Drain versus no drain in elective open incisional hernia operations: a registry-based analysis with 39,523 patients.

PURPOSE: Elective open incisional hernia operations are a frequently performed and complex procedure. Prophylactic drainage is widely practised to prevent local complications, but nevertheless the benefit of surgical drain placement remains a controversially discussed subject. Objective of this analysis was to evaluate the current status of patient care in clinical routine and outcome in this regard. METHODS: The study based on prospectively collected data of the Herniamed Register. Included were all patients with elective open incisional hernia between 1/2005 and 12/2020 and completed 1-year follow-up. Multiple linear and logistic regression analysis was performed to assess the relation of individual factors to the outcome variables. RESULTS: Analysed were data from 39,523 patients (28,182 with drain, 11,341 without). Patients with drain placement were significantly older, had a higher BMI, more preoperative risk factors, and a larger defect size. Drained patients furthermore showed a significant disadvantage in the outcome parameters intraoperative complications, general complications, postoperative complications, complication-related reoperations, and pain at the 1-year follow-up. No significant difference was observed with respect to the recurrent rate. CONCLUSION: With 71.3%, the use of surgical drainages has a high level of acceptance in elective open incisional hernia operations. The worse outcome of patients is associated with the use of drains, independent of other influencing factors in the model such as patient or surgical characteristics. The use of drains may be a surrogate parameter for other unobserved confounders.

Laparoscopic therapy of the coeliac artery compression syndrome: a critical analysis of the current standard procedure.

INTRODUCTION: Median arcuate ligament syndrome has been known anatomically for approximately 100 years and results from a compression of the coeliac axis by fibrous attachment of the diaphragmatic crura. Owing to the rarity of the disease and limited available data, many aspects of treatment are controversial. Currently, laparoscopic decompression is considered by several authors as standard surgical procedure. We present an analysis of the clinical routine of MALS therapy. METHODS: We conducted a prospective observational trial in patients with MALS between March 2016 and August 2018, in which clinical symptoms, diagnostic evaluation, procedures with complication analysis and follow-up data were recorded. RESULTS: A total of 18 patients (12 female, 6 male) with MALS, aged between 15 and 65 years, were included in this study. All patients presented with long-standing abdominal pain. Preoperative Doppler ultrasonography showed a flow velocity of the coeliac artery averaging 289.9cm/second in mid-position of the diaphragm, 285.9cm/second in expiration and 199.0cm/second in inspiration. All operated patients underwent laparoscopic decompression; two patients received an angiographic intervention. Postoperatively, a significant decrease of the flow velocity in mid-position of the diaphragm was detected (P = 0.018). At follow-up after 5.2 months, 50.0% of the patients were pain-free, 37.5% reported symptomatic relief and 12.5% showed evidence for a recurrence. CONCLUSION: MALS is challenging both diagnostically and therapeutically. Laparoscopy with release of the median arcuate ligament is an essential part of the therapy and can be confirmed by Doppler ultrasonography. Disease outcome is also influenced by several predictive factors.

Minimally invasive video-assisted thyroidectomy: a critical analysis of long-term cosmetic results using a validated tool.

INTRODUCTION: Since its first publication in 1997, minimally invasive video-assisted thyroidectomy (MIVAT) has developed into the predominant minimally invasive surgery of the thyroid. A major advantage over conventional thyroid surgery is the superior cosmetic result. However, there are still few data comparing the long-term cosmetic results of the two methods. This paper compares the long-term cosmetic results of the two methods, based on follow-up assessments. METHODS: Between 2004 and 2011, 143 preselected patients underwent a MIVAT in our department. Additionally, 134 patients underwent a conventional thyroidectomy in our hospital in 2011. A total of 117 patients from the MIVAT group and 102 patients from the conventional thyroidectomy group received follow-up assessments after 23.1 and 23.6 months, respectively, using the patient and observer scar assessment scale. RESULTS: The measurable cervical scar length averaged 1.9 cm in the MIVAT group and 3.9 cm in the conventional group (P < 0.001). Some 11.1% of the patients in the MIVAT group and 7.1% of the patients in the conventional group had developed keloid (P = 0.391). The patient scar assessment score was 10.4 for the MIVAT group compared with 9.9 for the conventional thyroidectomy group (P = 0.691) and the observer scare assessment score was 8.6 for MIVAT compared with 9.9 for conventional thyroidectomy (P = 0.011). CONCLUSION: In the patient assessment instrument, conventional thyroidectomy had a small advantage over MIVAT in the cosmetic long-term results. This difference between the two groups was, however, not significant. Our result contradicts short-term cosmetic results of published randomized studies with improvement for MIVAT. The Observer Score demonstrates a significant advantage of the MIVAT.

