Computerized Medical Evidence-Based Decision Assistance System "MEBDAS®" improves in-hospital outcome after pancreatoduodenectomy for pancreatic cancer.

BACKGROUND: Indication for pancreatoduodenectomy for pancreatic cancer can be challenging. Wrong decisions in indication processes lead to significant health impairments. Computerized decision support systems can take over parts of decision-making processes, making them more accurate. MEBDAS® is a decision-supporting software that predicts outcomes of proposed treatments. AIM: to determine the decision concordance between MEBDAS® and multidisciplinary tumour board (MTB) and the impact of MEBDAS® on in-hospital outcome at different indication thresholds. METHODS: 126 patients with pancreatoduodenectomy from a high-volume university hospital were included. Outcome indicators were in-hospital mortality, Comprehensive Complication Index (CCI®), therapy-related loss of "Quality-Adjusted-Life-Day" (QALD-loss) and prognostic gain of treatment-related "Quality-Adjusted-Life-Year" (QALY-gain). RESULTS: The concordance of decisions was 94.4% at the indication threshold of 0. By raising the indication threshold to 1 year, the concordance decreased to 0%, the in-hospital-mortality dropped from 2.52% to 0%, the CCI® decreased from 26.47 to 13.90, the therapy-related QALD-loss declined from 21.53 to 16.22 days and the prognostic QALY-gain increased from 0.374 to 0.906 years. At IT = 0.250 years, the concordance was 61.11% and differences between MTB and MEBDAS®-group were highly significant (p < 0.001) for all outcome parameters: mortality (3.97% vs. 1.30%), CCI® (28.96 vs. 18.29), therapy-related QALD-loss (24.41 vs. 15.19 days) and QALY-gain (0.351 vs. 0.501 years). CONCLUSION: MEBDAS® decisions are superior to those of MTB in terms of in-hospital-outcome. The inclusion of MEBDAS® in decision procedure makes the indication more accurate and reduces morbidity and mortality. In addition, MEBDAS® can increase patients' competence by involving them in decision-making process.

Comparison of conservative versus surgical therapy for acute appendicitis with abscess in five German hospitals.

INTRODUCTION: The aim of this study was to evaluate the effectiveness of initially conservative therapy compared to immediate appendectomy for acute appendicitis with abscess in terms of medical and economic outcomes. METHODS: Of all the patients treated for appendicitis from January 2009 to December 2017 in five German hospitals, 240 were included in the study. Fifty-three patients received conservative (CON) and 195 patients received surgical (SUR) therapy as initial treatment. RESULTS: Length of stay was similar (12.5 days in CON vs. 13.3 days in SUR, p = 0.530). Readmission rate was higher in the conservative group (54.7% vs. 6.2%, p < 0.001). The majority (53.7%) of the 41 operations in CON group were appendectomies (22 procedures), 1 (4.5%) of them was in the first hospital stay because of persisting symptoms, 21 (95.5%) after a recovery interval. Seven (33.3%) of the recovery appendectomies were performed due to persisting or recurrent symptoms and 14 (66.7%) due to the request of patient. Twenty-one patients (39.6%) in the CON group did not need surgery. The rates of complication-related operations per patient (0.04 versus 0.58, p < 0.001), conversions of surgical technique (1.9% vs. 34.9%, p = 0.0287), and extended resections (1.9% vs. 31.3%, p < 0.001) were higher in SUR group. Furthermore, morbidity, hospital costs, and loss in quality of life were significantly higher in the surgical group (17.0% vs. 66.2%, p < 0.001; € 5044 vs. € 8457, p < 0.001, and 4.3 days vs. 7.5 days, p < 0.001, CON vs. SUR). CONCLUSION: Initially, conservative treatment for acute appendicitis with abscess is preferable to immediate surgical treatment in reduction of morbidity, hospital costs, and loss in quality of life.

[Management of soft tissue infections in the region of the extremities and the trunk]. / Management von Weichgewebeinfektionen im Extremitäten- und Stammbereich.

