Conny Bürk

New Insights into the Epidemiology and Etiology of Fournier’s Gangrene: A Review of 33 Patients

AbstractBackground:Fournier’s gangrene is a necrotizing fasciitisninvolving the perineal and genital regions. Even today, thisnoften polymicrobial infection still carries a high mortality ratenand continues to be a major challenge to the medical community.nThe purpose of this study was to report our experiencenwith this condition and to compare it with thosenreported in published studies. We also introduce our approachnto treatment.Methods:We analyzed data from 33 patients with Fournier’sngangrene who were managed in our hospital from 1996 ton2007, focusing on patient gender, age, etiology, predisposingnconditions, comorbidities, bacteriology, sepsis, bloodnresults, mortality, and spread of gangrene.Results:18 (54.5%) of the 33 patients had been referred tonour department by smaller district hospitals. The patientncohort consisted of 23 men and ten women with a mediannage of 59 years (range 40–79 years). The median time betweennthe onset of symptoms and progression to gangrenenwas 6 days (range 2–28 days). An underlying cause wasnidentified in 27 patients (81.8%). The commonest etiologicalnevents were perianal and perirectal abscesses (n = 13;n39.4%). Predisposing factors included diabetes mellitus inn12 cases (36.4%), chronic alcoholism in ten cases (30.3%),nimmunosuppression in six cases (18.2%), and prolongednimmobilization in five cases (15.2%). 17 patients (51.5%)nhad a body mass index (BMI) of 25 or higher, and 13 patientsn(39.4%) had a BMI of 30 or higher. Positive culturesnwere obtained in 30 cases (90.9%). In 26 cases (78.8%),nmultiple microorganisms were recovered, including ninencases (27.3%) with both aerobes and anaerobes. Sepsis wasnpresent in 26 patients (78.8%). The mortality rate wasn18.2%.Conclusion:Fournier’s gangrene remains a major challengenwith a high mortality. Our results suggest that women arenmore commonly affected than has generally been assumed.nContrary to published reports, we found that anorectalnsources appear to account for more cases of Fournier’sngangrene than urological sources.

Fournier’s gangrene: is the female gender a risk factor?

ObjectiveFournier’s gangrene is a necrotizing fasciitis that affects the perineal, genital, or perianal regions. The objective of this study was to highlight this uncommon condition with a particular focus on the disease course in females.Materials and methodsFrom 1996 to 2008, we prospectively collected data from 38 patients with Fournier’s gangrene (12 women, 26 men) and retrospectively analyzed relevant parameters.ResultsThe mean age was 60.9u2009±u200911.3xa0years for females (group I) and 56.2u2009±u200911.7xa0years for males (group II). In both groups, the main predisposing factors were diabetes mellitus and obesity (body mass index of 30 or higher). Twelve men (46.2%), but no women, had chronic alcoholism. The most commonly isolated agents were Escherichia coli (nu2009=u200922), streptococcal species (nu2009=u200918), Pseudomonas aeruginosa (nu2009=u20099), and Staphylococcus aureus (nu2009=u20097). Mortality was significantly higher among females (50%) than males (7.7%; pu2009=u20090.011). Peritonitis was present in seven group I patients (58.3%) and in two group II patients (7.7%). The retroperitoneum was involved in seven female patients (58.3%) and four male patients (15.4%).ConclusionThe female gender is a risk factor for mortality in patients with Fournier’s gangrene and is associated with a higher incidence of inflammation of the retroperitoneal space and abdominal cavity. Differences in male and female genital anatomy may be the reason for the rapid spread of infection to the retroperitoneum and the fatal outcome in women. Fournier’s gangrene as a high-risk disease in females should attract exceeding attention.

Metachronous metastasis- and survival-analysis show prognostic importance of lymphadenectomy for colon carcinomas

BackgroundLymphadenectomy is performed to assess patient prognosis and to prevent metastasizing. Recently, it was questioned whether lymph node metastases were capable of metastasizing and therefore, if lymphadenectomy was still adequate. We evaluated whether the nodal status impacts on the occurrence of distant metastases by analyzing a highly selected cohort of colon cancer patients.Methods1,395 patients underwent surgery exclusively for colon cancer at the University of Lübeck between 01/1993 and 12/2008. The following exclusion criteria were applied: synchronous metastasis, R1-resection, prior/synchronous second carcinoma, age < 50 years, positive family history, inflammatory bowel disease, FAP, HNPCC, and follow-up < 5 years. The remaining 421 patients were divided into groups with (TM+, n = 75) or without (TM-, n = 346) the occurrence of metastasis throughout a 5-year follow-up.ResultsFive-year survival rates for TM + and TM- were 21% and 73%, respectively (p < 0.0001). Survival rates differed significantly for N0 vs. N2, grading 2 vs. 3, UICC-I vs. -II and UICC-I vs. -III (p < 0.05). Regression analysis revealed higher age upon diagnosis, increasing N- and increasing T-category to significantly impact on recurrence free survival while increasing N-and T-category were significant parameters for the risk to develop metastases within 5-years after surgery (HR 1.97 and 1.78; p < 0.0001).ConclusionsBesides a higher T-category, a positive N-stage independently implies a higher probability to develop distant metastases and correlates with poor survival. Our data thus show a prognostic relevance of lymphadenectomy which should therefore be retained until conclusive studies suggest the unimportance of lmyphadenectomy.

