Diverticulitis patient care during the Covid-19 pandemic in Germany-a retrospective nationwide population-based cohort study.

PURPOSE: Coronavirus disease 2019 (COVID-19) impacted health care systems around the world. Despite a decrease in emergency admissions, an increased number of complicated forms of diverticulitis was reported. It was the aim of this study to analyze the pandemic impact on diverticulitis management in Germany. METHODS: This is a retrospective population-wide analysis of hospital billing data (2012-2021) of diverticulitis in Germany. Patients were identified based on diagnosis (ICD10) and procedural codes to stratify by conservative and operative management. Primary outcome of interest was admission rates, secondary outcomes were rates of surgical vs conservative treatment and fraction of complicated clinical courses during the pandemic. RESULTS: Of a total of 991,579 cases, 66,424 (6.7%) were admitted during pandemic lockdowns. Conservative treatment was the most common overall (66.9%) and higher during lockdowns (70.7%). Overall admissions and population adjusted rates of surgically treated patients decreased, the latter by 12.7% and 11.3%, corrected to estimated rates, in the two lockdowns. Surgery after emergency presentation decreased by 7.1% (p=0.053) and 11.1% (p=0.002) in the two lockdowns with a higher rate of ostomy and/or revision (+5.6%, p=0.219, and +10.2%, p=0.030). In-hospital mortality was increased in lockdown periods (1.64% vs 1.49%). In detail, mortality was identical in case of conservative treatment during lockdown periods (0.5%) but was higher in surgically treated patients (4.4% vs 3.6%). CONCLUSION: During lockdowns, there was an overall decrease of admissions for diverticulitis, especially non-emergency admissions in Germany, and treatment was more likely to be conservative. In case of surgery, however, there was increased risk of a complicated course (ostomy, re-surgery), possibly due to patient selection.

Effect of Pre-Transplant Recipient Underweight on the Postoperative Outcome and Graft Survival in Primary Kidney Transplantation.

BACKGROUND: The objective of this study was to evaluate the influence of recipient underweight on the short- and long-term outcomes of patients undergoing primary kidney transplantation (KT). PATIENTS AND METHODS: Three hundred thirty-three patients receiving primary KT in our department between 1993 and 2017 were included in the study. Patients were divided according to their body mass index (BMI) into underweight (BMI <18.5 kg/m2; N = 29) and normal weight (BMI 18.5-24.9 kg/m2; N = 304) groups. Clinicopathological characteristics, postoperative outcomes, and graft and patient survival were analyzed retrospectively. RESULTS: The postoperative rate of surgical complications and renal function were comparable between the groups. One year and 3 years after KT, 70% and 92.9%, respectively, of the pre-transplant underweight patients reached a normal BMI (≥18.5 kg/m2). The mean death-censored graft survival was significantly lower in pre-transplant underweight patients than in pre-transplant normal-weight patients (11.5 ± 1.6 years vs 16.3 ± 0.6 years, respectively; P = .045). Especially KT recipients with a moderate or severe pre-transplant underweight (BMI <17 kg/m2; N = 8) showed an increased rate of graft loss (5- and 10-year graft survival: 21.4% each). No statistical difference could be observed between the 2 groups regarding causes of graft loss. In multivariate analysis, recipient underweight (P = .024) remained an independent prognostic factor for graft survival. CONCLUSION: Being underweight did not affect the early postoperative outcome after primary KT. However, underweight, and especially moderate and severe thinness, is associated with reduced long-term kidney graft survival, and therefore this group of patients should be monitored with special attention.

Robotic assisted nephrectomy for living kidney donation (RANLD) with use of multiple locking clips or ligatures for renal vascular closure.

BACKGROUND: Robotic assisted nephrectomy for living donation (RANLD) is a rapid emerging surgical technique competing for supremacy with totally laparoscopic and laparoscopic hand assisted techniques. Opinions about the safety of specific techniques of vascular closure in minimally invasive living kidney donation are heterogeneous and may be different for laparoscopic and robotic assisted surgical techniques. METHODS: We retrospectively analyzed perioperative and short-term outcomes of our first (n=40) RANLD performed with the da Vinci Si surgical platform. Vascular closure of renal vessels was performed by either double clipping or a combination of clips and non-transfixing suture ligatures. RESULTS: RANLD almost quintupled in our center for the observed time period. A total of n=21 (52.5%) left and n=19 (47.5%) right kidneys were procured. Renal vessel sealing with two locking clips was performed in 18 cases (45%) Both, clips and non-transfixing ligatures were used in 22 cases (55%). Mean donor age was 53.075±11.68 years (range, 28-70). The average total operative time was 150.75±27.30 min. Right donor nephrectomy (139±22 min) was performed significantly faster than left (160.95±27.93 min, P=0.01). Warm ischemia time was similar for both vascular sealing techniques and did not differ between left and right nephrectomies. No conversion was necessary. Clavien-Dindo Grade ≤IIIb complications occurred in (n=5) 12.5%. Grade IV and V complications did not develop. In particular no hemorrhage occurred using multiple locking clips or suture ligatures for renal vascular closure. Mortality was 0%. Thirteen kidneys (32.5%) were transplanted across the AB0 barrier. CONCLUSIONS: RANLD is an emerging minimally invasive surgical technique which facilitates excellent perioperative and short-term outcomes also when using multiple locking clips or suture ligatures for renal vascular closure.

Short and long-term metabolic outcomes in patients with type 1 and type 2 diabetes receiving a simultaneous pancreas kidney allograft.

