Daniel C. Steinemann

Atraumatic Chylous Ascites: Systematic Review on Symptoms and Causes

Chylous ascites, or chylaskos, is a rare form of ascites characterized by a milky-appearing fluid containing high levels of triglycerides. Its incidence ranges from 1 in 20,000 to 1 in 187,000 admissions at large tertiary referral hospitals. Therapeutic interventions and trauma are well-known causes of chylous ascites. In a cohort of 1,103 patients undergoing abdominal surgery, the incidence of postoperative chylous ascites was reported to be 1.1%. When retroperitoneal, esophageal, gastric, or cytoreductive surgeries were performed, the postoperative incidence was even higher, amounting to 7.4%. Apart from oncologic thoacic and abdominal surgery, chylous ascites can also occur fter abdominal aortic surgery and very rarely after donor nephrectomy. In contrast to the direct injury of lymphatic vessels during surgery, the hyperextension and hyperflexion of the body during a blunt abdominal trauma entail a rupture of lymphatic vessels, thus causing chylous ascites. An additional cause of indirect injury leading to the development of chylous ascites is radiotherapy. Abdominal radiation is thought to induce fibrosis of the lymphatic vessels within the small bowel and the mesentery, causing obstruction and subsequent extravasation of chylous. In patients fter radiation of the whole abdomen for gynecologic maignancies, the incidence was reported to be as high as 3%. The most common clinical presentation of chylous ascites is supposed to be increasing painless abdominal distension. Less frequently, postinterventional and posttraumatic chylous ascites can induce an acute abdomen. Although the clinical features and causes of chylous ascites secondary to surgery or trauma are familiar to most clinicians, little is known about the incidence, etiology, and distribution of different clinical symptoms of atraumatic chylous ascites. The incidental finding of a few milliliters of chylous ascites during a routine inguinal hernia repair in a 28-year-old man finally leading to the diagnosis of non-

Cosmesis and body image after single-port laparoscopic or conventional laparoscopic cholecystectomy: a multicenter double blinded randomised controlled trial (SPOCC-trial)

BackgroundEmerging attempts have been made to reduce operative trauma and improve cosmetic results of laparoscopic cholecystectomy. There is a trend towards minimizing the number of incisions such as natural transluminal endoscopic surgery (NOTES) and single-port laparoscopic cholecystectomy (SPLC). Many retrospective case series propose excellent cosmesis and reduced pain in SPLC. As the latter has been confirmed in a randomized controlled trial, patients satisfaction on cosmesis is still controversially debated.Methods/DesignThe SPOCC trial is a prospective, multi-center, double blinded, randomized controlled study comparing SPLC with 4-port conventional laparoscopic cholecystectomy (4PLC) in elective surgery. The hypothesis and primary objective is that patients undergoing SPLC will have a better outcome in cosmesis and body image 12 weeks after surgery. This primary endpoint is assessed using a validated 8-item multiple choice type questionnaire on cosmesis and body image. The secondary endpoint has three entities: the quality of life 12 weeks after surgery assessed by the validated Short-Form-36 Health Survey questionnaire, postoperative pain assessed by a visual analogue scale and the use of analgesics. Operative time, surgeons experience with SPLC and 4PLC, use of additional ports, conversion to 4PLC or open cholecystectomy, length of stay, costs, time of work as well as intra- and postoperative complications are further aspects of the secondary endpoint. Patients are randomly assigned either to SPLC or to 4PLC. Patients as well as treating physicians, nurses and assessors are blinded until the 7th postoperative day. Sample size calculation performed by estimating a difference of cosmesis of 20% (alpha = 0.05 and beta = 0.90, drop out rate of 10%) resulted in a number of 55 randomized patients per arm.DiscussionThe SPOCC-trial is a prospective, multi-center, double-blind, randomized controlled study to assess cosmesis and body image after SPLC.Trial registration(clinicaltrial.gov): NCT 01278472

