H. Scheidbach

Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents

BACKGROUND Surgery, as well as conservative treatment, in patients with clinically apparent intrathoracic esophageal anastomotic leaks often is associated with poor results and carries a high morbidity and mortality. The successful treatment of esophageal anastomotic insufficiencies and perforations when using covered, self-expanding metallic stents is described. METHODS The feasibility and the outcome of endoscopic treatment of intrathoracic anastomotic leakages when using silicone-covered self-expanding polyester stents were investigated. Twelve consecutive patients presented with clinically apparent intrathoracic esophageal anastomotic leak caused by resection of an epiphrenic diverticulum (n = 1), esophagectomy for esophageal cancer (n = 9), or gastrectomy for gastric cancer (n = 2), were endoscopically treated in our department. The extent of the dehiscences ranged from about 20% to 70% of the anastomotic circumference. After endoscopic lavage and debridement of the leakage at 2-day intervals (mean duration, 8.6 days), a large-diameter polyester stent (Polyflex; proximal/distal diameters 25/21 mm) was placed to seal the leakage. Simultaneously, the periesophageal mediastinum was drained by chest drains. OBSERVATIONS All 12 patients were successfully treated endoscopically without the need for reoperation. A complete closure of the leakage was obtained in 11 of 12 patients after stent removal (median time to stent retrieval, 4 weeks, range 2-8 weeks). In one patient, a persistent leak was sealed endoscopically after stent removal by using 3 clips. Distal stent migration was obtained in two patients. CONCLUSIONS The placement of silicone-covered self-expanding polyester stents seems to be a successful minimally invasive treatment option for clinically apparent intrathoracic esophageal anastomotic leaks.

Totally extraperitoneal endoscopic inguinal hernia repair (TEP).

Background: This report reviews our experience with 5,203 totally extraperitoneal (TEP) endoscopic hernia repairs performed in 3,868 patients over the 7.5-year period between May 1994 and December 2001, 34.5% of whom had bilateral hernias and 13% recurrent hernias. Methods: We performed TEP as the method of choice in more than 92% of all the patients presenting with inguinal hernia, including those with incarcerated, strangulated, or inguinoscrotal hernias. After reduction of the hernial sac and appropriate dissection of the preperitoneal space, we placed a slit-free 10 × 15-cm polypropylene mesh without the use of staple fixation. Results: Altogether, 29 recurrent hernias (0.6%) were observed, more than 50% of which occurred during the first 2 years after the technique was introduced (1.8%). During subsequent years, the recurrence rate settled to approximately 0.3%. Regarding intraoperative complications, we observed eight injuries to the bladder. At this writing, no bowel injuries or damage to iliac vessels has been seen. Postoperatively, we noted only a single case of mesh infection. In 14 cases (0.4%), postoperative hemorrhage necessitated either inguinal or endoscopic reoperation. As a further major complication, a small bowel obstruction caused by inadequate closure of a peritoneal lesion occurred in two patients (0.05%). The overall reoperation rate for the 3,868 patients was 0.6%. Conclusions: We consider TEP to be a procedure that carries an acceptably low complication rate, combining the advantages of minor access surgery and mesh reinforcement of the groin. This approach is associated with early postoperative return to usual activities and a very low recurrence rate.

In vivo studies comparing the biocompatibility of various polypropylene meshes and their handling properties during endoscopic total extraperitoneal (TEP) patchplasty: an experimental study in pigs

