Purpose
Defunctioning ileostomies reduce the consequences of distal anastomotic leakage following bowel resections. Ileostomy reversal in itself, however, is associated with appreciable morbidity ...(3–40%) and mortality (0–4%). Despite being a common teaching procedure, there is limited information on the impact of surgical proficiency levels on postoperative outcome.
Methods
Adult patients undergoing closure of a defunctioning ileostomy between September 2008 and January 2017 were identified from a surgical administrative database that was collected prospectively (
n
= 558). Baseline characteristics (age, ASA score, BMI, health care insurance coverage) and closure techniques were recorded. Operation time, rate of bowel resection, postoperative complications ranked by Clavien-Dindo classification and length of stay were analysed with respect to proficiency levels (residents vs. consultants).
Results
Two hundred three ileostomy reversals were performed by residents; 355 ileostomies were closed by consultants. Operation time was considerably shorter in the consultant group (
p
< 0.001). Major postoperative complication rates however were not different among the groups when adjusted for possible confounders (
p
= 0.948). The rate of anastomotic leakage was 3% and the overall major morbidity rate was 11%.
Conclusion
Operation time rather than surgical outcome and overall morbidity were affected by surgical proficiency levels. Therefore, ileostomy reversal can be considered an appropriate teaching operation for young general surgery trainees.
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EMUNI, FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
For hydrogen to become a serious contender for replacing fossil fuels, the manufacturing thereof has to be further investigated. One such process, the membrane based Hybrid Sulfur (HyS) process, ...where hydrogen is produced from the electrolysis of SO2, has received considerable interest recently. Since H2SO4 is formed during SO2 electrolysis, H2SO4 stability is a prerequisite for any membrane to be used in this process. In this study, pure as well as blended polybenzimidazole (PBI), partially fluorinated poly(arylene ether) (sFS) and nonfluorinated poly(arylene ethersulfone) (sPSU) membranes were investigated in terms of their acid stability as a function of acid concentration. Membranes were characterized using weight change, TGA, GPC, SEM/EDX and IEC. While a general stability was observed at 30 and 60 wt% H2SO4, the blended sFS-PBI and sPSU-PBI showed the highest stability throughout. According to the VI curve obtained for the SO2 electrolysis, the sPSU-PBI blend membrane performed slightly better than Nafion registered 117.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Aim
Reported recurrence rates after perineal rectosigmoidectomy (Altemeier's procedure) in patients with full‐thickness rectal prolapse vary from 0% to 60%. The object of this study was to analyse ...risk factors for recurrence after this procedure.
Method
From May 2004 to December 2012, 63 consecutive patients suffering from full‐thickness rectal prolapse undergoing perineal rectosigmoidectomy were included. Of these 46 were female and the median age of the whole group was 79 (30–90) years. The median follow‐up was 53 (3–99) months. Patient characteristics and operative parameters were compared between patients with and without recurrence.
Results
One patient died and another patient needed re‐operation. Eight full‐thickness recurrences occurred in eight patients after a median of 18 (6–48) months. Stapled compared with handsewn anastomosis (hazard ratio 7.96, 95% confidence interval 1.90–33.47; P = 0.001) and shorter specimen length (hazard ratio 4.06, 95% confidence interval 0.97–16.99; P = 0.03) increased the risk of recurrence in Cox regression analysis.
Conclusion
The operative technique including stapled anastomosis and length of the resected specimen seems to be associated with a high recurrence rate after perineal rectosigmoidectomy.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
During damage control surgery for blunt abdominal traumata simultaneous duodenal perforations can be missed making secondary sufficient surgical treatment challenging. Endoluminal vacuum (EndoVAC™) ...therapy has been shown to be a revolutionary option but has anatomical and technical limits.
A 59-year old man with hemorrhagic shock due to rupture of the mesenteric root after blunt abdominal trauma received damage control treatment. Within a scheduled second-look, perforation of the posterior duodenal wall was identified. Due to local and systemic conditions, further surgical treatment was limited. Decision for endoscopic treatment was made but proved to be difficult due to the distal location. Finally, double-barreled jejunal stoma was created for transstomal EndoVAC™ treatment. Complete leakage healing was achieved and jejunostomy reversal followed subsequently.
During damage control surgery simultaneous bowel injuries can be missed leading to life-threatening complications with limited surgical options. EndoVAC™ treatment is an option for gastrointestinal perforations but has anatomical limitations that can be sufficiently shifted by a transstomal approach for intestinal leakage.
