Cost analysis of inguinal hernia repair: the influence of clinical and hernia-specific factors

Introduction: As in the rest of the world, in Germany, inguinal hernia operations are among the most common operations. From an economic standpoint, very little is known about the influence of demographic, clinical or hernia-related parameters on the cost of inguinal hernia repair. We, therefore, evaluated individual patient parameters associated with higher costs with a special focus on multimorbidity. Methods: A total of 916 patients underwent hernia repair for primary or recurrent inguinal hernia between 2014 and 2017 at a single university center and were included in the analysis. The clinical and financial data of these patients were analyzed to identify cost-increasing parameters. Results: A majority of patients were male (90.7%), with a mean age of 55 years. The surgical methods utilized were mainly the TAPP (57.2%) and Lichtenstein (41.7%) procedures, with an average duration of surgery of 85 min and an average duration of anesthesia of 155 min. The mean cost of all procedures was 3338.3 euro (+/- 1608.1 euro). Older age, multimorbidity, emergency operations with signs of incarceration, longer hospital stays and postoperative complications were significant cost-driving factors. On the other hand, sex, the side of the hernia (left vs. right) and the presence of recurrent hernias had no influence on the overall direct costs. Conclusion: From a purely economic point of view, older age and multimorbidity are demographic cost-driving factors that cannot be influenced. The national hospital reimbursement system needs to consider and compensate for these factors. Emergency operations need to be prevented by early elective treatment. Long postoperative stays and postoperative complications need to be prevented by proper preoperative check-ups and accurate treatment

Hypothermic oxygenated machine perfusion for extended criteria donor allografts: Preliminary experience with extended organ preservation times in the setting of organ reallocation

Background: In times of critical organ shortage, poor organ pool utilization and increased use of extended-criteria donor (ECD) allografts remain a major problem. Hypothermic oxygenated machine perfusion (HOPE) has emerged as a promising and feasible strategy in ECD liver transplantation (LT). However, potential safety limits regarding the duration of perfusion are yet to be explored. Besides marginal allograft quality (steatosis), prolonged cold ischemia time remains the most important factor for a high number of liver allografts being declined for transplantation. Patients and methods: Two ECD-allografts were each allocated to two recipients, who proved to be unsuitable to receive the assigned allograft upon arrival at the transplant center. The organs were reallocated by Eurotransplant and accepted by our center for two different backup patients. During that time, HOPE was commenced and continued until the recipient hepatectomy was completed. Postoperative allograft function was assessed by serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, and International Normalized Ratio. Incidence of early allograft dysfunction (EAD), postoperative complications, and length of hospital stay were analyzed. Results: HOPE was applied for 4 h 35 min and 4 h 20 min, resulting in a total cold preservation time of 17 h 29 min and 15 h 20 min, respectively. Both recipients displayed decreasing serum transaminases and bilirubin levels postoperatively. No EAD or major postoperative complications occurred in either patient. Serum ALT and AST levels were within the normal range at discharge. Conclusions: Extended HOPE enables the safe extension of preservation time for up to 18 h in human LT. End-ischemic HOPE may significantly improve organ pool utilization, while simultaneously facilitating operating room logistics and preventing organ injury

Health-Related Quality of Life and Mental Health after Surgical Treatment of Hepatocellular Carcinoma in the Era of Minimal-Invasive Surgery: Resection versus Transplantation

Laparoscopic liver resection (LLR) is an increasingly relevant treatment option for patients with resectable hepatocellular carcinoma (HCC). Orthotopic liver transplantation (OLT) has been considered optimal treatment for HCC in cirrhosis, but is challenged by rising organ scarcity. While health-related quality of life (HRQoL) and mental health are well-documented after OLT, little is known about HRQoL in HCC patients after LLR. We identified all HCC patients who underwent LLR at our hospital between 2014 and 2018. HRQoL and mental health were assessed using the Short Form 36 and the Hospital Anxiety and Depression Scale, respectively. Outcomes were compared to a historic cohort of HCC patients after OLT. Ninety-eight patients received LLR for HCC. Postoperative morbidity was 25% with 17% minor complications. LLR patients showed similar overall HRQoL and mental health to OLT recipients, except for lower General Health (p = 0.029) and higher anxiety scores (p = 0.010). We conclude that LLR can be safely performed in patients with HCC, with or without liver cirrhosis. The postoperative HRQoL and mental health are comparable to that of OLT recipients in most aspects. LLR should thus always be considered an alternative to OLT, especially in times of organ shortage

