The Role of Surgical Expertise and Surgical Access in Retroperitoneal Sarcoma Resection - A Retrospective Study.

Background: Retroperitoneal sarcoma (RPS) is a rare disease often requiring multi-visceral and wide margin resections for which a resection in a sarcoma center is advised. Midline incision seems to be the access of choice. However, up to now there is no evidence for the best surgical access. This study aimed to analyze the oncological outcome according to the surgical expertise and also the incision used for the resection. Methods: All patients treated for RPS between 2007 and 2018 at the Department of Visceral Surgery and Medicine of the University Hospital Bern and receiving a RPS resection in curative intent were included. Patient- and treatment specific factors as well as local recurrence-free, disease-free and overall survival were analyzed in correlation to the hospital type where the resection occurred. Results: Thirty-five patients were treated for RPS at our center. The majority received their primary RPS resection at a sarcoma center (SC = 23) the rest of the resection were performed in a non-sarcoma center (non-SC = 12). Median tumor size was 24 cm. Resections were performed via a midline laparotomy (ML = 31) or flank incision (FI = 4). All patients with a primary FI (n = 4) were operated in a non-SC (p = 0.003). No patient operated at a non-SC received a multivisceral resection (p = 0.004). Incomplete resection (R2) was observed more often when resection was done in a non-SC (p = 0.013). Resection at a non-SC was significantly associated with worse recurrence-free survival and disease-free survival after R0/1 resection (2 vs 17 months; Log Rank p-value = 0.02 respectively 2 vs 15 months; Log Rank p-value < 0.001). Conclusions: Resection at a non-SC is associated with more incomplete resection and worse outcome in RPS surgery. Inadequate access, such as FI, may prevent complete resection and multivisceral resection if indicated and demonstrates the importance of surgical expertise in the outcome of RPS resection.

Primordial GATA6 macrophages function as extravascular platelets in sterile injury.

Most multicellular organisms have a major body cavity that harbors immune cells. In primordial species such as purple sea urchins, these cells perform phagocytic functions but are also crucial in repairing injuries. In mammals, the peritoneal cavity contains large numbers of resident GATA6+ macrophages, which may function similarly. However, it is unclear how cavity macrophages suspended in the fluid phase (peritoneal fluid) identify and migrate toward injuries. In this study, we used intravital microscopy to show that cavity macrophages in fluid rapidly form thrombus-like structures in response to injury by means of primordial scavenger receptor cysteine-rich domains. Aggregates of cavity macrophages physically sealed injuries and promoted rapid repair of focal lesions. In iatrogenic surgical situations, these cavity macrophages formed extensive aggregates that promoted the growth of intra-abdominal scar tissue known as peritoneal adhesions.

Effect of oxygen-producing suture material on hypoxic colonic anastomoses in an experimental model.

Background: Anastomotic leak remains a significant cause of morbidity and mortality after colorectal surgery. Among multiple risk factors considered, hypoxia-ischaemia is considered to be a primary cause of intestinal anastomotic leakage. The aim of this experimental study was to assess safety, usability for surgical tasks, and efficacy of a newly developed oxygen-producing suture material in the healing of colonic anastomoses under critical conditions. Methods: An oxygen-producing suture material was produced that is capable of releasing oxygen directly into the surrounding tissue. Off-the-shelf sutures loaded with calcium peroxide nano-crystals and covered with poly(d,l-lactide-co-glycolide) were assessed in vitro and in a rat model of hypoxic colonic anastomosis. Results: In vitro assessment showed that these sutures can increase oxygen levels in a hypoxic environment. Potential oxygen byproducts did not seem to have a negative impact on the viability of intestinal cells. The use of oxygen-producing sutures in vivo resulted in increased tissue oxygen saturation, measured by visible light spectroscopy, and increased mechanical stability of the anastomosis. Conclusion: Oxygen-producing suture material increased tissue oxygen saturation and mechanical stability of colonic anastomosis in a rat model.