Sinusectomy for primary pilonidal sinus: Less is more

BACKGROUND Wide excision with secondary wound healing is a frequently performed surgical procedure for pilonidal sinus. This intervention requires general anesthesia and has a wound healing time of up to several months with a long time to return to work. Sinusectomy of the track is an alternative operation. We here describe the long-term outcome of 257 patients operated between 2001 and 2010. METHODS Sinusectomy consisted of a selective minimal invasive excision of the sinus after marking the track with methylene blue. Data were collected retrospectively with questionnaires and telephone survey. The main endpoints of the study were recurrence and time off work. RESULTS With a median follow-up of 3.6 years, the overall recurrence rate was 7%. The median time to return to work was 7 days. The proportion of sinusectomies performed under local anesthesia increased from 59% to 93%. Consistently, the proportion of patients treated in 1-day surgery setting increased from 53% to 93%. One-day surgery had a clear impact on time to return to work in uni- and multivariate analyses (HR 1.959 {1.224, 3.137}, P = .005). CONCLUSION Sinusectomy for pilonidal sinus can be performed with a low recurrence rate. An outpatient setting, including operations under local anesthesia, allows a fast return to normal activity. Sinusectomy should become the first choice for primary non-infected symptomatic pilonidal sinus.

Cosmesis and Body Image in Patients Undergoing Single-port Versus Conventional Laparoscopic Cholecystectomy: A Multicenter Double-blinded Randomized Controlled Trial (SPOCC-trial).

OBJECTIVE To evaluate cosmesis, body image, pain, and quality of life (QoL) after single-port laparoscopic cholecystectomy (SPLC) versus conventional 4-port laparoscopic cholecystectomy (4PLC). BACKGROUND The impact of SPLC on improving cosmesis, body image, pain, and QoL has not been evaluated in double-blinded randomized controlled trials (RCT). This approach therefore remains controversial. METHODS Between October 2011 and February 2014, 110 patients from 2 centers were randomly assigned to SPLC (n = 55) or 4PLC (n = 55). Primary endpoints were a validated cosmesis (3-24 points) and body image (5-20 points) score after 3 and 12 months. Secondary endpoints included operative duration, postoperative pain, complications, QoL, and length of hospital stay. Patients, physicians, and nurses were blinded until the seventh postoperative day. RESULTS Demographics were equally distributed between both groups (mean age: 46 years, SD: 14, 62 females, 34 males). The SPLC-group showed superior mean cosmesis and body image compared with the 4PLC-group at 12-weeks (21 vs 16, P < 0.001 and 5 vs 6, P = 0.013, respectively) and at 1-year (24 vs 16, P < 0.001 and 5 vs 6, P < 0.017, respectively). Operation duration was longer in the SPLC-group (mean 101 vs 90 minutes, p = 0.031). Although postoperative pain was less in the SPLC-group (mean VAS 1 vs 2, p = 0.005), there were no differences in complications, and length of hospital-stay. CONCLUSIONS This is the first multicenter double-blinded RCT reporting superior short- and long-term cosmetic and body image, postoperative pain, and QoL in SPLC compared with 4PLC. Although cost-effectiveness is still a subject of ongoing debate, SPLC should be offered to patients undergoing surgery for benign gallbladder disease.

Laparoscopic gastric pouch and remnant resection: a novel approach to refractory anastomotic ulcers after Roux-en-Y Gastric Bypass: Case report

BackgroundAnastomotic or marginal ulcers occur in 0.6 to 16% of patients after laparoscopic Roux-en-Y-Gastric Bypass. Initial therapy aims at eliminating known risk factors including smoking, Helicobacter pylori infection, use of non-steroidal anti-inflammatory drugs and inhibition of gastric acid secretion. While this approach is successful in 68 to 88% of the cases, up to one third of patients need a subsequent surgical revision. However, marginal ulcers still recur in up to 10% of cases after revisional surgery, thus constituting a serious challenge for bariatric surgeons.Case presentationWe herein report a case of an insidious marginal ulcer refractory to both medical therapy with high-dosed proton pump inhibitors and sucralfate as well as surgical therapy consisting of the lengthening of a short alimentary limb and later resection of the gastroenterostomy and construction of a new tension-free anastomosis. Only after gastrectomy by laparoscopic en-bloc resection of the gastrojejunostomy, the gastric pouch and resection of the gastric remnant with reconstruction by esophagojejunostomy the patient remained free of symptoms.ConclusionBy laparoscopic resection of the entire gastric pouch and the gastric remnant the risk to leave a suboptimally vascularised or even ischemic pouch in situ was avoided. The esophagojejunostomy was then created in healthy, good vascularised tissue. In our case this novel approach was effective in the management of a refractory anastomotic ulcer and might represent a rescue option when simple revision of the gastrojejunostomy fails.