[The development process of colon cancer centres]. / Der Prozess der Entwicklung von Zentren am Beispiel des Darmkrebszentrums.

Colon carcinomas are the most common malignant tumours in the Western world. Important findings about the overall quality of medical care have been reported in multi-centre observational studies. A quality enhancement of therapeutic care can be achieved by an additional increase in diagnostic and therapeutic measures in the interdisciplinary setting. The development of colon cancer centres improves the chance to objectively observe the results of medical care induced by the development of an interdisciplinary and cross-sectoral unit that includes a comprehensive medical care for patients. The implementation of the current medical findings based on evidence in clinical routine, the inspection of the usage of guidelines by external specialists as part of an audit and the continuous correction of analysed deficits in the course of treatment guarantee a continuous improvement of service.

[Acute appendicitis - clinical health-service research on the current surgical therapy]. / Akute Appendizitis - Klinische Versorgungsforschung zur aktuellen chirurgischen Therapie.

INTRODUCTION: With about 135,000 operations every year appendectomy is one of the most frequent surgical operations in Germany. Acute appendicitis has shown changes in diagnosis and therapy with time. The status of the laparoscopic appendectomy has had to be redefined recently. The aim of this study was to make an analysis of the current surgical therapy for appendicitis and the individual procedures. PATIENTS AND METHODS: Three prospective multi-centre quality assurance studies (1988 / 89, 1996 / 97; 2008 / 09) of the "An-Institut" acquired 17,732 treatments from all supply levels of Germany. RESULTS: The average age of patients increased within of the three studies from 25.7 to 34.6 years. Within the studies in 1996 / 97 and in 2008 / 09 the share of laparoscopic appendectomy advanced from 33.1 to 85.8 percent. In the study from 2008 / 09 the laparoscopic appendectomy showed a significant advantage over the conventional technique in terms of wound-healing disturbances (p < 0.001) and a clinical duration of stay (p < 0.001). At no stage of the appendix inflammation did the laparoscopic appendectomy lead to a significant increase of intraabdominal abscesses. Compared with the conventional technique the operating time was shorter (46.6 min vs. 53.5 min). Currently the use of a stapler is the mostly frequently applied method of appendiceal stump closure (83.6 percent). CONCLUSION: The laparoscopic appendectomy is the most common method of current operative therapy. In comparison to former publications, there is no proof of any disadvantages of laparoscopic appendectomy.

Endorectal ultrasound in rectal carcinoma--do the literature results really correspond to the realities of routine clinical care?

