[Impact of bowel preparation on surgical site infections and anastomotic leakage after elective colon resection: results of a retrospective study with 260 patients]. / Einfluss der Darmvorbereitung auf Wundinfektionen und Anastomoseninsuffizienzen bei elektiven Kolonresektionen: Ergebnisse einer retrospektiven Studie mit 260 Patienten.

BACKGROUND: Bowel preparation is performed in different ways prior to elective colon surgery. The aim of this study was to evaluate the influence of different bowel preparations on surgical site infections, anastomotic leakage and postoperative ileus in elective colon surgery. MATERIAL AND METHODS: A retrospective analysis was performed in this institution with patients who underwent elective colon surgery from 2013-2019. Patients received different types of bowel preparation and were divided into three different groups: no mechanical bowel preparation (MBP-), mechanical bowel preparation without oral antibiotics (MBP+/OABP-) and with oral antibiotics (MBP+/OABP+). These groups were compared with respect to surgical site infections, anastomotic leakage, and the duration of postoperative ileus. RESULTS: A total of 260 consecutive patients (MBP- n = 48, MBP+/OABP- n = 145 and MBP+/OABP+ n = 67) were analyzed. With a combined bowel preparation, the rate of surgical site infections could be considerably reduced (MBP- vs. MBP+/OABP+ 16.7% vs. 4.5%, p = 0.05). The type of bowel preparation was identified as the only factor associated with the incidence of surgical site infections; however, the type of bowel preparation did not have an influence on the rate of anastomotic leakages or duration of postoperative ileus in univariate and multivariate analyses. CONCLUSION: Bowel preparation with mechanical cleansing and oral antibiotics (MBP+/OABP+) is beneficial due to a significant reduction of surgical site infections.

Retrospective single center analysis of outcome, risk factors and therapy in steroid refractory graft-versus-host disease after allogeneic hematopoietic cell transplantation.

Acute and chronic graft-vs.-host disease (aGvHD and cGvHD) are major complications after allogeneic hematopoietic cell transplantation (HCT) leading to substantial morbidity and mortality. This retrospective single-center study analyzes incidence, therapy, and outcome of GvHD in n = 721 patients ≥18 years having received allogeneic HCT 2004-2013 with a special focus on steroid refractory GvHD. Acute (n = 355/49.2%) and chronic (n = 269/37.3%) GvHD were mainly treated by steroids in first-line therapy. The proportion of steroid refractory aGvHD and cGvHD was 35.7% and 31.4%, respectively. As there is no standard therapy for steroid refractory GvHD, a range of different agents was used. In aGvHD, the overall response rate (ORR) of steroid refractory GvHD to second-line treatment was 27.4%. Mycophenolate mofetil (MMF) and mTOR inhibitors led to superior response rates (ORR 50.0% and 53.3%, respectively). In steroid refractory cGvHD therapy, ORR was 44.4%. Use of calcineurin inhibitors (CNI; n = 11/45.5%), MMF (n = 18/50.0%), mTOR inhibitors (n = 10/60.0%), and extracorporeal photophoresis (ECP; n = 16/56.3%) showed ORR above average. Targeted therapies lead to responses in 7.7% (n = 13). This data may help to improve the design of future prospective clinical studies in GvHD.

[Surgical Training in Germany: Desire and Reality]. / Chirurgische Weiterbildung an deutschen Kliniken - Wunsch und Realität.