Background: Polypropylene (PP) meshes are currently being used in millions of operations for hernial repair. We tested several recently modified PP meshes to evaluate them in terms of their biocompatibility and handling characteristics during minimally invasive procedures. Methods: Four different PP meshes (a heavyweight PP, Atrium; a lightweight PP incorporating absorbable polyglactic acid, Vypro II; a lightweight PP, Parietene; and a titanium-coated lightweight PP, Ti-Mesh Extralight), all implanted using the endoscopic total extrapreperitoneal (TEP) technique, were investigated in groups comprising 11 pigs each. After 94 ± 5 days, the animals were autopsied and tissue samples were studied histologically, immunohistochemically, and electron-microscopically. Results: Whereas endoscopic handling of the Vypro II mesh proved difficult, the already good properties of the Atrium mesh were significantly improved on by Parietene and the Ti-Mesh. Clear differences were also found in the shrinkage characteristics of the implant materials. In comparison with Atrium (12%), Vypro II mesh shrinkage was significantly greater (28%), whereas Parietene (7%) and Ti-Mesh (5%) incurred less shrinkage. With regard to the chronic inflammatory reaction, the titanium-coated mesh showed a significantly lower inflammatory activity (13.1% partial volume [%PV] vs 34.1%PV and 29.0%PV) than the lightweight meshes Vypro II and Parietene, but—with the exception of the monocytic (0.2 vs 9.1, 5.1, and 7.9) and B-lymphocytic reaction (1.1 vs 18.0, 11.7, and 12.2)—no significant difference was seen in comparison with Atrium. The various mediators in the extracellular matrix (matrix metalloproteinases 1 [MMP-1 transforming growth factor beta [TGF-β], urokinase plasminogen activator [uPA], and type I collagen) tended to show the highest expression with Vypro II (13.6, 113.2, 132.7, and 139.5, respectively) and the lowest expression with Ti-Mesh (11.9, 68.5, 92.8, and 75.0, respectively). With regard to cell proliferation, Parietene and Ti-Mesh appeared to have slight advantages, but no differences were observed in the apoptotic rate. Conclusion: In our opinion, despite a reduction in material, Vipro II, on account of the inflammatory reaction, does not represent a true improvement over the meshes currently used for hernia repair. In comparison, the two lightweight PP patches are characterized by a more favorable foreign body reaction, with the titanium coating of the Ti-Mesh providing an additional advantage in terms of its biocompatibility.

Experience as a factor influencing the indications for laparoscopic colorectal surgery and the results

BackgroundThe influence of experience on the results of treatment with laparoscopic surgery is indisputable. The establishment of indications and contraindications is relative, and varies depending on the experience of the surgeon. Learning curves have been described for a number of laparoscopic interventions, in particular laparoscopic cholecystectomy. The current prospective multicenter study investigates, among other things, the interrelation between experience and the results of treatment using laparoscopic colorectal surgery. The study makes no pronouncements on the long-term results achieved in patients with colorectal carcinoma who underwent an operation with curative intent, although relevant data were indeed collected.ResultsBetween August 1, 1995 and February 1, 1999, a total of 1,658 patients were recruited to the prospective multicenter study initiated by the Laparoscopic Colorectal Surgery Study Group. To investigate the influence of surgical experience, two groups were formed. Group A comprised all the institutions and surgeons with experience of more than 100 laparoscopic colorectal operations. Group B contained institutions and surgeons with experience of fewer than 100 such interventions. The results of this study clearly show that in Group A, significantly more procedures involving the rectum were performed (26.7% vs 9.5%), and significantly more carcinomas were surgically managed (37.3% vs 17.3%). Despite this significantly higher level of technically difficult procedures in the patient population of group A, which was comparable in terms of age, gender, height, and weight with the patient in group B, the postoperative mortality and morbidity was, with the exception of urinary tract infections, identical between the two groups. Conversion to open surgery was significantly less frequent in group A (4.3% vs 6.9%), and, finally, the duration of the procedures performed by the more experienced surgeons of group A was appreciably shorter than in institutions with a smaller frequency of such operations.ConclusionsLaparoscopic colorectal surgery is very demanding, and can be performed with low morbidity and mortality rates only by a surgeon with above-average experience with this type of surgery and a large caseload of laparoscopic colorectal procedures. The learning curve for such procedures is appreciably longer than for other laparoscopic operations. With increasing experience, technically more demanding operations, including radical oncologic rectal laparoscopic procedures, can be performed with appreciably reduced operating times and conversion rates, but with no increase in morbidity or mortality.

Influence of titanium coating on the biocompatibility of a heavyweight polypropylene mesh. An animal experimental model.

Introduction: In light of the fact that, to date, no information is available about titanium relative to its application in prosthetic material employed for hernial repair, the aim of the present work was to evaluate the fundamental possibilities of titanium-coated polypropylene meshes. Materials and Methods: In experiments with animals, two groups, each containing 11 pigs, received either a heavyweight polypropylene mesh (Atrium®) or an identical but titanium-coated mesh (titanium-coated Atrium) implanted into the left groin using the totally endoscopic extraperitoneal patchplasty technique. Results: A significant difference in the shrinkage behavior between conventional Atrium and titanium-coated Atrium was found (14.9 vs. 8.8%, p < 0.05). Furthermore, the partial volume of the inflammatory infiltrate also proved to be smaller with the titanium-coated mesh (14.9 vs. 12.4%). In addition, Ki-67 expression was lower in the group implanted with titanium-coated mesh (21.0 vs. 15.0%). No difference was observed with regard to the apoptosis index (7.6 vs. 6.5). Conclusions: Heavyweight titanium-coated polypropylene meshes induce a less pronounced foreign body reaction in comparison with identical meshes with no titanium coating, which, since the amount of material implanted is identical, must be attributed solely to the titanium coating.