Antecedentes: Las fugas anastomóticas siguen siendo una causa importante de morbilidad y mortalidad después de la cirugía colorrectal. Entre los múltiples factores de riesgo, se considera que la hipoxia/isquemia es una de las causas principales de la fuga anastomótica intestinal. El objetivo de este estudio experimental fue evaluar, en condiciones críticas, la seguridad, la facilidad de uso en los procedimientos quirúrgicos y la eficacia en la cicatrización de la anastomosis de colon de un material de sutura productor de oxígeno recientemente desarrollado. Métodos: Hemos producido un material de sutura productor de oxígeno que es capaz de liberar oxígeno directamente en el tejido circundante. Las suturas disponibles en el mercado cargadas con nanocristales de peróxido de calcio (calcium peroxide, CPO) y cubiertas con ácido poliláctico coglicólico (PLGA) se evaluaron in vitro y en un modelo de rata de anastomosis hipóxica de colon. Resultados: La evaluación in vitro mostró que estas suturas pueden aumentar los niveles de oxígeno en un ambiente hipóxico, y que los posibles subproductos de oxígeno no parecen tener un impacto negativo en la viabilidad de las células intestinales. El uso de suturas productoras de oxígeno in vivo causó una elevada saturación de oxígeno en el tejido medida por espectroscopia de luz visible, así como un aumento en la estabilidad mecánica de las anastomosis. Conclusión: El material de sutura productor de oxígeno aumenta la saturación de oxígeno en los tejidos y la estabilidad mecánica de la anastomosis de colon en un modelo de rata.

Surgical treatment strategies for hepatic alveolar echinococcosis.

Alveolar echinococcosis is a severe and rare helminthic disease with increasing incidence in endemic regions. Herein, available evidence on curative surgical and potential palliative approaches was reviewed. Such strategies have to be applied in the context of available resources in different health-care systems. Complete resection followed by adjuvant therapy remains the only curative treatment available. Curative surgery is performed by open or laparoscopic approach depending on the extent of the disease and the experience of the surgical team. Palliative resections are typically not indicated, because the availability of endoscopic treatments of biliary complications and long-term benzimidazoles represent efficient alternatives to surgery. Liver transplantation as an alternative to palliative surgery has not been shown to be superior to long-term conservative therapy. Immunosuppressive therapy might additionally contribute to fatal disease recurrence after transplantation.

Elevated incidence of alveolar echinococcosis in immunocompromised patients.

INTRODUCTION: Recent experimental data has revealed that the course of alveolar echinococcosis (AE) depends on adaptive immunity. For this study, we aimed to analyze the incidence and outcome of AE in immunocompromised humans. MATERIAL AND METHODS: Retrospective analysis of 131 patients with a median age of 54 years treated for AE between 1971 and 2017 at a Swiss tertiary referral Centre. Fifty-two percent were females and 65 patients (50%) were diagnosed incidentally. Fourteen patients (16%) were operated on laparoscopically. Overall, median follow-up was 48 months. RESULTS: New diagnoses have increased fourfold in immunocompetent and tenfold in immunocompromised patients in the past decade (p ≤ 0.005). Forty-one patients (31.3%) had co-existing or previous immunosuppressive conditions including 16 malignancies (36%), 11 auto-immune diseases or immunosuppressive therapies (31%), 5 infectious diseases (11%), 4 chronic asthma conditions (9%), 2 previous transplantations (4%) and 4 other immunocompromising conditions (9%). Serum levels of anti-Em18, -Em2 and -EgHF antibodies were neither associated with immunocompetence at diagnosis nor during follow-up, but significantly decreased after treatment with benzimidazole (n = 43) or surgery (n = 88) in all patients. Adjuvant therapy for ≥1 year (p = 0.007) with benzimidazole and resection status (R0) (p = 0.002) were both correlated with recurrence-free survival. Survival at 5 and 10 years after surgery was 97% and 94%, respectively, and after conservative treatment 91% and 73%, respectively. Curative surgery (p = 0.014) and immunocompetence (p = 0.048) correlated significantly with overall survival. CONCLUSION: The incidence of human AE has increased over the last 2 decades with surgical interventions resulting in excellent outcomes. We have observed an association of immunosuppressive conditions with both incidence and survival of AE eventually justifying the implementation of a screening program for patients at risk in endemic regions.