Закономерности микроструктурных изменений в титановом сплаве ВТ6 при деформации и наводороживании

Объектом исследования являются образцы титанового сплава марки ВТ6 прокатанные до различных степеней деформации методом механической прокатки. Исследование дефектной структуры проводилось с использованием методов позитронной спектроскопии, которые могут определять тип и концентрацию дефектов, а также химическое окружение данных дефектов. Однако, для получения количественной и качественной оценки количества дефектов методами позитронной спектроскопии необходима дополнительная информация о базовых дефектах и их влиянии на характеристики позитронной аннигиляции. Целью работы является анализ структурных изменений в титановом сплаве ВТ6 в зависимости от степени холоднокатаной пластической деформации и после наводороживания.The object of the study are samples of titanium alloy grade VT6 rolled to various degrees of deformation by mechanical rolling. The study of the defect structure was carried out using positron spectroscopy methods, which can determine the type and concentration of defects, as well as the chemical environment of these defects. However, to obtain a quantitative and qualitative assessment of the number of defects by the methods of positron spectroscopy, additional information is needed about the basic defects and their effect on the positron annihilation characteristics. The aim of the work is to analyze the structural changes in titanium alloy VT6, depending on the degree of cold-rolled plastic deformation and after hydrogenation

Hydroceles of the Canal of Nuck in Adults—Diagnostic, Treatment and Results of a Rare Condition in Females

Nuck’s hydroceles, which develop in a protruding part of the parietal peritoneum into the female inguinal canal, are rare abnormalities and a cause of inguinal swelling, mostly resulting in pain. They appear when this evagination of the parietal peritoneum into the inguinal canal fails to obliterate. Our review of the literature on this topic included several case reports and two case series that presented cases of Nuck hydroceles which underwent surgical therapy. We present six consecutive cases of symptomatic hydroceles of Nuck’s canal from September 2016 to January 2020 at the Department of Surgery of Charité Berlin. Several of these patients had a long history of pain and consecutive consultations to outpatient clinics without diagnosis. These patients underwent laparoscopic or conventional excision and if needed simultaneous hernioplasty in our institution. Ultrasonography and/or Magnetic Resonance Imaging were used to display the cystic lesion in the inguinal area, providing the diagnosis of Nuck’s hydrocele. This finding was confirmed intraoperatively and by histopathological review. Ultrasound and magnetic resonance imaging (MRI) captures, intraoperative pictures and video of minimal invasive treatment are provided. Nuck’s hydroceles should be included in the differential diagnosis of an inguinal swelling. We recommend an open approach to external Type 1 Nuck´s hydroceles and a laparoscopic approach to intra-abdominal Type 2 Nuck hydroceles. Complex hydroceles like Type 3 have to be evaluated individually, as they are challenging and the surgical outcome is dependent on the surgeon’s skills. If inguinal channel has been widened by the presence of a Nuck’s hydrocele, a mesh plasty, as performed in hernia surgery, should be considered

Evaluation of physiologic scoring systems as prognostic parameters of liver transplant in acute and chronic liver failure