Skin and soft tissue infections (SSTI) are amongst the most common bacterial infections in humans. SSTI have a broad range of aetiology, clinical manifestation and severity. The outcome may be spontaneous resolution or on the other end sepsis with lethal outcome. Useful classifications are those which differentiate SSTI according to urgency of surgical intervention. The definitive diagnosis should be made by the clinical picture of the lesion and the condition of the patient. The key to successful treatment of many severe necrotizing soft tissue infections is based on early detection and prompt surgical debridement. This procedure has to be followed by an optimal wound management. From the early beginning of treatment an adequately calculated antibiotic treatment is mandatory. At the end of the treatment the wound has to be closed by an aesthetic scar with high mechanical load capacity.

[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.

Anastomotic leakage following low anterior resection: results of a standardized diagnostic and therapeutic approach.

BACKGROUND AND AIMS: This study analyzed the results of a standardized approach in anastomotic leakage following low anterior resection for rectal cancer without performance of a protective ileostomy during the primary operation. PATIENTS AND METHODS: The study included all 306 patients with rectal cancer electively undergoing low anterior resection with retroperitonealization of the anastomosis over 9 years. The diagnostic procedure for anastomotic leakage included serum laboratory investigations and abdominal CT together with contrast enema. Minor leakages, i.e., small leakages and pelvic abscess, were treated with rectoscopic lavage and/or CT-guided drainage of the abscess, respectively. Major leakage was defined as broad insufficiency with or without septicemia. Nonseptic patients were treated by ileostomy and rectoscopic treatment. In septic patients a revision of the anastomosis with loop ileostomy was performed. RESULTS: Anastomotic leakage was diagnosed in 30 patients (overall 9.8%; 12 major, 18 minor leakages). Common clinical signs were pelvic pain and fever. No patient developed a peritonitis. The most accurate diagnostic instrument was CT (96.7%). CONCLUSION: Retroperitonealization appears to prevent peritonitis in patients with anastomotic leakage following low anterior resection. A differential treatment leads to good results in terms of mortality and anorectal function.

[Anticoagulation in the treatment of sepsis. Correction of microcirculation: a new approach manipulating endothelial cell function]. / Antikoagulation in der Sepsistherapie Korrektur der Mikrozirkulation oder Ansatz an der Endothelzellfunktion.

The correction of coagulation disorders is only one aspect in the treatment of severe sepsis. The metabolic changes caused by sepsis are complex. They include the interactions of hundreds of plasma proteins. The system works in balanced patterns of agonists and antagonists, not allowing a preference for single substances. The endothelial cell plays a key role in multiple defence functions in sepsis. Thus, future research in sepsis has to focus on the manipulation of endothelial cell function.

Hydro-jet assisted laparoscopic partial nephrectomy: initial experience in a porcine model.

PURPOSE: Hemostasis represents a challenge when performing laparoscopic partial nephrectomy. Hydro-Jet cutting is an advanced technology that has been used to create an ultra-coherent water force that functions like a sharp knife. In the surgical field, it has mainly been used for liver surgery and initial clinical experience with laparoscopic cholecystectomies has been favorable. This technique allowed selective parenchymal cutting with preservation of vessels and bile ducts. We describe a novel Hydro-Jet assisted dissection technique for laparoscopic partial nephrectomy in a porcine model. MATERIALS AND METHODS: Ten partial nephrectomies were performed in 5 pigs using a Muritz 1000 (Euromed Medizintechnik, A. Pein, Schwerin, Germany) Hydro-Jet generator. A thin stream of ultra coherent fluid is forced at a high velocity through a small nozzle. A modified probe allows both blunt dissection concomitantly with high-pressure water application. Coagulation can be applied via a bipolar thermoapplicator as needed. RESULTS: Laparoscopic partial nephrectomy was successful in all animals. Water-jet cutting through the parenchyma was virtually bloodless and preserved the vasculature and the collecting system. The vessels were then ligated or coagulated under direct vision. The continuous water flow established a bloodless operating field and a clear view for the surgeon. The mean dissection time and warm ischemia time were 45+/-9 and 17+/-3 minutes, respectively. CONCLUSIONS: This preliminary study supports the suitability of this technique for laparoscopic partial nephrectomy to improve hemostasis. The improved anatomical dissection and hemostasis may further decrease morbidity and operative time. Further studies are underway to compare this technique with laser coagulation for laparoscopic partial nephrectomy.