The Reuse of Immunoadsorption Columns in ABO-Incompatible Kidney Transplantation Is Efficient: The Swiss Experience.

Background We developed a multicentric Swiss protocol for ABO-incompatible kidney transplantation including immunoadsorption column reuse. The aim of this study was to assess efficacy and safety of immunoadsorption column reuse in ABO-incompatible kidney transplantation. Methods We performed a multicentric prospective trial including all ABO-incompatible kidney transplantations in Switzerland from 2005 to 2011. Patients received rituximab and standardized immunosuppression with tacrolimus, mycophenolate mofetil, and steroids. Antigen-specific perioperative immunoadsorption was performed. Immunoadsorption columns were reused after restoration. Graft survival, patient survival, kidney function, rejections, number of columns, adverse events after column reuse, and anti-A/anti-B antibody titers were assessed. Results Seventy-one ABO-incompatible patients underwent antigen-specific immunoadsorption and could be transplanted across the blood group barrier. Kaplan-Meier estimates for both, patient-censored and death-censored graft survivals were both 97.2% at 5 years. Allograft function was excellent with a mean estimated glomerular filtration rate of 54 mL per min after 1 year. The median number of pretransplant immunoadsorptions was 5. All centers performed column reuse. A total of 394 immunoadsorption procedures were performed with reused filters. Patient survival, graft survival, and adverse events did not differ when filters were reused. Column reuse resulted in cost savings of 21,458 USD per patient. Conclusion We have introduced a national protocol for ABO-incompatible kidney transplantation including immunoadsorption column reuse. Column reuse was efficient and safe.

Internal retraction in single-port laparoscopic cholecystectomy: initial experience and learning curve.

Abstract Introduction: We report our experience and learning curve in single-port laparoscopic cholecystectomy (SPLC) using an internal anchored retraction system. Methods: Usefulness of the retraction system was analysed in 18 SPLC. The first eight, the following ten SPLC and 20 consecutive four-port laparoscopic cholecystectomies (4PLC) were compared. Duration of operation, burns on nontarget tissue and gallbladder perforations were assessed by reviewing videotapes recorded during the procedures. Results: Use of the retraction system failed in three out of five patients (60%) with intraoperative signs of chronic inflammation and in one out of 13 (7.1%) without such signs (p = 0.0441). Median operation time was 90 (45–120) in the first eight and 55 (40–180) minutes in the following ten SPLC (p = 0.0361). Whereas the first eight SPLC lasted longer compared to 4PLC (70 (40–140) minutes, p = 0.0435) the difference disappeared after eight procedures (p = 0.2076). Median number of burns to nontarget tissue was seven (1–16) in the first eight and one (0–8) in the following ten SPLC (p = 0.0049). There was no difference in perforation of the gallbladder. Discussion: Internal retraction enables a safe exposure of the Calot triangle avoiding bile spillage in cholecystectomies without intraoperative signs of inflammation. Familiarisation with SPLC was rapidly achieved. Operation time and dexterity were equal to 4PLC after eight SPLC.

Transrectal Rigid-Hybrid Natural Orifice Translumenal Endoscopic Sigmoidectomy for Diverticular Disease: A Prospective Cohort Study.

