[The treatment of acute secondary peritonitis : A retrospective analysis of the use of continuous negative pressure therapy]. / Die Therapie der akuten sekundären Peritonitis : Eine retrospektive Erhebung zum Einsatz intraabdomineller Unterdrucktherapieverfahren.

BACKGROUND: Patients with acute secondary peritonitis often need relaparotomies and open abdominal lavages. Continuous negative pressure therapy seems to be beneficial. OBJECTIVES: Does the efficacy of the therapy depend on the continuous negative pressure system used? MATERIALS AND METHODS: A retrospective analysis was performed in the Chirurgische Klinik der Universitätsmedizin Berlin, Charité Campus Mitte, including all patients who underwent abdominal vacuum therapy between December 2013 and February 2015. Two different systems (ABThera®, KCI Medizinprodukte GmbH and Suprasorb® CNP Drainagefolie, Lohmann & Rauscher GmbH) were available for treatment. RESULTS: During the 14 month study period, 33 patients with acute secondary peritonitis were treated with abdominal negative pressure therapy. Vacuum therapy treatment was applied for a median of 4 days (range 0-22 days). Eight patients (24%) died during hospitalisation. After completion of intraabdominal vacuum therapy, direct fascial closure was feasible in 26 patients (79%). There were no differences concerning patient characteristics, duration of abdominal vacuum therapy, the possibility of direct fascial closure or morbidity and mortality with the two different systems used. CONCLUSIONS: Acute secondary peritonitis is associated with high morbidity. We achieved a lower mortality rate compared to prospective clinical trials using intraabdominal continuous negative pressure therapy. The effectiveness and cost efficiency of different therapy systems should be the topic of further research.

[Staff Satisfaction within Duty Hour Models: Longitudinal Survey on Suitability and Legal Conformity at a Surgical Maximum Care Department]. / Mitarbeiterzufriedenheit im Arbeitszeitmodell: Längsschnittstudie zu Praxistauglichkeit und Gesetzeskonformität in einer chirurgischen Klinik der Maximalversorgung.

Background Between the conflicting requirements of clinic organisation, the European Working Time Directive, patient safety, an increasing lack of junior staff, and competitiveness, the development of ideal duty hour models is vital to ensure maximum quality of care within the legal requirements. To achieve this, it is useful to evaluate the actual effects of duty hour models on staff satisfaction. Materials and Methods After the traditional 24-hour duty shift was given up in a surgical maximum care centre in 2007, an 18-hour duty shift was implemented, followed by a 12-hour shift in 2008, to improve handovers and reduce loss of information. The effects on work organisation, quality of life and salary were analysed in an anonymous survey in 2008. The staff survey was repeated in 2014. Results With a response rate of 95% of questionnaires in 2008 and a 93% response rate in 2014, the 12-hour duty model received negative ratings due to its high duty frequency and subsequent social strain. Also the physical strain and chronic tiredness were rated as most severe in the 12-hour rota. The 18-hour duty shift was the model of choice amongst staff. The 24-hour duty model was rated as the best compromise between the requirements of work organisation and staff satisfaction, and therefore this duty model was adapted accordingly in 2015. Conclusion The essential basis of a surgical department is a duty hour model suited to the requirements of work organisation, the Working Time Directive and the needs of the surgical staff. A 12-hour duty model can be ideal for work organisation, but only if augmented with an adequate number of staff members, the implementation of this model is possible without the frequency of 12-hour shifts being too high associated with strain on surgical staff and a perceived deterioration of quality of life. A staff survey should be performed on a regular basis to assess the actual effects of duty hour models and enable further optimisation. The much criticised 24-hour duty model seems to be much better than its reputation, if augmented by additional staff members in the evening hours.

Influence of postoperative fluid management on pulmonary function after esophagectomy.