Hydro-jet dissection for laparoscopic nephrectomy: a new technique.

OBJECTIVES: The Hydro-Jet technique has been used to cut various industrial materials. In the medical field, this technique has been successfully used for selective dissection of the parenchyma of organs such as the liver. Recently, this technique was successfully used for laparoscopic cholecystectomy in humans. We developed a new Hydro-Jet probe and a technique of Hydro-Jet dissection during laparoscopic nephrectomy (LN) in a porcine model and compared the results with those of conventional laparoscopy. METHODS: Fourteen pigs underwent unilateral LN using the Hydro-Jet and a conventional LN on the contralateral side. A Muritz 1000 Hydro-Jet generator was used. An adjustable water pressure gauge allowed manual control up to a maximum of 30 atm, and coagulation was applied by way of a bipolar thermoapplicator. The bent end of the probe allowed both blunt dissection and concomitant high-pressure water application. Results were compared with regard to ease of anatomic dissection, complications, and operative time between the two techniques. RESULTS: LN was successful in all animals with no conversion to open surgery. The dissector allowed anatomic planes to be created in a relatively bloodless field, and continuous water flow allowed a clear view for the operator. The high-pressure stream resulted in excellent dissection of adventitial and soft tissue adjacent to vascular structures, with complete preservation of vessels and ureter for selective ligation. The dissection time was shortened (mean 27 minutes for the Hydro-Jet versus 40 minutes for the conventional technique). CONCLUSIONS: To our knowledge, we describe the first report of Hydro-Jet dissection for LN as an alternative to the conventional technique. The improved anatomic dissection may decrease complications. Moreover, shorter operating times were achieved, which may result in cost savings. Further studies in humans are necessary to investigate this technique.

Outcome of palliative urinary diversion in the treatment of advanced malignancies.

BACKGROUND: It is unclear whether palliative endourologic or percutaneous urinary diversion in the treatment of advanced cancer provides significant improvement in quality or duration of life. The purpose of this study was to evaluate survival and performance status after endourologic palliative urinary diversion in patients with advanced malignancy and to compare the results for different malignancies. METHODS: One hundred three patients with advanced malignancies underwent palliative urinary diversion (stent or nephrostomy) between 1986 and 1997. Ninety-two patients and 11 patients had bilateral and unilateral obstruction, respectively. Indications, complications, performance status after diversion, and survival for patients with different malignancies were identified and compared. A modified Karnofsky performance scale (KPS) was used for assessment of physical performance. A scale of 0-4 was used: 0) hospitalized until death; 1) bedridden at home, severe pain despite analgesia; 2) moderate disability, moderate pain despite analgesia; 3) mild disability, pain free with medication; and 4) normal. RESULTS: The mean age of patients was 68 years. The mean pre- and postoperative creatinine levels were 6 mg/dL and 3.3 mg/dL, respectively (P < 0.0001). The median survival and days of hospitalization were 112 and 45, respectively. The median postdiversion KPS score was 2 (range, 0-4), and 15% of patients never left the hospital. Overall, 51% required secondary percutaneous procedures, and 68.4% had complications (minor, 63%; major, 5.4%). CONCLUSIONS: Most patients with advanced cancers had poor performance status and survival after diversion. Eighty six percent had cancer-related symptoms despite the diversion. The average survival was 5 months, 50% of which was spent in the hospital. Primary endourologic procedures had a high failure rate, and additional procedures were required.

[Future of endoscopic surgery--German health law and minimal access surgery in an university hospital]. / Zukunft der endoskopischen Chirurgie--GSG-Probleme der MIC in einer Universitätsklinik.

