MIS approach for diverticula of the esophagus.

PURPOSE: diverticula of the esophagus represent a rare pathological entity. Distinct classifications of the disease imply different surgical concepts. Surgery should be reserved for symptomatic patients only. Minimally invasive surgery (MIS) for treatment of esophageal diverticula encompasses rigid and flexible intraluminal endoscopy, thoracoscopy and laparoscopy. We here give an overview on the pathogenesis of esophageal diverticula, the minimally invasive surgical techniques for treatment and the recent literature. Additionally, we present our own experience with MIS for midthoracic diverticula. METHODS: we analyzed the cases of patients who underwent MIS for midthoracic diverticula with regard to preoperative symptoms, perioperative and follow-up data. RESULTS: three patients (two female, one male, age 79, 78 and 59 years) received thoracoscopic surgery for midthoracic diverticula. All patients reported of dysphagia and regurgitation. In two patients pH-investigation showed pathological reflux but manometry was normal in all patients. Operating time was 205, 135 and 141 minutes. We performed intraoperative intraluminal endoscopy in all patients. There were no intraoperative complications and although no surgical complications occured postoperatively one patient developed pneumonia which advanced to sepsis and lethal multi organ failure. Upon follow-up the two patients did not have recurrent diverticula or a recurrence of previous symptoms. CONCLUSIONS: surgery for diverticular disease of the esophagus has been associated with high rates of morbidity and mortality. Despite the lethal non-surgical complication we encountered, with regard to recent publications minimally invasive apporaches to treat patients with symptomatic esophageal diverticula entail lower rates of complications with better long term results in comparison to open surgery.

[Complicated skin and soft tissue infections]. / Komplizierte Haut- und Weichgewebsinfektionen.

Skin and soft tissue infections are common diseases. The spectrum ranges from slight furuncles to severe necrotizing soft tissue infections. Grampositive bacteria account for 70-80 % of cases as causative organisms. Diagnostics include rapid evaluation of locally limited or diffuse spreading extent of the disease. In complicated skin and soft tissue infections, surgical intervention with debridement and necronectomy is indicated. Necrotizing skin and soft tissue infections call for programmed redebridement. If systemic signs of inflammation are present (fever > 38 degrees C, leukocytosis, CRP elevation) or significant comorbidity exists, application of antibiotics is indicated. The prognosis in operatively treated patients is dependent on the time of surgical intervention.

[The value of different lavage treatment patterns in diffuse peritonitis]. / Die Wertigkeit der Spülbehandlung bei der Peritonitis.

The treatment of severe diffuse peritonitis is still associated with a mortality of up to 50 %. Particularly the postoperative peritonitis shows high mortality rates due to septic organ failures. The aim of surgical treatment is the definitive source control followed by removal of fibrin and abdominal lavage of contaminants and infectious fluids. Dependent on the severity of the peritoneal reaction, further treatment consists of primary abdominal closure and relaparotomy on demand, programmed lavage or laparostomy respectively. Septic complications have to be treated by intensive care medicine.

[Surgical management of peripheral arterial disease. Operative methods and results]. / Die chirurgische Behandlung der arteriellen Verschlusskrankheit. Operationsmethoden und Ergebnisse.

Various operative and interventional methods are available to treat patients with peripheral arterial disease (PAD). The selection of the appropriate therapy should be made after a careful review of the patient's general condition, the morphology of the arterial occlusion, the risk of possible complications, and the likelihood of long-term success for each type of treatment. The different procedures complement one another in their technical possibilities and their risk profile The combination of surgical and interventional methods offers new therapeutic possibilities. The different surgical procedures and their long-term outcome are presented in this publication.

[Current perioperative antibiotic prophylaxis]. / Neues in der perioperativen antibiotischen Prophylaxe.

Perioperative antimicrobial prophylaxis (PAP) leads to a reduction in surgical site infections. The aim of PAP is adequate serum and tissue concentrations of the antimicrobial drug in the field of operation. The antibiotic must be effective against the expected pathogens during the operation, safe, and have the fewest possible side effects. The indication for PAP should take into account the risks of the operative procedure and especially the individual risk factors of the patient. Depending on pharmacokinetics, the antibiotic should be administered within 60 min before incision. After closure of the wound, further applications of the antibiotic drug have no influence on the infection rate of the wound but do increase the side effects (resistance, CDT colitis, allergy). Operation-specific recommendations according to guidelines of the Paul Ehrlich Society are given.

Current status of laparoscopic therapy of colorectal cancer.

Laparoscopic colorectal resections offer several benefits postoperatively, including minimal impairment of gastrointestinal and pulmonary function, less immunosuppression, shorter hospital stay and improved reconvalescence. Since the introduction of laparoscopic surgery for the therapy of curable colorectal cancer, some concern was voiced in terms of oncologic radicality, the issue of port-site metastases and tumor cell distribution. However, the clinical reality has demonstrated that oncologic radicality is equivalent to open surgery, and the incidence of port-site metastases is not increased when compared to wound recurrence at the laparotomy site. Focusing on colon and rectum, various indications of laparoscopic-endoscopic 'rendezvous' procedures exist including laparoscopic-assisted endoscopic transluminal resection, endoscopic-assisted wedge or anatomical resections, and, finally, intraoperative tumor location by colonoscopy to achieve oncologic resection margins in laparoscopic curative resections. In terms of colorectal curative resections, long-term results provide level I evidence that laparoscopic surgery for colon cancer is oncologically adequate and can be performed with equivalent morbidity and mortality rates when compared to conventional surgery. In terms of rectal cancer, no level I evidence is available. However, short-term data from experienced centers do not report inferior oncologic outcome particularly related to laparoscopic total mesorectal excision.

[Fungi in the mediastinum: rare, but relevant]. / Pilze im Mediastinum: Selten aber relevant.

Fungal infections of the mediastinum are rare. There are five forms to be differentiated: (i) hematogenous fungal infection of the mediastinum after fungemia; (ii) postoperative fungal infection after cardiosurgical sternotomy; (iii) as special form of a descending necrotizing fasciitis; (iv) infection of the mediastinum per continuitatem; (v) fungal infection of the posterior mediastinum after esophageal perforation. In the surgical department, University of Schleswig-Holstein, Campus Lübeck, five patients with a fungal mediastinitis were treated during a period of 10 years. Three patients suffered from a descending mediastinitis, one patient from a fungal infection after pseudarthrosis of the sternum (postoperatively after cardiosurgery). The section results of one other patient with pulmonary aspergillosis showed a complete invasion of the mediastinum by Aspergillus fumigatus.

[Fungal infections in patients with necrotizing pancreatitis: risk-factors, incidence, therapy]. / Pilzinfektion bei hämorrhagisch-nekrotisierender Pankreatitis: Risikofaktoren, Inzidenz, Therapie.

Haemorraghic necrotizing pancreatitis may lead to a serious disease with multi-organ failure, which is to be treated with intensive care. Patients suffering from infected necrosis are usually operated (necrosectomy). By doing this, it is possible to get a microbiological analysis. The most common virulent species are Enterobacteriaceae. According to the literature, fungal infections appear in 15-30% of the cases. Since 1996, 73 patients were treated surgically in our department. A number of 50 patients (68,5%) developed a fungal infection during the course of the disease. The mortality rate was 62%.