Effects of methylene-blue staining on the extent of pilonidal sinus excision.

OBJECTIVE: We aimed to examine the effects of methylene-blue staining (MBS) on the volume of specimens after excision of pilonidal sinuses. METHOD: This was a retrospective analysis of 135 excised specimens after pilonidal sinus (PS) surgery. All patients underwent procedures at the Department of Surgery of University Hospital Jena between 2000 and 2010. All specimens were measured in three dimensions. To calculate the volumes of excised specimens, we used a model of a hemi-ellipsoid. Demographic information (age, height, weight, body mass index, smoking status) were also obtained for all patients. RESULTS: Excised specimens with MBS had significantly larger volumes (p<0.001) as reflected in length (p=0.001), width (p=0.001), and depth (p=0.017) of the excised specimen compared with specimens that were not stained with methylene blue (MB). In addition, the volume was larger in subjects with a recurrent PS (p=0.021), which was predominantly the case in female subjects (p=0.025). CONCLUSION: These data suggest that excised specimens with MBS had significantly larger volumes of the excised specimen compared with specimens that were not stained with MB. MBS of a fistula system could enable such a system to be marked sufficiently, thereby facilitating complete resection of a PS.

[Extended Pathohistological Criteria for Assessment of the Long-Term Prognosis of Gastric Cancer]. / Erweiterte pathohistologische Kriterien zur Bewertung der Langzeitprognose des Magenkarzinoms.

BACKGROUND: Gastric cancer is one of the most frequent tumour diseases worldwide. Despite numerous innovations in the diagnostic procedures and treatment the prognosis remains poor as the detection of the disease depends on tumour-associated symptoms which develop rather late in the majority of cases. The treatment outcomes may be improved by a more differentiated and individualised evaluation of the tumour biology. We present a detailed analysis of potentially relevant factors. MATERIAL AND METHODS: From 1995 to 2011, data from 923 patients with gastric cancer have been collected in a prospective tumour database. We performed monovariate and multivariate analyses of factors. For the statistical analyses, SPSS software version 19.0 was used. The literature research was performed with Medline. RESULTS: 748 patients underwent surgical exploration. The resection rate was 87 % with a morbidity and mortality of 27 and 9 % (2004 to 2001: 13 and 5 %), respectively. 36 and 29 % of patients survived 5 years or 10 years, respectively. The 5-year and 10-year survival after curative resection was 58 and 46 %, respectively. TNM-associated criteria, tumour size, histological growth pattern, intestinal metaplasia, location of the tumour and classification according to Lauren were of significant influence in the monovariate analyses. In the multivariate analysis, tumour size, curative resection and lymph node involvement were independent prognostic factors. 90 % of the tumour recurrences developed within five years. The median recurrence-free interval was 16 months. Depending on the type of tumour, different survival times were identified. The 228 patients with node-negative curatively resected gastric cancer had a markedly better long-term prognosis. Diffuse type according to Lauren, tumour size, non-tubular histological growth pattern, female sex and proof of serosa infiltration from the primary tumour were prognostic factors in the monovariate analysis. In the multivariate analysis, tumour size was an independent significant prognostic factor (p = 0.05). CONCLUSION: The data analyses showed that the evaluation of gastric cancer may be extended in a sensitive way by factors that have not been previously established. The benefit of an individualised structured treatment and follow-up on the basis of extended criteria should be investigated in future studies.

[Management of complications in endoscopic interventions of the upper gastrointestinal tract]. / Management von Komplikationen bei endoskopischen Interventionen im oberen Gastrointestinaltrakt.

