Fast Early Recovery After Transabdominal Preperitoneal Repair in Athletes with Sportsman's Groin: A Prospective Clinical Cohort Study.

BACKGROUND: Current literature on chronic groin pain suggests that laparoscopic mesh repair on athletes enables a faster recovery and subsequent return to unrestricted athletic activities. The aim of this study was to evaluate the role of transabdominal preperitoneal (TAPP) mesh repair in athletes resistant to conservative therapy. METHODS: A multidisciplinary approach with tailored physiotherapy. Thirty-nine professional athletes with chronic groin pain were referred to surgery at a single clinic. A full assessment was carried out on each, including medical history, physical examination, dynamic ultrasound, and pelvic magnetic resonance imaging. TAPP repair was performed using a polypropylene mesh and fibrin glue fixation on 30 athletes who had exhibited typical symptoms, shown resistance to conservative therapy, not benefited from accompanying physiotherapy, and had ceased training in the 3 to 6 months prior. The outcome measures were early postoperative recovery of 6 weeks and full resumption of athletic activities. RESULTS: Mean duration of symptoms from onset to surgical repair was 7 months. Conservative treatment had improved symptoms temporarily or to some extent in 7 athletes, while 2 ceased competing altogether. Twenty-three athletes exhibited unilateral and 16 bilateral groin pain. Laparoscopy confirmed posterior wall deficiency in 24 and true inguinal hernia in 6 athletes. Mild scrotal hematoma occurred in 2 athletes postoperatively; all were discharged within 24 hours of surgery. Twenty-one (70%) returned to sports activities after 6 weeks of convalescence. Persistent mild pain was experienced by 5 athletes postoperatively for up to 1 year, yet did not interfere with normal daily activity. Twenty-five participants (85%) reported full satisfaction with the procedure 1 year after treatment; all returned to the same or even higher level of athletic performance. CONCLUSION: The study confirms that the endoscopic placement of retropubic mesh is an efficient, safe, and minimally invasive treatment that enables fast early recovery.

[Surgical aspects of peritoneal dialysis]. / Chirurgische Aspekte der Peritonealdialyse.

Peritoneal dialysis (PD) has wide clinical range since die 70ies. Clinical data report a significantly higher 2 year survival rate for PD compared to patients treated with hemodialysis. Nevertheless, currently only about 10 % of patients suffering from end-stage renal disease are treated with PD. Long-term function of the catheter is based on patient's compliance as well as optimal surgical catheter implantation. Beside the classic "open" surgical approach by mini laparotomy new minimal invasive techniques of catheter implantation were developed during the last years. Advantages of laparoscopic techniques are the possibility for combined intraperitoneal procedures and optimal placement of the catheter. Most of surgery-related complications are caused by leakage or migration, infection is very rare. Several studies did not find an advantage of minimal invasive procedures regarding complications.This review should give an overview on currently established surgical techniques for PD-catheter implantation.

Non-isotopic tyrosine kinetics using an alanyl-tyrosine dipeptide to assess graft function in liver transplant recipients - a pilot study.

BACKGROUND: Although accurate assessment of liver function in liver transplant recipients is of crucial importance for optimal timing of the procedure and for determining graft viability, none of the many available methods has proven reliable in the clinical routine. Thus, a novel non-isotopic assay of tyrosine kinetics using the tyrosine-containing dipeptide L-alanyl-L-tyrosine (Ala-Tyr) was tested for its clinical feasibility in patients undergoing orthotopic liver transplantation (OLT). METHODS: Plasma levels of tyrosine and clearance of tyrosine released after infusion of the dipetide Ala-Tyr were assessed before and one day after OLT in 10 liver transplant recipients with normal graft function, also in three organ donors and in three recipients showing poor graft function. Standard laboratory parameters (e.g. aminotransferases) and the plasma disappearance rate of indocyanine green were also measured. RESULTS: Following uneventful OLT, tyrosine plasma levels (before 127 +/- 15 micromol/vs. post-OLT 52 +/- 6 micromol/l, P < 0.05) and kinetics (tyrosine clearance: before 206 +/- 77 ml/min vs. post-OLT 371 +/- 109 ml/min, P < 0.05) were normalized. In cases of severe graft dysfunction, tyrosine kinetics (tyrosine clearance: 238 +/- 61 ml/min) resembled the situation in end-stage liver disease, whereas no such correlation was seen with conventional markers of liver function. Organ preservation had only a minor impact on tyrosine kinetics (n.s.). CONCLUSION: OLT rapidly normalizes both the plasma levels and the kinetics of tyrosine. Graft failure is associated with an immediate rise in plasma tyrosine levels and a delay in tyrosine elimination. Our results show that tyrosine clearance using the dipetide Ala-Tyr is a suitable non-isotopic, non-invasive indicator of graft viability in the early postoperative course following OLT.