Externalized Percutaneous Stent Versus Internal Double J Stent: Short- and Long-term Complications After Kidney Transplantation.

BACKGROUND: In patients undergoing kidney transplantation, ureteral stents are an established technique to reduce major urologic complications such as leakage and stenosis of the ureter. However, the best technique for ureteral stenting remains unclear. The aim of this study was to compare the outcome of percutaneous ureteral stents (PS) with internal double J stents (JJS) after kidney transplantation. METHODS: All patients undergoing kidney transplantation between 2005 and 2014 were retrospectively analyzed. After excluding patients <18 years old, patients without stenting, and patients who underwent multiorgan transplantation, a total of 308 patients were included in the study. Two consecutive cohorts of patients were compared. In the cohort transplanted between 2005 and 2010, stenting was routinely performed using PS (216 patients), and in the second cohort, those transplanted after 2011, stenting was routinely performed using JJS (92 patients). For ureteric anastomosis, the Lich-Grégoir technique was used in all patients. RESULTS: There was no statistical difference in postoperative urinary tract infections (P = .239) between the 2 cohorts. In patients with PS, the incidence of major urologic complications (11.6% vs 3.3%; P = .018), vesicoureteral reflux (14.3% vs 2.2%; P < .001), and urologic reinterventions (14.4% vs 5.4%; P = .031) was significantly higher when compared with JJS patients. Multivariable logistic regression revealed increased incidence of major urologic complications (odds ratio [OR] 3.66, 95% confidence interval [CI] 1.07-12.55, P = .039) and vesicoureteral reflux (OR 5.29, 95% CI 1.21-23.10, P = .027) in patients with PS compared with JJS. CONCLUSION: Stenting of ureterovesical anastomosis using JJS is associated with reduced complications compared with PS after kidney transplantation.

Accuracy assessment of a potential clinical use of navigation-guided intra-operative liver metastasis brachytherapy-a planning study.

For patients with inoperable liver metastases, intra-operative liver high dose-rate brachytherapy (HDR-BT) is a promising technology enabling delivery of a high radiation dose to the tumor, while sparing healthy tissue. Liver brachytherapy has been described in the literature as safe and effective for the treatment of primary or secondary hepatic malignancies. It is preferred over other ablative techniques for lesions that are either larger than 4 cm or located in close proximity to large vessels or the common bile duct. In contrast to external beam radiation techniques, organ movements do not affect the size of the irradiated volume in intra-operative HDR-BT and new technical solutions exist to support image guidance for intra-operative HDR-BT. We have retrospectively analyzed anonymized CT datasets of 5 patients who underwent open liver surgery (resection and/or ablation) in order to test whether the accuracy of a new image-guidance method specifically adapted for intra-operative HDR-BT is high enough to use it in similar situations and whether patients could potentially benefit from navigation-guided intra-operative needle placement for liver HDR-BT.

Mesh-augmented versus direct abdominal closure in patients undergoing open abdomen treatment.