Endoscopic procedures are frequently performed interventions in the clinical routine. Whereas endoscopy was initially regarded as being a secondary diagnostic tool, over the last decades endoscopic procedures have now become an integral part of various treatment strategies. The appeal of these methods is without any doubt the minimally invasive approach in contrast to open surgery. Endoscopic interventions per se necessitate representative technical equipment and the various components are continually being refined. Considering the complexity of the method, profound skills in endoscopic diagnostic procedures and therapeutic interventions are essential prerequisites for adequate procedural quality and patient safety. Endoscopic examinations are in fact invasive interventions in the same way as surgical procedures and are associated with a certain risk of potential complications. The awareness about potential complications and their respective risk factors is of crucial importance for both the patient and the physician. Complications may harm patients and may lead to increased mortality rates; therefore, it is not only important to be aware of them but also to have an efficient management strategy in order to minimize the damage. Recognition and consistent actions are the basic pillars of correct complication management. These aspects are addressed in this article.

[Classic Limberg Flap Procedure for Treatment of a Sacrococcygeal Pilonidal Sinus Disease - Explanation of the Surgical Technique]. / Klassische Rautenplastik nach Limberg zur Behandlung einer sakrokokzygealen Pilonidalsinuserkrankung - Erklärung der OP-Technik.

INTRODUCTION: Sacrococcygeal pilonidal sinus disease is frequently encountered in surgical practice. Besides excision only, the current pilonidal sinus guideline of the Association of the Scientific Medical Societies in Germany (AWMF-S3) also recommends plastic surgical procedures such as the cleft-lift operation described by Bascom, the Karydakis flap procedure and, due to the low recurrence rates, the Limberg flap procedure, for the treatment of this disease. INDICATION: In our case we show the surgical procedure performed on a 23-year-old male patient, who was previously treated for an acute abscess-forming sacrococcygeal pilonidal sinus. METHOD: Our video shows the fasciocutaneous rhombic flap procedure described by Limberg step by step. CONCLUSION: The Limberg flap procedure is a simple operation for the treatment of sacrococcygeal pilonidal sinus disease.

[Assessment of bovine pericardium (tutomesh®) and coated polypropylene (proceed®) in the para-oesophageal position in a pig model]. / Untersuchung von bovinem Perikard (Tutomesh®) und beschichtetem Polypropylen (Proceed®) in paraösophagealer Position im Schweinemodell.

BACKGROUND: Hiatal hernias are nowadays increasingly treated with meshes. Often, biological implants are being used for this application. Oesophageal perforations have been reported as rare but serious complications from the application of synthetic meshes at the oesophageal hiatus. The role of the different mesh types has not been clearly established by experimental research so far. In the present large animal model, we investigated two implant types (Tutomesh® and Proceed®) with respect to their biocompatibility and mechanical stability. MATERIAL AND METHODS: We used 12 domestic pigs aged three months. Tutomesh® and Proceed® were implanted in 6 animals each for bridging at the oesophageal hiatus. After a follow-up of 3 months, the experiment was terminated. We performed endoscopy and intraoperative macroscopic evaluation of the situs. In representative histological sections, established histopathological and immunohistochemical parameters of biocompatibility were investigated and tensile strength testing was performed on standardised tissue samples. RESULTS: One animal of the Proceed® group had grade 2 oesophagitis. None of the animals had an oesophagus arrosion. The analysis of adhesions revealed slightly less adhesions in the Tutomesh® group. There was no significant difference with respect to the investigated inflammation response and immune response between both meshes. The most substantial finding of the mechanical analysis was a loss of tear strength of the Tutomesh®-tissue-complex of 30 % as compared to native tissue and more than 50 % compared to Tutomesh® prior to implantation, respectively. CONCLUSIONS: After 3 months, there was no significant difference between the two implant types with respect to the inflammatory response. The loss of tear strength of the Tutomesh®-tissue-complex at the oesophageal hiatus is probably clinically not relevant and may be explained by the so-called biological remodeling of biological materials. The remodeling depends on the extent of the cross-linking of the respective material. It is expected that biological hernia implants, such as Tutomesh®, may have a marked potential for avoiding complications at the oesophageal hiatus in the long run. This potential cannot be proven after 3 months from our data. Further experimental investigations are necessary to clarify this issue, in particular with respect to the long-term results.