Laparoscopic abdominoperineal resection: early postoperative results of a prospective study involving 116 patients. The Laparoscopic Colorectal Surgery Study Group.

PURPOSE: Although laparoscopic colorectal surgery is attracting ever more attention, its use for curative treatment of colorectal carcinoma in particular continues to be controversial. The present study was an attempt to analyze the results of the perioperative course, oncologic quality, and preliminary long-term results. METHOD: The data considered here were collected within the framework of a prospective, observational study initiated on August 1, 1995, and involving a total of 18 institutions in Germany and Austria. At the end of three years, the results are now being presented selectively,i.e., focusing only on abdominoperineal resection. RESULTS: A total of 116 patients underwent laparoscopic abdominoperineal resections, 98 (84.5 percent) of which were performed with curative intent. The mean operating time was 226 (confidence interval, 140–365) minutes. Seven patients (6 percent) experienced an intraoperative complication, which in more than one-half of the cases was a vascular injury involving the presacral venous plexus; the conversion rate was 3.4 percent. Postoperatively, 40 patients developed 97 complications—including those of a very minor nature—giving an overall morbidity rate of 34.4 percent. Reoperation in six patients (5.2 percent) had to be performed for an afterbleed in one-half of the cases and ileus in the other one-half. Postoperative mortality was a low 1.7 percent. In most of the curative resections, an oncologically radical operation with high transection of the inferior mesenteric artery and a complete dissection of the pelvis down to the floor was performed. The median number of lymph nodes investigated was 11.5, and there was wide fluctuation in the numbers among the individual institutions. Tumor cell dissemination occurred intraoperatively in five patients. In the meantime, 79 patients (81 percent) underwent at least one follow-up examination, the mean follow-up period being 491 days. Seven patients developed a local recurrence, and a further six patients developed distant metastases. For recurrence-free survival rate, the Kaplan-Meier estimation calculated a probability of 71 percent. CONCLUSION: Not all of the reservations about laparoscopic abdominoperineal resection, in particular with regard to resection with curative intent, have yet been eliminated. The present study does, however, show that a laparoscopic approach can in principle meet oncologic requirements of radicality and, with regard to the postoperative course, is associated with considerable benefits to the patient.

Laparoscopic treatment of rectal prolapse: experience gained in a prospective multicenter study

Background. We report the findings of a prospective multicenter observational study carried out by the Study Group for Laparoscopic Colorectal Surgery on patients undergoing laparoscopic or laparoscopic-assisted surgery for rectal prolapse. The study investigated the safety of various laparoscopic techniques in terms of perioperative and postoperative general and technique-specific complications and compared the results with those reported for open surgery in this area. Methods. Of the 150 patients undergoing laparoscopic or laparoscopic-assisted colorectal surgery for rectal prolapse 124 received rectopexy combined with resection and 26 rectopexy alone. In 85 patients a mesh was employed during rectopexy. The conversion rate was 5.3%. Results. Perioperative complications (21 surgical and 35 general perioperative) were recorded in 37 patients (24.7%). The reoperation rate was 5.3% (bleeding 2, anastomotic leak 2, ileus 4). No procedure-specific perioperative complications were observed. In particular, reduced surgical trauma led to fewer severe postoperative complications such as cardiopulmonary problems (3.3%). Conclusions. The techniques of conventional prolapse surgery can readily be translated to the laparoscopic modality, since oncological criteria do not have to be considered. The usually elderly patients in this group benefit to a particular degree from the known advantages associated with reduced surgical trauma. Perioperative morbidity is determined largely by the surgeons experience. We therefore believe that rectal prolapse is a suitable indication for the minimally invasive modality in the hands of trained surgeons.

Oncological quality and preliminary long-term results in laparoscopic colorectal surgery.