BACKGROUND: Open abdomen (OA) may be required in patients with abdominal trauma, sepsis or compartment syndrome. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) is a widely used approach for temporary abdominal closure to close the abdominal wall. However, this method is associated with a high incidence of re-operations in short term and late sequelae such as incisional hernia. The current study aims to compare the results of surgical strategies of OA with versus without permanent mesh augmentation. METHODS: Patients with OA treatment undergoing vacuum-assisted wound closure and an intraperitoneal onlay mesh (VAC-IPOM) implantation were compared to VAWCM with direct fascial closure which represents the current standard of care. Outcomes of patients from two tertiary referral centers that performed the different strategies for abdominal closure after OA treatment were compared in univariate and multivariate regression analysis. RESULTS: A total of 139 patients were included in the study. Of these, 50 (36.0%) patients underwent VAC-IPOM and 89 (64.0%) patients VAWCM. VAC-IPOM was associated with reduced re-operations (adjusted incidence risk ratio 0.48 per 10-person days; CI 95% = 0.39-0.58, p < 0.001), reduced duration of stay on intensive care unit (ICU) [adjusted hazard ratio (aHR) 0.53; CI 95% = 0.36-0.79, p = 0.002] and reduced hospital stay (aHR 0.61; CI 95% = 0.040-0.94; p = 0.024). In-hospital mortality [22.5 vs 18.0%, risk difference - 4.5; confidence interval (CI) 95% = - 18.2 to 9.3; p = 0.665] and the incidence of intestinal fistula (18.0 vs 22.0%, risk difference 4.0; CI 95% = -10.0 to 18.0; p = 0.656) did not differ between the two groups. In Kaplan-Meier analysis, hernia-free survival was significantly increased after VAC-IPOM (p = 0.041). CONCLUSIONS: In patients undergoing OA treatment, intraperitoneal mesh augmentation is associated with a significantly decreased number of re-operations, duration of hospital and ICU stay and incidence of incisional hernias when compared to VAWCM.

Quality of life after hepatic resection.

BACKGROUND: Long-term quality of life (QoL) after liver resection is becoming increasingly important, as improvements in operative methods and perioperative care have decreased morbidity and mortality rates. In this study, postoperative QoL after resection of benign or malignant liver tumours was evaluated. METHODS: In this single-centre study, QoL was evaluated prospectively using the European Organisation for Research and Treatment of Cancer QLQ-C30 and the liver-specific QLQ-LMC21 module before, and 1, 3, 6 and 12 months after open or laparoscopic liver surgery. RESULTS: Between June 2007 and January 2013, 188 patients (130 with malignant and 58 with benign tumours) requiring major liver resection were included. Global health status was no different between the two groups before and 1 month after liver resection. All patients showed an improvement in global health status at 3, 6 and 12 months after surgery. Patients with benign tumours had better global health status than those with malignant tumours at these time points (P < 0·001, P = 0·002 and P = 0·006 respectively). Patients with benign disease had better physical function scores (P = 0·011, P = 0·025 and P = 0·041) and lower fatigue scores (P = 0·001, P = 0·002 and P = 0·002) at 3, 6 and 12 months than those with malignant disease. CONCLUSION: This study confirmed overall good QoL in patients undergoing liver resection for benign or malignant tumours, which improved after surgery. Benign diseases were associated with better short- and long-term QoL scores.

Effect of music on surgical hand disinfection: a video-based intervention study.

Surgical hand disinfection (SHD) is likely to be influenced by various factors. The aim of this study was to evaluate the effect of listening to music on the duration of SHD. In total, 236 SHD procedures were recorded on video. The duration of SHD exceeded 2min in both the intervention group and the control group, with background music unable to achieve an increase in the time spent scrubbing. However, listening to music reduced the proportion of very short scrub times (<90s) from 17% to 9% (P=0.07). The following four factors increased mean scrub time significantly: female sex; lower staff seniority; scrubbing hands in groups; and use of a stopwatch. Although the improvement observed did not reach significance, it is suggested that background music may be useful for the 10% of healthcare workers who perform very short scrubs.

[The Psychometric Properties of the Abdominal Surgery Impact Scale]. / Übersetzung und Testung der Abdominal Surgery Impact Scale.