Hydro-Jet–Assisted Pneumonectomy: A New Technique in a Porcine Model

BACKGROUND AND OBJECTIVESnHydro-jet technology has long been used to cut various materials, such as metal and wood, in the industrial field. In the medical field, this technology has been applied successfully in selective cutting of the parenchyma of the liver. However, to our knowledge, no data are available on the use of the hydro-jet technique for pneumonectomy. The purpose of this study was to evaluate a new dissection technique in which a high-pressure water stream (hydro-jet) and a new dissection probe for pulmonary resection are used.nnnMETHODSnThirty pigs underwent right pneumonectomy. Pigs were randomized to either the conventional or hydro-jet-assisted dissection technique. The feasibility of this technique and the features of surgical dissection were evaluated and compared between the two groups.nnnRESULTSnPneumonectomy was successful in all animals. The mean operative times were 55 and 65 minutes and the mean volumes of blood loss were 37 and 65 mL for the hydro-jet and conventional dissection techniques, respectively. Complications included vascular injury in 6% and 20% of cases with the hydro-jet and conventional techniques, respectively. The use of hydro-jet for pneumonectomy had clear technical advantages over the conventional dissection. Hydro-jet resulted in a selective dissection of fibrous and connective tissue, preserving blood vessels for later ligation. Therefore, the dissection was performed in a relatively bloodless field. The ease of dissection with the bent-tip dissector represents another advantage. The continuous water flow allows a clear view for the operator.nnnCONCLUSIONSnThis study shows that hydro-jet dissection represents an excellent alternative to the conventional technique for pulmonary resection. The improved anatomic dissection combined with an almost bloodless operating field secondary to continuous water flow may decrease dissection-related complications.

Evaluation of an online navigation system for laparoscopic interventions in a perfused ex vivo artificial tumor model of the liver

BACKGROUNDnLaparoscopic radiofrequency ablation (RFA) is a safe and effective method for tumor destruction in patients with unresectable liver tumors. However, accurate probe placement using laparoscopic ultrasound guidance is required to achieve complete tumor ablation. After evaluation of an ultrasound navigation system for transcutaneous and open RFA, we now intend to transfer this technique to laparoscopic liver surgery. This study aimed to evaluate an electromagnetic navigation system for laparoscopic interventions using a perfusable ex vivo artificial tumor model.nnnMATERIALS AND METHODSnFirst a special adapter was developed to attach the ultrasound and electromagnetic tracking-based navigation system to a laparoscopic ultrasound probe. The laparoscopic online navigation system was studied in a laparoscopic artificial tumor model using perfused porcine livers. Artificial tumors were created by injection of a mixture of 3% agarose, 3% cellulose, and 7% glycerol, creating hyperechoic lesions in ultrasound.nnnRESULTSnThis study showed that laparoscopic ultrasound-guided navigation is technically feasible. Even in cases of angulation of the ultrasound probe no disturbances of the navigation system could be detected. Artificial tumors were clearly visible on laparoscopic ultrasound and not felt during placement of the RFA probe. Anatomic landmarks and simulated tumors in the liver could be reached safely.nnnDISCUSSIONnLaparoscopic RFA requires advanced laparoscopic ultrasound skills for accurate placement of the RFA probe. The use of an ultrasound-based, laparoscopic online navigation system offers the possibility of out-of-plane needle placement and could increase the safety and accuracy of punctures. The perfused artificial tumor model presented a realistic model for the evaluation of this new technique.

Giant Bladder Diverticulum as a Rare Cause of Intestinal Obstruction: Report of a Case

We report a case of intestinal obstruction as an unusual manifestation of bladder diverticulum. To our knowledge, this is the first report of a giant bladder diverticulum causing acute abdomen as a result of mechanical bowel obstruction.

