Background: Anesthesia per se and pneumoperitoneum during laparoscopic surgery lead to atelectasis and impairment of oxygenation. We hypothesized that a ventilation with positive end‐expiratory ...pressure (PEEP) during general anesthesia and laparoscopic surgery leads to a more homogeneous ventilation distribution as determined by electrical impedance tomography (EIT). Furthermore, we supposed that PEEP ventilation in lung‐healthy patients would improve the parameters of oxygenation and respiratory compliance.
Methods: Thirty‐two patients scheduled to undergo laparoscopic cholecystectomy were randomly assigned to be ventilated with ZEEP (0 cmH2O) or with PEEP (10 cmH2O) and a subsequent recruitment maneuver. Differences in regional ventilation were analyzed by the EIT‐based center‐of‐ventilation index (COV), which quantifies the distribution of ventilation and indicates ventilation shifts.
Results: Higher amount of ventilation was examined in the dorsal parts of the lungs in the PEEP group. Throughout the application of PEEP, a lower shift of ventilation was found, whereas after the induction of anesthesia, a remarkable ventral shift of ventilation in ZEEP‐ventilated patients (COV: ZEEP, 40.6 ± 2.4%; PEEP, 46.5 ± 3.5%; P<0.001) was observed. Compared with the PEEP group, ZEEP caused a ventral misalignment of ventilation during pneumoperitoneum (COV: ZEEP, 41.6 ± 2.4%; PEEP, 44 ± 2.7%; P=0.013). Throughout the study, there were significant differences in the parameters of oxygenation and respiratory compliance with improved values in PEEP‐ventilated patients.
Conclusion: The effect of anesthesia, pneumoperitoneum, and different PEEP levels can be evaluated by EIT‐based COV monitoring. An initial recruitment maneuver and a PEEP of 10 cmH2O preserved homogeneous regional ventilation during laparoscopic surgery in most, but not all, patients and improved oxygenation and respiratory compliance.
Background
Patients with rectovaginal fistulas have a significantly reduced quality of life. Therefore, surgical therapy is often needed even in palliative cases. The aim of the present study was to ...perform an analysis of the results of the different treatment options available today.
Methods
We performed a retrospective analysis of patients who underwent treatment for rectovaginal fistulas at the Department of Surgery, University of Schleswig–Holstein, Campus Luebeck and the Department of Surgery, WKK Heide, between January 2000 and September 2016. Complication and recurrence rate were retrospectively evaluated. The median follow-up period was 13 months (range 3–36 months).
Results
During the observation period, 58 patients underwent surgery (53 curative, 5 palliative) for rectovaginal fistulas. All patients who underwent curative surgery had an omentoplasty, and 39 of 53 (73.6%) patients underwent a resection. Thirty of 39 (77.0%) resections were low anterior resection, while non-continence-preserving resection included subtotal colectomy (
n
= 5), pelvic exenteration (
n
= 2), and proctectomy (
n
= 2). The fistulas were mainly secondary to inflammatory bowel disease (
n
= 18) or diverticulitis (
n
= 13), while 19 fistulas were a complication of different cancers or precancerous lesions. The median follow-up time was 13 months (range 6–36). Four patients (6.9%) had fistula recurrence (3 recurrences after low anterior resection, 1 after primary fistula closure). The mortality rate was 6.9% (
n
= 4).
Conclusions
Non-resecting methods should be used only in uncomplicated fistulas. Rectovaginal fistulas secondary to inflammatory or malignant disease mostly require extensive therapy. Omentoplasty is effective for the treatment of both high and low rectovaginal fistulas.
This study analyzed the results of a standardized approach in anastomotic leakage following low anterior resection for rectal cancer without performance of a protective ileostomy during the primary ...operation.
The study included all 306 patients with rectal cancer electively undergoing low anterior resection with retroperitonealization of the anastomosis over 9 years. The diagnostic procedure for anastomotic leakage included serum laboratory investigations and abdominal CT together with contrast enema. Minor leakages, i.e., small leakages and pelvic abscess, were treated with rectoscopic lavage and/or CT-guided drainage of the abscess, respectively. Major leakage was defined as broad insufficiency with or without septicemia. Nonseptic patients were treated by ileostomy and rectoscopic treatment. In septic patients a revision of the anastomosis with loop ileostomy was performed.
