RESUMEN

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.

Asunto(s)

Neoplasias/complicaciones , Epiplón/cirugía , Fístula Rectovaginal/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Colectomía , Colitis Ulcerosa/complicaciones , Colostomía , Enfermedad de Crohn/complicaciones , Diverticulitis/complicaciones , Femenino , Estudios de Seguimiento , Humanos , Laparoscopía , Persona de Mediana Edad , Exenteración Pélvica , Lesiones Precancerosas/complicaciones , Fístula Rectovaginal/etiología , Recurrencia , Estudios Retrospectivos

RESUMEN

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.

Asunto(s)

Colon/patología , Colon/cirugía , Neoplasias del Colon/cirugía , Laparoscopía , Adulto , Anciano , Anciano de 80 o más Años , Demografía , Femenino , Humanos , Masculino , Análisis por Apareamiento , Persona de Mediana Edad , Estadificación de Neoplasias , Análisis de Supervivencia

RESUMEN

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.

Asunto(s)

Encuestas de Atención de la Salud , Obstrucción Intestinal/epidemiología , Obstrucción Intestinal/cirugía , Laparoscopía , Abdomen/cirugía , Alemania/epidemiología , Tamaño de las Instituciones de Salud , Humanos

RESUMEN

INTRODUCTION: The gastric and duodenal perforations are a life-threatening complication of peptic ulcer disease with the indication for immediate surgical intervention. To which extent laparoscopy is a suitable method in an acute situation was examined in the present investigation. MATERIALS AND METHODS: The data of all patients within a period of 15 years (01/1996-12/2010) who were operated laparoscopically because of a perforated gastric or duodenal ulcer, were collected prospectively in terms of age, gender, localisation of perforation, diagnostics, symptoms, surgical procedures, intraoperative and postoperative complications and postoperative course, and were analysed retrospectively. RESULTS: During the observation period 45 patients were operated laparoscopically due to gastric or duodenal perforation. The median age at operation was 58 (18-91) years. An NSAID medication was present in 11 (24.4 %) patients. The perforation was juxtapyloric in 12 (26.7 %) patients, postpyloric in 10 (22.2 %) patients, one (2.2 %) patient in each small and greater curvature, in 18 (40.0 %) at the front and in three (6.7 %) patients on the rear wall. In two cases, previous surgical treatment in the upper abdomen was performed. After primary diagnostic laparoscopy, an indication for conversion was seen in 20 (44.4 %) patients. During laparoscopically completed operations simple suturing was done in 18/25 (72.0 %) patients and excision and suturing was performed in 7/25 (37.8 %) patients. After conversion simple suturing was observed in 7/20 (35.0 %) patients, whereas in 10/20 (50.0 %) patients excision and suturing was performed. 3/20 (15.0 %) patients underwent a resective operation. The median operative time was 105 (40-306) minutes and mean hospitalisation 11 (4-66) days. The ICU stay was in median 2 (0-37) days. Major complications were seen in 11 (24.4 %) patients, namely re-laparotomy (n = 7; 15.6 %) and haemorrhage (n = 4; 8.9 %). Minor complications were observed in 8 (17.8 %) of cases. The mortality rate was 11.1 % (n = 5). CONCLUSION: The laparoscopic treatment of gastric and duodenal perforations is a minimally invasive therapeutic option for the definitive treatment of this life-threatening disease. The indication for a laparoscopic approach has to be considered individually and depends to a decisive extent on the experience of the laparoscopic surgeon.