Combination of extended donor criteria and changes in the Model for End-Stage Liver Disease score predict patient survival and primary dysfunction in liver transplantation: a retrospective analysis.

BACKGROUND: The purpose of this study was to analyze the impact of extended donor criteria (EDC) and of changes in the Model for End-Stage Liver Disease (MELD) score while waiting for liver-transplantation (Delta-MELD) on patient survival and initial graft function. METHODS: We included 386 consecutive patients with end-stage liver disease who underwent orthotopic liver transplantation at the Medical University Vienna between 1997 and 2003. Primary outcome was patient survival and secondary outcome was initial graft function. EDC included: age >60 years, >4 days intensive medical care, cold ischemia time >10 hr, need for noradrenalin >0.2 microg/kg/min or doputamin >6 microg/kg/min, a donor peak serum sodium >155 mEq/L, a donor serum creatinine >1.2 mg/100 mL, and a body mass index >30. RESULTS: Delta-MELD was significantly higher in the nonsurvivor population (P=0.01) and EDC showed a significant influence on initial graft function (P=0.01). Worsening in either Delta-MELD or the presence of at least two EDC was not associated with an increased risk of primary graft dysfunction and death. Worsening in Delta-MELD and the presence of at least two EDC was significantly associated with primary graft dysfunction (P=0.01) and death (P=0.008). CONCLUSION: The combination of a liver recipient with worsening Delta-MELD and a potential donor with at least two EDC should be avoided.

Predictors for complications after loop stoma closure in patients with rectal cancer.

PURPOSE: This unmatched case control study was undertaken to evaluate factors contributing to surgery-related complications of loop stoma closure in patients with rectal cancer. METHODS: Cases were consecutive patients with complications identified from a local registry. Complications were defined as surgery-related and included 30 days overall mortality. Controls were all other patients with stoma closure from the same population of the registry without the endpoint. RESULTS: Of the 243 patients, 47 (19%) patients experienced a surgery-related complication, including 5 patients who died within 30 days after surgery. Significant risk factors in the univariate analysis were supervised operation (odds ratio 0.50; 95% confidence interval 0.27-0.95; P=0.04), stapled anastomosis (odds ratio 0.40; 95% confidence interval 0.17-0.91; P=0.04) and using a soft silicone drain (odds ratio 2.03; 95% confidence interval 1.07-3.85; P=0.04). Using a soft silicone drain (odds ratio 2.17; 95% confidence interval 1.10-4.26; P=0.03) and stapled anastomosis (odds ratio 0.38; 95% confidence interval 0.15-0.98; P=0.04) were the only significant predictors in the multivariate analysis. CONCLUSIONS: The present study in a homogeneous group of patients with rectal cancer as elective indication for temporary loop stoma construction confirms the high complications rate and mortality rate associated with stoma closure. Intraperitoneal drains should be omitted after loop stoma closure.

Mortality and complications after stoma closure.

HYPOTHESIS: This study was undertaken to evaluate factors contributing to hospital mortality and complications of stoma closure. DESIGN: Retrospective cohort study. SETTING: Department of Surgery of a 2500-bed university hospital. PATIENTS: Consecutive eligible patients who underwent stoma closure were selected from a local registry containing 30 219 patients. The medical records of 587 adult patients were reviewed according to a predefined extraction form. Patients with additional, unrelated surgical interventions or younger than 18 years were excluded. Follow-up was complete for all included patients. MAIN OUTCOME MEASURES: The primary outcome variable was 30-day mortality; the secondary outcome variable was presence of surgery-related complications within 30 days. RESULTS: We analyzed 533 patients with stoma closure between 1993 and 2001. The overall stoma closure-related mortality rate was 3% (15 patients); the overall stoma closure-related surgical complications rate was 20% (107 patients). Wound infections (9%) and anastomotic leakage (5%) were the most common surgical complications. Age was the only significant risk factor for survival (P = .02). Use of a soft silicone drain for intraperitoneal drainage (odds ratio, 1.62 [95% confidence interval, 1.07-2.45]; P = .03) was the only significant risk factor for complications. In patients with carcinoma as the primary disease (odds ratio, 0.61 [95% confidence interval, 0.40 to 0.93]; P = .02), we observed significantly fewer complications. CONCLUSIONS: We found considerable mortality and complications after stoma closure. Apart from age, we could not identify any predictor for mortality in patients with stoma closure. Randomized studies are needed to determine whether certain types of drains influence outcome.