PURPOSE: The aim of this study was to investigate the effects of a restrictive vs. a liberal postoperative fluid therapy guided by intrathoracic blood volume index (ITBVI) on hemodynamic and pulmonary function in patients undergoing elective esophagectomy. Perioperative fluid therapy may influence postoperative physiology and morbidity after esophageal surgery. Definitions of adequate infusion amounts and evident rules for a fluid therapy are missing. METHODS: After esophagectomy, 22 patients were randomized either to a restrictive group (RG) with low range of ITBVI (600-800 ml/m2) or a liberal group (LG) with normal ITBVI (800-1000 ml/m2). Infusion regimen was modified twice a day according to transpulmonary thermodilution measurements until the 5th postoperative day. Primary endpoint was paO2/FIO2-ratio. Secondary endpoints were pulmonary function, fluid balance and hemodynamic as well as morbidity. RESULTS: Demographic and surgical details did not differ between both groups. The calculated sample size was not reached. There were no postoperative differences in paO2/FIO2-ratio, ITBVI, hemodynamic parameters, or morbidity either. Cumulative fluid uptake was 4.1 liter less in the RG on the 5th postoperative day (p = 0.01), and pulmonary function was better in these patients (area under curve day 2-7 for forced vital capacity (FVC), forced expiratory volume in one second (FEV1), peak expiratory flow (PEF) each <0.05). CONCLUSION: ITBVI guided restrictive infusion therapy yields a lower fluid uptake, but may not result in a difference of clinical relevant parameters. A fluid restriction after esophagectomy should always be combined with hemodynamic monitoring because additional infusions may be required.

Analysing the serum levels of tumour markers and primary tumour data in stage III melanoma patients in correlation to the extent of lymph node metastases--a prospective study in 231 patients.

BACKGROUND: Serum tumour markers correlate with biological tumour behaviour and prognosis of patients. We collected prospective data of melanoma patients in tumour stage III before radical lymph node dissection. MATERIALS AND METHODS: Between 2003 until 2007 we collected 231 tumour stage III patients and analysed the preoperative serum tumour markers S100 (S100 calcium binding protein), NSE (Neuron specific enolase, Enolase 2), Albumin, LDH (Lactate dehydrogenase) and CRP (C-reactive protein) and evaluated the correlation to clinical and pathological data. We divided patients into a group with only a positive sentinel lymph node (group 1; n = 109) and a second with further lymph node metastases (group 2; n = 122). RESULTS: Patients of group 2 had a significant higher T level (p < 0.0001) and Breslow index (p < 0.0001). Patients with a higher Breslow index had a higher S100 serum level (p = 0.021). Patients of group 2 displayed a significant higher level of serum S100. The serum level of CRP correlated with increasing number of lymph node metastases. CONCLUSIONS: A higher Breslow index in tumour stage III patients seems to have an influence on lymph node metastases and on S100 serum level. Patients with more than a positive sentinel lymph node do have a higher S100 level.

Influence of surgical complications on the level of pain after radical inguinal/iliacal lymph node dissection.

BACKGROUND: We collected the data of 288 patients with malignant skin tumours. We analysed the postoperative pain assessed by a visual analogue scale (VAS) to evaluate the quality of our standard peri-operative pain therapy after a radical inguinal and iliacal lymph node dissection (RILND) as well as the influence of postoperative surgical complications on the level of pain. MATERIALS AND METHOD: The postoperative level of pain of 85 patients with malignant skin tumours who underwent a RILND between August 2003 and December 2007 was recorded prospectively. Patients received a standardised perioperative pain therapy according to level I or II of the World Health Organisation (WHO) ladder of pain. The efficiency of our pain therapy was registered via VAS in the morning of the first three postoperative days. RESULTS: Using our standard pain therapy, we determined a VAS < 30 in rest during the first three postoperative days, but significantly more pain (VAS median 50-30) (p < 0.001) under stress. Patients with surgical complications in the postoperative period (n = 71) had significantly more pain in the postoperative period compared to patients with a regular postoperative course (p = 0.047). CONCLUSIONS: Immediately after a RILND, an analgesic therapy according to level I or II of the WHO pain ladder does not seem to be effective enough. Postoperative surgical complications lead to a higher VAS level of pain in the postoperative period.

[Surgical technique and postoperative morbidity following radical inguinal/iliacal lymph node dissection--a prospective study in 67 patients with malignant melanoma metastatic to the groin]. / Technik und Morbidität der radikalen inguinal / iliakalen Lymphknoten-dissektion--eine prospektive Untersuchung an 67 Patienten mit lymphogen metastasiertem malignen Melanom.

