Hubert Scheuerlein

New methods for clinical pathways—Business Process Modeling Notation (BPMN) and Tangible Business Process Modeling (t.BPM)

PurposeClinical pathways (CP) are nowadays used in numerous institutions, but their real impact is still a matter of debate. The optimal design of a clinical pathway remains unclear and is mainly determined by the expectations of the individual institution. The purpose of the here described pilot project was the development of two CP (colon and rectum carcinoma) according to Business Process Modeling Notation (BPMN) and Tangible Business Process Modeling (t.BPM).MethodsBPMN is an established standard for business process modelling in industry and economy. It is, in the broadest sense, a computer programme which enables the description and a relatively easy graphical imaging of complex processes. t.BPM is a modular construction system of the BPMN symbols which enables the creation of an outline or raw model, e.g. by placing the symbols on a spread-out paper sheet. The thus created outline can then be transferred to the computer and further modified as required. CP for the treatment of colon and rectal cancer have been developed with support of an external IT coach.ResultsThe pathway was developed in an interdisciplinary and interprofessional manner (55 man-days over 15 working days). During this time, necessary interviews with medical, nursing and administrative staffs were conducted as well. Both pathways were developed parallel. Subsequent analysis was focussed on feasibility, expenditure, clarity and suitability for daily clinical practice. The familiarization with BPMN was relatively quick and intuitive. The use of t.BPM enabled the pragmatic, effective and results-directed creation of outlines for the CP. The development of both CP was finished from the diagnostic evaluation to the adjuvant/neoadjuvant therapy and rehabilitation phase. The integration of checklists, guidelines and important medical or other documents is easily accomplished. A direct integration into the hospital computer system is currently not possible for technical reasons.ConclusionBPMN and t.BPM are sufficiently suitable for the planned modelling and imaging of CP. The application in medicine is new, and transfer from the industrial process management is in principle possible. BPMN-CP may be used for teaching and training, patient information and quality management. The graphical image is clearly structured and appealing. Even though the efficiency in the creation of BPMN-CP increases markedly after the training phase, high amounts of manpower and time are required. The most sensible and consequent application of a BPMN-CP would be the direct integration into the hospital computer system. The integration of a modelling language, such as BPMN, into the hospital computer systems could be a very sensible approach for the development of new hospital information systems in the future.

Epidemiological Pattern of Hepatitis B and Hepatitis C as Etiological Agents for Hepatocellular Carcinoma in Iran and Worldwide

Context Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections constitute a major global health problem. About 60,000 and 350,000 deaths occur as the results of HBV and HCV infections, respectively. Chronic hepatitis B and C infections are leading causes of cirrhosis and hepatocellular carcinoma (HCC) which are considered as the third cancer-associated cause of deaths worldwide. Iran suffers from the same problem but to a lesser extent as it is considered as a low endemic area for HBV and HCV infections and also as a low incidence area of HCC. This study was conducted to assess and provide a clear picture about epidemiology of HBV and HCV infections in Iran and worldwide, with the consequence on HCC distribution all over the world including Iran, and to analyze current literature regarding the modes of transmission and risk factors of HBV and HCV infections. Evidence Acquisition In this review, we performed electronic and manual searches on available databases such as MEDLINE, PubMed, Ovid, Embase, and the Iranian databases such as IranMedex. We also performed a Google search to find related articles. Results HBV and HCV infections are the most common risk factors of hepatocellular carcinoma. The epidemiology of HCC usually follows that of HBV and HCV infections. With the introduction of HBV national vaccine in Iran and worldwide, there is a noticeable effect on reduction in HBV prevalence in most countries, and we expect that HCV will replace HBV as a major risk factor of HCC in Iran and worldwide. Alcohol plays a minor role as a risk factor for cirrhosis and HCC in Iran, Asia, and Africa, despite its noticeable role in Europe and the USA. Conclusions Vaccination against HBV remains the most effective approach against HBV infection with consequence decrease in HBV-related HCC. There is a need to improve the awareness about epidemiology of HBV and HCV infections, modes of transmission, and their complications, specifically HCC among population.