Hintergrund: Der Spenderorganmangel und die Sterblichkeit auf der Warteliste zur Lebertransplantation (OLT) stellen weiterhin eine große Herausforderung dar. Durch die Einführung von klinischen Evaluationssystemen sollen objektive Kriterien die Patientenselektion zur OLT optimieren. Patienten und Methoden: Untersucht wurden der MELD (model of end-stage liver disease) score und der SALT (survival after liver transplantation) score von 462 Patienten (Pt) mit chronischem Lebersagen vor OLT und mit dem 1-Jahres-Überleben verglichen. Für 58 Pt mit polyzystischer Lebererkrankung (PCLD) erfolgte eine separate Analyse des Einflusses des MELD score auf die OLT. Die King´s College Criteria (KCC), der laborchemische MELD score und der Bilirubin-Laktat-Ätiologie (BiLE) score wurden für 155 Pt mit akutem Leberversagen (ALV) erhoben und der Zusammenhang mit der konservativen Behandlung oder OLT bzw. Tod analysiert. Für 129 Pt mit ALV wurde die prognostische Wertigkeit der APACHE II und III scores in Bezug auf die 30-Tages-Mortalität nach OLT untersucht. Ergebnisse: Pt mit chronischem Leberversagen, die das erste Jahr nach OLT überlebten, hatten einen signifikant niedrigeren prä-OLT MELD score (17.99±9.22 vs. 24.68±10.8, p<0.001). Die gleiche Beobachtung wurde auch für den SALT score gemacht (1.22±0.93 vs. 1.65±0.89, p=0.020). Bei einem MELD score >30 überlebten nur 52.6% der Pt (p1.7 war ebenfalls ein signifikanter Prognosefaktor (p=0.007). PCLD-Pt hatten einen medianen MELD score von 6. Das 5-Jahres-Überleben war mit 92.3% deutlich besser im Vergleich zu anderen OLT- Indikationen. Beim ALV zeigten sich die KCC als signifikante Überlebens- parameter (p=0.0213). Pt mit ALV, die eine OLT benötigten oder unter medikamentöser Therapie verstarben, hatten einen signifikant erhöhten MELD [26(20-31) vs. 32(26-37), p=0.0007] und BiLE score [4.6(1.6-8.1) vs. 9.8(6.5-13.1), p=0.003]. Die Kaplan-Meier Analyse bestätigte dieses Ergebnis, bei einem Trennwert von 32 für den MELD score (p=0.003) und 6.9 für den BiLE score (p=0.0023). ALV Pt, die 30 Tage post OLT überlebten, hatten einen signifikant niedrigeren APACHE III score (62±19.4 vs. 82±18, p<0.01). Bei Pt mit >68 Punkten erreichte die Mortalität 18.8% (p=0.001). Der APACHE II score hatte keinen signifikanten Einfluss. Jeder zusätzliche Punkt im APACHE III score führt zu einer Zunahme des Sterberisikos um 3.1%.Introduction: The current organ shortage and the mortality on waiting list for liver transplant (OLT) remain a particular challenge for transplant community. With the introduction of clinical scoring systems, objective criteria could optimize the patient selection for OLT. Patients and Methods: The MELD (model of end-stage liver disease) score and the SALT (survival after liver transplantation) score of 462 patients with chronic liver failure were examinated before OLT and compared to 1-year survival. An separate analysis of MELD score 58 polycystic liver disease (PTLD) patients on the OLT outcome was performed. The King`s College Criteria (KCC), the lab-MELD score and the bilirubin-lactate-etiology (BiLE) score were determined in 155 cases of acute liver failure (ALF) and compared to the outcome under medical therapy before OLT or death. The prognostic accuracy of the APACHE II and III scores for the 30-day post OLT mortality of 129 patients with ALF were analyzed. Results: Patients with chronic liver failure, who survived 1st year after OLT had a significantly lower pre-transplant MELD score (17.99±9.22 vs. 24.68±10.8, p<0.001). The same results was observed for the SALT score (1.22±0.93 vs. 1.65±0.89, p=0.020). Only 52.6% of the patients with a MELD score >30 survived (p1.7 was a significant predictor of death (p=0.007). PCLD patients had a median MELD score of 6. The 5-year survival was with 92.3% higher compared to other OLT indications. The KCC were significant predictors of ALF (p=0.0213). ALF patients, who died under medical support or needed a OLT, had a significantly higher MELD [26(20-31) vs. 32(26-37), p=0.0007] and BiLE score [4.6(1.6-8.1) vs. 9.8(6.5-13.1), p=0.003]. The Kaplan-Meier analysis confirmed this results for a MELD score threshold of 32 (p=0.003) and a BiLE score cut-off of 6.9 (p=0.0023). ALF patients, who survived 20 days after OLT, had a significantlly lower APACHE III score (62±19.4 vs. 82±18, p68 achieved a mortality rate of 18.8% (p=0.001). The APACHE II had no impact on survival. Each additional point in the APACHE III score system increases mortality risk by 3.1%