Surgical management of complicated rectovaginal fistulas and the role of omentoplasty.

BACKGROUND: Patients with rectovaginal fistulas have a significantly reduced quality of life. Therefore, surgical therapy is often needed even in palliative cases. The aim of the present study was to perform an analysis of the results of the different treatment options available today. METHODS: We performed a retrospective analysis of patients who underwent treatment for rectovaginal fistulas at the Department of Surgery, University of Schleswig-Holstein, Campus Luebeck and the Department of Surgery, WKK Heide, between January 2000 and September 2016. Complication and recurrence rate were retrospectively evaluated. The median follow-up period was 13 months (range 3-36 months). RESULTS: During the observation period, 58 patients underwent surgery (53 curative, 5 palliative) for rectovaginal fistulas. All patients who underwent curative surgery had an omentoplasty, and 39 of 53 (73.6%) patients underwent a resection. Thirty of 39 (77.0%) resections were low anterior resection, while non-continence-preserving resection included subtotal colectomy (n = 5), pelvic exenteration (n = 2), and proctectomy (n = 2). The fistulas were mainly secondary to inflammatory bowel disease (n = 18) or diverticulitis (n = 13), while 19 fistulas were a complication of different cancers or precancerous lesions. The median follow-up time was 13 months (range 6-36). Four patients (6.9%) had fistula recurrence (3 recurrences after low anterior resection, 1 after primary fistula closure). The mortality rate was 6.9% (n = 4). CONCLUSIONS: Non-resecting methods should be used only in uncomplicated fistulas. Rectovaginal fistulas secondary to inflammatory or malignant disease mostly require extensive therapy. Omentoplasty is effective for the treatment of both high and low rectovaginal fistulas.

Laparoscopic resection of right colon cancer-a matched pairs analysis.

PURPOSE: Laparoscopy for colorectal cancer resection bares early post-operative advantages and results in equal oncologic long-term outcome. However, data on laparoscopic right hemi-colectomy is scarce. Aim of the present study was to analyze a well selected collective of patients with right-sided colon cancer treated open and laparoscopically with regard to peri-operative and long-term outcome. METHODS: We analyzed all patients who underwent right-sided hemi-colectomy for colon cancer between January 1996 and March 2013. Data was extracted from our prospective database. Inclusion criteria were tumor localization in the ascending colon, oncologic resection, histology of an adenocarcinoma, tumors UICC I-III, and R0 resection. Exclusion criteria were multiple malignancies including colon, emergency operation, adenoma or pT0 status, and UICC IV. For the matched pairs approach between patients undergoing laparoscopic (LAP) or open (OPEN) surgery, the parameters age, UICC stage, tumor grading, and sex were applied. RESULTS: A total of 188 patients was included in the analysis with n = 94 in both the LAP and the OPEN group. Some peri-operative results demonstrated advantages for laparoscopy including median return to liquid (p < 0.0001) and solid diet (p = 0.008), median length of ICU stay (p < 0.0001), and median length of hospital stay (p = 0.022). No significant differences were revealed for complication rates, rates of anastomotic leakage, or 30-day mortality. Lymph node yield was identical. Also, no differences in oncologic long-term outcome were detected. Rates for local recurrence were 4.3 and 2.0 %. CONCLUSION: This matched pairs analysis verifies peri-operative advantages of laparoscopy explicitly for the sub-group of CRC patients undergoing right-sided hemi-colectomy in comparison to open surgery while demonstrating equivalent oncologic long-term results.

Laparoscopy for bowel obstruction--a contradiction? Results of a multi-institutional survey in Germany.

PURPOSE: The purpose of the present study was to investigate on the acceptance and frequency of laparoscopic surgery for the management of acute and chronic bowel obstruction in a general patient population in German hospitals. METHODS: To receive an authoritative opinion on laparoscopic treatment of bowel obstruction in Germany, a cross-sectional online study was conducted. We designed an online-based survey, supported by the German College of Surgeons (Berufsverband der Deutschen Chirurgen, BDC) to get multi-institutional-based data from various level providers of patient care. RESULTS: Between January and February 2014, we received completed questionnaires from 235 individuals (16.7 %). The participating surgeons were a representative sample of German hospitals with regard to hospital size, level of center size, and localization. A total of 74.9 % (n = 176) of all responders stated to use laparoscopy as the initial step of exploration in expected bowel obstruction. This procedure was highly statistically associated with the frequency of overall laparoscopic interventions and laparoscopic experience. The overall conversion rate was reported to be 29.4 %. CONCLUSIONS: This survey, investigating on the use of laparoscopic exploration or interventions in bowel obstruction, was able to show that by now, a majority of the responding surgeons accept laparoscopy as an initial step for exploration of the abdomen in the case of bowel obstruction. Laparoscopy was considered to be at least comparable to open surgery in an emergency setting. Furthermore, data analysis demonstrated generally accepted advantages and disadvantages of the laparoscopic approach. Indications for or against laparoscopy are made after careful consideration in each individual case.

