[Technical aspects of pancreatoenteric anastomosis]. / Anastomosentechniken am Pankreas.

Advances in pancreatic surgery during the last two decades have resulted in significant improvement of patient outcome leading to mortality rates as low as 3-5% following Whipple's procedure in specialized centers. However, morbidity remains considerably high at 30-50% which is primarily caused by insufficiency of the pancreato-enteric anastomosis which becomes manifested as a pancreatic fistula. Therefore, numerous studies have aimed to identify the ideal pancreatic anastomosis. The most frequently used techniques comprise end-to-end duct-to-mucosa pancreaticojejunostomy, end-to-end invagination pancreatojejunostomy as well as end-to-side pancreatogastrostomy. In randomized controlled trials the frequency of pancreatic fistulas ranges between 4% and 20% depending on the particular technique. However, no single technique was able to demonstrate a significant superiority in several independent studies. The heterogeneity of definitions for pancreatic fistula represents the main problem in evaluating and comparing clinical studies on pancreato-enteric anastomosis. However, recent clinical trials applied commonly accepted definitions for pancreatic fistula as well as precise study endpoints to address the question of the ideal pancreatic anastomosis.

Complicated sigmoid diverticulitis--Hartmann's procedure or primary anastomosis?

INTRODUCTION: Diverticular disease of the colon is a common condition in developed countries. For perforated diverticulitis Hartmann's procedure is a safe and quick treatment option. But intestinal restoration needs further interventions. This leads to high complication rates and cost. Therefore a critical evaluation of surgical treatment options is necessary. METHODS: During a period of 18 months 88 patients underwent surgical resection for diverticulitis. Forty patients had emergency surgery. Among those a primary anastomosis was performed in 21 patients. The other 19 patients had interval colostomy. Among 21 patients with primary anastomosis major complications occurred in two patients, vs. twelve in patients with Hartmann's operation (p = 0.03). In the Hartmann group eight patients had major general complications, vs. one patient in the group with primary anastomosis (p = 0.06). The mean hospital stay was 38 days after Hartmann's procedure, vs. 13 days for patients with primary anastomosis (p < 0.01). CONCLUSION: In emergency surgery for complicated diverticulitis primary anastomosis is not associated with an increased postoperative morbidity. A primary anastomosis reduces the need for further surgical interventions and complex re-operations. Thus, an overall reduction of morbidity, cost, complication rate and hospital stay is possible. Therefore this technique is advantageous for patients and hospitals.

[Prevention and management of postoperative complications in pancreatic surgery]. / Prävention und Management von postoperativen Komplikationen in der Pankreaschirurgie.

During the last decades mortality after pancreatic surgery has decreased. Nevertheless, morbidity still remains at a high level. It is important to differentiate between pancreatic head resection and distal pancreatectomy. The complication rates of both procedures are high, however the need for intervention to manage perilous complications is higher after pancreaticoduodenectomy. The main complications after pancreatic surgery are delayed gastric emptying (DGE), pancreatic fistula, anastomotic leakage and bleeding. The current literature on the different techniques of pancreatic anastomosis and pancreatic remnant closure, respectively, does not show consistent results or an advantage for a particular technique. The same is true for the perioperative use of somatostatin and its analogues for the prevention of complications. It is widely agreed that the smooth texture of the pancreas and a small pancreatic duct < 3 mm are risk factors for pancreatic leakage or fistula. Today, the trend is more for conservative or interventional therapy for pancreatic fistulas or intraabdominal collections with, e. g., persisting intraoperative drain, TPN, somatostatin therapy or CT-controlled drainage. The opinions about the optimal treatment of the dreaded postoperative bleeding differ significantly in the surgical community. There are early and late bleedings and the management varies from endoscopical treatment or angiographic coiling / stenting to revision. Nevertheless, every bleeding is accompanied with high mortality. Here we present a review of literature and demonstrate the various strategies for the management of complications.

[Appendicitis in the elderly. CRP value as decision support for diagnostic laparoscopy]. / Altersappendizitis. CRP-Wert als Entscheidungshilfe für eine diagnostische Laparoskopie.