Asunto(s)

Úlcera Duodenal/cirugía , Urgencias Médicas , Laparoscopía , Úlcera Péptica Perforada/cirugía , Úlcera Gástrica/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Duodeno/cirugía , Femenino , Alemania , Humanos , Unidades de Cuidados Intensivos , Complicaciones Intraoperatorias/etiología , Complicaciones Intraoperatorias/mortalidad , Complicaciones Intraoperatorias/cirugía , Tiempo de Internación , Masculino , Persona de Mediana Edad , Tempo Operativo , Selección de Paciente , Úlcera Péptica Perforada/mortalidad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Reoperación , Estudios Retrospectivos , Estómago/cirugía , Úlcera Gástrica/mortalidad , Técnicas de Sutura , Adulto Joven

RESUMEN

BACKGROUND: In obstructive defecation syndrome (ODS) combinations of morphologic alterations of the pelvic floor and the colorectum are nearly always evident. Laparoscopic resection rectopexy (LRR) aims at restoring physiological function. We present the results of 19 years of experience with this procedure in patients with ODS. METHODS: Between 1993 and 2012, 264 patients underwent LRR for ODS at our department. Perioperative and follow-up data were analyzed. RESULTS: The female/male ratio was 25.4:1, mean age was 61.3 years (±14.3 years), and mean body mass index (BMI) was 25.2 kg/m(2) (±4.2 kg/m(2)). The pathological conditions most frequently found in combination were a sigmoidocele plus a rectocele (n = 79) and a sigmoidocele plus a rectal prolapse or intussusception (n = 69). The conversion rate was 2.3 % (n = 6). The mortality rate was 0.75 % (n = 2), the rate of complications requiring surgical re-intervention was 4.3 % (n = 11), and the rate of minor complications was 19.8 % (n = 51). Follow-up data were available for 161 patients with a mean follow-up of 58.2 months (±47.1 months). Long-term results showed that 79.5 % of patients (n = 128) reported at least an improvement of symptoms. In cases of a sigmoidocele (n = 63 available for follow-up) or a rectal prolapse II°/III° (n = 72 available for follow-up), the improvement rates were 79.4 % (n = 50) and 81.9 % (n = 59), respectively. CONCLUSIONS: LRR is a safe and effective procedure. Our perioperative results and long-term functional outcome strengthen the evidence regarding benefits of LRR in patients with an outlet obstruction. However, careful patient selection is essential.

Asunto(s)

Estreñimiento/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Recto/cirugía , Anciano , Algoritmos , Enfermedad Crónica , Comorbilidad , Estreñimiento/epidemiología , Estreñimiento/fisiopatología , Femenino , Humanos , Laparoscopía , Masculino , Persona de Mediana Edad , Recuperación de la Función , Prolapso Rectal/cirugía , Rectocele/epidemiología , Recto/fisiopatología , Técnicas de Sutura , Síndrome , Resultado del Tratamiento

RESUMEN

BACKGROUND: Spinal anesthesia causes sympathetic blockade which leads to changes in the local temperature of the skin surface due to hyperemia. MATERIALS AND METHODS: These changes in skin temperature were used in a newly developed method for estimating the level of analgesia. A total of 11 patients who were scheduled for surgical procedures of the lower extremities with symmetrical spinal anesthesia were included in the clinical study. By means of an electronic digital multi-channel body temperature measurement device with eight high precision temperature sensors placed on defined dermatomes, patient skin temperature was continuously measured at 2 s intervals and documented before, during and for 45 min after spinal anesthesia. Simultaneously, a neurological pin-prick test was carried on at regular intervals every 2 min on the defined dermatomes to calculate the correlation between the effects of analgesia and corresponding changes in skin temperature. RESULTS: The analyzed correlations showed that there is a minimum of 1.05°C temperature difference before and after spinal anesthesia especially on the lower extremities (foot, knee, inguinal) of patient dermatomes. The collected data of varying temperature differences were systematically evaluated using statistical software which led to a deeper understanding of the interdependency between temperature differences at different dermatomes. These interdependencies of temperature differences were used to develop a systematic analgesia level measurement algorithm. The algorithm calculates the skin temperature differences at specified dermatomes to find the accurate level of analgesia and also to find the forward and reverse progresses of analgesia. The developed mathematical method shows that it is possible to predict the level of analgesia up to an accuracy of 95% after spinal anesthesia. CONCLUSIONS: Therefore, it can be concluded that systematic processing of skin temperature data, collected at defined dermatomes can be used as a promising parameter for predicting surgical tolerance. The objective is to improve this experimental method with an extended patient population study.