[Sequential intervention with primary excision and Limberg plastic surgery procedure for treatment of sacrococcygeal pilonidal sinus : Results of a pilot study]. / Zweizeitiges Verfahren mit primärer Exzision und Limberg-Plastik zur Therapie eines sakrokokzygealen Pilonidalsinus : Ergebnisse einer Pilotstudie.

BACKGROUND: The current German S3 guidelines recommend radical excision for pilonidal sinus disease. Furthermore, the Karydakis operation and the plastic surgery procedure according to Limberg are also recommended. Contrary to the S2 guidelines of 2008, these two plastic surgery procedures for coverage are recommended for the treatment of the first-time manifestation of this disease. Most studies on the classical Limberg plastic surgical procedure are comparative in nature and describe a simultaneous intervention from which patients with an abscess are excluded. AIM: The aim of this present study was to analyze the results of a sequential procedure including primary excision followed by a Limberg plastic surgery procedure for the treatment of acute abscesses and chronic pilonidal sinus disease. MATERIAL AND METHODS: From July 2010 to June 2013 a total of 50 patients with pilonidal sinus disease were treated at the University Hospital Jena with an initial radical excision. In accordance with the Association of the Scientific Medical Societies in Germany (AWMF) guidelines which were valid during that time, patients were offered plastic surgery coverage for recurrence prophylaxis and in cases of recurrence a Limberg plastic surgery procedure was recommended. RESULTS: Of the 50 patients 22 opted for a Limberg plastic surgery procedure during the interval. The mean follow-up after the Limberg plastic surgery procedure was 20.1 months (range 2-36 months). During the follow-up period, there were no recurrences (0 %) but four major complications (18.2 %) and one minor complication (4.5 %) were observed. CONCLUSION: This concept can be applied in cases of acute abscess formation and in chronic pilonidal sinus disease. The patient's decision with respect to a Limberg plastic surgery procedure for recurrence prophylaxis does not have to be made immediately. In addition, the Limberg plastic surgery procedure is performed in an infection-free stage. The second inpatient stay, second surgical procedure and prolonged time off work are a disadvantage.

[Minimal access surgery: A survey among surgeons in Central Germany]. / "Minimal access surgery" : Ein Meinungsbild bei Chirurgen in Mitteldeutschland.

INTRODUCTION: A survey about perceptions concerning natural orifice transluminal endoscopic surgery (NOTES) and single port operations (SPO) was conducted among medical professionals at hospitals in Central Germany. The identity of the participants remained anonymous. The focus was on the subjective perception of medical colleagues and included a statement of preferred methods if the medical professional would need to undergo surgery. METHODS: Within a radius of 120 km of the city of Erfurt, all 150 surgical departments were approached and asked to complete a series of questionnaires containing general and personal questions. The analysis was performed according to the professional rank, age and sex of the participants. The questionnaires contained questions on patient preferences, cosmetic aspects and other factors, such as marketing, industry-driven, playful approach of the surgeon and appeal of a new procedure. RESULTS: In total 83 surgical departments participated in the survey resulting in 432 eligible questionnaires. Of the participants 29 % were female, the average age was 44 years, 20 % were heads of departments, 37 % senior surgeons, 20 % specialist surgeons and 23 % residents. The proportion of conventional minimally invasive surgical procedures was on average 30 % of all surgical interventions. Two hospitals offered transvaginal hybrid NOTES (cholecystectomy), 45 % performed SPOs, 36 % of the participants agreed strongly or moderately with the concept of SPO and 34 % rejected NOTES. The factors industry-driven, promotion/marketing and appeal of a new procedure were evaluated as very important or relatively important by the majority of the participants (> 70 %). When evaluating the factor playful approach of the surgeon, the proportion was 55 %. The factor patient preferences was evaluated as very high or high by 25% of the participants while it had no impact on 8 % or only a minor impact on 36 %. In case of undergoing surgery themselves, conventional laparoscopy would be preferred and NOTES was rated last among all options. CONCLUSION: The soft factors that were analyzed (i.e. marketing, industry-driven, playful approach of the surgeon and appeal of something new) were evaluated as much more important in the surgeons' opinion compared to patient criteria (i.e. patient preferences and cosmetic results). The soft factors are, however, not to be judged as generally negative as they are to a certain extent necessary (marketing), useful (impulses from industry) or are part of the surgical creativity (playfulness). The discrepancies in the medical professional evaluation of the different factors shows that the reasoning and the motivation of the actions are not necessarily identical.