[CAMIC Recommendations for Surgical Laparoscopy in Non-Obstetric Indications during Pregnancy]. / CAMIC-Empfehlungen zur chirurgischen Laparoskopie aus nicht geburtshilflicher Indikation während der Schwangerschaft.

In the operative surgical primary care, the laparoscopic surgical technique has firmly established itself in recent years. Meanwhile, in the normal population over 90 % of all cholecystectomies and over 80 % of all appendectomies are performed in a minimally invasive manner. The proven benefits of the laparoscopic surgical technique, compared with conventional open surgery, are a comparatively rapid early postoperative recovery with early resumption of the general physical and occupational activity. As these benefits are equally applicable for necessary interventions during pregnancy, in recent years laparoscopy has become the preferred treatment for non-obstetric indications in the gravid patient. Overall, it can be assumed that such interventions have to be performed in approximately 2 % of all pregnant patients. Numerous studies have proven here that the use of laparoscopic techniques, in particular for the expectant mother, is safe and not associated with an increased risk. On the other hand, the current pregnancy makes necessary an adapted approach to the solution of surgical problems to ensure the protection of the unborn child. On the basis of currently available data situation, recommendations are formulated which can be used as a decision-making support for a variety of clinical situations.

Hydraulic architecture and tracheid allometry in mature Pinus palustris and Pinus elliottii trees.

Pinus palustris Mill. (longleaf pine, LL) and Pinus elliottii Engelm. var. elliottii (slash pine, SL) frequently co-occur in lower coastal plain flatwoods of the USA, with LL typically inhabiting slightly higher and better-drained microsites than SL. The hydraulic architecture and tracheid dimensions of roots, trunk and branches of mature LL and SL trees were compared to understand their role in species microsite occupation. Root xylem had higher sapwood-specific hydraulic conductivity (k(s)) and was less resistant to cavitation compared with branches and trunk sapwood. Root k(s) of LL was significantly higher than SL, whereas branch and trunk k(s) did not differ between species. No differences in vulnerability to cavitation were observed in any of the organs between species. Across all organs, there was a significant but weak trade-off between water conduction efficiency and safety. Tracheid hydraulic diameter (D(h)) was strongly correlated with k(s) across all organs, explaining >73% of the variation in k(s). In contrast, tracheid length (L(t)) explained only 2.4% of the variability. Nevertheless, for trunk xylem, k(s) was 39.5% higher at 20 m compared with 1.8 m; this increase in k(s) was uncorrelated with D(h) and cell-wall thickness but was strongly correlated with the difference in L(t). Tracheid allometry markedly changed between sapwood of roots, trunks and branches, possibly reflecting different mechanical constraints. Even though vulnerability to cavitation was not different for sapwood of roots, branches or the trunks of LL and SL, higher sapwood to leaf area ratio and higher maximum sapwood-specific hydraulic conductivity in roots of LL are functional traits that may provide LL with a competitive advantage on drier soil microsites.

[A favourite adversary: "classic long-term psychoanalysis". Commentary on Rief and Hofmann's "Psychoanalysis should be rescued. By all means?"]. / Geliebtes Feindbild "klassische Langzeitpsychoanalyse". Kommentar zu Rief und Hofmann "Die Psychoanalyse soll gerettet werden. Mit allen Mitteln?"

Rief and Hofmann (2009, Nervenarzt 80:593-597) harshly criticise the meta-analysis on the effectiveness of long-term psychodynamic psychotherapy (LTPP) by Leichsenring and Rabung (2008, JAMA 300(13):1551-1565). They find fault with the inclusion of naturalistic studies in addition to randomised clinical trials. Furthermore, they criticise the heterogeneity of the treatments included and the disorders studied. They suspect that a number of RCTs of LTPP with negative results for LTPP have been done and not been published. This paper comments on the following issues: the strict determination of RCTs is scientifically outdated and in order to investigate the effectiveness of psychotherapy naturalistic studies have to be included; the heterogeneity of studies included in meta-analysis as well as the heterogeneity of the patients studied reflect clinical reality, which is the purpose of effectiveness studies. The accusation of repressing results of LTPP RCTs is unsustainable. All in all, the meta-analysis by Leichsenring and Rabung was done accurately, and the results were controlled for by separate analyses of single subgroups. Therefore, their study does provide evidence of the effectiveness of long-term psychodynamic psychotherapy for patients with complex mental disorders.

[Dissection of the superior mesenteric artery: a rare cause of abdominal pain]. / Dissektion der Arteria mesenterica superior als Ursache abdomineller Schmerzen.