BACKGROUND AND STUDY AIMS: This multicenter, prospective, country-wide quality-assurance study at more than 300 hospitals in Germany was designed to characterize and analyze the diagnostic accuracy of rectal endoscopic ultrasound (EUS) in the routine clinical staging of rectal carcinoma (depth of tumor infiltration). PATIENTS AND METHODS: Patients were surveyed between 1 January 2000 and 31 December 2008. Those who received neoadjuvant therapy after EUS were excluded. The correspondence between the EUS assessment of tumor depth (uT) and that determined by histology (pT) was calculated, and the influence of hospital volume upon the sensitivity, specificity, and positive and negative predictive values was investigated. RESULTS: At 384 hospitals providing care at all levels, 29 206 patients were included; of the 27 458 treated by surgical resection, EUS was performed for 12 235 (44.6 %). Of these, 7096 did not receive neoadjuvant radiochemotherapy, allowing a uT-pT comparison. The uT-pT correspondence was 64.7 % (95 % confidence interval [CI] 63.6 % - 65.8 %); the frequency of understaging was 18 % (95 %CI 17.1 % - 18.9 %) and that of overstaging was 17.3 % (95 %CI 16.4 % - 18.2 %). The kappa coefficient was greatest in the category T1 (κ = 0.591). For T3 tumors κ was 0.468. The poorest correspondence was found for T2 and T4 tumors (κ = 0.367 and 0.321, respectively). A breakdown by hospital volume showed that the uT-pT correspondence was 63.2 % (95 %CI 61.5 % - 64.9 %) for hospitals undertaking ≤ 10 EUS/year, 64.6 % (95 %CI 62.9 % - 66.2 %) for doing 11 - 30 EUS/year, and 73.1 % (95 %CI 69.4 % - 76.5 %) for those hospitals performing > 30 EUS/year. CONCLUSIONS: In clinical routine, the diagnostic accuracy of transrectal ultrasound in staging rectal carcinoma does not attain the very good results reported in the literature. Only in the hands of diagnosticians with a large case volume of rectal carcinoma patients can EUS lead to therapy-relevant decisions.

[Acute appendicitis - changes in epidemiology, diagnosis and therapy]. / Akute Appendizitis - Wandel in Epidemiologie, Diagnostik und Therapie.

Appendicitis is the most common cause of an -acute abdomen. Around 135 000 patients undergo appendectomy in Germany every year. Acute -appendicitis shows changes in epidemiology, -diagnosis and therapy. Epidemiological data indicate a continuing decrease in the incidence of acute non-perforated appendicitis. The incidence of perforated appendicitis has remained constant despite laparoscopy and imaging diagnostics. The status of sonography and CT scanning is increasing in the diagnosis of appendicitis. But there are differences between the sensitivity and specifity of study results and the clinical routine. The in-crease of imaging diagnostics does not correlate with a decrease in the incidence of perforated -appendicitis. Laparoscopic appendectomy has -developed as a dominant method for operative therapy. There is no proof of a higher rate of postoperative intraabdominal abscesses any more. The use of a stapler is mostly required for appendical stump closure.

Anastomotic leakage after colon cancer surgery: a predictor of significant morbidity and hospital mortality, and diminished tumour-free survival.

AIM: The objective of this study was to find out the effects of anastomotic leakage (AL) following resection of colon cancer upon perioperative outcome and long-term oncological result. PATIENTS AND METHODS: Using the database of a country-wide quality assurance study "Quality Assurance in Primary Colorectal Carcinoma" we analysed the data from the complete sub-population of 844 patients who had AL after resection of colon cancer. These were compared with corresponding data from 27 427 similar patients without AL. Hospital mortality, AL-associated post-operative morbidity and long-term outcome were investigated. RESULTS: Hospital mortality after AL was 18.6%, compared with 2.6% for patients without AI. AL-related secondary complications occurred in 62.7% cases, while patients without AL had a corresponding rate of 19.9%. Those with AL had a poorer long-term oncological result, with a five-year survival rate of 51.0% (p<0.001) and a five-year tumour-free survival rate of 63.0% (compare 74.6% without AL; p<0.001). CONCLUSIONS: Post-operative AL after resection of colon cancer is associated with significant morbidity and hospital mortality rates and with a greater risk of a poor oncological outcome.

Rectusbanding: a method for the repair of incisional hernias.