BACKGROUND: In-house surgical education and practical training of surgical skills are inhomogeneous in German hospitals and vary greatly in terms of teaching content and forms. The present survey provides an overview of the currently practiced surgical education and practical training of surgical skills in German hospitals. MATERIAL AND METHODS: An online survey was performed among members of the "Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie" (DGAV). It was a prospective data collection, divided into the following two groups: "junior physicians/consultants/senior physicians" and "chief physicians". The questionnaire consisted of 30 questions concerning the frequency, type and quality of in-house surgical education and practical training of surgical skills in German hospitals. RESULTS: A total of 325 physicians participated in the survey, including 61 chief physicians and 264 junior physicians/consultants/senior physicians. Amongst the participants, 107 (33 %) worked in university hospitals, 57 (18 %) in maximum care clinics, 73 (22 %) in major regional hospitals with specialised medical services and 88 (27 %) in basic care facilities. 199 (75.4 %) of the junior physicians/consultants/senior physicians reported a regular, 57 (21.6 %) an irregular and 8 (3.0 %) no formal surgical education or practical training of surgical skills in their hospitals. Assistance in substeps of an operation was considered to be very important by 72 % of the survey participants. Similarly, 71 % rated the practical teaching of basic surgical skills as very important. Furthermore, we investigated the availability of theoretical and practical training offerings as well as satisfaction with educational measures and their importance as assessed by the respondents. SUMMARY: The present survey illustrates the current state of surgical education and training in German hospitals. An implementation of pragmatic approaches such as the assistance in substeps of an operation and guided practical training of surgical skills might help to improve the satisfaction of physicians undergoing surgical training.

Pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) with a new elongated, curved Transanal Endoscopic Operation (TEO) device for rectosigmoid resection: a survival study in a porcine model.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) has seen considerable new developments in its evolution to a platform for rectal and sigmoid resection, but to date no true single NOTES procedure has been convincing. This study investigates the safety and feasibility of a further developed transanal NOTES platform for single-access NOTES rectosigmoid resection. METHODS: Ten large female pigs, mean weight 99.3 kg [standard deviation (SD) 7 kg, range 85.1-112.6 kg], underwent transanal rectosigmoid resection. Five animals were included in an acute study group with immediate postoperative euthanization. A second group included five animals in a survival study. Transanal rectosigmoid resections were performed with an elongated and curved transanal endoscopic operation (TEO) device. Coloanal anastomosis was performed using the transanal circular stapler technique. Survival follow-up was at 7 and 28 days via colonoscopy under sedation. RESULTS: Single-access NOTES transanal rectosigmoid resection with coloanal anastomosis was performed in nine out of ten female pigs. Mean length of rectosigmoid specimens exteriorized was 18.7 cm (SD 2.9 cm, range 14-23 cm). Mean operating time was 124 min (SD 35.7 min, range 70-166 min). Within the survival group, no complications occurred during the monitoring phase. In one case, there was ascites and colitis at necropsy as well as fibrosis at the anastomosis site. CONCLUSIONS: Pure transanal rectosigmoid resection is a feasible procedure. The approach via a single transanal access is demanding but viable with the elongated and curved TEO device. The newly developed scope offers an excellent view of the area cephalad to the promontory.

[Laparoscopic Resection Rectopexy for the Treatment of External Rectal Prolapse]. / Die laparoskopische Resektionsrektopexie zur Behandlung des externen Rektumprolapses.

Laparoscopic resection rectopexy is one of the surgical options for the treatment of external rectal prolapse. A standardised and reproducible procedure for this operation is a decisive advantage for such cases. The operation can be divided in 11 substeps, so-called nodal points, which must be reached before further progress can be made and simplify the operation by dividing the procedure into substeps. This manuscript and the accompanying film demonstrate the standardised laparoscopic resection rectopexy as taught in the "Surgical Training Center Tübingen," and performed at the University Hospital of Tübingen.

Use of self-retaining barbed suture for rectal wall closure in transanal endoscopic microsurgery.

