Management of acute small bowel obstruction from intestinal adhesions: indications for laparoscopic surgery in a community teaching hospital

Purpose: The aim of this study is to compare the results of laparoscopic management of acute small bowel obstruction (SBO) from abdominal adhesions to both exploratory laparotomy and secondary conversion to open surgery. Materials and methods: Ninety-three patients (mean age 61years) with adhesion-induced SBO were divided into successful laparoscopy (66 patients [71%]), secondary conversion (24 [26%]), and primary laparotomy (three patients). Results: Patients with successful laparoscopy had more simple adhesions (57%), fewer prior operations, and lower American Society of Anesthesiologists (ASA) class. Operative time was shortest in the laparoscopy group (74.3 ± 4.4min), as was the duration of both intensive care unit and hospital stay. Mortality was 6%, regardless of operative technique. Conclusions: A trial of laparoscopic adhesiolysis by a surgeon with advanced laparoscopic skills seems advisable in the majority of patients with acute adhesive SBO, whereas patients with more extensive adhesions, higher ASA class, and more than two prior abdominal operations often require laparotomy to achieve equally satisfactory outcom

Laparoscopic cholecystectomy as a teaching operation: comparison of outcome between residents and attending surgeons in 1,747 patients

Purpose: Standardized surgical training is increasingly confronted with the public demand for high quality of surgical care in modern teaching hospitals. The aim of this study was to compare the results of laparoscopic cholecystectomy (LC) performed by resident surgeons (RS) and attending surgeons (AS). Methods: In this retrospective review of prospectively collected data 1,747 LC were performed in a community hospital between 1999 and 2009. Seven hundred seventy operations were performed by RS. Parameters analysed included the duration of operation and length of hospital stay, intraoperative complications, 30-day morbidity and mortality. Results: Duration of operation was 88 (25-245) min for RS vs. 75 (30-190) min by AS (p = 0.001). Elective operations were shorter when performed by AS (70 (30-190) [AS] vs. 85 (25-240) [RS] min, p = 0.001). Length of hospital stay was shorter in patients treated by RS (4 (1-49) days [RS] vs. 5 (1-83) days [AS], p = 0.1). Intraoperative complications showed no differences between the groups (1.0% [RS] vs. 1.3% [AS], p = 0.6), whereas 30-day morbidity was lower in patients treated by RS (3.8% [RS] vs. 6.2% [AS], p = 0.02). Overall mortality was 0.6% and independent of surgical expertise (0.5% [RS] vs. 0.8% [AS], p = 0.5). Conclusions: Provided adequate training, supervision and patient selection, surgical residents are able to perform LC with results comparable to those of experienced surgeon