[Preparation and in-vitro analysis of a polyethylenimine coating on hernia meshes]. / Herstellung und In-vitro-Analyse einer Polyethylenimin-Beschichtung auf Herniennetzen.

BACKGROUND: Certain coatings such as titanium may improve the biocompatibility of hernia meshes. The coating with biopolymers such as polyethylenimine (PEI) can also improve the material characteristics of implants. This approach has, however, not yet been explored. Thus, it was the aim of the present work to clarify if and how hernia meshes with their three-dimensional structure can be successfully coated with PEI and with which technique this coating can be best analysed. METHODS: Commercially available meshes made from polypropylene, polyester and ePTFE have been coated with PEI. The coating was analysed via cell proliferation test (mouse fibroblasts), electron microscopy, X-ray photoelectron spectroscopy (XPS) and fluorescence microscopy. Cell viability and cytotoxicity were tested by the MTT test. RESULTS: With the PEI surface modification, mouse fibroblasts grow faster and in greater numbers on the mesh surface. XPS as well as fluorescence microscopy show weaknesses in their applicability and meaningfulness because of the three-dimensional mesh structure while XPS showed overall better results. Optical proof in the electron microscope after cell fixation was not unambiguously accomplished with the techniques used here. In the MTT test, no cellular damage from the PEI coating was detected after 24 hours. CONCLUSION: The present results show for the first time that PEI coating of hernia meshes is possible and effective. The PEI coating can be achieved in a fast and cost-efficient way. Further investigations are necessary with respect to coating quality and cytotoxicity before such a coating may be used in the clinical routine. In conclusion, PEI is a promising polymer that warrants further research as a coating for medical implants.

[Incidence of non-metastatic liver lesions in tumor patients: consequences for chemotherapy and local ablative procedures]. / Inzidenz nichtmetastatischer Leberläsionen bei Tumorpatienten: Konsequenzen für Chemotherapie und lokal-ablative Verfahren.

INTRODUCTION: Even in patients with a history of solid malignant tumors, especially of gastrointestinal origin, newly diagnosed solid liver lesions do not necessarily correspond to metastases of the respective primary tumor. A reliable diagnosis can only be made by definitive histological examination. MATERIAL AND METHODS: Data of all patients who underwent liver resection under the preoperative diagnosis of liver metastases between 1997 and 2011 and for whom liver specimens were examined histologically, were extracted from the prospectively maintained cancer registry. RESULTS: An unexpected histological result occurred in 47 out of 770 patients (6.1 %). Primary tumors in these patients included renal cell (n=12), colorectal (n=11), breast (n=8), gastric (n=4), pancreatic (n=3), skin (n=3) and other cancers (n=6). Liver lesions were diagnosed synchronously in 15 cases or metachronously after a median of 17 months following primary therapy in 32 patients. Histology revealed a benign tumor in 38 cases (81 %) as well as 6 cases of HCC, 2 cases of CCC and in 1 case metastasis of a previously unknown colorectal cancer in a patient with known esophageal carcinoma. Suspicion of metastatic disease was based on four different imaging modalities in two cases and on three different imaging modalities in nine cases. Either computed tomography (CT) or magnetic resonance imaging (MRI) was combined with ultrasound in another 23 patients and with positron emission tomography (PET) CT in 6 more cases. In two patients CT plus MRI and CT only, respectively, was performed. In the remaining three patients, suspicion of metastases occurred intraoperatively after macroscopic examination of the liver. Preoperative percutaneous biopsy was attempted in four patients with indeterminate results. CONCLUSION: Even with modern diagnostics the risk of treating a benign or other form of malignant tumor with neoadjuvant or palliative chemotherapy persists. The same holds true for local ablative procedures. Prior to local ablation or definitive palliative chemotherapy histological confirmation of metastases should be attempted.