Does additional doxorubicin chemotherapy improve outcome in patients with hepatocellular carcinoma treated by liver transplantation?

The aim of this prospective randomized study was to determine whether additional doxorubicin chemotherapy improves outcome in patients with hepatocellular carcinoma (HCCA) treated by liver transplantation. Stratification parameters were tumor stage (UICC I-IVa), gender, age 50 years, alpha-fetoprotein 20 ng/mL, cirrhosis and HbsAg status. For pre-operative chemotherapy doxorubicin (15 mg/m2) was given biweekly, intra-operative chemotherapy was a single dose administered before surgical manipulation. Post-operative chemotherapy from day 10 was as given preoperatively for a total dosage of 300 mg/m2. Outcome parameters were overall survival (OS) and disease-free survival. Of the 75 consecutive patients who received liver transplantation for treatment of HCCA, 62 patients were enrolled. Thirty-four patients were randomized in the chemotherapy group; 28 patients were in the control group and transplanted only. OS rates at 5 years were 38% in the chemotherapy group and 40% in the control group, disease-free survival rates at 5 years 43% and 53%, respectively. Tumor stage and vascular invasion were identified as independent risk factors for recurrence of disease. Doxorubicin chemotherapy did not improve organ survival and disease-free survival in patients undergoing liver transplantation for HCCA.

Treatment and outcome of intrahepatic cholangiocellular carcinoma.

BACKGROUND: Treating intrahepatic cholangiocarcinoma (ihCCC) tumor resection leads to the best patient survival. The aim of this study was to investigate prognostic factors in resected patients. METHODS: This was a clinical observational series of 31 resected patients with ihCCC. Univariate analysis of clinical and pathologic factors in relation to patient survival and tumor recurrence were performed. Possible benefit of chemotherapy, although not given randomly, was investigated separately. RESULTS: The median follow-up time was 37.3 months. Of 31 resected patients a tumor-free resection (R0) was achieved in 26; 2 patients died postoperatively. Chemotherapy was administered to 19 patients. Overall survival was significantly better in patients with R0 resection, negative lymph nodes, a solitary tumor, and a width of resection margin greater than 3 mm. Recurrence-free survival was prolonged in patients with negative lymph nodes, early International Union Against Cancer (UICC) stages and solitary tumors. In UICC stages III and IV, patients receiving chemotherapy experienced a better overall survival. CONCLUSIONS: Impact of various parameters on recurrence-free and overall survival was identified; a possible beneficial effect of adjuvant chemotherapy in advanced tumor stages was observed. A prospective, randomized trial is necessary to fully evaluate the role of adjuvant therapy.

Histidine-tryptophan-ketoglutarate solution for organ preservation in human liver transplantation-a prospective multi-centre observation study.

Based on experimental work and clinical small studies, histidine-tryptophan-ketoglutarate (HTK) solution was found to be suitable not only for heart and kidney preservation but also for liver preservation. We decided, therefore, to use this preservation solution for clinical liver preservation in a prospective multi-centre trial. Enrolment to the study was from 1996 to 1999 in four European centres, and the results of 214 patients with HTK-preserved organs were analysed. Analysis showed a primary dysfunction (PDF) rate of 8.8%, with a primary non-function (PNF) rate of 2.3% and initial poor function (IPF) in 6.5%. Patient survival rate at 1 year was 83% and 1-year graft survival rate was 80%. In a univariate and a multivariate analysis PDF, early surgical complications and tendentiously severe infections (septicaemia, pneumonia, cholangitis) were identified as independent risk factors for graft and patient survival. Preservation with HTK can be regarded as an established alternative to preservation with University of Wisconsin (UW) solution when preservation times are short. Definitive assessment of the efficacy of preservation solutions requires further prospective randomised clinical trials that compare HTK and UW.

Anatomic basis of right renal vein extension for cadaveric kidney transplantation.

