Transanal Minimally Invasive Surgery: State of the Art.

The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.

Pilot study of a novel pain management strategy: evaluating the impact on patient outcomes.

BACKGROUND: Our objective was to evaluate the impact of a novel multimodal pain management strategy on intraoperative opioid requirements, postoperative pain, narcotic use, and length of stay. METHODS: Consecutive patients undergoing elective laparoscopic colorectal resection were managed with an experimental protocol. The protocol uses a post-induction, pre-incision bilateral TAP block and local peritoneal infiltration at port sites with long-acting liposomal bupivacaine (20 mL long-acting liposomal bupivacaine, 30 mL 0.25 % bupivacaine, 30 mL saline). Experimental patients were matched on age, body mass index, gender, comorbidity, diagnosis, and procedure to a control group that received no block or local wound infiltration. Both groups followed a standardized enhanced recovery pathway. Demographics, perioperative, and postoperative outcomes were evaluated. The main outcome measures were intraoperative opioids, postoperative pain, opioid use, and length of stay. RESULTS: Fifty patients were analyzed-25 experimental and 25 controls. Patients were well matched on all demographics. In both cohorts, the main diagnosis was colorectal cancer and primary procedure performed a segmental resection. Operative times were similar (p = 0.41). Experimental patients received significantly less intraoperative fentanyl (mean 158 mcg experimental vs. 299 mcg control; p < 0.01). The experimental group had significantly lower initial (p < 0.01) and final PACU pain scores (p = 0.04) and shorter LOS (3.0 vs. 4.1 days, p = 0.04) compared to controls. Experimental patients trended toward shorter PACU times and lower opioid use and daily pain scores throughout the hospital stay. Postoperative complication and readmission rates were similar across groups. There were no reoperations or mortality. CONCLUSIONS: Our multimodal pain management strategy reduced intraoperative opioid administration. Postoperatively, improvements in PACU time, postoperative pain and narcotic use, and lengths of stay were seen in the experimental cohort. With the favorable finding from the pilot study, further investigation is warranted to fully evaluate the impact of this pain management protocol on patient satisfaction, clinical and financial outcomes.

[Independence in Plastic Surgery - Benefit or Barrier? Analysis of the Publication Performance in Academic Plastic Surgery Depending on Varying Organisational Structures]. / Vorteil durch Eigenständigkeit? Analyse der Publikationsleistung der universitären Plastischen Chirurgie in verschiedenen Organisationsstrukturen.

INTRODUCTION: Despite its recognition as an independent specialty, at German university hospitals the field of plastic surgery is still underrepresented in terms of independent departments with a dedicated research focus. The aim of this study was to analyse the publication performance within the German academic plastic surgery environment and to compare independent departments and dependent, subordinate organisational structures regarding their publication performance. MATERIAL AND METHODS: Organisational structures and number of attending doctors in German university hospitals were examined via a website analysis. A pubmed analysis was applied to assess the publication performance (number of publications, cumulative impact factor, impact factor/publication, number of publications/MD, number of publications/unit) between 2009 and 2013. In a journal analysis the distribution of the cumulative impact factor and number of publications in different journals as well as the development of the impact factor in the top journals were analysed. RESULTS: Out of all 35 university hospitals there exist 12 independent departments for plastic surgery and 8 subordinate organisational structures. In 15 university hospitals there were no designated plastic surgery units. The number of attending doctors differed considerably between independent departments (3.6 attending doctors/unit) and subordinate organisational structures (1.1 attending doctors/unit). The majority of publications (89.0%) and of the cumulative impact factor (91.2%) as well as most of the publications/MD (54 publications/year) and publications/unit (61 publications/year) were created within the independent departments. Only in departments top publications with an impact factor > 5 were published. In general a negative trend regarding the number of publications (- 13.4%) and cumulative impact factor (- 28.9%) was observed. 58.4% of all publications were distributed over the top 10 journals. Within the latter the majority of articles were published in English journals (60% of publications, 79.9% of the cumulative impact factor). The average impact factor of the top 10 journals increased by 13.5% from 2009 to 2013. CONCLUSION: In contrast to subordinate and dependent organisational structures, independent departments of plastic surgery are the key performers within German academic plastic surgery which, however, suffers from a general declining publication performance. Hence, the type of organisational structure has a crucial influence on the research performance.

Minimally invasive colorectal surgery: status and technical specifications.

Laparoscopy was the most significant technologic advance in colorectal surgery in the last quarter century. The safety, feasibility and oncologic equivalence have been proven, and undisputed clinical benefits have also been demonstrated over open approaches. Despite proven benefits, laparoscopic has not dominated the market, especially for colon and rectal cancer cases. Adaptations in laparoscopic technique were developed to increase use of minimally invasive surgery. Concurrently, there has been a paradigm shift toward less invasive technologies to further optimize patient outcomes. From these needs, hand assisted laparoscopic surgery (HALS), single incision laparoscopic surgery (SILS), and robotic assisted laparoscopic surgery (RALS) were applied to colorectal surgery. Each platform has unique costs and benefits, and similar outcomes when likened to each other in comparative studies. However, conventional laparoscopy, HALS, SILS, and RALS actually serve a complementary role as tools to increase the use of minimally invasive colorectal surgery. The goal of this paper is to review the history, current status, technical specifications, and evolution of the major minimally invasive platforms for colorectal surgery.

[Optimising care structures for severe hand trauma and replantation and chances of launching a national network]. / Über Versorgungsstrukturen und Möglichkeiten der Optimierung durch Vernetzung bei schweren Handverletzungen und Replantationen.

