[Fecal incontinence--a treatable problem!]. / Stuhlinkontinenz - ein behandelbares Problem!

Faecal incontinence has an enormous negative impact on patients' quality of life. Although the causes for faecal incontinence may vary (idiopatic, neurogenic, due to pregnancy, birth trauma or anorectal surgery), nowadays different therapies are available to cure or support patients after failure of conservative treatment. During the past decade, sacral nerve stimulation has shown to provide major improvement to patients with faecal incontinence. Regardless of the underlying disease (sphincter defect, diabetes mellitus, multiple sclerosis or idiopathic) the success rate of SNS lies over 80 %. The operation is performed under local anaesthesia and has a low morbidity rate. Not only its good long time results but also its cost effectiveness is based on scientific evidence.

Prospective randomized controlled trial of simulator-based versus traditional in-surgery laparoscopic camera navigation training.

BACKGROUND: Surgical residents often use a laparoscopic camera in minimally invasive surgery for the first time in the operating room (OR) with no previous education or experience. Computer-based simulator training is increasingly used in residency programs. However, no randomized controlled study has compared the effect of simulator-based versus the traditional OR-based training of camera navigation skills. METHODS: This prospective randomized controlled study included 24 pregraduation medical students without any experience in camera navigation or simulators. After a baseline camera navigation test in the OR, participants were randomized to six structured simulator-based training sessions in the skills lab (SL group) or to the traditional training in the OR navigating the camera during six laparoscopic interventions (OR group). After training, the camera test was repeated. Videos of all tests (including of 14 experts) were rated by five blinded, independent experts according to a structured protocol. RESULTS: The groups were well randomized and comparable. Both training groups significantly improved their camera navigational skills in regard to time to completion of the camera test (SL P = 0.049; OR P = 0.02) and correct organ visualization (P = 0.04; P = 0.03). Horizon alignment improved without reaching statistical significance (P = 0.20; P = 0.09). Although both groups spent an equal amount of actual time on camera navigation training (217 vs. 272 min, P = 0.20), the SL group spent significantly less overall time in the skill lab than the OR group spent in the operating room (302 vs. 1002 min, P < 0.01). CONCLUSION: This is the first prospective randomized controlled study indicating that simulator-based training of camera navigation can be transferred to the OR using the traditional hands-on training as controls. In addition, simulator camera navigation training for laparoscopic surgery is as effective but more time efficient than traditional teaching.

Sinusectomy for primary pilonidal sinus: less is more.

BACKGROUND: Wide excision with secondary wound healing is a frequently performed surgical procedure for pilonidal sinus. This intervention requires general anesthesia and has a wound healing time of up to several months with a long time to return to work. Sinusectomy of the track is an alternative operation. We here describe the long-term outcome of 257 patients operated between 2001 and 2010. METHODS: Sinusectomy consisted of a selective minimal invasive excision of the sinus after marking the track with methylene blue. Data were collected retrospectively with questionnaires and telephone survey. The main endpoints of the study were recurrence and time off work. RESULTS: With a median follow-up of 3.6 years, the overall recurrence rate was 7%. The median time to return to work was 7 days. The proportion of sinusectomies performed under local anesthesia increased from 59% to 93%. Consistently, the proportion of patients treated in 1-day surgery setting increased from 53% to 93%. One-day surgery had a clear impact on time to return to work in uni- and multivariate analyses (HR 1.959 {1.224, 3.137}, P = .005). CONCLUSION: Sinusectomy for pilonidal sinus can be performed with a low recurrence rate. An outpatient setting, including operations under local anesthesia, allows a fast return to normal activity. Sinusectomy should become the first choice for primary non-infected symptomatic pilonidal sinus.

Quality assessment in surgery: riding a lame horse.

BACKGROUND: Quality assessment in surgery is paramount for patients and health care providers. In our center, quality assessment is based on the recording of preoperative risk factors of each patient and a well-established grading system to track complications. Our prospective quality database is administrated by residents. However, the validity of such data collection is unknown. METHODS: To evaluate the validity of the recorded data, a specially trained study nurse audited our prospective quality database over a 6-month period. In the first 3 months, the audit was done in an undisclosed manner. Then, the audit was disclosed to the residents who were again subjected to a teaching course. Thereafter, the audit was continued in a disclosed manner for another 3 months, and data were compared between the 2 periods. Furthermore, we inquired about the strategies to assess surgical quality in 108 European medical centers. RESULTS: Surprisingly, residents failed to report most complications; 80% (164/206) and 79% (275/347; P = 0.27) of the negative postoperative events were not recorded during the first and the second period, respectively. When captured, however, grading of complications was correct in 97% of the cases. Moreover, comorbidities were incorrectly assessed in 20% of the patients in the first period and in 14% thereafter (P = 0.07). The survey disclosed that residents and junior staff are responsible of recording surgical outcome in 80% of the participating European centers. CONCLUSIONS: Recording of outcome by surgical residents is unreliable,despite active and focused training. Hence, surgery should be evaluated by dedicated personnel.