HISTORY: A previously healthy 47-year-old man had suffered from intermittent subacute abdominal pain for six weeks. He had no significant past medical history except of smoking (30 pack years). INVESTIGATIONS: Physical examination and laboratory tests were unremarkable. Sonography and endoscopy showed no pathological findings. Eventually contrast-enhanced computed tomography revealed dissection of the superior mesenteric artery and an additional angiography showed a false aneurysm. TREATMENT AND COURSE: Because of the extended dissection thrombarterectomy was preferred to percutaneous stent placement. Five months later the patient was free of symptoms and continues to take 100 mg aspirin daily. CONCLUSIONS: Although spontaneous visceral artery dissection is uncommon, awareness of this event is crucial for diagnosis and therapy to prevent hemorrhage and potential bowel infarction. This case highlights the importance of computed tomography in the work-up of nonspecific abdominal pain.

[Incisional hernia repair: sublay or intraperitoneal onlay mesh (IPOM)?]. / Versorgung von Narbenhernien: Sublay- oder Intra-Peritoneale Onlay-Mesh (IPOM)-Technik?

The last decade has brought new technical developments to incisional hernia repair. Agreement has been achieved that tension-free hernia repair using prostheses reduces recurrence rates significantly. Currently, discussion focusses on laparoscopic (intraperitoneal onlay mesh = IPOM) versus open (sublay) approach, and on the question as to which mesh should be used. We have evaluated publications of the last years comparing the IPOM and the sublay techniques. All studies concern small cohorts and only short follow-up times. Nevertheless, in a descriptive analysis both techniques are associated with low recurrence rates (< 5 %). Furthermore, it seems that laparoscopic repair leads to a better quality of life and reduced total hospital costs. None of the available materials can be described as the "ideal mesh", so far. Due to the quality of the available studies, the question concerning the best approach and the best mesh cannot be answered sufficiently yet. For these decisions, prospective, randomised studies are urgently needed.

[Total videoendoscopic thyroid resection by the axillobilateral breast approach. Operative method and first results]. / Total-videoendoskopische Strumaresektion via "axillobilateral breast approach". Operative Technik und erste Ergebnisse.

BACKGROUND: The axillobilateral breast approach (ABBA) is a procedure allowing thyroid resection without scarring at the neck. We operated on a series of 26 patients with this technique. METHOD: Via incisions at the edge of the mamilla and axilla, trocars are placed subcutaneously under the platyma. Dissection is performed bluntly and with an ultrasonographic scalpel under videoscopic control. The procedure itself corresponds to conventional surgery. The specimen is removed through the axillary trocar. RESULTS: Twenty-six female patients underwent thyroid resection using the ABBA technique. Subtotal resection was performed in 24. Mean operation times were 111 min (unilateral) and 187 min (bilateral). In none of these cases was conversion necessary. One transient recurrent laryngeal nerve palsy and one paresis of the arm plexus were found postoperatively. CONCLUSION: In selected patients the ABBA technique is feasible and safe with the mandatory radicalness. The primary aim of this method is the cosmetic result.

Effect of fibroids on fertility in patients undergoing assisted reproduction. A structured literature review.

OBJECTIVE: The aim of this study is to evaluate the current data to understand the impact of intramural leiomyomata on pregnancy outcome in assisted reproduction. PATIENTS AND METHODS: In this review, articles were found by means of computerized Medline and Cochrane Library search using the key words uterine myomata, leiomyomata, fibroids, implantation, pregnancy, infertility and in vitro fertilization. Limitations were English, human, 1990-2002. Inclusion criteria were pregnancy data on in vitro fertilization, intramural myomata with no cavitary distortion and control groups without myomas for each patient with a myoma. RESULTS: There was a significant negative impact on implantation rate in the intramural myomata groups versus the control groups, 16.4 vs. 27.7% OR 0.62 (0.48-0.8). The delivery rate per transfer cycle was also significantly lower (myomata vs. control), 31.2 vs. 40.9% OR 0.69 (0.50-0.95). CONCLUSION: Our study supports the notion that patients with intramural fibroids have a lower implantation rate per cycle. The studies did not shed new light on the size of intramural myomata that could affect the outcome. In previous failed in vitro fertilization cycles, microsurgical removal of myomata must be considered.

Pulsed, laser-induced holographic coupling gratings for waveguides made of cross-linkable polymers.

We report a simple and efficient laser-pulse technique for producing surface-relief gratings in polymer waveguides. The gratings are created in the non-cross-linked sample areas of waveguides by exposure to the interference pattern of frequency-doubled Nd:YAG laser pulses in a dual-beam interferometer. Since light does not affect the cross-linked portions of the samples, our technique is particularly appropriate for channel waveguides created by selective bleaching and/or cross linking.