Asunto(s)

Anestesia Raquidea/métodos , Temperatura Cutánea/fisiología , Algoritmos , Analgesia , Anestésicos Locales , Bupivacaína , Humanos , Extremidad Inferior/cirugía , Modelos Estadísticos , Monitoreo Intraoperatorio , Dimensión del Dolor , Valor Predictivo de las Pruebas , Probabilidad , Programas Informáticos , Procedimientos Quirúrgicos Operativos/efectos adversos , Termómetros

RESUMEN

Anorectal outlet obstruction constitutes one form of chronic constipation. Combinations of morphological alterations of the pelvis, the pelvic floor and the colorectum are nearly always evident. The goal of the diagnostic work-up is to identify those patients who will profit from a surgical intervention. Resection rectopexy aims at restoring the physiological anatomy thereby ameliorating the functional interaction of structures effected with the laparoscopic approach entailing all advantages of minimally invasive surgery. Besides a detailed description of the surgical technique used and an algorithm for indications to operate we present our results after 19 years of experience. Throughout this period, 264 laparoscopic resection rectopexies for outlet obstruction were performed. With a mean follow-up of 58.2 months the rate of improvement of obstructive symptoms was 79.5 % (n = 128 of 161 available for follow-up). Present studies suggest that (laparoscopic) resection rectopexy entails better results in comparison to non-resecting procedures and procedures with the implantation of allogenic material. Certainly, in order to achieve these results a correct patient selection and an expertise in laparoscopic surgery are essential. Both the perioperative and the functional results of our own collective fortify the advantages of laparoscopic resection rectopexy in patients with an outlet obstruction.

Asunto(s)

Estreñimiento/cirugía , Obstrucción Intestinal/cirugía , Laparoscopía/métodos , Trastornos del Suelo Pélvico/cirugía , Recto/cirugía , Anciano , Algoritmos , Competencia Clínica , Estreñimiento/etiología , Femenino , Humanos , Obstrucción Intestinal/etiología , Masculino , Persona de Mediana Edad , Posicionamiento del Paciente , Selección de Paciente , Diafragma Pélvico/cirugía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Prolapso Rectal/etiología , Prolapso Rectal/cirugía , Rectocele/etiología , Rectocele/cirugía , Reoperación , Estudios Retrospectivos , Síndrome , Resultado del Tratamiento

RESUMEN

INTRODUCTION: The rectovaginal fistula is a rare entity with heterogenic causality. Its genesis seems to predict the extent of operative treatment and the prognostic outcome. The aim of this study was to present different surgical techniques in the treatment of rectovaginal fistulas and their results in correspondence to the genesis. MATERIAL AND METHODS: Between 1 / 2000 and 1 / 2010, the data of patients with rectovaginal fistulas were collected. The retrospective analysis included biographic and anamnestic data as well as clinical parameters, general and specific complications and postoperative data. RESULTS: In a timespan of ten years 36 patients with rectovaginal fistulas were treated. The most common causes were inflammatory diseases (n = 21) and earlier surgical measures (n = 6). Moreover tumour-associated fistulas (n = 5) and fistulas with unknown genesis (n = 4) were seen. As surgical techniques anterior resection (n = 21), transrectal flap plasty (n = 7), subtotal colectomy (n = 3), pelvine exenteration (n = 2) and rectal exstirpation (n = 1) were used. The closure of the vaginal lesion was performed by single suture (n = 25), flap plasty (n = 6), transvaginal omental plasty (n = 2) and posterior vaginal plasty (n = 1). All patients were provided with an omental plasty to perform a safe division of the concerned regions. Patients with a low fistula ( < 6 cm) were treated with transperineal omental plasty. The median follow-up was 12 months (6 - 36). Within this timespan 6 patients suffered from major complications [ARDS, anastomosis insufficiency, postoperative bleeding, recurrence of fistula (n = 3)]. Three patients died in the postoperative period (cerebellar infarct, septic complication associated with Crohn's disease, multiorgan failure in tumour recurrence). CONCLUSION: The genesis of rectovaginal fistulae is an important predictor for the size of resection which can range from simple excision to exenteration. For optimal therapy the surgical intervention needs to be integrated into an interdisciplinary therapy concept.