BACKGROUND: We report on a new method of incisional hernia repair applicable to any size of hernia and the long-term results of this method. Musculus rectus abdominis is bandaged or partially bandaged in a loose way with a 2-cm-wide band of polypropylene (Prolene) on both sides at a distance of 2 cm, depending on the size of the hernial opening. The aims of this technique, which were defined in 1999 when we started using the method, were to find a simple method for surgeons, a safe mesh fixation and the prevention of a postoperative stiff abdomen. Another aim was to find a method for optimal patient care at reasonable costs. METHODS: Two hundred and seventeen patients underwent an operation according to this method in our department from June 1999 until December 2007. The first 75 patients of this cohort were treated using a technique in which the musculus rectus abdominis was bandaged in a loose way. One hundred and forty-two patients (since October 2001) were treated using a technique in which the muscle was not entirely bandaged. Instead, the polypropylene bands, which had been placed in sublay position, were penetrating the lateral rim through incisions and were fastened there. We included 124 patients (October 2001 to December 2006) in our further examination with a follow-up of 17-79 months. RESULTS: We found a recurrence rate of 6%, 80.1% of the patients had no trouble, 18.1% of the patients had very rarely any complaint, 0.9% of the patients had problems after exercise and 0.9% had permanent problems. All patients had excellent mobility of the abdomen. CONCLUSION: This method was proven to give good results in the long run and can be easily learned by any surgeon. This method is a true alternative to all methods which have been published so far.

[Anastomotic leakage following bowel resections for colon cancer: multivariate analysis of risk factors]. / Anastomoseninsuffizienzen nach Kolonkarzinomresektionen : Multiple Analyse der Risikofaktoren.

BACKGROUND: The aim of this study was to evaluate the incidence and risk factors associated with anastomotic leakage after colon cancer surgery using data compiled in the nationwide German qualitative multi-center study "Colon/Rectum Cancer" (WGCRC). METHODS: From 01/01/2000 to 12/31/2004 data recorded from patients with anastomotic leakages were evaluated to determine independent predictors of leakage using logistic regression analysis. RESULTS: A total of 28,271 patients underwent colon resection with anastomoses and anastomotic leaks occurred in 3.0% (n=844). Multivariate analysis identified long duration of surgery, a high ASA score, male gender, obstruction, left-sided tumor, cardiovascular hepatic comorbidity, single-layer hand suture, anastomoses using the biofragmentable Valtrac ring, intraoperative complications and BMI>30 kg/m(2) as risk factors for postoperative occurrence of anastomotic leakage. CONCLUSIONS: Even though the rate of anastomotic leaks in patients with anastomoses after resection for colon cancer is low, it remains a significant complication, associated with significant morbidity and mortality. The knowledge of risk factors should be considered in perioperative decision-making regarding anastomotic technique and indications for Hartmann's procedure.

[Clinical value of laparoscopic surgery for colon cancer]. / Stellenwert der laparoskopischen Chirurgie des Kolonkarzinoms in der klinischen Routine.

BACKGROUND: Using data and analysis compiled in the nationwide German Colon/Rectal Cancer qualitative multicenter study, the aim of this study was to determine the value of laparoscopic surgery for colon cancer in clinical routine. METHODS: From 1 January 2000 to 31 December 2003, patients with colon cancer resections were evaluated for short-term postoperative and long-term oncologic results associated with operative approach (laparoscopic vs conversion vs open). RESULTS: Of 21,721 patients with colon cancer, 949 (4.4%) underwent laparoscopic resection. These patients were younger (P<0.001) with lower ASA risk factors (P<0.001) and earlier UICC tumor stages (P<0.001) than open resected patients. They also showed reduced overall morbidity (P<0.001), in-hospital mortality (P=0.001), and shorter hospital stays (P<0.001). The rates of intraoperative and specific complications remained unchanged. Nineteen percent of the patients had resections converted to open approaches. These had the highest overall morbidity and longest hospital stays. Their mortality was three times that of the group with complete laparoscopic resection. CONCLUSIONS: The open approach remained the standard of surgical care in colon cancer for the study duration. Laparoscopic surgery was used in only a small number of patients. By virtue of preferential patient selection, better early postoperative and long-term results could be achieved for the laparoscopic group than with the open approach. Conversions were shown to be associated with inferior results at the high rate of 19%. To ensure optimal results, laparoscopic surgery for colon carcinoma should be conducted by an experienced surgeon in an appropriately selected patient pool.