Anastomotic leakage was diagnosed in 30 patients (overall 9.8%; 12 major, 18 minor leakages). Common clinical signs were pelvic pain and fever. No patient developed a peritonitis. The most accurate diagnostic instrument was CT (96.7%).
Retroperitonealization appears to prevent peritonitis in patients with anastomotic leakage following low anterior resection. A differential treatment leads to good results in terms of mortality and anorectal function.
Objective Although many efforts have been made to generate small-diameter (≤5 mm) vascular grafts by means of tissue engineering, improvement in patency and functionality still remains a great ...challenge. It is our hypothesis that to achieve long-term functionality and patency, not only the complete lining with endothelial cells but also full biocompatibility is essential. Design The aim was the development of a conduit from a scaffold and endothelial progenitor cells (EPC) separated from peripheral blood of a single donor. Materials and methods EPC and a fibrin preparation were separated from porcine peripheral blood. Fibrin segments were generated seeded with EPC and were perfused in a bioreactor in vitro. Results From 100 ml blood 12–15 cm long fibrin tubes were successfully generated lined with endothelial-like cells. Seeded tubes showed a remarkable elasticity and burst strength up to 90 mm mercury. Conclusions Stable fibrin tubes were successfully generated completely lined with an endothelium-like monolayer from fibrin and EPC, both isolated from the same volume of blood. Although their stability is not those needed for arterial grafting, our results raise the hope, that with distinct improvements in future studies functional autologous vascular grafts could be engineered from the patient's own blood.
Background The pathogenesis of diverticular disease (DD) is attributed to several aetiological factors (e.g. age, diet, connective tissue disorders) but also includes distinct intestinal motor ...abnormalities. Although the enteric nervous system (ENS) is the key‐regulator of intestinal motility, data on neuropathological alterations are limited. The study aimed to investigate the ENS by a systematic morphometric analysis.
Methods Full‐thickness sigmoid specimens obtained from patients with symptomatic DD (n = 27) and controls (n = 27) were processed for conventional histology and immunohistochemistry using anti‐HuC/D as pan‐neuronal marker. Enteric ganglia, nerve and glial cells were quantified separately in the myenteric, external and internal submucosal plexus compartments.
Key Results Compared to controls, patients with DD showed significantly (P < 0.05) (i) reduced neuronal density in all enteric nerve plexus, (ii) decrease of ganglionic nerve cell content in the myenteric plexus, (iii) decreased ganglionic density in the internal submucosal plexus, (iv) reduced glial cell density in the myenteric plexus, (v) decrease of ganglionic glial cell content in the myenteric plexus and increase in submucosal plexus compartments, (vi) increased glia index in all enteric nerve plexus. About 44.4% of patients with DD exhibited myenteric ganglia displaying enteric gliosis.
Conclusions & Inferences Patients with DD show substantial structural alterations of the ENS mainly characterized by myenteric and submucosal oligo‐neuronal hypoganglionosis which may account for intestinal motor abnormalities reported in DD. The morphometric data give evidence that DD is associated with structural alterations of the ENS which may complement established pathogenetic concepts.