Asunto(s)

Fístula Rectovaginal/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Colectomía , Colitis Ulcerosa/complicaciones , Colitis Ulcerosa/patología , Colitis Ulcerosa/cirugía , Conducta Cooperativa , Enfermedad de Crohn/complicaciones , Enfermedad de Crohn/patología , Enfermedad de Crohn/cirugía , Diverticulitis del Colon/complicaciones , Diverticulitis del Colon/patología , Diverticulitis del Colon/cirugía , Femenino , Humanos , Ileostomía/métodos , Comunicación Interdisciplinaria , Persona de Mediana Edad , Estadificación de Neoplasias , Epiplón/cirugía , Exenteración Pélvica , Perineo/cirugía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Proctoscopía , Pronóstico , Neoplasias del Recto/complicaciones , Neoplasias del Recto/patología , Neoplasias del Recto/cirugía , Fístula Rectovaginal/diagnóstico , Fístula Rectovaginal/etiología , Recto/patología , Recto/cirugía , Reoperación , Estudios Retrospectivos , Colgajos Quirúrgicos , Mallas Quirúrgicas , Vagina/cirugía , Neoplasias Vaginales/complicaciones , Neoplasias Vaginales/patología , Neoplasias Vaginales/cirugía

RESUMEN

BACKGROUND: The initial manifestation of Crohn's disease is often located within the terminal ileum. Other portions of the G.I. tract may be affected, however, as the disease involves the entire organ system. The disease often progresses chronically in flares and remissions and involves all layers of the intestinal wall, leading to strictures, stenosis and fistulas. These complications should only be treated surgically when clinically relevant in order to prevent acute exacerbations. METHODS: Laparoscopic surgery offers one the possibility to minimize surgical trauma with its very small incisions and proper dissection through the correct anatomical layers with 10-fold optic magnification. RESULTS: Multifocal procedures can be carried out in the same operation. We present the case of a 26-year-old female with terminal ileum stenosis and gastric outlet obstruction, who underwent simultaneous laparoscopic pyloroplasty and ileocecal resection. DISCUSSION: Providing the surgeon possesses the necessary expertise, complex laparoscopic simultaneous procedures.

Asunto(s)

Ciego/cirugía , Enfermedad de Crohn/cirugía , Obstrucción de la Salida Gástrica/cirugía , Íleon/cirugía , Laparoscopía , Píloro/cirugía , Adulto , Enfermedad de Crohn/complicaciones , Femenino , Obstrucción de la Salida Gástrica/complicaciones , Humanos

RESUMEN

PURPOSE: Complete resection constitutes the only curative approach in pancreatic cancer but is possible only in a minority of patients due to advanced stages upon diagnosis. Consequently, early detection is crucial for curative treatment. Clinical routine still lacks efficient, non-invasive screening assays, and 80-90% of pancreatic carcinomas are detected at unresectable stages. A wide range of serum proteins have been in the focus of intensive search for biomarkers specific for pancreatic cancer. This article will give an overview on serum biomarkers with screening potential for pancreatic malignancy. DESIGN AND METHODS: PUBMED database was searched for articles, and 43 manuscripts were selected that provided data regarding biomarkers used, type of assay, study population, sample cohort quality and diagnostic performance. RESULTS: Superior values for diagnostic performance were shown for MIC-1, PAM4, OPN, HSP27, TPS, TSGF, and CAM17.1 as individual markers. Panels of biomarkers comprised CA 19-9, MCSF, CEA, SAA, Haptoglobin, TSGF, CA 242, and HSP27. Individually or in concerted form, sensitivity and specificity ranged from 77 to 100% and 84-100%, respectively. CONCLUSIONS: While the above named markers show high screening potential for pancreatic cancer, standardized validation studies using multiplex assays are required to pave the way for clinical routine application.