BACKGROUND: The surgical radical inguinal / iliacal lymph node dissection (RLND) is the procedure of choice in patients presenting with lymphatic metastasis of melanoma of the lower extremity or the lower part of the trunk. The perioperative morbidity of patients includes not only local wound complications, seroma formation or lymphatic fistula but also leg oedema, deep venous thrombosis and neuralgic disorders postoperatively. The aim of this prospective study was the evaluation of postoperative morbidity in patients undergoing radical inguinal/iliacal RLND in a standardised surgical fashion. PATIENTS AND METHODS: 67 patients suffering from malignant melanoma of the lower extremity or the lower trunk with metastatic lymph nodes in the groin or the iliacal region underwent a combined RLND of the inguinal / iliacal region or the groin alone between 2003 and 2006. All operations were performed in a standardised technique. The main criterion of the study was the incidence of postoperative wound complications. Minor endpoints included the incidence of lymphatic fistula, the length of hospital stay, and the development of temporary or permanent leg oedema. RESULTS: 64 patients underwent inguinal / iliacal and 3 patients only inguinal LND (lymph node dissection). All patients tolerated the procedure well. The overall wound complication rate was 34 %. One patient died on the 21st postoperative day due to a pulmonary embolism and a simultaneous cerebral apoplexy. Lymphatic fistula occurred in 22 (33 %) patients whereas seroma resulted in 23 (34 %) patients. The length of hospital stay was 15 (3-41) days. A relevant leg oedema was observed in 9 (13 %) patients. CONCLUSION: Even with a proper perioperative management and a precise wound care management, one-third of the patients undergoing radical inguinal / iliacal lymphadenectomy suffer from a complication requiring medical or interventional treatment. Our data demonstrate that most of these complications can be treated sufficiently by conservative treatment. A fitted surgical support hose could prevent long-term complications.

Stress takotsubo cardiomyopathy after pylorus preserving pancreaticoduodenectomy for cancer. A case report.

A pylorus-preserving cephalic pancreaticoduodenectomy was performed for tumor removal in a male elderly patient. In the following course no surgical complications occurred but ST-elevations and increase of Troponin T were observed. A coronary angiography revealed no relevant stenosis although a severe hypokinesis of the apex region was determined by echocardiography--a Takotsubo syndrome was assumed. This led to a significant prolonged clinical course. No residual problems remained but the cause of Takotsubo could not be identified. Analyzing the current knowledge, a feasible preoperative screening for this severe condition seems to be quite impossible.

A prospective randomized trial: the influence of intraoperative application of fibrin glue after radical inguinal/iliacal lymph node dissection on postoperative morbidity.

BACKGROUND: Effects of intraoperative application of fibrin glue following combined radical inguinal and iliacal lymph node dissection (RILND) on the amount of postoperative lymphatic secretion are discussed controversially. To detect whether fibrin glue application results in a decreased lymphatic secretion following RILND a randomized patient blinded clinical trial was conducted. METHOD: Between September 2003 and September 2006 58 patients with stage IV melanoma underwent therapeutic RILND and were randomized into two groups. 29 Patients received 4 cc fibrin glue after RILND whereas 29 patients were only irrigated with saline 0.9 percent. Postoperatively all patients received two inguinal and one iliacal closed suction drain. The main outcome criteria were the duration of drain placement in the wound. Minor criteria were the total amount of secretion and the length of hospital stay. RESULTS: There was no difference between the treatment and the control group in the duration of drain placement (fibrin group: 4 days (1-27); control group 5 days (1-26); p=0.64). The total amount of fluid was 310 cc (30-6005) in the fibrin group vs. 365 cc (30-3945 cc) in the control group (p=0.9) and the length of hospital stay 10 days (3-41) (group 1) compared to 11 days (3-41) (p=0.99) were not different between both groups either. CONCLUSION: Intraoperative application of 4 cc fibrin glue does not reduce the length of drain placement, drain output or hospitalisation of patients undergoing RILND with melanoma metastasis to the lymph node basin.