BACKGROUND Our aim here was interpret data on the perioperative course, oncological quality, and preliminary long-term results of laparoscopic colorectal surgery carried out with a curative intent. METHODS The data were collected within the framework of a prospective multicenter observational study that has been ongoing since 1 Aug 1995 and includes 46 hospitals. Of a total of 3133 patients, 826 (26.4%) underwent a curative resection for colorectal carcinoma. RESULTS The average age of the patients was 67.9 years; the sex distribution was almost 1:1. UICC staging of tumors (stages I, II, and III) showed the following figures: 301/36.4%, 265/32.1%, and 260/31.5%. In the majority of cases, an oncologically radical resection with high transection of the supplying vessels was performed. Intraoperative seeding of tumor cells was reported in 1.8% of the patients. In eight cases, the seeding was due to spontaneous rupture of the tumor. A mean of 13.5 lymph nodes in the resected specimen were investigated histopathologically (10.9 lymph nodes in stage I, 15 each in stages II and III). Depending on the individual hospital, we found a remarkable variation in the number of lymph nodes investigated. With a mean follow-up period of 2.1 years, Kaplan-Meier survival function showed acceptable results, both for rectal and colonic carcinoma, in comparison with conventional colorectal surgery. A stage-related consideration of the survival data yielded similar results. CONCLUSION All in all, the results show that a laparoscopic colorectal procedure can meet oncological radicality criteria, even though certain reservations-in particular, in the case of procedures done with a curative intent-have not been completely eliminated.

Totally extraperitoneal repair of recurrent inguinal hernia.

Background: A variety of procedures with substantial differences in results are employed to treat recurrent inguinal hernia. The advantages of totally extraperitoneal patch repair (TEP) are even more evident when it is applied to recurrent compared to primary hernias. To investigate the superiority of this method more closely, we reviewed our results obtained for recurrent inguinal hernias over a period of 2 years. Methods: We performed a prospective single-center study using data obtained in consecutive patients with recurrent inguinal hernia who were operated on in 1997 and 1998. Results: A total of 179 patients with recurrent inguinal hernia were recruited. Overall, 1329 patients with inguinal hernia were treated in the 2-year period, of whom 1270 underwent TEP. The percentage of recurrent hernias was 14%. The average age of the patients was 56 years. The follow-up rate was 87.5%, and the mean follow-up period was 2.3 years. The 154 patients who were followed up underwent a total of 225 hernia repairs, of which 181 were for recurrent hernias. The average operating time was 57 min. In 68% (104/154) of the patients, adhesions, adherent epigastric vessels, or cicatricial changes were found, which resulted in the inadvertant opening of the peritoneum in 26.3% of the patients. All the openings in the peritoneum were closed by endoscopic suturing. Intraoperative complications developed in 4 patients (2.3%), including one injury to the bladder and three cases of bleeding from side branches of the epigastric vessels. The conversion rate was 0%. The sole postoperative complication was treatment requiring hematomas in 7 patients, in 2 of whom reoperation became necessary. In both cases, a diffuse hemorrhage due to a preoperatively undiagnosed coagulation disorder was found. No cases of wound or patch infection were observed. In a patient undergoing both primary and recurrent hernia repair, displacement of a mesh led to a recurrence on the primary hernia side (recurrence rate, 0.4%; re-recurrence rate, 0%). Conclusions: Although for its definitive management, recurrent hernia requires a reliable operative technique, current data do not support the recommendation of any of the currently available procedures as the gold standard. In a representative patient population with recurrent hernia, we were able to demonstrate that TEP achieves very good results in terms of re-recurrence rate, intraoperative and postoperative complications, and rehabilitation. Prerequisites for the reliable and low-complication application of the method are a high level of standardization of the procedure and an advanced learning curve.

Laparoscopic surgery in the old patient: do indications and outcomes differ?

Background and aimsIn view of the increasing numbers of old and very old people in the general population, we evaluated the short-term outcomes of laparoscopic colorectal surgery for differences between younger and older patients.MethodsA total of 4823 patients with complete data sets from a prospective, clinical observational multicentre study initiated by the “Laparoscopic Colorectal Surgery Study Group” were analysed for this investigation.ResultsOf the patients, 909 (18.8%) were older and 3914 (81.2%) younger than 75 years. In the older patient group, malignant disease was a significantly more common indication for surgery. As was expected, the rate of general complications (pneumonia, cardiopulmonary problems, urinary tract infection) was significantly higher in the older patient group with its greater prevalence of preoperative comorbidity, but there no differences in terms of intraoperative or postoperative surgical complications or conversion rate between the groups.ConclusionThe higher rate of postoperative complications resulting from preoperative comorbidity in the older patients makes it necessary that the indication for surgery be established with care. In view of the advantages of the laparoscopic approach with regard to the postoperative course, the preferential use of laparoscopy for the treatment of colorectal problems requiring surgery in older patients should receive serious consideration.