Background: Assessment of quality of life immediately after abdominal surgery is critical; however, potent tools that provide timely information about patient health are required in order to assess and improve postoperative quality of care. Interestingly, such assessment scales for early postoperative quality of life do not exist in German. The aim of this pilot study was to translate the English version of the "Abdominal Surgery Impact Scale" (ASIS) into German and to empirically test the German version. Methods: After the standardized translation, 30 German-speaking patients who had undergone visceral surgery (laparotomy) were recruited at the ward of the Bern University Hospital Visceral Surgery and Medicine. The internal consistency of the translated instrument (ASIS-D) was assessed on the third postoperative day; reliability, retest-reliability and construct validity were also assessed on the fifth postoperative day. Results: ASIS-D faithfully represented the content of the original version. Cronbach's α overall was 0.85 and for the 6 subscales 0.45-0.88. The overall score of retest-reliability was 0.57** and the construct validity was confirmed. Conclusion: The ASIS-D was shown to be reliable and valid even if other investigations are necessary. It provides specific insights into special postoperative symptoms such as wound pain and postoperative quality of sleep. After further tests, it might be suitable not only for capturing the short-term postal-surgical quality of life, but possibly also for evaluating nursing interventions.

Impact of case-relevant and case-irrelevant communication within the surgical team on surgical-site infection.

BACKGROUND: Surgical-site infections (SSIs) are the most common complications after surgery. An influence from talking and distractions during surgery on patient outcomes has been suggested, but there is limited evidence. The aim of this prospective observational study was to assess the relationship between intraoperative communication within the surgical team and SSI, and between intraoperative distractions and SSI. METHODS: This prospective observational study included patients undergoing elective, open abdominal procedures. For each procedure, intraoperative case-relevant and case-irrelevant communication, and intraoperative distractions were observed continuously on site. The influence of communication and distractions on SSI after surgery was assessed using logistic regressions, adjusting for risk factors. RESULTS: A total of 167 observed procedures were analysed; their mean(s.d.) duration was 4·6(2·1) h. A total of 24 SSIs (14·4 per cent) were diagnosed. Case-relevant communication during the procedure was independently associated with a reduced incidence of organ/space SSI (propensity score-adjusted odds ratio 0·86, 95 per cent c.i. 0·77 to 0·97; P = 0·014). Case-irrelevant communication during the closing phase of the procedure was independently associated with increased incidence of incisional SSI (propensity score-adjusted odds ratio 1·29, 1·08 to 1·55; P = 0·006). Distractions had no association with SSI. CONCLUSION: More case-relevant communication was associated with fewer organ/space SSIs, and more case-irrelevant communication during wound closure was associated with incisional SSI.

Significant lethality following liver resection in A20 heterozygous knockout mice uncovers a key role for A20 in liver regeneration.

Hepatic expression of A20, including in hepatocytes, increases in response to injury, inflammation and resection. This increase likely serves a hepatoprotective purpose. The characteristic unfettered liver inflammation and necrosis in A20 knockout mice established physiologic upregulation of A20 as integral to the anti-inflammatory and anti-apoptotic armamentarium of hepatocytes. However, the implication of physiologic upregulation of A20 in modulating hepatocytes' proliferative responses following liver resection remains controversial. To resolve the impact of A20 on hepatocyte proliferation and the liver's regenerative capacity, we examined whether decreased A20 expression, as in A20 heterozygous knockout mice, affects outcome following two-third partial hepatectomy. A20 heterozygous mice do not demonstrate a striking liver phenotype, indicating that their A20 expression levels are still sufficient to contain inflammation and cell death at baseline. However, usually benign partial hepatectomy provoked a staggering lethality (>40%) in these mice, uncovering an unsuspected phenotype. Heightened lethality in A20 heterozygous mice following partial hepatectomy resulted from impaired hepatocyte proliferation due to heightened levels of cyclin-dependent kinase inhibitor, p21, and deficient upregulation of cyclins D1, E and A, in the context of worsened liver steatosis. A20 heterozygous knockout minimally affected baseline liver transcriptome, mostly circadian rhythm genes. Nevertheless, this caused differential expression of >1000 genes post hepatectomy, hindering lipid metabolism, bile acid biosynthesis, insulin signaling and cell cycle, all critical cellular processes for liver regeneration. These results demonstrate that mere reduction of A20 levels causes worse outcome post hepatectomy than full knockout of bona fide liver pro-regenerative players such as IL-6, clearly ascertaining A20's primordial role in enabling liver regeneration. Clinical implications of these data are of utmost importance as they caution safety of extensive hepatectomy for donation or tumor in carriers of A20/TNFAIP3 single nucleotide polymorphisms alleles that decrease A20 expression or function, and prompt the development of A20-based liver pro-regenerative therapies.