Hereditäre gastrointestinale Tumoren

Eine familiäre Veranlagung liegt in einem Viertel aller Fälle von kolorektalen Karzinomen vor. Sehr viel weniger Patienten (ca. 5 %) sind von einer vererbbaren genetischen Veranlagung betroffen. Dabei ist es interessant, dass ein nennenswerter Prozentsatz der hereditären Tumoren durch Neumutationen verursacht wird – die Familiengeschichte ergibt also keinen Hinweis, die Diagnose ist aber wichtig für die PatientInnen und ihre Nachkommen. Verbesserte Diagnostik führt dazu, dass der Anteil hereditärer Ursachen bei den kolorektalen Karzinomerkrankungen zunimmt und wohl noch weiter zunehmen wird. Das insgesamt verbesserte Überleben onkologischer Patienten wiederum führt dazu, dass auch häufiger Patienten mit Zweit- oder Drittkarzinomen behandelt werden. Aber zu häufig noch werden Patienten tatsächlich erst bei einem zweiten oder dritten Karzinom der entsprechenden Diagnostik zugeführt. Es sollen in diesem Artikel die häufigsten polypösen und nichtpolypösen kolorektalen hereditären Tumorerkrankungen, die dazugehörigen Surveillance-Programme und Operationsmethoden vorgestellt werden. Ebenso wird aufgezeigt, welche anderen Organe betroffen sein können. = Une prédisposition familiale est présente dans un quart de tous les cancers colorectaux. Beaucoup moins de patients (~ 5 %) sont touchés par une prédisposition génétique héréditaire. Dans ce contexte, il est intéressant qu’un pourcentage important de tumeurs héréditaires est dû à de nouvelles mutations; les antécédents familiaux ne fournissent alors aucun indice, mais le diagnostic est important pour les patients et patientes ainsi que pour leurs descendants. Lʼamélioration des méthodes de diagnostic signifie que la proportion de causes héréditaires des cancers colorectaux augmente et continuera sans doute à augmenter. La survie globalement accrue des patients oncologiques signifie à son tour que plus souvent les patients atteints d’un deuxième ou troisième cancer sont également traités. Mais il arrive encore trop souvent que des patients ne soient effectivement diagnostiqués correctement que lors d’un deuxième ou troisième cancer. Cet article entend présenter les tumeurs colorectales héréditaires polypeuses et non polypeuses les plus fréquentes ainsi que les programmes de surveillance correspondants et les méthodes chirurgicales. Il montre aussi quels autres organes peuvent être affectés. = Un quarto dei casi di carcinoma colorettale è associato a una predisposizione familiare. Molti meno pazienti (circa il 5 %) sono affetti da una predisposizione genetica ereditaria. È interessante notare che una percentuale significativa di tumori ereditari è causata da nuove mutazioni – la storia familiare non fornisce dunque alcun indizio, la diagnosi è tuttavia importante per i pazienti e i loro discendenti. Grazie a una diagnostica più accurata la percentuale delle cause ereditarie del carcinoma colorettale è in aumento e probabilmente continuerà ad aumentare in futuro. D’altra parte, il miglioramento complessivo della sopravvivenza dei pazienti oncologici comporta anche una maggiore frequenza delle cure rivolte a pazienti con un secondo o un terzo carcinoma. Troppo spesso tuttavia i pazienti vengono indirizzati verso la diagnosi appropriata solo dopo un secondo o un terzo carcinoma. In questo articolo saranno presentate le più comuni malattie tumorali ereditarie poliposiche e non poliposiche insieme ai relativi programmi di sorveglianza e ai metodi chirurgici. Saranno anche indicati gli altri organi che possono essere colpiti

The Severity of Injury and the Extent of Hemorrhagic Shock Predict the Incidence of Infectious Complications in Trauma Patients

Abstract : Background: : Trauma patients are at high risk of developing systemic inflammatory response syndrome (SIRS) and infections. The aim of this study was to evaluate the influence of the severity of injury and the extent of hemorrhagic shock at admission on the incidence of SIRS, infection and septic complications. Methods: : A total of 972 patients who had an injury severity score (ISS) of ≥ 17, survived more than 72 h, and were admitted to a level I trauma center within 24 h after trauma were included in this retrospective analysis. SIRS, sepsis and infection rates were measured in patientswith different severities of injury as assessed by ISS, or with various degrees of hemorrhagic shock according to ATLS® guidelines, andwere compared using both uni- and multivariate analysis. Results: : Infection rates and septic complications increase significantly (p < 0.001) with higher ISS. Severe hemorrhagic shock on admission is associated with a higher rate of infection (72.8%) and septic complications (43.2%) compared to mild hemorrhagic shock (43.4%, p < 0.001 and 21.7%, p < 0.001, respectively). Conclusion: : The severity of injury and the severity of hemorrhagic shock are risk factors for infectious and septic complications. Early diagnostic and adequate therapeutic work up with planned early "second look" interventions in such high-risk patients may help to reduce these common posttraumatic complication

Recurrent desmoids determine outcome in patients with Gardner syndrome: a cohort study of three generations of an APC mutation-positive family across 30years