Microbiology of the infected recurrent sacrococcygeal pilonidal sinus

The aim of the present retrospective single centre study was to define the changes in the microbiological flora of the recurring sacrococcygeal pilonidal sinus (PS). Microbiological findings of swab samples of abscess‐forming PS from 2000 to 2010 were evaluated. Within this time span, 73 swab samples were taken from primary sacrococcygeal pilonidal sinus (pPS) and 23 swab samples of patients with recurring sacrococcygeal pilonidal sinus (rPS). Our results show a statistically significant shift of the bacterial flora towards the gram‐positive range (P = 0·029) and a shift with tendency towards the aerobic range (P = 0·090). Pathogens of pPS are not always solely anaerobic or gram‐negative, and those of rPS not always aerobic or gram‐positive. Therefore, antibiosis preceding microbiological examination should cover both the aerobic and anaerobic bacteria as well as the gram‐positive and the gram‐negative spectrum.

Waiting time, not donor-risk-index, is a major determinant for beneficial outcome after liver transplantation in high-MELD patients

BACKGROUND Due to the increasing donor shortage, patients undergo liver transplantation actually mostly with high MELD-scores. In this study, we analyze high-MELD patients who underwent liver transplantation at a german single center. MATERIAL AND METHODS Since implementation of the MELD-score within the Eurotransplant region (December 2006) up to May 2011, 45 patients with a lab-MELD-score ≥ 36 underwent liver transplantation at our center. We correlated the 1-year-survival with donor data (especially the donor risk index, DRI), the time interval from reaching a lab-MELD-score ≥ 36 up to liver transplantation and the recipients state prior transplantation. RESULTS The overall 1-year-survival in our cohort is 68,8%. Waiting time of survivors was significantly shorter compared to non-survivors (MedianSurvivors: 2 days vs. MedianNon-survivors: 4 days; p=0.049). DRI showed no significant differences between both groups. Furthermore, the recipients state prior transplantation (dialysis, mechanical ventilation, catecholamines) showed no significant association with the outcome. CONCLUSIONS The outcome after liver transplantation in high-MELD patients is worse compared to that of patients with a marked lower MELD-score. Especially the time interval between reaching a lab-MELD score ≥ 36 to the transplantation is a major determinant for survival. Since the DRI is not associated with a worsened outcome, transplantation centers should accept even marginal organs for high-MELD patients to keep the waiting time as short as possible.

Ruptured aneurysm of the ulnar artery in a woman with neurofibromatosis

A 61-year-old woman with neurofibromatosis type 1 (Recklinghausens disease) was referred for massive swelling of the right forearm, pain, increasing numbness, and impaired movement of the fingers. Angiography demonstrated a 13- x 11-mm aneurysm and a capped rupture of the ulnar artery. Because of the complicated soft-tissue condition, interventional treatment was indicated. Two 360 degrees coils were placed for embolization of the ruptured aneurysm. Arterial involvement in neurofibromatosis is a well known but infrequent occurrence. Stenotic lesions predominate. Aneurysmal defects are less common, and rupture of peripheral arteries is exceptional.

Post-operative internal hernia through an orifice underneath the right common iliac artery after Dargent's operation.

We report the case of a 39-year-old woman with ileus resulting from a small bowel incarceration underneath the right common iliac artery. The patient had a history of a radical trachelectomy with laparoscopic pelvic lymphadenectomy (“Dargent’s operation”) for cervical carcinoma. After dissection of the iliac vessels, a small bowel loop could slide underneath the common iliac artery. The hernia was closed by gluing a collagen patch over the right common iliac artery onto the retroperitoneal cavity. To our knowledge, such a case has not previously been reported in the medical literature.