In vitro rescue of FGA deletion by lentiviral transduction of an afibrinogenemic patient's hepatocytes.

BACKGROUND: Congenital afibrinogenemia is a rare inherited autosomal recessive disorder in which a mutation in one of three genes coding for the fibrinogen polypeptide chains Aα, Bß and γ results in the absence of a functional coagulation protein. A patient with congenital afibrinogenemia, resulting from an FGA homozygous gene deletion, underwent an orthotopic liver transplant that resulted in complete restoration of normal hemostasis. The patient's explanted liver provided a unique opportunity to further investigate a potential novel treatment modality. OBJECTIVE: To explore a targeted gene therapy approach for patients with congenital afibrinogenemia. METHODS AND RESULTS: At the time of transplant, the patient's FGA-deficient hepatocytes were isolated and transduced with lentiviral vectors encoding the human fibrinogen Aα-chain. FGA-transduced hepatocytes produced fully functional fibrinogen in vitro. CONCLUSIONS: Orthotopic liver transplantation is a possible rescue treatment for failure of on-demand fibrinogen replacement therapy. In addition, we provide evidence that hepatocytes homozygous for a large FGA deletion can be genetically modified to restore Aα-chain protein expression and secrete a functional fibrinogen hexamer.

Impact of team familiarity in the operating room on surgical complications.

BACKGROUND: The quality of surgical performance depends on the technical skills of the surgical team as well as on non-technical skills, including teamwork. The present study evaluated the impact of familiarity among members of the surgical team on morbidity in patients undergoing elective open abdominal surgery. METHODS: A retrospective analysis was performed to compare the surgical outcomes of patients who underwent major abdominal operations between the first month (period I) and the last month (period II) of a 6-month period of continuous teamwork (stable dyads of one senior and one junior surgeon formed every 6 months). Of 117 patients, 59 and 58 patients underwent operations during period I and period II, respectively, between January 2010 and June 2012. Team performance was assessed via questionnaire by specialized work psychologists; in addition, intraoperative sound levels were measured. RESULTS: The incidence of overall complications was significantly higher in period I than in period II (54.2 vs. 34.5 %; P = 0.041). Postoperative complications grade <3 were significantly more frequently diagnosed in patients who had operations during period I (39.0 vs. 15.5 %; P = 0.007), whereas no between-group differences in grade ≥3 complications were found (15.3 vs. 19.0 %; P = 0.807). Concentration scores from senior surgeons were significantly higher in period II than in period I (P = 0.033). Sound levels during the middle third part of the operations were significantly higher in period I (median above the baseline 8.85 dB [range 4.5-11.3 dB] vs. 7.17 dB [5.24-9.43 dB]; P < 0.001). CONCLUSIONS: Team familiarity improves team performance and reduces morbidity in patients undergoing abdominal surgery.

Discrete improvement in racial disparity in survival among patients with stage IV colorectal cancer: a 21-year population-based analysis.