Aneuploidy and elevated CEA indicate an increased risk for metachronous metastasis in colorectal cancer

PurposePresently, no markers exist to predict metachronous metastasis at the time a primary colorectal cancer is diagnosed. While aneuploidy indicates poor survival prognosis and elevated carcinoembryonic antigen (CEA) levels the presence of recurrent disease, the predictive value of both markers regarding imminent metachronous metastases is unclear.MethodsSixty patients with distant recurrence throughout a 5-year follow-up (TM+) were randomly chosen and 60 patients without metastasis matched to this cohort (TM−). In addition, an enlarged collective (nu2009=u2009217; nTM+u2009=u200985, nTM-u2009=u2009132) with median follow-up of 79.2xa0months was assessed by logistic regression regarding metachronous metastases. Univariate and stepwise regression analyses included clinicopathological characteristics, preoperative CEA levels and aneuploidy assessed by DNA image cytometry.ResultsThe matched-pair collective showed aneuploidy in 71.1xa0% (TM−) and 85.0xa0% (TM+; pu2009=u20090.076), and elevated CEA in 24.5xa0% (TM−) and 52.2xa0% [TM+; odds ratio (OR), 3.414; pu2009=u20090.007]. The enlarged collective presented aneuploidy in 71.2xa0% (TM−) and 83.5xa0% (TM+; OR 2.050, pu2009=u20090.038), and elevated CEA in 28.6xa0% (TM−) and 48.9xa0% (TM+; OR 2.391, pu2009=u20090.020). Elevated CEA and aneuploidy did not show any association (pu2009=u20090.919). In contrast, logistic regression analyses demonstrated that besides increased T category (OR 1.745, pu2009=u20090.019), both elevated CEA level (OR 2.633, pu2009=u20090.015) and aneuploidy (OR 1.929, pu2009=u20090.058) were independent predictive markers for metachronous metastasis.ConclusionsOur data show that aneuploidy and elevated CEA levels besides increased T category could serve for individual risk assessment to predict metachronous metastases. The fact that still aneuploidy missed the significance level by a small margin emphasizes the need for larger validation studies.

Navigation in der Viszeralchirurgie

Die Integration von Navigationstechniken ist bislang besonders in Fachbereichen gelungen, die die Registrierung auf starre Körperstrukturen ausrichten können (z. B. Orthopädie und Neurochirurgie). In der Viszeralchirurgie steht in erster Linie die Leber im Mittelpunkt der Navigation, da die intrahepatischen Gefäßstrukturen sowohl für die diagnostischen Verfahren als auch für therapeutische Resektionsverfahren eine Leit- und Zielstruktur bieten. Wir beschreiben die Anwendung eines ultraschallbasierten Navigationssystem in der interventionellen, offenen und laparoskopischen Leberchirurgie.