In trauma related laparotomy complete mobilization of the duodenum is crucial. As ultima ratio, transstomal EndoVAC™ is a safe and feasible option and can be considered for similar cases.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
To evaluate the outcome after surgical resection in patients with gastrointestinal stromal tumors and to determine the factors influencing local tumor recurrence or distant metastatic disease after ...locally complete tumor resection (R0).
Outcomes of 100 patients with primary gastrointestinal stromal tumors (GIST) surgically managed between 1997 and 2006 at a single institution were reviewed. Univariate and bivariate analyses were used to determine factors affecting recurrence-free and tumor-free survival.
All patients (n = 100) had c-kit-positive GIST. There were 17% (n = 17) very low risk, 41% (n = 41) low risk, 19% (n = 19) intermediate risk and 23% (n = 23) high risk GIST originating from the stomach, small bowel, colon and rectum. The median patient age was 68 years (range 39-92). Seventy-three percent of the patients had symptomatic local disease. Most (94%; n = 94) of them underwent R0 resections of their primary tumor. R0 resection was significantly associated with a lower tumor-related mortality rate (p = 0.0001). The patients with recurrence/metastases had significantly larger tumors (p = 0.0017) and a mitotic index higher than 5/50 HPF (p = 0.0001). Seven of 20 patients from the high-risk group and 2 of 7 patients with metastatic disease developed local recurrence or further metastatatic tumor spread following R0 resection.
Surgical removal continues to be the mainstay of GIST treatment. R0 resection, tumor size and mitotic index are significant prognostic factors. Overall, more than 30% of the patients with high-risk GIST develop local recurrences and distant metastases despite R0 resection. Additional molecular pathological markers are needed to yield a more accurate tumor profile and to thus achieve a better predictability of the biological behavior of GIST.
Multiblock‐co‐polymers with different ion exchange capacities were synthesised by nucleophilic aromatic step‐growth polycondensation of hydrophilic and hydrophobic oligomers. The main focus of this ...work was to investigate the dependence of oligomer reactivity on molecular weight and how the reaction conditions need to be changed to obtain high‐molecular multiblock‐co‐polymers, consisting of long block segments. Multiblock‐co‐polymers composed of short oligomers could be synthesised under mild reaction conditions. The coupling of longer oligomers required more basic reaction conditions, because the reactive functional end‐groups were shielded by the long oligomeric main chain. The membranes were investigated further in terms of their properties relevant for use as polymer electrolyte membrane in direct methanol fuel cells (DMFCs). The mechanical stability of the acidic polymers was improved through ionical crosslinking with basic polybenzimidazole. A series of membranes was tested in a self‐ and in an air‐breathing DMFC.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background
Anastomotic leakage (AL) is one of the most common and serious complications following visceral surgery. In recent years, endoluminal vacuum therapy has dramatically changed therapeutic ...options for AL, but its use has been limited to areas easily accessible by endoscope.
Case presentation
We describe the first use of endoluminal vacuum therapy in the small intestine employing a combined surgical and endoscopic “rendezvous technique” in which the surgeon assists the endoscopic placement of an endoluminal vacuum therapy sponge in the jejunum by means of a pullback string. This technique led to a completely closed AL after 27 days and 7 changes of the endosponge.
Conclusion
The combined surgical and endoscopic rendezvous technique can be useful in cases of otherwise difficult endosponge placement.
Robotik in der Chirurgie Krajinovic, K.; Kim, M.
Coloproctology,
04/2018, Volume:
40, Issue:
2
Journal Article
Peer reviewed
Zusammenfassung
Hintergrund
Der Stellenwert der computergestützten Chirurgie wird trotz zunehmender Etablierung der Technik kontrovers diskutiert.
Kosten-Nutzen-Vergleich
Häufiger Gegenstand der ...Diskussion sind die höheren Kosten und die bislang unzureichende Evidenz für eine Überlegenheit der robotergestützten Technik im Vergleich zu den konventionell laparoskopischen Verfahren. Die Frage nach dem Mehrwert der Robotik erfordert darüber hinaus die Auseinandersetzung mit der Thematik aus der Perspektive der Anwender. Nicht zuletzt sollte eine Betrachtung des aktuellen und zukünftigen technischen und digitalen Potenzials der computergestützten Chirurgie in die Beantwortung der Frage nach dem Mehrwert einfließen.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Fast track (FT) is a modern concept to enhance postoperative recovery after elective surgery. It has been approved during the last years. Beside its medical benefits, fast-track (FT) concepts may ...provide an economic incentive, although a cost-benefit analysis in the daily clinical routine has not yet been realised. In addition to this an elevated consumption of resources is postulated.
