Complications after end-to-end vs. side-to-side anastomosis in ileocecal Crohn's disease--early postoperative results from a randomized controlled multi-center trial (ISRCTN-45665492).

BACKGROUND: Recurrent Crohn's disease activity at the site of anastomosis after ileocecal resection is of great surgical importance. This prospective randomized multi-center trial with an estimated case number of 224 patients was initially planned to investigate whether stapled side-to-side anastomosis, compared to hand-sewn end-to-end anastomosis, results in a decreased recurrence of Crohn's disease following ileocolic resection (primary endpoint). The secondary endpoint was to focus on the early postoperative results comparing both surgical methods. The study was terminated early due to insufficient patient recruitment and because another large study investigated the same question, while our trial was ongoing. METHODS AND STUDY DESIGN: Patients with stenosing ileitis terminalis in Crohn's disease who underwent an ileocolic resection were randomized to side-to-side or end-to-end anastomosis. Due to its early discontinuation, our study only investigated the secondary endpoints, the early postoperative results (complications: bleeding, wound infection, anastomotic leakage, first postoperative stool, duration of hospital stay). RESULTS: From February 2006 until June 2010, 67 patients were enrolled in nine participating centers. The two treatment groups were comparable to their demographic and pre-operative data. BMI and Crohn's Disease Activity Index were 22.2 (± 4.47) and 200.5 (± 73.66), respectively, in the side-to-side group compared with 23.3 (± 4.99) and 219.6 (± 89.03) in the end-to-end group. The duration of surgery was 126.7 (± 42.8) min in the side-to-side anastomosis group and 137.4 (± 51.9) min in the end-to-end anastomosis group. Two patients in the end-to-end anastomosis group developed an anastomotic leakage (6.5%). Impaired wound healing was found in 13.9% of the side-to-side anastomosis group, while 6.5% of the end-to-end anastomosis group developed this complication. The duration of hospital stay was comparable in both groups with 9.9 (± 3.93) and 10.4 (± 3.26) days, respectively. CONCLUSIONS: Because of the early discontinuation of the study, it is not possible to provide a statement about the perianastomotic recurrence rates regarding the primary endpoint. With regard to the early postoperative outcome, we observed no difference between the two types of anastomosis.

Single institution's experience in laparoscopic appendectomy as a suitable therapy for complicated appendicitis.

PURPOSE: Although laparoscopic appendectomy (LA) for acute appendicitis (AA) is widely performed, the value of LA for the treatment of complicated appendicitis (CA) is still controversially discussed. METHODS: In a retrospective study, we analyzed the clinical records of 404 patients who underwent LA or conversion (intention-to-treat group) or open appendectomy (OA) for AA or CA at the Alfried Krupp Hospital Essen-Rüttenscheid, Germany between January 2007 and December 2010. RESULTS: AA was treated in 64.2 % by LA and in 35.8 % by OA; the LA-to-OA conversion rate amounts to 3.7 %. CA was treated in 56 % by LA and in 44 % by OA. The LA-to-OA conversion rate here is 13.1 %, and compared to AA, it is significantly (P < 0.01) higher. Comparing LA with OA in both patient groups, we find no significant difference in the overall complication rate, the rate of postoperative intraabdominal abscesses and postoperative ileus. However, in both patient groups, the wound infection rate was significantly lower in patients who had undergone LA (AA P < 0.05 versus CA P < 0.01). In contrast to patients suffering from AA, patients with CA needed significantly less resurgery when treated by LA as compared to OA (P < 0.001). While the duration of surgery for the treatment of AA and CA was similar, the hospitalization time was significantly shorter with LA than with OA (AA P < 0.05 versus CA P < 0.001). CONCLUSIONS: The data suggest that LA is advantageous not only in the treatment of AA, but also in the therapy of CA. Thus, LA may become a proper and safe routine method if performed by an experienced surgeon.

Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group.