The Clavien-Dindo classification of surgical complications: five-year experience.

BACKGROUND AND AIMS: The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients', nurses', and doctors' perception. MATERIAL AND METHODS: Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication. RESULTS: We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test). CONCLUSIONS: This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as "minor or major" should be removed from the surgical literature.

Kinetics of D-dimer after general surgery.

D-dimers may be elevated after surgery. However, the kinetics of postoperative D-dimers remains unknown hampering the use of D-dimer testing in surgical patients with suspected venous thromboembolism. D-dimer levels were prospectively measured in 154 patients after general surgery at predefined time points (kinetics were determined in an initial cohort of 108 patients; for validation, these findings were applied to a second cohort of 46 patients). Clinical factors influencing the peak of D-dimers were analyzed using multivariate regression. Surgical operations were stratified based on severity (type I: not entering abdominal cavity; type II: intraabdominal; type III: retroperitoneal/liver surgery). D-dimer levels increased postoperatively reaching a peak on day 7. After type I surgery, peak D-dimer levels did not exceed normal range (300 ng/ml, 100-500). After type II procedures, peak D-dimer level was 1500 ng/ml (200-7800) and returned to normal values after 25 days (+/-14). Peak level was 4000 ng/ml (500-14 400) after type III surgery normalizing within 38 days (+/-11). Clearance of D-dimer was exponential after having reached the peak with 6.0% per day (95% confidence interval 4.8-7.1%). By this clearance, D-dimer values could be adequately predicted in the validation cohort after day 7 (r2 = 0.63). Peak D-dimer levels were independently influenced by the type of surgery (P < 0.001), the operation time (P < 0.001) and by preoperatively elevated D-dimer levels (P < 0.001). Based on this data, duration of postoperative D-dimer elevation after abdominal surgery is predictable. This study indicates for the first time when D-dimers may be used again in the diagnostic algorithm for venous thromboembolism exclusion after surgery in patients with low or moderate clinical probability.

Impact of clinical pathways in surgery.

BACKGROUND: One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities. METHOD: Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65). RESULTS: Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4 days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from euro 6,390 to euro 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from euro 1,810 to euro 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07). CONCLUSIONS: This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalization.

Clinical and morphologic correlation after stapled transanal rectal resection for obstructed defecation syndrome.

PURPOSE: The clinical and morphologic outcome of patients with obstructed defecation syndrome after stapled transanal rectal resection was prospectively evaluated. METHODS: Twenty-four consecutive patients (22 women; median age, 61 (range, 36-74) years) who suffered from obstructed defecation syndrome and with rectal redundancy on magnetic resonance defecography were enrolled in the study. Constipation was assessed by using the Cleveland Constipation Score. Morphologic changes were determined by using closed-configuration magnetic resonance defecography before and after stapled transanal rectal resection. RESULTS: After a median follow-up of 18 (range, 6-36) months, Cleveland Constipation Score significantly decreased from 11 (range, 1-23) preoperatively to 5 (range, 1-15) postoperatively (P = 0.02). In 15 of 20 patients, preexisting intussusception was no longer visible in the magnetic resonance defecography. Anterior rectoceles were significantly reduced in depth, from 30 mm to 23 mm (P = 0.01), whereas the number of detectable rectoceles did not significantly change. Complications occurred in 6 of the 24 patients; however, only two were severe (1 bleeding and 1 persisting pain requiring reintervention). CONCLUSIONS: Clinical improvement of obstructed defecation syndrome after stapled transanal rectal resection correlates well with morphologic correction of the rectal redundancy, whereas correction of intussusception seems to be of particular importance in patients with obstructed defecation syndrome.

A novel approach for treatment of sacrococcygeal pilonidal sinus: less is more.

BACKGROUND: The surgical management of sacrococcygeal pilonidal sinus (PS) is still a matter of discussion. Therapy ranges from complete wide excision with or without closure of the wound to excochleation of the sinus with a brush. In this paper, we introduce a novel limited excision technique. The aim of this study was to assess the morbidity and recurrence rate of this technique. MATERIALS AND METHODS: Limited excision consisted of a selective extirpation of the sinus after tagging the tract with methylene blue. Ninety-three consecutive patients, who underwent surgery between 2001 and 2004, were analyzed. The patients' survey was performed by mail questionnaire and telephone interview inquiring recurrence, time off work, and time to wound healing. RESULTS: Seventy-three percent of the patients were treated in an outpatient setting. With a median follow-up of 2 years, the recurrence rate was 5%. The median time off work was 2 weeks. The median wound healing time was 5 weeks. CONCLUSION: Limited excision for PS can be done in an outpatient setting with a low recurrence rate and short time off work.

Cationic long-chain ceramide LCL-30 induces cell death by mitochondrial targeting in SW403 cells.