Purpose: Screening of Gardner syndrome (GS) patients is tailored towards prevention of colorectal cancer (CRC). However, many patients suffer from desmoid tumors, which are challenging to treat due to invasive growth and local recurrence. The aims of our study were to determine the effectiveness of screening in GS and analyze outcome of desmoid tumors by treatment modality. Methods: This was a cohort study of a family of 105 descendants with GS. All family members who agreed were screened by endoscopy, and colorectal resection was performed upon pending malignancy. Resectable desmoids were excised, whereas large tumors were treated by a combination of brachytherapy (BT) and radiotherapy (RT). Main outcome measures were the incidence of CRC and overall and disease-specific mortality (ClinicalTrial.gov ID NCT01286662). Results: Thirty-seven of 105 family members have GS. Preventive colorectal resections were performed in 16 patients (15%), with one death due to gastric cancer. In four patients who denied screening endoscopy, invasive tumors of the colon (three patients) and stomach developed. Of 33 desmoid tumors, 10 (30%) were located in the mesentery, 17 (52%) in the abdominal wall, and 6 (18%) in extra-abdominal sites. Excision of 12 desmoids was performed in eight patients. Four desmoids were treated by BT and RT and showed full or partial remission. Conclusions: Provided adequate screening, good long-term control of colorectal tumors is achievable. However, desmoid tumors determine survival and quality of life in many patients. Our data suggest good local control using a combination of brachytherapy/radiotherapy in large desmoids unsuitable for surgical resectio

Early Serum Procalcitonin, Interleukin-6, and 24-Hour Lactate Clearance: Useful Indicators of Septic Infections in Severely Traumatized Patients

Background: Elevated lactate and interleukin-6 (IL-6) levels were shown to correlate with mortality and multiple organ dysfunction in severely traumatized patients. The purpose of this study was to test whether an association exists between 24-hour lactate clearance, IL-6 and procalcitonin (PCT) levels, and the development of infectious complications in trauma patients. Methods: A total of 1757 consecutive trauma patients with an Injury Severity Score (ISS)>16 admitted over a 10-year period were retrospectively analyzed over a 21-day period. Exclusion criteria included death within 72h of admission (24.5%), late admission>12h after injury (16%), and age3days) was 10%. Patients with insufficient 24-hour lactate clearance had a high rate of overall mortality and infections. Elevated early serum procalcitonin on days 1 to 5 after trauma was strongly associated with the subsequent development of sepsis (p<0.01) but not with nonseptic infections. The kinetics of IL-6 were similar to those of PCT but did differentiate between infected and noninfected patients after day 5. Conclusions: This study demonstrates that elevated early procalcitonin and IL-6 levels and inadequate 24-hour lactate clearance help identify trauma patients who develop septic and nonseptic infectious complications. Definition of specific cutoff values and early monitoring of these parameters may help direct early surgical and antibiotic therapy and reduce infectious mortalit

Chronic β-blocker therapy improves outcome and reduces treatment costs in chronic type B aortic dissection

Objectives: To compare the medical treatment of chronic type B aortic dissection with β-blockers versus other antihypertensive treatments in terms of their requirement for surgical intervention and treatment costs. Methods: Case records of the 130 patients treated for aortic dissection type B in this unit between 1988 and 1997 were reviewed. Seventy-eight of 130 patients with chronic dissection have received isolated medical treatment. Seventy-one of 78 patients were discharged alive. Fifty-one of 71 received β-blocker treatment, 20/71 were treated with other antihypertensive drugs. Results: Surgery for aortic dissection became necessary in 20/71 patients (28%) during follow-up (mean, 4.2 years): 10/51 in the β-blocker group and 9/20 in the other antihypertensive drug group. The freedom from subsequent aortic operation was 80 and 47%, respectively (P=0.001). Indications for emergency surgery were increased aortic diameter (79%), symptomatic aortic aneurysm (11%), and renal artery hypoperfusion (5%). The median hospitalization time during follow-up (dissection-related) was 2 days for patients who received β-blockers and 16 days for patients who received other antihypertensive drug treatments (P=0.001). The cost of treatment/patient per year amounted to 644 and 12 748 euros, respectively. Conclusions: A substantial proportion of patients with chronic type B dissection who receive initial medical management will later need surgery. Long-term treatment with β-blockers reduces the progression of aortic dilatation, the incidence of subsequent hospital admissions, as well as the incidence of late dissection-related aortic procedures and the cost of treatment. Patients with chronic type B dissection need, in addition to frequent follow-up of aortic diameter, continuous treatment with β-blocking agent