BACKGROUND: In contrast to insulin-dependent type 1 diabetes mellitus (T1DM), the indication for Simultaneous pancreas-kidney transplantation (SPK) in patients with type 2 diabetes mellitus (T2DM) is still ambiguous and wisely Eurotransplant (ET) only granted transplant-permission in a selected group of patients. However, with regard to improvement of metabolic conditions SPK might still be a considerable treatment option for lean insulin dependent type 2 diabetics suffering from renal disease. METHODS: Medical data (2001-2013) from all consecutive T1DM and T2DM patients who received a SPK or kidney transplant alone (KTA) at the University Hospital of Leipzig were analyzed. Donor, recipients and long-term endocrine, metabolic and graft outcomes were investigated for T1DM and T2DM-SPK recipients (transplanted upon a special request allocation by ET) and T2DM patients who received a KTA during the same period. RESULTS: Eighty nine T1DM and 12 T2DM patients received a SPK and 26 T2DM patients received a KTA. Patient survival at 1 and 5 years was 89.9 and 88.8% for the T1DM group, 91.7 and 83.3% for the T2DM group, and 92.3 and 69.2% for the T2DM KTA group, respectively (p < 0.01). Actuarial pancreas graft survival for SPK recipients at 1 and 5 years was 83.1 and 78.7% for the T1DM group and 91.7 and 83.3% for the T2DM group, respectively (p = 0.71). Kidney allograft survival at 5 years was 79.8% for T1DM, 83.3% for T2DM, and 65.4% for T2DM KTA (p < 0.01). Delayed graft function (DGF) rate was significantly higher in type 2 diabetics received a KTA. Surgical, immunological and infectious complications showed similar results for T1DM and T2DM recipients after SPK transplant and KTA, respectively. With regard to the lipid profile, the mean high-density lipoprotein (HDL)- cholesterol levels were significantly higher in T1DM recipients compared to T2DM patients before transplantation (p = 0.02) and remained significantly during follow up period. CONCLUSION: Our data demonstrate that with regard to metabolic function a selected group of patients with T2DM benefit from SPK transplantation. Consensus guidelines and further studies for SPK transplant indications in T2DM patients are still warranted.

Hyperspectral Imaging (HSI) in anatomic left liver resection.

INTRODUCTION: Anatomic liver resection is based on the description of functional segments, which rely on the organs arterial and portal venous blood supply. Vascular inflow control of the left liver is performed by occlusion of the left hepatic artery (LHA) and left portal vein (LPV). Depending on the quality of the parenchyma a sharp demarcation line (Cantlie Line) between segments IV and V/VIII can hence be detected. MATERIAL AND METHODS: TIVITA® is a novel contact free tool which facilitates non-invasive hyperspectral imaging (HSI) and near infrared spectroscopy (NIRS) for the assessment of tissue- oxygenation (StO2) and perfusion (NIR Perfusion). We hypothesized that this imaging modality might be practicable to identify the future resection plane after left vascular inflow occlusion in anatomic liver resection. PRESENTATION OF CASE: TIVITA ® is a viable tool for the identification of segments with reduced StO2 (inflow occlusion: 0.23 ±â€¯0.03 vs normal: 0.50 ±â€¯0.06) and NIR Perfusion (inflow occlusion: 0.02 ±â€¯0.04 vs normal: 0.47 ±â€¯0.06) and allows for a visual differentiation of well oxygenated, perfused (green) and low oxygenated, poorly perfused (blue) liver tissue in a patient undergoing left hemihepatectomy for hepatocellular carcinoma. CONCLUSION: Hyperspectral Imaging is an emerging optical technique with the potential to identify exact resection planes for anatomic liver resection based on the optically determined perfusion and oxygenation status of liver segments lined up for resection. This novel Hyperspectral Demarcation Technique (HSI DT) is non- contact, non-ionizing and non-invasive.

A new small animal model for simulating a two-stage-revision procedure in implant-related methicillin-resistant Staphylococcus aureus bone infection.

BACKGROUND: Implant-related bone infections with methicillin-resistant Staphylococcus aureus (MRSA) remain a challenge for orthopedic surgeons. This devasting complication may lead to functional impairment and loss of the affected limbs. High failure rates in treatment make improvement of surgical treatment necessary. Beside an already established demanding and costly large animal model, a small animal model of a two-stage revision does not exist, yet. Thus, the purpose of this study was to establish a preclinical small animal model to simulate a two-stage revision in implant-related MRSA infection. MATERIALS AND METHODS: In twelve rabbits Steel K-wires were implanted into the intramedullary canal of the left tibia, followed by inoculation with MRSA. Two different clinical isolates of MRSA-strains were used in two different concentrations (CFUs; 105 and 107 colony forming units (CFUs). This led to four groups of three rabbits each. Eleven rabbits survived the whole study period. After four weeks the inoculated K-wires were removed and replaced with vancomycin loaded PMMA-spacers (stage 1). Twenty-eight days later new K-wire implants were placed intramedullary (stage 2). After 84 days all animals were sacrificed. Tibiae were analyzed microbiologically, radiologically and histologically. RESULTS: In every rabbit K-wire associated infection could be established within the first four weeks. After irrigation and debridement at revision one (stage 1), infection could be eradicated in 67% of group I, in 50% of group II and in 33% of group III and IV. Recurrence of the infection could be determined in all animals of group I and IV at day 84. X-ray analysis and histology both demonstrated clear signs of osteomyelitis after twelve weeks. Survival, clinical observations and weight assessment confirmed the ethical justifiable stress of the animals during the experiment. CONCLUSION: The presented small animal model of a two-stage revision in implant-related infection is a promising preclinical set-up for assessment of new treatment strategies of implant-related infections. Both high survival as well as reinfection rates were possible by simulating the clinical gold standard of two-stage revision surgery in an MRSA implant-related infection model. Therefore, the model can be deemed suitable for further preclinical in vivo testing.