[Transanal extraction vs. minilaparotomy : For laparoendoscopic left-sided colon resection]. / Transanale Bergung vs. Minilaparotomie : Bei laparoendoskopischer linksseitiger Kolonresektion.

BACKGROUND: Recent developments in classical minimally invasive surgical procedures for colon resection aimed to minimize or even eliminate abdominal wall incisions, thus improving postoperative pain, patient recovery and aesthetics. A promising approach is the total laparoendoscopic colectomy (LEC) with transanal sample extraction. The aim of this study was the comparison of total LEC with conventional laparoscopic assisted surgery (LAS) and extraction incision. METHOD: We included 168 consecutive patients (LEC:112; LAS:56) with diverticular disease, rectal prolapse, benign or malignant tumors and analyzed retrospectively. The specimen was extracted transanally by LEC with a specially developed rectoscope; the LAS group required a minilaparotomy of 5 cm. The primary outcome was postoperative pain. Secondary outcomes included operating time, minor and major complication rates, number and length of extracted specimens, additional pain medication and duration of hospital stay. RESULTS: The measured postoperative pain score values did not significantly differ between the two groups; however, consumption of postoperative pain medication was significantly higher in the LAS-group (p < 0.001). Due to the learning curve, the median operating time in the LEC group (120 min) was slightly longer than in the LAS group (100 min); however, it was reduced to 95 min in the last 50 operations. Patients in the LEC group were discharged from hospital one day earlier (median duration of hospital stay 6 days, p = 0.003). Compliaction rates were similar in both groups. CONCLUSION: The technique of total LEC with transanal specimen extraction is designed to avoid a minilaparotomy and its associated morbidities. The LEC operation is feasible for a large group of patients, including overweight patients. The superiority of LEC in terms of reduced pain medication, shorter hospital stay and faster patient recovery, as shown in this study, needs to be confirmed by randomized controlled trials with longer follow-up periods.

Tacrolimus- (FK 506) based immunosuppression in severe systemic lupus erythematosus.

In a 30-year-old male patient systemic lupus erythematosus was diagnosed based on the presence of 8 out of 11 ARA criteria. Disease onset was acute and included renal function impairment with biopsy-proven lupus nephritis (WHO class IV) requiring renal replacement therapy. Although conventional immunosuppressive therapy regimens proved effective in controlling disease activity, all of the administered drugs were accompanied by serious side effects: bilateral femur head necrosis with corticosteroids, allergic skin reaction in response to azathioprine, nephrotoxicity with cyclosporine, nausea and abdominal pain with mycophenolate mofetil and life-threatening septicemia with cyclophosphamide treatment. In search for alternative treatment options, tacrolimus (FK506, trough serum levels 3-6 ng/ml) was started. FK506 was well-tolerated and lupus activity completely resolved within 7 months after initiation of therapy. During 36 months of follow-up no arthritic complaints occurred and renal function stabilized at a serum creatinine of 2.1 mg/dl with negative anti-ds-DNA antibodies and ANA titers. In conclusion, FK506 may be considered as alternative immunosuppressive for maintenance treatment in patients with severe lupus erythematosus and side effects to conventional regimens.