PURPOSE: Recently, multiple clinical trials have demonstrated improved outcomes in patients with metastatic colorectal cancer. This study investigated if the improved survival is race dependent. PATIENTS AND METHODS: Overall and cancer-specific survival of 77,490 White and Black patients with metastatic colorectal cancer from the 1988-2008 Surveillance Epidemiology and End Results registry were compared using unadjusted and multivariable adjusted Cox proportional hazard regression as well as competing risk analyses. RESULTS: Median age was 69 years, 47.4 % were female and 86.0 % White. Median survival was 11 months overall, with an overall increase from 8 to 14 months between 1988 and 2008. Overall survival increased from 8 to 14 months for White, and from 6 to 13 months for Black patients. After multivariable adjustment, the following parameters were associated with better survival: White, female, younger, better educated and married patients, patients with higher income and living in urban areas, patients with rectosigmoid junction and rectal cancer, undergoing cancer-directed surgery, having well/moderately differentiated, and N0 tumors (p < 0.05 for all covariates). Discrepancies in overall survival based on race did not change significantly over time; however, there was a significant decrease of cancer-specific survival discrepancies over time between White and Black patients with a hazard ratio of 0.995 (95 % confidence interval 0.991-1.000) per year (p = 0.03). CONCLUSION: A clinically relevant overall survival increase was found from 1988 to 2008 in this population-based analysis for both White and Black patients with metastatic colorectal cancer. Although both White and Black patients benefitted from this improvement, a slight discrepancy between the two groups remained.

Gadoxetate uptake as a possible marker of hepatocyte damage after liver resection-preliminary data.

AIM: To determine the feasibility of evaluating surgically induced hepatocyte damage using gadoxetate disodium (Gd-EOB-DTPA) as a marker for viable hepatocytes at magnetic resonance imaging (MRI) after liver resection. MATERIAL AND METHODS: Fifteen patients were prospectively enrolled in this institutional review board-approved study prior to elective liver resection after informed consent. Three Tesla MRI was performed 3-7 days after surgery. Three-dimensional (3D) T1-weighted (W) volumetric interpolated breath-hold gradient echo (VIBE) sequences covering the liver were acquired before and 20 min after Gd-EOB-DTPA administration. The signal-to-noise ratio (SNR) was used to compare the uptake of Gd-EOB-DTPA in healthy liver tissue and in liver tissue adjacent to the resection border applying paired Student's t-test. Correlations with potential influencing factors (blood loss, duration of intervention, age, pre-existing liver diseases, postoperative change of resection surface) were calculated using Pearson's correlation coefficient. RESULTS: Before Gd-EOB-DTPA administration the SNR did not differ significantly (p = 0.052) between healthy liver tissue adjacent to untouched liver borders [59.55 ± 25.46 (SD)] and the liver tissue compartment close to the resection surface (63.31 ± 27.24). During the hepatocyte-specific phase, the surgical site showed a significantly (p = 0.04) lower SNR (69.44 ± 24.23) compared to the healthy site (78.45 ± 27.71). Dynamic analyses revealed a significantly lower increase (p = 0.008) in signal intensity in the healthy tissue compared to the resection border compartment. CONCLUSION: EOB-DTPA-enhanced MRI may have the potential to be an effective non-invasive tool for detecting hepatocyte damage after liver resection.

[Treatment practice in patients with isolated blunt splenic injuries. A survey of Swiss traumatologists]. / Die Behandlungspraxis bei Patienten mit isolierter stumpfer Milzverletzung. Eine Befragung der Schweizer Traumatologen.