Severe hand traumata have a significant impact on our health system and on insurance companies, respectively. It is estimated that 33% of all occupational injuries and 9% of all invalidity pensions are due to severe hand trauma. Unfortunately, these high numbers are not only due to the severity of the trauma but to organisational deficiencies. Usually, the patient is treated at the general surgical emergency in the first place and only then forwarded to a microsurgeon. This redirection increases the time that is required for the patient to finally arrive at an expert for hand surgery. On the one hand, this problem can be explained by the population's lack of awareness for distinguished experts for hand and microsurgery, on the other hand, the emergency network, or emergency doctors in particular are not well informed about where to take a patient with a severe hand trauma - clearly a problem of communication between the hospitals and the ambulance. It is possible to tackle this problem, but put participating hand trauma centres have to work hand in hand as a network and thus exploit synergy effects. The French system "FESUM" is a good example for such a network and even comprises centres in Belgium and Switzerland. To improve the treatment of severe hand trauma, a similar alliance was initiated in Germany just recently. The pilot project "Hand Trauma Alliance" (www.handverletzung.com) was started in April 2013 and currently comprises two hospitals within the region of upper Bavaria. The network provides hand trauma replantation service on a 24/7 basis and aims at shortening the way from the accident site to the fully qualified hand surgeon, to improve the therapy of severe hand injuries and to optimise acute patient care in general. In order to further increase the alliance's impact it is intended to extend the project's scope from regional to national coverage - nevertheless, such an endeavour can only be done in collaboration with the German Society for Hand Surgery (DGH). This article comprises 2 parts. First, the state-of-the-art of acute severe hand trauma care is summarised and explained. Subsequently, the above-mentioned pilot project is described in every detail, including positive effects but also barriers that still have to be overcome.

Internal and external validation of the long-term QSARs for neutral organics to fish from ECOSAR™.

This study concentrates on the external validation of an existing Quantitative Structure-Activity Relationship (QSAR) model widely used for long-term aquatic toxicity to fish. In the context of the REACH legislation, QSARs are used as an alternative for experimental data to achieve a complete environmental assessment without the need for animal testing. The predictivity of the model was evaluated in order to increase the reliability of the model. We assessed whether the model met all of the OECD principles. The model was adapted to become more robust, and predictions were made with an external validation set collected from several databases. For the internal validation of the QSAR, the r², Q²(Loo) and Q²(LMO) were used as validation criteria, and for the external validation r², Q²(ext), h and the validation ratio were used. A few substances were classified as outliers and therefore the applicability domain of the QSAR had to be adjusted. The QSAR passed all validation criteria and met all the OECD principles for QSAR validation, and the long-term toxicity QSAR for fish can be applied with high certainty of a correct prediction within the limits of the inherent uncertainty of the model in cases where the substance falls within the applicability domain.

Single-incision laparoscopic colectomy: a novel approach through a Pfannenstiel incision.

BACKGROUND: Single-incision laparoscopic colectomy is evolving as a safe and feasible approach for the management of various diseases of the colon and rectum. The modality affords completion of "scarless" surgery through a transumbilical incision; however, this approach is associated with several limitations when performing colorectal procedures involving the pelvis. Collinear alignment of the camera and instruments through a single umbilical incision results in restricted visualization, inadequate dissection and mobilization, and the potential for inadvertent injury. We have developed an innovative approach utilizing a Pfannenstiel incision for single-incision access to the pelvis. METHODS: Single-incision laparoscopic colon resection was performed using a single-access device placed through a mini-Pfannenstiel incision. RESULTS: Three consecutive patients underwent single-incision laparoscopic anterior rectosigmoid resection for recurrent diverticulitis through a 4-cm Pfannenstiel incision. The procedures were performed at 150, 180, and 195 min with an estimated blood loss of 50, 150, and 75 mL, respectively. The resected specimen lengths were 10.5, 20.2, and 15.0 cm, respectively. There were no conversions to multi-port laparoscopic or open surgery. The length of hospital stay was 4 days for patients 1 and 2, and 3 days for patient 3. There were no major complications or readmissions during postoperative follow-up. CONCLUSION: Single-incision laparoscopic anterior rectosigmoid resection for diverticulitis can be performed successfully through a Pfannenstiel incision. This approach facilitates direct visualization and access for rectal and pelvic dissection while maintaining adequate exposure to the left colon and splenic flexure during the procedure.

Contaminated sediments and bioassay responses of three macroinvertebrates, the midge larva Chironomus riparius, the water louse Asellus aquaticus and the mayfly nymph Ephoron virgo.

Bioassays are widely used to estimate ecological risks of contaminated sediments. We compared the results of three whole sediment bioassays, using the midge larva Chironomus riparius, the water louse Asellus aquaticus, and the mayfly nymph Ephoron virgo. We used sediments from sixteen locations in the Dutch Rhine-Meuse Delta that differed in level of contamination. Previously developed protocols for each bioassay were followed, which differed in sediment pretreatment, replication, and food availability. The Chironomus bioassay was conducted in situ, whereas the other two were conducted in the laboratory. The measured endpoints, survival and growth, were related to contaminant levels in the sediment and to food quantity in water and sediment. Only the response of A. aquaticus in the bioassay was correlated with sediment contamination. Food availability in overlying water was much more important for C. riparius and E. virgo, thereby masking potential sediment contaminant effects. We conclude that growth of A. aquaticus was depressed by sediment contamination, whereas growth of E. virgo and C. riparius was stimulated by seston food quantity. We discuss that the trophic state of the ecosystem largely affects the ecological risks of contaminated sediments.