Laparoscopic Incisional Hernia Repair After Solid-Organ Transplantation

BACKGROUND Incisional hernias are a frequent problem after liver transplantation. Mesh repair techniques including laparoscopic repair have been employed in order to address this problem. We have introduced intraperitoneal onlay mesh repair (IPOM) in 2008 because of advantages that had been reported in the literature. To perform a structured comparison of methods and outcomes, we compared patients who have been treated with IPOM and those who have been treated conventionally. METHODS We included 29 consecutive patients (15 IPOM, 14 conventional hernia repair [CHR] who have been analyzed and have been examined clinically and sonographically during their follow-up. RESULTS Recurrence rate was 6% (IPOM) and 50% (CHR), complication rate was 33% (IPOM) and 21% (CHR), mean hospital stay was 7.2 (IPOM) and 9.7 (CHR) days. None of the 29 patients had an impaired wound healing or infectious complications. Of the 29 patients, 10 received sirolimus for immunosuppression, which was switched preoperatively to a calcineurin inhibitor. CONCLUSION IPOM results in a shorter hospital stay. The complication rate with IPOM was higher compared with CHR, recurrence rate was considerably lower. The role of perioperative sirolimus switch needs to be interpreted with caution, but should be further investigated because of potential advantages with respect to fewer wound healing complications.

Zweizeitiges Verfahren mit primärer Exzision und Limberg-Plastik zur Therapie eines sakrokokzygealen Pilonidalsinus

BACKGROUND The current German S3 guidelines recommend radical excision for pilonidal sinus disease. Furthermore, the Karydakis operation and the plastic surgery procedure according to Limberg are also recommended. Contrary to the S2 guidelines of 2008, these two plastic surgery procedures for coverage are recommended for the treatment of the first-time manifestation of this disease. Most studies on the classical Limberg plastic surgical procedure are comparative in nature and describe a simultaneous intervention from which patients with an abscess are excluded. AIM The aim of this present study was to analyze the results of a sequential procedure including primary excision followed by a Limberg plastic surgery procedure for the treatment of acute abscesses and chronic pilonidal sinus disease. MATERIAL AND METHODS From July 2010 to June 2013 a total of 50 patients with pilonidal sinus disease were treated at the University Hospital Jena with an initial radical excision. In accordance with the Association of the Scientific Medical Societies in Germany (AWMF) guidelines which were valid during that time, patients were offered plastic surgery coverage for recurrence prophylaxis and in cases of recurrence a Limberg plastic surgery procedure was recommended. RESULTS Of the 50 patients 22 opted for a Limberg plastic surgery procedure during the interval. The mean follow-up after the Limberg plastic surgery procedure was 20.1 months (range 2-36 months). During the follow-up period, there were no recurrences (0 %) but four major complications (18.2 %) and one minor complication (4.5 %) were observed. CONCLUSION This concept can be applied in cases of acute abscess formation and in chronic pilonidal sinus disease. The patients decision with respect to a Limberg plastic surgery procedure for recurrence prophylaxis does not have to be made immediately. In addition, the Limberg plastic surgery procedure is performed in an infection-free stage. The second inpatient stay, second surgical procedure and prolonged time off work are a disadvantage.ZusammenfassungHintergrundDie aktuelle deutsche S3-Leitlinie empfiehlt bei Pilonidalsinus die radikale Exzision. Es werden auch die Karydakis-Operation und die Rautenplastik nach Limberg empfohlen. Gegenüber der S2-Leitlinien von 2008 werden nun diese zwei plastischen Deckungen bereits beim erstmaligen Auftreten dieser Erkrankung empfohlen. Die meisten Studien zur klassischen Limberg-Plastik sind Vergleichsstudien und beschreiben ein einzeitiges Verfahren, wobei Patienten mit einem Abszess ausgeschlossen wurden.ZielDas Ziel der vorliegenden Studie war es, die Ergebnisse des zweizeitigen Verfahrens mit primärer Exzision und Limberg-Plastik im Intervall zur Therapie sowohl für die akut-abszedierende als auch für die chronische Pilonidalsinuserkrankung zu analysieren.Material und MethodeBei 50 Patienten mit einer Pilonidalsinuserkrankung wurde im Zeitraum von Juli 2010 bis Juni 2013 am Universitätsklinikum