Post-operative internal hernia through an orifice underneath the right common iliac artery after Dargent's operation.

We report the case of a 39-year-old woman with ileus resulting from a small bowel incarceration underneath the right common iliac artery. The patient had a history of a radical trachelectomy with laparoscopic pelvic lymphadenectomy ("Dargent's operation") for cervical carcinoma. After dissection of the iliac vessels, a small bowel loop could slide underneath the common iliac artery. The hernia was closed by gluing a collagen patch over the right common iliac artery onto the retroperitoneal cavity. To our knowledge, such a case has not previously been reported in the medical literature.

[Portal vein embolisation prior to extended liver resection - current and future aspects]. / Pfortaderembolisation zur Konditionierung erweiterter Leberresektionen - aktueller Stand und Ausblick.

Extended liver resections are associated with the risk of postoperative liver dysfunction up to liver failure. For this reason, prior to extended liver resections patients are conditioned in multi-modal therapy regimes. Portal vein embolisation is an essential part of such a multi-modal therapy. The aim of this intervention is an induction of hypertrophy of the future remnant liver volume. Thereby, the risk of postoperative liver failure is decreased. This article summarises the actual aspects of portal vein embolisation prior to extended liver resections.

Liver resection in selected patients with metastatic breast cancer: a single-centre analysis and review of literature.

PURPOSE: Despite the development of modern chemotherapeutics and target-specific drugs as well as improved surgical techniques, prognosis of metastatic breast cancer remains poor. Only a small number of selected patients will be eligible for liver resection and/or alternative metastatic ablation. Data on prognostic factors for patients with surgically resectable liver metastases of breast cancer are scarce at present. METHODS: From 1997 to 2010, 50 patients with hepatic metastases of breast cancer have undergone laparotomy with the intention to undergo a curative liver resection at our institution. Data from these patients were collected in a prospectively maintained standardized liver resection data base. RESULTS: Liver resection was performed in 34 patients. Resection margins were clear in 21 cases (R0). Nine patients lived for more than 60 months after liver resection. The observed 5-year survival rate was 21% for all 50 patients, 28% for resected patients and 38% after R0-resection. On univariate analysis, survival rates of the resected patients were statistically significantly influenced by R-classification, age, extrahepatic tumour at the time of liver resection, size of metastases and HER2 expression of liver metastases. Multivariate analysis revealed absence of HER2 expression, presence of extrahepatic tumour and patient's age ≥50 years as independent factors of poor prognosis. CONCLUSIONS: Breast cancer patients younger than 50 years with technically resectable hepatic metastases, minimal extrahepatic tumour and positive HER2 expression appear to be suitable candidates for liver resection with curative intent. An aggressive multi-disciplinary management of those patients including surgical treatment may improve long-term survival.

[Liver transplantation - current aspects of allocation, indication and donor pool expansion]. / Lebertransplantation - aktuelle Aspekte der Allokation, Indikation und Strategien zur Erweiterung des Spenderpools.