Background: Fournier's gangrene is a necrotizing fasciitis involving the perineal and genital regions. Even today, this often polymicrobial infection still carries a high mortality rate and continues ...to be a major challenge to the medical community. The purpose of this study was to report our experience with this condition and to compare it with those reported in published studies. We also introduce our approach to treatment. Methods: We analyzed data from 33 patients with Fournier's gangrene who were managed in our hospital from 1996 to 2007, focusing on patient gender, age, etiology, predisposing conditions, comorbidities, bacteriology, sepsis, blood results, mortality, and spread of gangrene. Results: 18 (54.5%) of the 33 patients had been referred to our department by smaller district hospitals. The patient cohort consisted of 23 men and ten women with a median age of 59 years (range 40-79 years). The median time between the onset of symptoms and progression to gangrene was 6 days (range 2-28 days). An underlying cause was identified in 27 patients (81.8%). The commonest etiological events were perianal and perirectal abscesses (n = 13; 39.4%). Predisposing factors included diabetes mellitus in 12 cases (36.4%), chronic alcoholism in ten cases (30.3%), immunosuppression in six cases (18.2%), and prolonged immobilization in five cases (15.2%). 17 patients (51.5%) had a body mass index (BMI) of 25 or higher, and 13 patients (39.4%) had a BMI of 30 or higher. Positive cultures were obtained in 30 cases (90.9%). In 26 cases (78.8%), multiple microorganisms were recovered, including nine cases (27.3%) with both aerobes and anaerobes. Sepsis was present in 26 patients (78.8%). The mortality rate was 18.2%. Conclusion: Fournier's gangrene remains a major challenge with a high mortality. Our results suggest that women are more commonly affected than has generally been assumed. Contrary to published reports, we found that anorectal sources appear to account for more cases of Fournier's gangrene than urological sources.
Background
Many different techniques to treat rectal prolapse have been introduced. Laparoscopic resection rectopexy has been shown to entail benefits regarding both perioperative results and ...short-term outcome, whereas data for long-term outcome are scarce.
Methods
Between 1993 and 2008, all laparoscopic resection rectopexies for rectal prolapse II° or III° were selected from a prospective laparoscopic colorectal surgery database. We analyzed demographic, perioperative, and follow-up results. We defined two periods (1993–2000 and 2001–2008) for comparison of data. Long-term follow-up was obtained by sending questionnaires to all patients. Evaluation included constipation, incontinence, and recurrence of prolapse.
Results
Between January 1993 and November 2008, we performed 152 laparoscopic resection rectopexies for rectal prolapse. Median age was 64.1 years (±14.6). Conversion rate was 0.7% (1), mean operation time was 204 (±65.3) min, and was significantly shorter in the second period compared with the first (
P
< 0.0001). Mortality was 0.7% (
n
= 1). Complication rates were 4% (
n
= 6; major) and 19.2% (
n
= 29; minor), respectively. Mean length of hospital stay was 11.3 (±6.4) days and was significantly shorter in the second period compared with the first period (
P
< 0.0001). Mean time of follow-up was 47.7 (±41.6) months. Improvement or complete elimination of constipation was stated by 81.3% (65), and improvement or elimination of incontinence was stated by 67.3% (72). Overall recurrence rate was 11.1% (
n
= 10) with a rate of 5.6% (
n
= 5) for a 5-year period. Of those patients with previous perineal surgery for rectal prolapse, 53.8% (7/13) experienced recurrent prolapse after laparoscopic resection rectopexy in contrast to 3.9% (3/77) of patients without previous perineal prolapse surgery (
P
< 0.0001).
Conclusions
Our data support the benefits of laparoscopic resection rectopexy for rectal prolapse regarding both perioperative results and long-term functional outcome. Preceding perineal or open abdominal operations have an impact on recurrence after laparoscopic resection rectopexy.
Clinical studies have shown that probiotics influence gastrointestinal motility, e.g. Escherichia coli Nissle 1917 (EcN) (Mutaflor®) proved to be at least as efficacious as lactulose and more potent ...than placebo in constipated patients. As the underlying mechanisms are not clarified, the effects of EcN culture supernatants on human colonic motility were assessed in vitro. Human colonic circular smooth muscle strips (n = 94, 17 patients) were isometrically examined in an organ bath and exposed to different concentrations of EcN supernatants. Contractility responses were recorded under (i) native conditions, (ii) electrical field stimulation (EFS), (iii) non‐adrenergic non‐cholinergic conditions, and (iv) enteric nerve blockade by tetrodotoxin (TTX). As concentrations of acetic acid were increased in EcN supernatants, contractility responses to acetic acid were additionally tested. EcN supernatants significantly increased the maximal tension forces both at low and high concentrations. Neither blockade of both adrenergic and cholinergic nerves nor application of TTX abolished these effects. EFS‐induced contractility responses were not altered after exposure to EcN supernatants. Acetic acid elicited effects comparable to EcN supernatants only under TTX conditions. EcN supernatants modulate in vitro contractility of the human colon. As neither partial nor TTX blockade of enteric nerves abolished these effects, EcN supernatants appear to enhance colonic contractility by direct stimulation of smooth muscle cells. Active metabolites may include other substances than acetic acid, as acetic acid only partially resembled the effects elicited by EcN supernatants. The data provide a rationale for therapeutical application of probiotics in gastrointestinal motility disorders.