Jena initial eine radikale Exzision durchgeführt. Gemäß der zu diesem Zeitpunkt gültigen AWMF-Leitlinie wurde den Patienten eine plastische Deckung zur Rezidivprophylaxe angeboten und bei Vorhandensein eines Rezidivs die Rautenplastik nach Limberg empfohlen.ErgebnisseVon 50 Patienten entschieden sich 22 für eine Limberg-Plastik im Intervall. Das mittlere Follow-up nach der Limberg-Plastik betrug 20,1 Monate (Range 2–36). Es wurden im Nachbeobachtungszeitraum keine Rezidive (0 %) nachgewiesen, jedoch wurden vier Major-Komplikationen (18,2 %) und eine Minor-Komplikation (4,5 %) beobachtet.SchlussfolgerungenUnser Konzept kann sowohl für die akut-abszedierende als auch für die chronische Pilonidalsinuserkrankung angewandt werden. Die Entscheidung des Patienten bezüglich einer Rezidivprophylaxe mittels Limberg-Plastik muss nicht unmittelbar bzw. unter Zeitdruck gefällt werden. Zusätzlich erfolgt die Limberg-Plastik in einem entzündungsfreien Stadium. Ein Nachteil besteht vor allem wegen des nochmaligen stationären Aufenthalts, der Zweitoperation und der längeren Zeit der Arbeitsunfähigkeit.AbstractBackgroundThe current German S3 guidelines recommend radical excision for pilonidal sinus disease. Furthermore, the Karydakis operation and the plastic surgery procedure according to Limberg are also recommended. Contrary to the S2 guidelines of 2008, these two plastic surgery procedures for coverage are recommended for the treatment of the first-time manifestation of this disease. Most studies on the classical Limberg plastic surgical procedure are comparative in nature and describe a simultaneous intervention from which patients with an abscess are excluded.AimThe aim of this present study was to analyze the results of a sequential procedure including primary excision followed by a Limberg plastic surgery procedure for the treatment of acute abscesses and chronic pilonidal sinus disease.Material and methodsFrom July 2010 to June 2013 a total of 50 patients with pilonidal sinus disease were treated at the University Hospital Jena with an initial radical excision. In accordance with the Association of the Scientific Medical Societies in Germany (AWMF) guidelines which were valid during that time, patients were offered plastic surgery coverage for recurrence prophylaxis and in cases of recurrence a Limberg plastic surgery procedure was recommended.ResultsOf the 50 patients 22 opted for a Limberg plastic surgery procedure during the interval. The mean follow-up after the Limberg plastic surgery procedure was 20.1 months (range 2–36 months). During the follow-up period, there were no recurrences (0 %) but four major complications (18.2 %) and one minor complication (4.5 %) were observed.ConclusionThis concept can be applied in cases of acute abscess formation and in chronic pilonidal sinus disease. The patient’s decision with respect to a Limberg plastic surgery procedure for recurrence prophylaxis does not have to be made immediately. In addition, the Limberg plastic surgery procedure is performed in an infection-free stage. The second inpatient stay, second surgical procedure and prolonged time off work are a disadvantage.

Suture granuloma mimicking a recurrent sacro-coccygeal pilonidal sinus after Limberg flap

Sacro‐coccygeal pilonidal sinus disease is classified as an asymptomatic, acutely abscess‐forming or chronic subcutaneous inflammation in the sacro‐coccygeal region featuring characteristic pits in the bottom cleft. Due to high rates of recurrence, two flap techniques have been established in the course of the past three decades. One of them is the Karydakis operation, the other option is a rotation flap named Limberg procedure. We report about a case of suture granuloma in the area of a Limberg flap after recurrent pilonidal sinus with extrusion of the suture material, thus mimicking recurrence. In case of recurrent pilonidal sinus following plastic coverage or primary closure, respectively, the differential diagnosis of suture granuloma should be considered.

In vivo assessment of the hepatic microcirculation after mesenterico-portal bypass (REX-shunt) using orthogonal polarization spectral imaging.

Background: Extrahepatic portal vein thrombosis, not associated with cirrhosis or tumours, is the second most frequent cause of portal hypertension worldwide. Especially in children, anatomic mesenterico‐portal interposition (REX‐shunt) has become an established treatment. The changes in hepatic microcirculation after reperfusion of the shunt have not been investigated so far.