Prognostic factors in patients with acute mesenteric ischemia-novel tools for determining patient outcomes

BACKGROUND Acute mesenteric ischemia (AMI) is a devastating disease with poor prognosis. Due to the multitude of underlying factors, prediction of outcomes remains poor. We aimed to identify factors governing diagnosis and survival in AMI and develop novel prognostic tools. METHODS This monocentric retrospective study analyzed patients with suspected AMI undergoing imaging between January 2014 and December 2019. Subgroup analyses were performed for patients with confirmed AMI undergoing surgery. Nomograms were calculated based on multivariable logistic regression models. RESULTS Five hundred and thirty-nine patients underwent imaging for clinically suspected AMI, with 216 examinations showing radiological indication of AMI. Intestinal necrosis (IN) was confirmed in 125 undergoing surgery, 58 of which survived and 67 died (median 9 days after diagnosis, IQR 22). Increasing age, ASA score, pneumatosis intestinalis, and dilated bowel loops were significantly associated with presence of IN upon radiological suspicion. In contrast, decreased pH, elevated creatinine, radiological atherosclerosis, vascular occlusion (versus non-occlusive AMI), and colonic affection (compared to small bowel ischemia only) were associated with impaired survival in patients undergoing surgery. Based on the identified factors, we developed two nomograms to aid in prediction of IN upon radiological suspicion (C-Index = 0.726) and survival in patients undergoing surgery for IN (C-Index = 0.791). CONCLUSION As AMI remains a condition with high mortality, we identified factors predicting occurrence of IN with suspected AMI and survival when undergoing surgery for IN. We provide two new tools, which combine these parameters and might prove helpful in treatment of patients with AMI

Combining staged laparoscopic colectomy with robotic completion proctectomy and ileal pouch-anal anastomosis (IPAA) in ulcerative colitis for improved clinical and cosmetic outcomes: a single-center feasibility study and technical description

Robotic proctectomy has been shown to lead to better functional outcomes compared to laparoscopic surgery in rectal cancer. However, in ulcerative colitis (UC), the potential value of robotic proctectomy has not yet been investigated, and in this indication, the operation needs to be adjusted to the total colectomy typically performed in the preceding 6 months. In this study, we describe the technique and analyze outcomes of a staged laparoscopic and robotic three-stage restorative proctocolectomy and compare the clinical outcome with the classical laparoscopic procedure. Between December 2016 and May 2021, 17 patients underwent robotic completion proctectomy (CP) with ileal pouch-anal anastomosis (IPAA) for UC. These patients were compared to 10 patients who underwent laparoscopic CP and IPAA, following laparoscopic total colectomy with end ileostomy 6 months prior by the same surgical team at our tertiary referral center. 27 patients underwent a 3-stage procedure for refractory UC (10 in the lap. group vs. 17 in the robot group). Return to normal bowel function and morbidity were comparable between the two groups. Median length of hospital stay was the same for the robotic proctectomy/IPAA group with 7 days [median; IQR (6-10)], compared to the laparoscopic stage II with 7.5 days [median; IQR (6.25-8)]. Median time to soft diet was 2 days [IQR (1-3)] vs. 3 days in the lap group [IQR 3 (3-4)]. Two patients suffered from a major complication (Clavien-Dindo ≥ 3a) in the first 90 postoperative days in the robotic group vs. one in the laparoscopic group. Perception of cosmetic results were favorable with 100% of patients reporting to be highly satisfied or satisfied in the robotic group. This report demonstrates the feasibility of a combined laparoscopic and robotic staged restorative proctocolectomy for UC, when compared with the traditional approach. Robotic pelvic dissection and a revised trocar placement in staged proctocolectomy with synergistic use of both surgical techniques with their individual advantages will likely improve overall long-term functional results, including an improved cosmetic outcome