BACKGROUND: The aim of this study was to investigate the safety and efficacy of self-retaining barbed sutures in comparison with monofilament clip-fixated sutures for rectal wall closure in transanal endoscopic microsurgery. METHODS: Horizontal full-thickness wall defects (3.5 cm) of cattle rectal specimens were closed via transanal endoscopic microsurgery using a monofilament suture with clips at the end (Surgipro(®) 2/0; Covidien, Mansfield, MA, USA, n = 25) or a self-retaining barbed suture (V-Loc™ 180 3/0; Covidien, Mansfield, MA, USA, n = 25). The primary endpoint was the pneumatic leakage pressure of the suture line. As a secondary endpoint, suture time was evaluated. RESULTS: The median pneumatic leakage pressure for barbed sutures was 45.5 mbar (range 17-106 mbar) and 33.5 mbar (range 19-106 mbar) for monofilament sutures (p = 0.58). A pneumatic leak at a critical pressure below 25 mbar occurred in 3 cases with barbed sutures and in 7 cases with monofilament sutures (p = 0.29). Median suturing time [19:25 min:s (range 12:00-33:30) vs. 20:41 (17:00-28:33), p = 0.23] did not differ between the two groups. CONCLUSIONS: Barbed sutures display the same bursting pressure as monofilament sutures and their use for rectal wall closure seems feasible.

[Laparoscopic cholecystectomy as standardised teaching operation to treat symptomatic cholecystolithiasis]. / Die laparoskopische Cholezystektomie als standardisierter Lehreingriff zur Behandlung der symptomatischen Cholezystolithiasis.

Currently laparoscopic cholecystectomy is the gold standard of therapy for diseases related with gallstones, namely symptomatic cholecystolithiasis, acute and chronic cholecystitis and also as therapy for gallbladder adenoids. Together with laparoscopic appendectomy, this procedure often is one of the first laparoscopic operations performed by new interns. Therefore a standardised, reproducible approach to ensure the patient safety is necessary. The procedure can be subdivided into 10 substeps--so-called "nodal points"--which must be completed before the next substep can be started. This article and the attached video show the ten "nodal points" of a standardised laparoscopic cholecystectomy.

[3D in laparoscopy: state of the art]. / 3-D in der Laparoskopie: Stand der Technik.

High definition stereoscopic (3D) vision has been introduced into the operation theatre. This review exposes the optical and physiological background as well as the state of the art of 3D in laparoscopy. The distinguishing marks of 3D laparoscopes and monitors are listed and characteristics of stereoscopy, such as comfort zones and ghosting are explained. Suggestions for the practical use in the clinical routine should help to extract the best benefit possible from the new technology.

Evidence for a multivalent interaction of symmetrical, N-linked, lidocaine dimers with voltage-gated Na+ channels.

The interaction of symmetrical lidocaine dimers with voltage-gated Na+ channels (VGSCs) was examined using a FLIPR membrane potential assay and voltage-clamp. The dimers, in which the tertiary amines of the lidocaine moieties are linked by an alkylene chain (two to six methylene units), inhibited VGSC activator-evoked depolarization of cells heterologously-expressing rat (r) Na(v)1.2a, human (h) Na(v)1.5, and rNa(v)1.8, with potencies 10- to 100-fold higher than lidocaine (compound 1). The rank order of potency (C4 (compound 4) > C3 (compound 3) > or = C2 (compound 2) = C5 (compound 5) = C6 (compound 6) >> compound 1) was similar at each VGSC. Compound 4 exhibited strong use-dependent inhibition of hNa(v)1.5 with pIC50 values < 4.5 and 6.0 for tonic and phasic block, respectively. Coincubation with local anesthetics but not tetrodotoxin attenuated compound 4-mediated inhibition of hNa(v)1.5. These data suggest that the compound 4 binding site(s) is identical, or allosterically coupled, to the local anesthetic receptor. The dissociation rate of the dimers from hNa(v)1.5 was dependent upon the linker length, with a rank order of compound 1 > compound 5 = compound 6 > compound 2 >> compound 3. The observation that both the potency and dissociation rate of the dimers was dependent upon linker length is consistent with a multivalent interaction at VGSCs. hNa(v)1.5 VGSCs did not recover from inhibition by compound 4. However, "chase" with free local anesthetic site inhibitors increased the rate of dissociation of compound 4. Together, these data support the hypothesis that compound 4 simultaneously occupies two binding sites on VGSCs, both of which can be bound by known local anesthetic site inhibitors.