[Rectusbanding variation II - a method for the repair of incisional hernias - further developments]. / Reparation von Narbenbrüchen mittels Rectusbanding Variante II - eine Weiterentwicklung.

We report on further developments of the rectusbanding variation II method which is used for the repair of large incisional hernias in 70 patients. Using this method the musculus rectus abdominis is not entirely looped. Instead, the polypropylene bands, which have been placed in sublay position, are penetrating the lateral rim through incisions and are fastened there. Important to note that the polypropylene bands are not used to ligate the abdominal wall. The bands must be placed loosely. This allowed us to reduce the applied material by almost 50 per cent. Although a high number (n = 70) of large incisional hernias (about 150 cm (2), variation I n = 16/20,3%, variation II n = 29/41,4%) were operated upon with this method (rectusbanding variation II) previous excellent results could be further improved (wound infectionrate 2,8%, recurrence rate after 18 months 0%, patients had no complaints and their mobility was excellent). Only the seroma formation rate was slightly increased due to the large size of the hernias. These excellent results are mainly based on the absolutely reliable fixing of the polypropylene bands and the complete mesh coverage by soft tissue. This method can be easily learned by any surgeon and is a true alternative to all conventional methods which have been published so far. In particular laparoscopic methods for incisional hernia repair can be replaced by this technique.

[The role of the ultracision technique in visceral surgery. Ligature-free operation--an illusion?]. / Ein Erfahrungsbericht mit Ultrazision in der offenen Chirurgie.Die ligaturfreie Operation--eine Illusion?

We report on 431 operations in conventional visceral surgery with the general use of the ultracision technique for preparation (thyroid resections n = 356, colonic resections n = 28, local excisions of the gastric wall n = 3, gastrectomy n = 14, anterior resections of the rectum n = 19, abdominoperineal resection of the rectum [Miles' operation] n = 11). Ligatures were only used for truncal blood vessel ligation. A thorough study of the technical possibilities is a prerequisite for the use of the ultracision technique. The general use of the ultracision technique leads to a revolutionary change of the surgical technique and saves a considerable amount of suture material. In combination with the use of bipolar electrocoagulation the ultracision technique makes the operation fast and leads to a major reduction of bleeding. The biggest disadvantage of the ultracision technique in comparison to the conventional surgical technique is the high cost of the device at present. Despite of savings of suture material, swabs and blood transfusions, the costs for the ultracision scissors are still higher due to its single use.

Effect of ultraviolet radiation on melanogenesis in four different types of cultured bovine ocular pigmented cells.

BACKGROUND: Ultraviolet radiation is thought to play a causative role in various ocular diseases such as macular degeneration, cataract, and possibly melanomas. Since most of the energy is absorbed by pigmented cells, the aim of this study was to examine and compare the reactions of different ocular melanocytic cells to ultraviolet light in vitro. MATERIALS AND METHODS: Bovine iris melanocytes, choroidal melanocytes, iris pigment epithelial cells, and retinal pigment epithelial cells were isolated and cultured. Semiconfluent cultures were exposed to ultraviolet radiation (280-380 nm). Cell number and melanin content were measured 10 days after radiation. Selected samples were examined by transmission electron microscopy. RESULTS: Following irradiation with ultraviolet light for 30 s, 60 s, and 120 s, the number of cells in culture decreased markedly. In contrast, total melanin content in the cultures of iris melanocytes, choroidal melanocytes, and iris pigment epithelial cells did not decrease despite the reduced number of cells. This finding suggested an increase in melanin per cell. However, the increase in average melanin content observed was not due to melanogenesis, because treatment with the melanogenesis inhibitor alpha-methyl-p-tyrosine did not reduce the melanin content of the cultures and electron-microscopic examination showed no morphological evidence of increased melanogenesis. CONCLUSION: In vitro, there was no convincing evidence of ultraviolet radiation-induced melanogenesis in ocular pigmented cells. Thus, it seems that ultraviolet radiation is a selection factor: more densely pigmented cells survive the treatment better than less pigmented cells.

