse was introduced in a feasibility study in 2008. This study now presents the first results of a larger patient group with functional outcome in a mid-term follow-up.
From December 2007 to April 2009 PSP was performed by the same surgeon team on patients with external rectal prolapse. The prolapse was completely pulled out and then axially cut open with a linear stapler at three and nine o'clock in lithotomy position. Finally, the prolapse was resected stepwise with the curved Contour Transtar stapler at the prolapse's uptake. Perioperative morbidity and functional outcome were prospectively measured by appropriate scores.
32 patients participated in the study; median age was 80 years (range 26-93). No intraoperative complications and 6.3% minor postoperative complications occurred. Median operation time was 30 minutes (15-65), hospital stay 5 days (2-19). Functional outcome data were available in 31 of the patients after a median follow-up of 6 months (4-22). Preoperative severe faecal incontinence disappeared postoperatively in 90% of patients with a reduction of the median Wexner score from 16 (4-20) to 1 (0-14) (P < 0.0001). No new incidence of constipation was reported.
The PSP is an elegant, fast and safe procedure, with good functional results.
[show abstract][hide abstract] ABSTRACT: Radio Frequency Identification (RFID) devices are becoming more and more essential for patient safety in hospitals. The purpose of this study was to determine patient safety, data reliability and signal loss wearing on skin RFID devices during magnetic resonance imaging (MRI) and computed tomography (CT) scanning.
Sixty RFID tags of the type I-Code SLI, 13.56 MHz, ISO 18000-3.1 were tested: Thirty type 1, an RFID tag with a 76 x 45 mm aluminum-etched antenna and 30 type 2, a tag with a 31 x 14 mm copper-etched antenna. The signal loss, material movement and heat tests were performed in a 1.5 T and a 3 T MR system. For data integrity, the tags were tested additionally during CT scanning. Standardized function tests were performed with all transponders before and after all imaging studies.
There was no memory loss or data alteration in the RFID tags after MRI and CT scanning. Concerning heating (a maximum of 3.6 degrees C) and device movement (below 1 N/kg) no relevant influence was found. Concerning signal loss (artifacts 2 - 4 mm), interpretability of MR images was impaired when superficial structures such as skin, subcutaneous tissues or tendons were assessed.
Patients wearing RFID wristbands are safe in 1.5 T and 3 T MR scanners using normal operation mode for RF-field. The findings are specific to the RFID tags that underwent testing.
[show abstract][hide abstract] ABSTRACT: Selective decontamination of the digestive tract (SDD) to eliminate gram-negative bacteria is still not widely accepted, although it reduces the incidence of nosocomial infections. In a previous retrospective study, a clear benefit to perioperative morbidity, and a reduction in nosocomial infections were found in patients who underwent an esophageal anastomosis. Thus, SDD was applied routinely for esophageal anastomoses. We report the outcome of a cohort of 81 patients who underwent this treatment.
From 2002, patients who underwent an esophageal anastomosis (esophagojejunostomy) were prospectively recorded. Perioperatively, patients received polymyxin, tobramycin, vancomycin and nystatin by mouth four times a day. Outcome was compared to a control group that was treated before 2002 (68 patients without SDD and 53 patients with SDD). Postoperative morbidity and mortality were assessed.
Between 2002 and 2007, 81 patients who underwent an esophageal anastomosis received SDD. Compared to a retrospective control group, patients with SDD had significantly less pneumonia (OR 0.06 (0.01-0.46), p < 0.001) and lower morbidity (OR 0.16 (0.05-0.49), p < 0.001). Furthermore, fewer anastomotic insufficiencies and complications were found. Similar results were found in the analysis of the patients treated before 2002.
SDD significantly reduces perioperative morbidity and mortality in patients who undergo a distal esophageal anastomosis compared to a historical control group. In patients with an anastomotic leakage, there was a strong tendency of SDD to reduce postoperative mortality.