Asunto(s)

Biomarcadores de Tumor/sangre , Neoplasias Pancreáticas/sangre , Detección Precoz del Cáncer/métodos , Humanos , Neoplasias Pancreáticas/diagnóstico

RESUMEN

BACKGROUND: Mucoceles of the appendix are rare. After appendectomy, mucoceles are detected with a frequency of 0.2 to 0.3 %. Both stenosing / obliterating processes and alterations of the epithelium (hyperplasia, mucinous cystadenoma, cystadenoma with uncertain malignant potential (UMP), mucinous cystadenocarcinoma lead to the occurrence of mucoceles. The perforation of a mucocele with possible spread of mucus and cells into the abdominal cavity constitutes a severe complication (pseudomyxoma peritonei). Surgical resection is the curative approach for mucoceles of the appendix. MATERIALS AND METHODS: Data of patients who were treated for an appendiceal mucocele between 1995 and 2009 were analysed retrospectively with regard to clinical presentation, diagnostic measures, surgical procedure and histopathological result. Follow-up was evaluated in telephone interviews. RESULTS: We extracted 5 cases from our database. Clinical symptoms varied greatly among the individual patients, ranging from peracute abdominal pain in the right lower quadrant to chronic obstipation. Results from abdominal ultrasound and / or abdominal CT scans contributed to the indication for surgical intervention in all cases. In 2 patients surgery was stated as urgent whereas in 3 the operation was scheduled electively. In one patient the diagnosis of an appendiceal mucocele was stated preoperatively and in another intraoperatively. In 3 patients only the histopathological result revealed the underlying mucocele. We performed 1 open and 1 laparoscopic appendectomy, 1 open appendectomy with a partial resection of the coecum and 2 laparoscopic ileocoecal resections. One of the patients had a pseudomyxoma peritonei. The histopathological diagnoses ranged from mere epithelial hyperplasia to an adenoma with uncertain malignant potential and a mucinous cystadenocarcinoma. One patient's long-term follow-up could not be evaluated. All other patients had neither recurrence nor any complications after discharge. CONCLUSIONS: Mucoceles of the appendix present with a wide spectrum of clinical symptoms and histopathological alterations. Only an accurate histological analysis reveals the underlying pathological lesion correctly. This study emphasises that a mucocele of the appendix constitutes an important differential diagnosis in patients presenting with pathologies in their right lower abdominal quadrant.

Asunto(s)

Apendicectomía , Neoplasias del Apéndice/patología , Neoplasias del Apéndice/cirugía , Apendicitis/patología , Apendicitis/cirugía , Cistadenocarcinoma Mucinoso/patología , Cistadenocarcinoma Mucinoso/cirugía , Cistoadenoma Mucinoso/patología , Cistoadenoma Mucinoso/cirugía , Mucocele/patología , Mucocele/cirugía , Neoplasias Peritoneales/etiología , Seudomixoma Peritoneal/etiología , Anciano , Neoplasias del Apéndice/diagnóstico por imagen , Apendicitis/diagnóstico por imagen , Apéndice/patología , Cistadenocarcinoma Mucinoso/diagnóstico por imagen , Cistoadenoma Mucinoso/diagnóstico por imagen , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mucocele/complicaciones , Mucocele/diagnóstico por imagen , Invasividad Neoplásica , Neoplasias Primarias Múltiples/patología , Neoplasias Primarias Múltiples/cirugía , Neoplasias Primarias Múltiples/ultraestructura , Neoplasias Ováricas/diagnóstico por imagen , Neoplasias Ováricas/patología , Neoplasias Ováricas/cirugía , Ovariectomía , Ovario/patología , Neoplasias Peritoneales/diagnóstico por imagen , Neoplasias Peritoneales/patología , Neoplasias Peritoneales/cirugía , Lesiones Precancerosas/diagnóstico por imagen , Lesiones Precancerosas/patología , Lesiones Precancerosas/cirugía , Seudomixoma Peritoneal/diagnóstico por imagen , Seudomixoma Peritoneal/patología , Seudomixoma Peritoneal/cirugía , Estudios Retrospectivos , Rotura Espontánea , Ultrasonografía , Adulto Joven