In 2007 we prospectively studied the implementation of the FT concept for elective colonic surgery in the daily clinical routine at the Department of General Surgery of Nuremberg Hospital. In a representative subgroup of patients studied, we performed a cost-cost analysis by comparing these patients to a retrospectively analysed group that had been treated in a conventional traditional manner in 2002.
369 patients were included and treated according to the FT concept. Discharge criteria were met at the 4(th) postoperative day in median (SD 3.9 days, minimum 1, maxiumum 29 days). The rate of general postoperative complications was 24.4 % (16 % minor complications) for all patients and 6.6 % in the group of patients who were discharged within 9 postoperative days or less (n=182). With respect to the main FT items, implementation of the FT concept was considered as effective. Cost-cost analyses showed a cost reduction of 32 % in favour of patients treated with the FT concept.
This study clearly shows the clinical and economic benefits of the FT concept considering health services research. Therefore further clinical implementation of the FT concept seems beneficial, not only in the view of medical aspects, but also for economic reasons.
Eine 59-jährige Patientin mit bekannter familiärer adenomatöser Polyposis (FAP) hatte sich zur Abklärung eines schmerzlosen Ikterus vorgestellt. In der Vorgeschichte waren bereits eine ...Proktokolektomie und eine pyloruserhaltene Pankreaskopfresektion aufgrund von Duodenaladenomen mit hochgradigen intraepithelialen Neoplasien erfolgt. Im Rahmen der Diagnostik wurde eine Ösophagogastrojejunoskopie durchgeführt. Diese zeigte ein großes Adenom, das die biliopankreatische Schlinge vollständig okkludierte und aufgrund seiner breitbasigen Ausdehnung nicht endoskopisch abtragbar war.
Nach interdisziplinärer Fallbesprechung wurde die Indikation zur Laparotomie und Resektion des betreffenden Jejunumsegments gestellt. Trotz schwerstem Verwachsungsbauch gelang die Jejunumsegmentresektion und in der Histologie fand sich ein 6 cm großes tubulo-villöses Adenom mit Übergang in ein invasives Adenokarziniom des Jejunums (pT3, G2, R0).
Postoperativ entwickelte die Patientin eine ventralseitige Anastomoseninsuffizienz der Jejuno-Jejunostomie. Bei der daraufhin durchgeführten operativen Revision war eine primäre chirurgische Readaptation der Anastomose aufgrund eines totalen Verwachsungsbauchs mit vollständig fixiertem Intestinum nicht möglich.
Daraufhin erfolgte in Zusammenarbeit mit den Kollegen der Gastroenterologie das Einbringen eines Endo-VAC-Schwamms im Rendezvous-Verfahren. Die Positionierung des Endo-VAC war massiv erschwert, da zunächst der Pylorus überwunden werden musste und anschließend die insuffiziente Schlinge stark abgewinkelt war. Für die korrekte Führung und Positionierung des Endo-VAC wurde daher ein Schwammführungssystem konstruiert. Hierzu wurde an der Führungsschlaufe des endoskopisch eingebrachten Endo-VAC über den abdominellen Zugang ein 100 cm langer „Rückholfaden“ geknotet und über die Laparotomiewunde ausgeleitet. Die Medianlaparotomiewunde wurde anschließend mit einem externen VAC-System verschlossen.
Bei den folgenden Schwamm-Wechseln konnte, nach endoskopischer Entfernung des alten VAC, mithilfe des „Rückhohlfadens“ der neue Endo-VAC immer wieder korrekt platziert werden. Nachdem der Endoskopiker den Endo-VAC durch den Pylorus gedrückt hatte, zog der Assistent am distalen Ende des „Rückholfadens“ an der Bauchdecke. Durch dieses „push and pull“ Manöver mit endoskopischer und externer Führung konnte der Endo-VAC trotz komplizierter Lokalisation nach jedem Wechsel wieder ideal im Bereich der Insuffizienz positioniert werden. Letztendlich gelang durch dieses interdisziplinäre vakuum-assistierte Vorgehen ein vollständiger Verschluss der Anastomoseninsuffizienz.
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