OBJECTIVES: The right renal vein (RRV) may be difficult to anastomose in right cadaveric kidney transplantation, especially in obese recipients in whom iliac vessels are deep. In this study, gain of length and feasibility in the presence of vascular variations obtained with three common techniques of renal vein augmentation--clamshell (CS), transverse closure of the inferior vena cava (TC), and cava conduit (CC)--were analyzed and compared to the Carrel-patch technique. METHODS: The renal vasculature and the inferior vena cava of 119 cadavers were accurately dissected and measured, and the vascular variations documented. The CS technique augmented the RRV at most by one fourth, the TC by one half the diameter of the inferior vena cava, and the CC by the length of the infrarenal inferior vena cava. An experienced transplant surgeon evaluated the situs for the feasibility of the techniques. RESULTS: The variations found were multiple veins (right, 23%; left, 6.7%), a retroaortal left vein (2.5%), a renal collar (6%); and multiple arteries (right, 20.2%; left, 19%). The RRV length varied from 21 to 71 mm, and the right renal artery (RRA) length varied between 44 and 111 mm. The RRA/RRV ratios ranged between 3.4 and 1.2. The achieved gains of length were 129% with the CS (possible in 81.5%), 190% with the TC (possible in 62.4%), and 388.4% with the CC (possible in 80.7%). CONCLUSIONS: The median RRV is one half the RRA in length so that length augmentation could be an advantage. Anatomic variations limit the choice of technique. Overall, augmentation was possible in 80%; the CS technique seldom resulted in a length equal to that of the RRA, the TC was the most susceptible to variations, and the CC always surpassed the RRA in length. Harvesting the RRV en bloc with the inferior vena cava enables the surgeon to best adapt donor vessels to the recipient's anatomy.

Acute colonic pseudo-obstruction (Ogilvie's-syndrome) and pneumatosis intestinalis in a kidney recipient patient.

Acute colonic pseudo-obstruction (Ogilvie's syndrome) is a clinical entity characterized by massive nontoxic dilatation of the colon in the absence of mechanical obstruction and is associated with increased morbidity and mortality in the immunosuppressed patient. We present a case of a kidney transplant recipient developing a life-threatening condition with acute colonic pseudo-obstruction associated with radiologic findings of a linear pneumatosis intestinalis (PI). Urgent laparotomy and resection of the dilated cecum, colon ascendens and transversum was performed because of bowel necrosis with multiple serosal defects. Stool cultures and special stains for microorganisms were all negative, and there was no evidence for viral or fungal infection. The patient was discharged 31 days after transplantation with normal renal function. In conclusion, this steroid-induced ileus (pseudo-obstruction) is a potentially malignant early form of colonic dysmotility rarely reported in transplant recipients. Awareness and early recognition of the condition are critical for a successful outcome. Colonoscopic decompression can achieve reversal of colonic dilatation in most cases, but in some patients prophylactic laparotomy is indicated for prevention of the catastrophic consequences of perforation.

Resection of hilar cholangiocarcinomas: pivotal prognostic factors and impact of tumor sclerosis.

The well-known poor prognosis of proximal bile duct cancer is due to its unfortunate anatomical location and its late diagnosis. Successful tumor resection, which is considered to be optimal treatment, depends on many factors. Eighty-eight patients suffering from proximal bile duct cancer underwent surgical exploration at our institution between 1977 and 1998. In 37 patients the tumor was resectable; in the remaining 51 patients exploratory laparotomy or a palliative operation was performed. The median survival after tumor resection was 18.6 months, but median survival after a palliative procedure or an exploratory laparotomy was only 3.4 months (p < 0.001). A curative R0 resection was possible in 11 patients, an R1 resection was performed in 22 patients, and 4 patients had an R2 resection. The median survival rate after R0 resection was 83.6 months, 12.3 months after R1 resection, and 2.7 months after R2 resection (p < 0.001). Survival after resection in patients with negative lymph nodes (n = 30) was significantly longer than in those with positive lymph nodes (n = 7) (p = 0.022). Grade of tumor sclerosis tended to have an influence on resectability rate (p = 0.076). The pattern of tumor growth was without statistical influence. Multivariate analysis revealed resection (p < 0.001) as the only significant prognostic marker for patient survival. Radical resection is the only therapy that provides a chance for long-term survival, with sclerosis of the cancer tending to have an influence on univariate analysis.