BACKGROUND: The non-operative management (NOM) of blunt splenic injuries has gained widespread acceptance. However, there are still many controversies regarding follow-up of these patients. The purpose of this study was to survey active members of the Swiss Society of General and Trauma Surgery (SGAUC) to determine their practices regarding the NOM of isolated splenic injuries. MATERIALS AND METHODS: A survey of active SGAUC members with a written questionnaire was carried out. The questionnaire was designed to elicit information about personal and facility demographics, diagnostic practices, in-hospital management, preferred follow-up imaging and return to activity. RESULTS: Out of 165 SGAUC members 52 (31.5%) completed the survey and 62.8% of all main trauma facilities in Switzerland were covered by the sample. Of the respondents 14 (26.9%) have a protocol in place for treating patients with splenic injuries. For initial imaging in hemodynamically stable patients 82.7% of respondents preferred ultrasonography (US). In cases of suspected splenic injury 19.2% of respondents would abstain from further imaging. In cases of contrast extravasation from the spleen half of the respondents would take no specific action. For low-grade injuries 86.5% chose to admit patients for an average of 1.6 days (range 0-4 days) with a continuously monitored bed. No differences in post-discharge activity restrictions between moderate and high-grade splenic injuries were found. CONCLUSION: The present survey showed considerable practice variation in several important aspects of the NOM of splenic injuries. Not performing further CT scans in patients with suspected splenic injuries and not intervening in cases of a contrast extravasation were the most important discrepancies to the current literature. Standardization of the NOM of splenic injuries may be of great benefit for both surgeons and patients.

Three-dimensional vision enhances task performance independently of the surgical method.

BACKGROUND: Within the next few years, the medical industry will launch increasingly affordable three-dimensional (3D) vision systems for the operating room (OR). This study aimed to evaluate the effect of two-dimensional (2D) and 3D visualization on surgical skills and task performance. METHODS: In this study, 34 individuals with varying laparoscopic experience (18 inexperienced individuals) performed three tasks to test spatial relationships, grasping and positioning, dexterity, precision, and hand-eye and hand-hand coordination. Each task was performed in 3D using binocular vision for open performance, the Viking 3Di Vision System for laparoscopic performance, and the DaVinci robotic system. The same tasks were repeated in 2D using an eye patch for monocular vision, conventional laparoscopy, and the DaVinci robotic system. RESULTS: Loss of 3D vision significantly increased the perceived difficulty of a task and the time required to perform it, independently of the approach (P < 0.0001-0.02). Simple tasks took 25 % to 30 % longer to complete and more complex tasks took 75 % longer with 2D than with 3D vision. Only the difficult task was performed faster with the robot than with laparoscopy (P = 0.005). In every case, 3D robotic performance was superior to conventional laparoscopy (2D) (P < 0.001-0.015). CONCLUSIONS: The more complex the task, the more 3D vision accelerates task completion compared with 2D vision. The gain in task performance is independent of the surgical method.

Gender, age and ethnic aspects of analgesia in acute abdominal pain: is analgesia even across the groups?

BACKGROUND: Numerous studies have shown differences in pain perception between men and women, which may affect pain management strategies. AIM: Our primary aim was to investigate whether there are gender-based differences in pain management in patients admitted to our emergency department with acute, non-specific abdominal pain (NSAP). Our secondary aim was to evaluate if other factors influence administration of analgesia for patients admitted with NSAP. METHODS: From June 2007 to June 2008, we carried out a retrospective, gender-based, frequency-matched control study with 150 patients (75 consecutive men and 75 women) who presented with NSAP at our emergency department. Pain was documented using a numerical rating scale ('0' no pain, '10' most severe pain). A multinomial regression model was used to assess factors that might influence pain management. RESULTS: No statistically significant difference was seen between men and women with respect to pain management (P= 0.085). Younger patients were, however, more likely to receive weaker (P= 0.011) and fewer analgesics (P < 0.001). Patients with previous abdominal surgery (P= 0.012), known chronic pain conditions (P= 0.029) or relevant comorbidities (P= 0.048) received stronger analgesia. Nationality (P= 0.244), employment status (P= 0.988), time of admission (P= 0.487) and known psychiatric illness (P= 0.579) did not influence pain management. CONCLUSIONS: No statistically significant gender-dependent differences in pain management were observed. However, younger patients received less potent analgesic treatment. There is no reason for certain groups to receive suboptimal treatment, and greater efforts should be made to offer consistent treatment to all patients.