Short-time application of latanoprost does not stimulate melanogenesis in bovine ocular melanin-containing cells in vitro.

Topical use of latanoprost for glaucoma can lead to an increase in iris and eye lash pigmentation but the precise mechanism is unclear. To study the possible effect of this drug on ocular melanogenesis, we used cultures of bovine iris melanocytes, iris pigment epithelial cells, retinal pigment epithelial cells, and choroidal melanocytes. Latanoprost (at concentrations of 10(-8) and 10(-6) mol) was applied for 3 days, and cell numbers as well as melanin content were measured prior to and 10 days after exposure and compared to untreated controls. In none of the cell types examined a significant increase in melanin content or an increase in cell proliferation was observed. Additional treatment with the tyrosinase inhibitor alpha-methyl-p-tyrosine showed no significant effect either. Our results support the concept of a rather complex mechanism underlying the increased iris pigmentation after treatment with latanoprost.

Is stage conversion the initiating event for reactivation of Toxoplasma gondii in brain tissue of AIDS patients?

Reactivation of chronic toxoplasmosis resulting in Toxoplasma encephalitis (TE) is a common event in acquired immune deficiency syndrome (AIDS) patients. Conversion from Toxoplasma gondii bradyzoites to tachyzoites is a prerequisite for reactivation. Until recently, the study of stage conversion in human tissue was not possible due to the lack of antibodies that recognize stage-specific epitopes after long-term formaldehyde fixation. Using the combination of a polyclonal anti-T. gondii antibody, the cyst-stage-specific monoclonal antibody CC2, and a tachyzoite-specific polyclonal antibody (anti-SAG1, recombinant), we tried to demonstrate parasite differentiation in the brain tissue of 10 AIDS patients with clinically suspected TE. Double labeling of the stage-specific antibodies enabled us to demonstrate interconversion between tachyzoites and bradyzoites for the first time in human tissue. The study confirmed that the transformation process is nonsynchronous and that the manifestation of TE depends on the degree and site of tissue destruction caused by invading tachyzoites. The original source of tachyzoites could never be located, but a few samples suggested that tachyzoites may invade by dissemination across the blood-brain barrier. Cyst rupture as the first event in the process of reactivation was not seen. We conclude that the initial site(s) of reactivation will be destroyed by tissue-destructive tachyzoites long before clinical symptoms occur.

Light and electron microscopic examination of endothelial cells from bovine retinal vessels in long-term cultures.

The aim of the present work was to examine and compare the ultrastructure of bovine retinal endothelial cells (BRECs) in vitro during several passages in a medium selective for endothelial cells. The identity of the endothelial cells was confirmed immunohistochemically, up to the tenth passage. Changes in their ultrastructure in comparison to endothelial cells in vivo occurred at the onset of culturing and not progressively with repeated passages. The cultured BRECs show high metabolic activity in all passages. While retaining their identity as endothelial cells, they modify their lipid metabolism, so that lipids are stored. This change in lipid metabolism was induced by the medium.

Infection and stage conversion during murine pulmonary toxoplasmosis: a study with three different strains of Toxoplasma gondii.

A murine model of pulmonary toxoplasmosis was examined morphologically and immunochemically using 3 strains of Toxoplasma gondii. BALB/c and NMRI mice were infected with tachyzoites of a virulent strain (RH) or with brain cysts of an avirulent (GAIL), or moderately virulent, strain (NED). Depending on the strain of T. gondii, the degree of infection, number of parasites, and replicative potential of T. gondii in lungs varied. In lungs of mice infected with the RH strain, the number of parasites increased in mice during the survival period. Only tachyzoites were found, as confirmed by stage-specific monoclonal antibodies. In lungs of mice infected with the GAIL strain or the NED strain, different stages of parasites were detected. Up to day 14 after infection, only tachyzoites were present, followed by bradyzoites between days 14 and 20 after infection. The number of cysts decreased and finally could not be detected in this organ. In general, the number of cysts that developed in the lungs was smaller than the number that developed in the brain.