PURPOSE: Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year. MATERIALS AND METHODS: The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement). RESULTS: Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy. CONCLUSION: The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.

Current practice patterns in pancreatic surgery: results of a multi-institutional analysis of seven large surgical departments in Germany with 1454 pancreatic head resections, 1999 to 2004 (German Advanced Surgical Treatment study group).

Despite decreasing mortality rates, morbidity is still high after pancreatic head resection. Comparative data in the United States and Europe show a relationship between hospital volume and mortality. Treatment strategies vary frequently, partially because of the lack of evidence-based data. We performed a multi-institutional analysis in Germany evaluating current numbers, indications, techniques, and complication rates of pancreatic head resection. Questionnaires were completed by seven high-volume surgical departments regarding quantitative and qualitative aspects of pancreatic head resections in the period from 1999 to 2004 (five prospective and two retrospective institutional databases). A total of 1454 pancreatic head resections (944 for malignancy) were reported. Mean annual hospital volume ranged from 14 to 52 (10 to 43 in malignancy). Mortality was between 1.1% and 4.8%, morbidity was between 24% and 46%, and pancreatic leakage was between 9% and 20%. In malignant disease, all centers perform standard lymphadenectomy and regard arterial infiltration as a contraindication for resection. However, the rate of portal vein resection varied from 0% to 28%. No consensus is seen on the type of surgery for malignancy and chronic pancreatitis. After resection for pancreatic cancer less than one fourth of the patients receive adjuvant therapy. The results of our analysis in Germany confirm that pancreatic head resection can be performed with low mortality in specialized units. Variations in indications, operative technique, and perioperative care may demonstrate the lack of evidence-based data and/or personal and institutional experience. The low number of patients receiving adjuvant therapy after resection of pancreatic cancer suggests that more efforts must be made to establish novel adjuvant therapies under randomized study conditions.

Comparing paper-based with electronic patient records: lessons learned during a study on diagnosis and procedure codes.

Paper-based and electronic patient records generally are used in parallel to support different tasks. Many studies comparing their quality do not report sufficiently on the methods used. Few studies refer to the patient. Instead, most regard the paper record as the gold standard. Focusing on quality criteria, the current study compared the two records patient by patient, presuming that each might hold unique advantages. For surgical patients at a nonuniversity hospital, diagnosis and procedure codes from the hospital's electronic patient record (EPR set) were compared with the paper records (PPR set). Diagnosis coding from the paper-based patient record resulted in minor qualitative advantages. The EPR documentation showed potential advantages in both quality and quantity of procedure coding. As in many previous studies, the current study relied on a single individual to extract and transform contents from the paper record to compare PPR with EPR. The exploratory study, although limited, supports previous views of the complementary nature of paper and electronic records. The lessons learned from this study are that medical professionals should be cognizant of the possible discrepancies between paper and electronic information and look toward combining information from both records whenever appropriate. The inadequate methodology (transformations done by a single individual) used in the authors' study is typical of other studies in the field. The limited generalizability and restricted reproducibility of this commonly used approach emphasize the need to improve methods for comparing paper-based with electronic versions of a patient's chart.

Amplification of a Streptomyces lividans 4.3 kb DNA element causes overproduction of a novel hypha- and vesicle-associated protein.

The wild-type Streptomyces lividans 66 genome contains a 4.3 kb amplifiable DNA unit (AUD), and its four ORFs encode proteins that could not be identified by sequence comparison with databases. One of the gene products (encoded by orf-2) was purified and determined to be a novel 23 kDa protein. This protein is synthesized by the wild-type strain, absent in a variant lacking the AUD and overproduced in a variant in which the AUD is amplified (ADS). Immunological studies and analyses by confocal laser microscopy showed that the 23 kDa protein is associated with the substrate hyphae of the wild-type and the ADS-containing variant. Examination by microscopy revealed that the strain carrying the ADS forms bulges within the substrate hyphae and apical vesicles. These bulges have high levels of associated 23 kDa protein and contain storage-like material.