Ceramides are sphingolipid second messengers that are involved in the mediation of cell death. There is accumulating evidence that mitochondria play a central role in ceramide-derived toxicity. We designed a novel cationic long-chain ceramide [omega-pyridinium bromide D-erythro-C16-ceramide (LCL-30)] targeting negatively charged mitochondria. Our results show that LCL-30 is highly cytotoxic to SW403 cells (and other cancer cell lines) and preferentially accumulates in mitochondria, resulting in a decrease of the mitochondrial membrane potential, release of mitochondrial cytochrome c, and activation of caspase-3 and caspase-9. Ultrastructural analyses support the concept of mitochondrial selectivity. Interestingly, levels of endogenous mitochondrial C16-ceramide decreased by more than half, whereas levels of sphingosine-1-phosphate increased dramatically and selectively in mitochondria after administration of LCL-30, suggesting the presence of a mitochondrial sphingosine kinase. Of note, intracellular long-chain ceramide levels and sphingosine-1-phosphate remained unaffected in the cytosolic and extramitochondrial (nuclei/cellular membranes) cellular fractions. Furthermore, a synergistic effect of cotreatment of LCL-30 and doxorubicin was observed, which was not related to alterations in endogenous ceramide levels. Cationic long-chain pyridinium ceramides might be promising new drugs for cancer therapy through their mitochondrial preference.

Central necrosis in isolated hypoxic human pancreatic islets: evidence for postisolation ischemia.

A variety of explanations have been provided to elucidate the requirement of the large islet mass that is essential for a successful treatment of patients with type I diabetes by intrahepatic transplantation. The purpose of this study was to investigate islet cell survival under the effect of prolonged hypoxia and/or nutrient withdrawal, which mimics posttransplantation environment of transplanted islets in the liver. We studied the influence of 24 h of hypoxia (1% O2) in intact isolated human and rat islets as well as the effect of combined oxygen/nutrient deprivation in a mouse insulinoma cell line (MIN6). In intact human islets, 24 h of hypoxia led to central necrosis combined with apoptotic features such as nuclear pyknosis and DNA fragmentation. In the course of hypoxic treatment, ultrastructural analysis demonstrated a gradual transition from an apoptotic to a necrotic morphology particularly pronounced in central areas of large islets. In MIN6 cells, on the other hand, hypoxia led to a twofold (p < 0.01) increase in caspase-3 activity, an indicator of apoptosis, but not to necrosis, as determined by release of lactate dehydrogenase (LDH). Only in combination with nutrient/serum deprivation was a marked increase in LDH release observed (sixfold vs. control, p < 0.01). We therefore conclude that, similar to MIN6 cells, central necrosis in isolated hypoxic islets is the result of the combined effects of hypoxia and nutrient/serum deprivation, most likely due to limited diffusion. Provided that transplanted islets undergo a similar fate as shown in our in vitro study, future emphasis will require the development of strategies that protect the islet graft from early cell death and accelerate the revascularization process.

Laparoscopic gastric bypass is superior to laparoscopic gastric banding for treatment of morbid obesity.

OBJECTIVE: To define whether laparoscopic gastric banding or laparoscopic Roux-en-Y gastric bypass represents the better approach to treat patients with morbid obesity. SUMMARY BACKGROUND DATA: Two techniques, laparoscopic gastric bypass or gastric banding, are currently widely used to treat morbid obesity. Since both procedures offer certain advantages, a strong controversy exists as to which operation should be proposed to these patients. Therefore, data are urgently needed to identify the best therapy. METHODS: Since randomized trials are most likely not feasible because of the highly different invasiveness and irreversibility of these procedures, a matched-pair design of a large prospectively collected database appears to be the best method. Therefore, we used our prospective database including 678 bariatric procedures performed at our institution since 1995. A total of 103 consecutive patients with laparoscopic gastric bypass were randomly matched to 103 patients with laparoscopic gastric banding according to age, body mass index, and gender. RESULTS: Both groups were comparable regarding age, gender, body mass index, excessive weight, fat mass, and comorbidites such as diabetes, heart disease, and hypertension. Feasibility and safety: All gastric banding procedures were performed laparoscopically, and one gastric bypass operation had to be converted to an open procedure. Mean operating time was 145 minutes for gastric banding and 190 minutes for gastric bypass (P < 0.001). Hospital stay was 3.3 days for gastric banding and 8.4 days for gastric bypass. The incidence of early postoperative complications was not significantly different, but late complications were significantly more frequent in the gastric banding group (pouch dilatation). There was no mortality in both groups. Efficiency: Body mass index decreased from 48.0 to 36.8 kg/m in the gastric banding group and from 47.8 to 31.9 kg/m in the gastric bypass group within 2 years of surgery. These differences became significant from the first postoperative month until the end of the follow-up (24 months). The gastric bypass procedure achieved a significantly better reduction of comorbidities. CONCLUSIONS: Laparoscopic gastric banding and laparoscopic gastric bypass are feasible and safe. Pouch dilatations after gastric banding are responsible for more late complications compared with the gastric bypass. Laparoscopic gastric bypass offers a significant advantage regarding weight loss and reduction of comorbidities after surgery. Therefore, in our hands, laparoscopic Roux-en-Y gastric bypass appears to be the therapy of choice.