The future development of endoscopic surgery depends on a medical and economical benefit. Medical advantages are demonstrated under professional conditions of practice in a retrospective study: endoscopical repair of the groin (TEP n = 44) vs. conventional Shouldice- (n = 17) and Lichtenstein (n = 19) method, laparoscopical hemifundoplication (n = 7) vs. traditional Nissen-Rosetti procedure (n = 3) and also resection of the sigmoid (lap. n = 26) vs. open surgery (n = 12). The overall hospital stay is shortend dramatically (primary hernia of the groin 8.8 (Shouldice) and 7.4 (Lichtenstein) vs. 3.1 days (TEP); (hemi-) fundoplication 11.1 (open) vs. 5.0 days (lap.); resection of sigmoid 19.0 (open) vs.17.0 days (lap.)) At the same time quality of care is held or improved. Comparison of real cost analysis revealed a better economical result (593-970 DM lower cost for TEP, 1.256 DM lower costs for lap. hemifundoplication, and 1.918 DM in case of lap. resection of sigmoid) for minimal-access-surgery (MAS), although particular costs for the endoscopic surgical procedure are increasing up to 100%, especially at the beginning (learning curve). The German payment-system does not regard the special conditions of MAS. There is no case-related payment for MAS due to the lower overall costs. Therefore the financial result is worse than for conventional treatment.

[Choice of vascular prosthesis material in treatment of infrarenal abdominal aortic aneurysms--initial results of a prospective randomized study]. / Zur Wahl des Gefässprothesenmaterials in der Behandlung infrarenaler Bauchaortenaneurysmen--erste Ergebnisse einer prospektiv-randomisierten Studie.

A prospective, randomized trial was performed to compare 40 patients with aortic aneurysms which were treated by implantation of dacron or PTFE prostheses. Follow up was done according to a defined protocol for 3 to 34 months postoperatively. There was observed neither graft failure, vascular occlusion, perigraft-reaction nor infection in any case. In one patient a periprosthetic haematoma occurred. During postoperative follow up in each group one patient died. There were no significant differences in dilation of the material in both groups. Dacron prostheses dilated to 28.2%, PTFE to 30.5%. In both groups the graft limb dilated more in comparison to the tube.

[In vitro evaluation of blood vessel prosthesis dilatation--Dacron and PTFE--a new measuring technique]. / In-vitro-Evaluation der Gefässprothesendilatation--Dacron und PTFE--eine neue Messmethode.

Dilatation is the most significant complication of prosthetic vascular grafts. It is suspected to be a nidus of other graft complications. There have been a few studies on in-vitro-dilatation of the prosthetic vascular grafts. This is due to the lack of an effective and simple method to measure the transverse dilatation of the graft. We developed a new simple, reliable and cost-effective technique to evaluate the in-vitro-dilatation of prosthetic vascular grafts. The dilatation behavior of two different types of grafts (dacron and PTFE) was observed and compared under static pressure between 0 and 300 mmHg. The in-vitro- dilatations of dacron and PTFE grafts were 6.9% and 8.4% respectively. Interestingly, the dilatation rate for PTFE vascular grafts is higher than the indicated rate in the literature.

[Clostridium myonecrosis as a sequelae of intramuscular injections--description of 3 fatal outcomes]. / Clostridiale Myonekrose als Folge intramuskulärer Injektionen--Beschreibung dreier fataler Verläufe.

In three fatal cases of clostridial myonecrosis, the following criteria were found: repeated intramuscular injections over several years with anti-inflammatory substances, delay in diagnosis in outpatient care, and following uncontrollable systemic septic complications, despite radical surgical treatment. Only early, aggressive surgical interventions can stop the rapid course of necrotizing soft-tissue infections.

[Quality assurance in surgical education]. / Qualitäts-Sicherung der chirurgischen Ausbildung (QuaSi).

UNLABELLED: The authors determine the reliability, validity and usefulness of the "QuaSi"-test, a test for the evaluation of surgical residents. METHODS: A test with multiple-choice (MC) answers was given to 47 surgeons, residents and interns of our surgery clinic. The reliability and validity of the tests were determined using statistical methods. RESULTS: The reliability of the test was very high. Performance varied significantly according to the level of training (postgraduate year). Surgeons performed best, then the senior residents; students and interns performed worst. CONCLUSION: The QuaSi-test is a highly reliable and valid examination that provides unique information about the performance of individual residents and the quality of postgraduate-training programs.

[Current status of laparoscopic colorectal surgery--a nationwide survey]. / Aktueller Stand der laparoskopischen kolorektalen Chirurgie--eine bundesweite Umfrage.

Fifteen percent of all departments of surgery in Germany have experience with laparoscopic colorectal operations. Of the overall number of 143,000 cases, only about 1% were performed minimally invasively.