Background and Aims:
Esophageal perforation is a life-threatening disease. Factors impacting morbidity and mortality include the cause and site of the perforation, the time to diagnosis, and the ...therapeutic procedure. This study aimed to identify risk factors for morbidity and mortality after esophageal perforation.
Patients and Methods:
This retrospective study analyzed data collected from all patients treated for esophageal perforation at the Department of Surgery, University of Schleswig–Holstein, Luebeck Campus, from January 1986 through December 2011.
Results:
Altogether, 80 patients (52 men, 28 women; mean age 65 years) were treated. The cause of perforation was intraluminal in 44 (55%) (group A) and extraluminal in 2 (3%) (group B). Spontaneous perforations were observed in 12 (15%) (group C). Perforations were due to a preexisting esophageal disease in 22 (28%) (group D). The survival rate was higher for group A (82%) than for groups B (50%), C (57%), and D (59%). The distal third of the esophagus had the highest prevalence of perforations (49, 61%) independent of the cause. Mortality, however, was independent of the perforation site. Perforations were diagnosed within 24 h in 57% (n = 46) of patients, associated with a statistically significant lower mortality rate (p = 0.035). Altogether, 40 patients underwent non-operative treatment, and among those 27 had endoscopic treatment. Emergency thoracic surgery was performed in 40 patients: direct suture of the defect (n = 26), partial esophageal resection (n = 11), other (n = 3). Significantly higher morbidity (p = 0.007) and prolonged hospitalization (p < 0.0001) was observed among patients who underwent emergency surgery. Mortality was higher in the surgical group (14/40) than in the non-operative treatment group (9/40) but without statistical significance.
Conclusion:
Intraluminal perforations, rapid initiation of therapy, and non-operative treatment were associated with favorable outcomes. The perforation site did not have an impact on outcomes. Esophageal resection was associated with high mortality.
Purpose
Laparoscopy for colorectal cancer resection bares early post-operative advantages and results in equal oncologic long-term outcome. However, data on laparoscopic right hemi-colectomy is ...scarce. Aim of the present study was to analyze a well selected collective of patients with right-sided colon cancer treated open and laparoscopically with regard to peri-operative and long-term outcome.
Methods
We analyzed all patients who underwent right-sided hemi-colectomy for colon cancer between January 1996 and March 2013. Data was extracted from our prospective database. Inclusion criteria were tumor localization in the ascending colon, oncologic resection, histology of an adenocarcinoma, tumors UICC I–III, and R0 resection. Exclusion criteria were multiple malignancies including colon, emergency operation, adenoma or pT0 status, and UICC IV. For the matched pairs approach between patients undergoing laparoscopic (LAP) or open (OPEN) surgery, the parameters age, UICC stage, tumor grading, and sex were applied.
Results
A total of 188 patients was included in the analysis with
n
= 94 in both the LAP and the OPEN group. Some peri-operative results demonstrated advantages for laparoscopy including median return to liquid (
p
< 0.0001) and solid diet (
p
= 0.008), median length of ICU stay (
p
< 0.0001), and median length of hospital stay (
p
= 0.022). No significant differences were revealed for complication rates, rates of anastomotic leakage, or 30-day mortality. Lymph node yield was identical. Also, no differences in oncologic long-term outcome were detected. Rates for local recurrence were 4.3 and 2.0 %.
Conclusion
This matched pairs analysis verifies peri-operative advantages of laparoscopy explicitly for the sub-group of CRC patients undergoing right-sided hemi-colectomy in comparison to open surgery while demonstrating equivalent oncologic long-term results.
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