BACKGROUND: The diagnosis of acute appendicitis in the elderly bears many pitfalls due to a broad range of differential diagnoses and uncommon clinical presentation. This may result in late detection of appendicitis leading to poor outcome. The aim of this study was to examine the characteristics of appendicitis in elderly patients in order to facilitate early diagnosis. MATERIALS AND METHODS: All patients who underwent appendectomy in our institution were prospectively recorded over a 30 month period. Data on patient's age (>60 years versus < or =60 years), clinical findings, the inflammatory parameters leucocytes and C-reactive protein (CRP) and histological-findings (perforated versus non-perforated) were collected. Statistical analysis was carried out by ROC analysis, chi(2) and t-tests. RESULTS: In the examination period 403 patients underwent appendectomy and 11.2% (n=45) were older than 60 years. These patients were characterized by significantly more frequent perforations compared to those patients < or =60 years (35.6% versus 7.0%, p< or =0.05), peritonitis (42.2% versus 9.5%, p< or =0.05), conversion to open surgery (23% versus 5%, p< or =0.005), longer postoperative hospital stay (9.2 days versus 4.3 days, p< or =0.05) and a higher complication rate (28.9% versus 3.6%, p< or =0.005). CRP values in patients >60 years were on average 123.2 mg/l and significantly higher than in patients < or =60 years (35.5 mg/l, p< or =0.005). The ROC analysis resulted in a CRP cut-off value of 101.9 mg/l for patients >60 years for the existence of a perforation with a specificity of 72.4% and a sensitivity of 81.3% (AUC 0.811). CONCLUSIONS: The CRP value showed a strong correlation with respect to the grade of inflammation and perforation. In conclusion, elderly patients with symptoms of appendicitis and a CRP value higher than 102 mg/l should undergo early diagnostic laparoscopy.

[Distal pancreatectomy: radical or spleen-preserving?]. / Pankreaslinksresektion: Wann radikal, wann milzerhaltend?

During recent years, spleen-preserving distal pancreatectomy (SPDP) has broadened the operative spectrum in pancreatic surgery. The rationale for spleen-preserving procedures comprises prevention of overwhelming postsplenectomy infection syndrome (OPSI) and possibly an advantage regarding reduced carcinogenesis. Although there are no prospective randomized trials, SPDP and distal pancreatectomy with splenectomy (DPSx) seem to be equivalent in terms of blood loss, operative time, mortality and frequency of reoperation. Concerning pancreatic fistulas and other major surgical complications, current data from the literature are conflicting. Long-term effects of SPDP, such as development of gastric varices due to portal hypertension, are still insufficiently investigated. However, SPDP should always be considered in patients with benign tumors of the pancreatic tail and chronic pancreatitis. Spleen-preserving distal pancreatectomy can also be combined with resection of the splenic vessels (DPSx-SVx) if the blood supply of the spleen via the small gastric vessels and the gastro-epoploic arcade is sufficient. In the presence of malignant tumors, DPSx is necessary for oncological reasons.

[Interdisciplinary ethics consultation on the surgical intensive care unit]. / Das interdisziplinäre Ethikkonsil auf der operativen Intensivstation.

BACKGROUND: An interdisciplinary ethics consultation (EC) on the intensive care unit (ICU) can be requested by the clinical team as a result of a subjective assessment of the patient's situation. The aim of this study was to objectify the initiation of EC by means of the SOFA score and to examine its impact on the clinical course. PATIENTS AND METHODS: Over a two-year period, all patients receiving an EC on the ICU were recorded. Age, hospital stay and mortality were compared with ICU patients who did not receive EC. SOFA score values of EC patients at the time of admission to the ICU and the time of EC were compared. Furthermore, the effect of different EC decisions (maximisation/limitation of treatment) on hospital stay and mortality were defined. RESULTS: EC was carried out in 52 of a total of 764 patients (6.8 %). Age (76.6 years; range: 40-99), hospital stay (20.5 days; range: 5-286) and ICU mortality (92.3 %) were significantly higher in EC patients compared to patients without EC (68.3 years; range: 10-100; p