BACKGROUND Our goal was to evaluate the feasibility of transrectal rigid hybrid natural orifice translumenal endoscopic surgery (NOTES) sigmoidectomy (trNS) in a series of consecutive prospective patients with diverticular disease. The NOTES for left colectomy offers patients reduced pain and easier recovery. Limited data are available for trNS, which is considered safe for various indications. However, the technique is not standardized, and patients in the reported series are highly selected. STUDY DESIGN Patients scheduled for trNS were entered into a prospective registry on an intention-to-treat basis. The primary endpoint was trNS feasibility, and secondary endpoints were morbidity, pain, length of stay, and inflammatory response. A medial-to-lateral dissection with full mobilization of the splenic flexure and total intracorporeal anastomosis was performed. The rectum was covered with a wound protector for transrectal extraction. RESULTS Of 95 elective sigmoidectomies, 81% (n = 77) were enrolled for either transvaginal NOTES resection (n = 37) or trNS (n = 40). There was no difference in body mass index or indication between patients undergoing laparoscopic-assisted sigmoidectomy (LAS), transvaginal resection, or trNS, although trNS patients were younger. Mainly because of a mismatch of bulky specimen and narrow pelvis, 17.5% of trNS were converted to LAS. Major morbidity was 10%, including 2 septic complications. During the study, the anastomosis technique was changed from double stapled end-to-end to side-to-end anastomosis. CONCLUSIONS Transrectal rigid hybrid natural orifice translumenal endoscopic sigmoidectomy is feasible and safe in a high proportion of unselected consecutive patients with diverticular disease undergoing elective treatment. Intracorporeal side-to-end anastomosis is the preferred technique, and trNS should be offered for elective sigmoidectomy presupposing advanced laparoscopic experience.

Abdominal Wall Expanding System Obviates the Need for Lateral Release in Giant Incisional Hernia and Laparostoma

Background:In large incisional hernias and after laparostoma midline closure may be impossible. A novel abdominal wall expander system (AWEX) is proposed and evaluated. Methods: In patients with large incisional hernias and laparostoma where primary midline closure was impossible, AWEX was used. Patients undergoing abdominal wall reconstruction using AWEX between May 2012 and December 2015 were included. Intraoperative the abdominal wall was stretched by attaching the midline fascia borders to a retraction system under tension for 30 minutes. Length and width of the hernia defect were measured in preoperative computed tomography. Width gain after AWEX procedure, operative time, morbidity, and presence of remaining midline gap was evaluated. Patients were followed for hernia recurrence. Results: Ten patients with incisional hernias (N = 4) and grafted laparostoma (N = 6) underwent abdominal wall reconstruction using AWEX. Median (interquartile range) length and width of the hernia defect was 18.0 (15.0-20.5) and 12.0 (11.8-13.3) cm. Width gain after AWEX was 8.5 (8.0-10.5) cm. Operative time was 270 (135-379) minutes. The major morbidity was 20%. In 4 patients a gap of 4 (4-5) cm was bridged by intraperitoneal onlay mesh. After a median follow-up of 21 (7-36) months no hernia recurrence was observed. Conclusions: Stretching of the abdominal wall that has been shown successful using progressive restressed retention sutures and progressive preoperative pneumoperitoneum is reduced from days and weeks to 30 minutes in AWEX. AWEX is a promising alternative to component separation in repair of large incisional hernias. After refinement of the system prospective evaluation is required.

[Scarless surgery: a vision becoming reality?].

As minimal invasive abdominal surgery became established in the last decades, further minimization of the surgical access is in the focus now. Although laparoscopic instruments and camera systems become diminished in size there is still a need for a minilaparotomy for extraction and anastomosis of organs. NOTES (Natural orifice transluminal endoscopic surgery) aims to avoid this minilaparotomy. Consequently, laparoscopic-assisted procedures become pure laparoscopic surgery. The transvaginal access is the most common performed NOTES procedure. The acceptance in women is high. The feasibility of NOTES cholecystectomy is scientifically proofed. The procedure is associated with less pain than the common four-port laparoscopic surgery and does not interfere with the sexual well-being. There are no access-related infections; the abdominal wound infection and incisional hernia rate are low. In left sided colonic resection the transrectal access makes NOTES available for both genders.