[show abstract][hide abstract] ABSTRACT: We report the case of a 41-year-old female patient who presented in the emergency department with recurrent pain in the lower abdomen 3 years after haemorrhoidopexy (Longo's procedure). At clinical examination a space-occupying mass between the rectum and the vagina was present which was identified as a stool-loaded diverticulum of the rectum by magnetic resonance imaging. Using a perineal approach the diverticulum could be excised at its base and the defect of the mucosa was closed transanally with sutures. A diverticulum of the rectum is a rare complication (2.5%) after stapled haemorrhoidopexy. In the diagnostic of complications after Longo's haemorroidopexy the MRI constitutes an excellent auxiliary modality.
Der Chirurg 08/2009; 81(1):61-3. · 0.52 Impact Factor
[show abstract][hide abstract] ABSTRACT: Long-term outcome for curative colon cancer surgery may be impaired by anastomotic leakage, but most studies regard colon and rectal cancer patients as one group. The aim of this study was to determine whether anastomotic leakage following potentially curative resection for colon cancer is a risk factor for postoperative mortality and for long-term survival.
Medical records of a cohort of 440 consecutive patients undergoing 445 curative resections for explicit colon cancer with primary anastomosis above the peritoneal reflection were reviewed. Therefore patients with rectal cancer were not included. Diagnosis of leakage was made by clinical features or abdominal CT-scans.
The study population consisted of 266 men and the mean age was 68.6 years. Median follow-up time was 66.5 months. Anastomotic leakage occurred in 12 patients. Four of these died within 30 days after surgery compared to 15 of the remaining 428 patients without leakage (p<0.001). The 5-year overall survival rate was 25% in patients with anastomotic leakage compared to 61.2% in those without leakage (p<0.001). Excluding 30-day mortality, respective values were 33.3 and 63.7% (p=0.02).
Although anastomotic failure after colon cancer surgery is rare, it is a very severe complication that not only impairs the perioperative morbidity and mortality but also significantly influences the long-term outcome negatively.
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 03/2009; 35(10):1060-4. · 2.56 Impact Factor
[show abstract][hide abstract] ABSTRACT: Because fundoplication-related side effects are frequent, we evaluated laparoscopic mesh-augemented hiatoplasty (LMAH) as a potential treatment option for gastroesophageal reflux disease and/or symptomatic hiatal herania. LMAH aims to prevent reflux solely by mesh-reinforced narrowing of the hiatus and lengthening of the intra-abdominal esophagus.
Twenty-two consecutive patients with LMAH were evaluated prospectively using a modified Gastrointestinal Symptom Rating Scale questionnaire, pH measurement, manometry, and endoscopy. Follow-up was scheduled at 3 and 12 months after surgery.
Total reflux decreased from 16.3% before surgery to 3.5% 3 months after surgery (P = .001). The reflux score decreased from 3.8 before surgery to 2.1 1 year after surgery (P = .001). The respective values of the indigestion score were 3.4 and 2.0 (P < .001). After surgery, all patients were able to belch. Vomiting was impossible only for 2 patients, and 90% of patients assessed their results as good to excellent.
LMAH seems to be feasible, safe, and has no significant side effects.
American journal of surgery 06/2008; 195(6):749-56. · 2.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Anastomotic failure after ultra-low anterior rectum resection is the most important complication, and it is influenced by the type of reconstruction. The aim of this study was to compare retrospectively the straight coloanal anastomosis with the J-pouch reconstruction concerning the development of anastomotic leakage.
Fifty-six of 381 consecutive patients underwent low anterior rectum resection with total mesorectal excision and ultra-low coloanal anastomosis at 3-4 cm from the anocutan line. A 5-cm J-pouch (side-to-end) was performed in 25, a straight coloanal anastomosis in 25, and a coloplasty in 6 patients, respectively.
No influence by age, body mass index, and operating time on anastomotic leakage rate was found. Leakage was found in eight patients with straight coloanal anastomosis, resulting in a leakage rate of 32% compared to one patient in the J-pouch group (P = 0.023).
Patient's safety is higher after J-pouch reconstruction because of the lower anastomotic failure rate, and functional results had been reported as similar after J-pouch reconstruction and straight coloanal anastomosis. Therefore, we clearly argue for a J-pouch reconstruction as the standard method after ultra-low coloanal anastomosis.
International Journal of Colorectal Disease 04/2008; 23(3):277-81. · 2.24 Impact Factor