Qualität in der Krankenhausbehandlung

BACKGROUNDnInternal quality control of medical performance in the interest of patient safety is not a new idea. In fact it has been implemented in varying degrees since the beginnings of medicine.nnnACTUAL SITUATION AND METHODSnEver since hospitals are compelled by law to apply methods of quality assurance and external quality control, the question arises as to whether this law can achieve a concrete increase in quality of patient care or whether it rather serves to support economically motivated goals of health care policies, in the sense of an increase in efficiency of performance by physicians. Seen in the light of the overall situation of hospital care, the attempt to create mandatory quality standards is problematical. A reduction of hospital beds and a decrease in the average length of hospital stay contrasts the growing number of treated patients. This presents a problem which must be compensated for, despite cutbacks in budget and personnel. Methods of quality analysis are of the implicit as well as of the explicit type. Implicit methods are based on retrospective data analysis lacking previously set standards of comparison. These methods harbor the danger of viewer-dependent subjectivity (restricted reliability). Explicit methods are based upon comparison to previously defined standards. These methods are more objective, but often fail to give consideration to individual situations (restricted validity). The infrastructure necessary in order to sensibly apply quality control in the hospitals is not yet present in Germany. The software required in order to record and analyse data is still in a stage of development in many places.nnnCONCLUSIONnIt is of importance not to leave external quality control to politicians and economists unfamiliar with the subject matter, but rather that quality control is implemented by experts in the medical field.Zusammenfassung□ HintergrundDer Gedanke einer internen Qualitätskontrolle ärztlichen Handelns im Interesse der Patientensicherheit ist nicht neu und wird seit den Anfängen der Heilkunst in unterschiedlichem Ausmaß praktiziert.□ Aktuelle Situation und MethodikSeit der gesetzlichen Verpflichtung der Krankenhäuser zu Maßnahmen der Qualitätssicherung und externen Qualitätskontrolle stellt sich die Frage, ob dieses Gesetz einen konkreten Qualitätszuwachs in der Krankenbehandlung erbringen kann oder ob es eher dazu dient, ökonomisch motivierte Zielsetzungen der Gesundheitspolitik im Sinne einer Effizienzsteigerung der ärztlichen Tätigkeit zu unterstützen. Problematisch ist der Versuch, verbindliche Qualitätsstandards zu schaffen, angesichts der Gesamtsituation der stationären Versorgung. Einer Dezimierung von Krankenhausbetten und Verkürzung der durchschnittlichen Verweildauer steht eine steigende Anzahl behandelter Patienten gegenüber. Diese Mehrbelastung muß trotz Budgetkürzungen und Personalabbau aufgefangen werden. Methoden der Qualitätsanalyse sind impliziter und expliziter Art. Implizite Methoden beruhen auf retrospektiver Datenanalyse ohne vorher festgelegte Vergleichsstandards. Sie bergen die Gefahr einer beobachterabhängigen Subjektivität (eingeschränkter Reliabilität). Explizite Methoden beruhen auf dem Vergleich mit zuvor definierten Standards; sie sind zwar objektiver, werden aber individuellen Situationen nicht immer gerecht (eingeschränkte Validität).In Deutschland sind die infrastrukturellen Voraussetzungen für eine sinnvolle Qualitätssicherung an den Krankenhäusern noch nicht gegeben. Die entsprechende Software zur Datenerfassung und- analyse befindet sich vielerorts noch in der Entwicklungsphase.□ SchlußfolgerungEs ist wichtig, daß die externe Qualitätskontrolle nicht fachfremden Politikern und Ökonomen überlassen, sondern von Experten aus den Reihen der Ärzteschaft wahrgenommen wird.Summary□ BackgroundInternal quality control of medical performance in the interest of patient safety is not a new idea. In fact it has been implemented in varying degrees since the beginnings of medicine.□ Actual Situation and MethodsEver since hospitals are compelled by law to apply methods of quality assurance and external quality control, the question arises as to whether this law can achieve a concrete increase in quality of patient care or whether it rather serves to support economically motivated goals of health care policies, in the sense of an increase in efficiency of performance by physicians. Seen in the light of the overall situation of hospital care, the attempt to create mandatory quality standards is problematical. A reduction of hospital beds and a decrease in the average length of hospital stay contrasts the growing number of treated patients. This presents a problem which must be compensated for, despite cutbacks in budget and personell. Methods of quality analysis are of the implicite as well as of the explicite type. Implicite methods are based on retrospective data analysis lacking previously set standards of comparison. These methods harbor the danger of viewer-dependent subjectivity (restricted reliability). Explicite methods are based upon comparison to previously defined standards. These methods are more objective, but often fail to give consideration to individual situations (restricted validity).The infrastructure necessary in order to sensibly apply quality control in the hospitals is not yet present in Germany. The software required in order to record and analyse data is still in a stage of development in many places.□ ConclusionIt is of importance not to leave external quality control to politicians and economists unfamiliar with the subject matter, but rather that quality control is implemented by experts in the medical field.

CUP Syndrome in Neuroendocrine Neoplasia: Analysis of Risk Factors and Impact of Surgical Intervention

BackgroundNeuroendocrine neoplasia (NEN) with unknown primary site (NEN-CUP tumors) may have a poor prognosis. We evaluated the clinical presentation, therapy, outcome, and risk factors for adverse outcomes in patients who had these tumors.MethodsIn 243 patients who had NEN, a retrospective review was performed in 38 patients who had NEN-CUP tumors. The 38 patients who had NEN-CUP tumors were evaluated in three groups: group 1 (surgery; primary tumor detected; ten patients); group 2 (surgery; no primary tumor detected; ten patients); and group 3 (no surgery; 18 patients). Risk factors were evaluated with univariate and multivariate analyses.ResultsMost patients who had NEN-CUP tumors [32 patients (84xa0%)] had World Health Organization (WHO) performance score of 0 or 1, and most tumors [24 patients (63xa0%)] were well differentiated (WHO grade, G1 or G2; Ki-67 index, ≤20xa0%). Univariate analysis showed that greater survival was significantly associated with lower patient age, lower WHO performance score, lower WHO grade, lower number of metastatic sites, treatment with surgery, and no treatment with chemotherapy. Multivariate analysis showed that low WHO performance score (hazard ratio 7.63, 95xa0% confidence interval (CI) 2.63–22.19) and treatment with surgery (hazard ratio 0.10, CI 0.028–0.381) were significant independent predictors of improved survival.ConclusionsIn patients with NEN-CUP tumors, surgical treatment is an independent predictor of better survival. Therefore, surgical treatment may be indicated in patients with good general health status and well-differentiated NEN-CUP tumors.