Liver transplantation is nowadays an established treatment option for end-stage liver disease and the associated complications. In this article, we summarise the actual aspects of allocation, indication for transplantation as well as approaches for donor pool expansion in the field of liver transplantation in Germany. Beside the maintenance of long-term survival and quality of life, the actual donor organ shortage is the most important issue worldwide. While trying to control this shortage, there is a lot of discussion about the transplantation for malignant liver disease. In our opinion, the focus in this topic should be the utilisation and expansion of the donor pool. There are many logistic and medical aspects which could be optimised. Furthermore, there are open questions in public and political discussions (up to the revision of the transplantation law) which should be improved for the purpose of the waiting list patients.

[The latissimus dorsi myocutaneous free flap--a salvage option for abdominal wall reconstruction in complex incisional hernias]. / Die M. latissimus dorsi-Lappenplastik--Salvage-Option bei der komplizierten Rezidiv-Narbenhernie.

Complex incisional hernias are a serious burden for the patient and a challenge for the surgeon. The main problem is the covering of the defect after the resection of large proportions of low-grade tissue. In this work, we describe 2 patients who underwent complex reconstruction of recurrent incisional hernias using a bovine pericardium mesh (Tutomesh®) and a latissimus dorsi myocutaneous free flap.

[Liver transplantation for hilar cholangiocarcinoma]. / Lebertransplantation beim hilären Cholangiokarzinom.

Local non-resectable, hilar cholangiocarcinoma can be cured by performing a liver transplantation. The initially poor results after transplantation have significantly improved since neoadjuvant therapy protocols have been established. Therefore, hilar cholangiocarcinoma is now an accepted indication for liver transplantation in selected patients. This article summarizes the current state, recommendations and results of liver transplantation for these patients.

Adherent appendix vermiformis within an incisional hernia after kidney transplantation mimicking acute appendicitis: report of a case.

PURPOSE: We report a very rare case concerning a 69-year-old woman with acute onset pain in the right lower abdomen. PATIENT HISTORY: Kidney transplantation for chronic renal insufficiency had been performed 4 years previously. Clinical examination and diagnostic imaging revealed an appendix-associated incisional hernia at the lateral edge of the inguinal scar. We performed a laparoscopic appendectomy and hernia repair with external knots. The postoperative course was uneventful and the patient was discharged on the 5th postoperative day in a good general condition. CONCLUSIONS: Appendix-associated hernias are very rare but can cause severe complications in case of delayed diagnosis, particularly in patients undergoing immunosuppressive treatment.

[Approaches to the abdominal cavity and closure of the abdominal wall]. / Abdominelle Zugänge und Bauchdeckenverschluss.

Although minimally invasive approaches to the abdominal cavity are becoming increasingly more important, open surgical techniques are still of essential interest and must be mastered by general and visceral surgeons. The choice of the particular approach depends on the specificity and location of the scheduled procedure. The following article is intended to give an overview on the current literature as well as experiences in the field of open surgical approaches to the abdominal cavity.

Implantation of the liver during reperfusion of the heart in combined heart-liver transplantation: own experience and review of the literature.

BACKGROUND: There are only a few reports about combined heart-liver transplantations. The surgical techniques differ widely, ranging from sequential implantation of the organs to simultaneous transplantations. We report our experience with simultaneous, combined heart-liver transplantations without using a veno-venous bypass demonstrating that this is a feasible surgical technique. METHODS: Since 2005, we performed 4 combined heart-liver transplantations by implanting the liver during the reperfusion period of the newly implanted heart. We retrospectively reviewed patient clinical data and outcomes. RESULTS: The mean operative time was 534 ± 247 minutes and the ischemia times for heart and liver were 190 ± 72 minutes (cold ischemia time for the heart), 98 ± 96 minutes (warm ischemia time for the heart), 349 ± 101 minutes (cold ischemia time for the liver), and 36.25 ± 3.5 minutes (warm ischemia time for the liver). Three patients were discharged from the hospital after an uneventful clinical course. One patient died due to multi-organ failure during the intensive care unit stay on the 23rd postoperative day. CONCLUSION: We suggest that combined, simultaneous heart-liver transplantation without veno-venous bypass is a feasible surgical technique.