J. M. Müller

Laparoscopic versus conventional colorectal resection: a prospective randomised study of postoperative ileus and early postoperative feeding

Background: A shorter duration of postoperative ileus and earlier oral alimentation of patients may be a clinically relevant benefit of laparoscopic compared with conventional colorectal resection. Patients/Methods: A total of 60 patients were randomised to either laparoscopic (n=30) or conventional (n=30) resection of colorectal tumours. Major endpoints were the postoperative time to the first bowel movement and the time until oral feeding without parenteral alimentation was tolerated. Minor endpoints were the postoperative interval to the first peristalsis and first passage of flatus, the distribution of radio-opaque markers in abdominal radiographs on day 3 and day 5 and the incidence of postoperative vomiting. Results: Age, gender, ASA-classification and type of resection were comparable in thetwo groups. Peristalsis was first noticed 26±9 h after laparoscopic and 38±17 h after conventional colorectal resection (P<0.01). First flatus occurred 50±19 h after laparoscopic and 79±21 h after conventional surgery (P<0.01). The incidence of postoperative vomiting was similar in both groups. Three days after surgery radio-opaque markers were found more often in the right colon (P<0.01) and less often in the small intestine (P<0.05) in laparoscopic compared with conventional patients. Five days after laparoscopic surgery, more markers had reached the left colon (P<0.05). The first bowel movement occurred 70±32 h after laparoscopic and 91±22 h after conventional resection (P<0.01). Oral feeding without additional parenteral alimentation was tolerated 3.3±0.7 days after laparoscopic and 5.0±1.5 days after conventional surgery (P<0.01). Conclusion: The shorter duration of postoperative ileus allows earlier restoration of oral feeding after laparoscopic compared with conventional colorectal resection and therefore increases quality of life immediately after resection of colorectal tumours.

Fast-track multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: A controlled prospective evaluation

BackgroundLaparoscopic colorectal resection improves patient outcome by reducing pain, postoperative pulmonary dysfunction, gastrointestinal paralysis, and fatigue. A multimodal rehabilitation program (“fast-track”) with epidural analgesia, early oral feeding, and enforced mobilization may further improve the excellent results of laparoscopic colorectal resection, enabling early ambulation of these patients.MethodsFifty two consecutive patients underwent laparoscopic sigmoidectomy with standardized regular perioperative treatment (standard) or multimodal rehabilitation program (“fast-track”). Outcome measures included pulmonary function, duration of postoperative ileus, pain perception, fatigue, morbidity, and mortality.ResultsTwenty nine standard-care patients (19 men and 10 women) and 23 fast-track patients (15 men and eight women) were evaluated. Demographic and operative data were similar for the two groups. On the 1st postoperative day, pulmonary function was improved (p = 0.01) in fast-track patients. Oral feeding was achieved earlier (p < 0.01) and defecation occurred earlier (p < 0.01) in the fast-track group. Visual analogue scale scores for pain were similar for the two groups (p > 0.05), but fatigue was increased in the standard-care group on the 1st (p = 0.06) and 2nd (p < 0.05) postoperative days. Morbidity was not different for the two groups. Fast-track patients were discharged on day 4 (range, 3–6) and standard-care patients on day 7 (range, 4–14) (p < 0.001).ConclusionMultimodal rehabiliation can improve further on the excellent results of laparoscopic sigmoidectomy and decrease the postoperative hospital stay.

Cellular and humoral inflammatory response after laparoscopic and conventional colorectal resections

Background: Surgical trauma and anesthesia are known to cause transient postoperative suppression of the immune system. In randomized controlled trials, it has been shown that laparoscopic colorectal resections have short-term benefits not observed with conventional colorectal resections. We hypothesized that these benefits were due to the reduction in surgical trauma, leading to a diminished cytokine response and less depression of cell-mediated immunity after laparoscopy. Methods: In a prospective randomized trial, colorectal cancer patients without evidence of metastatic disease underwent either laparoscopic (n = 20) or conventional (n = 20) tumor resection. Postoperative immune function was assessed by measuring the white blood cell (WBC) count, the CD4+ and CD8+ lymphocytes, the CD4+/CD8+/ratio, and the HLA-DR expression of CD14+ monocytes. In addition, the production of interleukin-6 (IL = 6) and TNF-a were measured after ex vivo stimulation of mononuclear blood cells with lipopolysaccharide (LPS) and compared to the plasma levels of these cytokines. Postoperative mean levels of the immunologic parameters for the two groups were calculated and compared using the Mann-Whitney U test. Results: Preoperatively, there were no differences between the two groups in terms of patient characteristics or immunologic parameters. Although the postoperative peak concentrations of white blood cells were significant lower in the laparoscopic group than the conventional group (p < 0.05), there were no differences between the two groups in the subpopulation of lymphocytes (CD4+, CD8+). HLA-DR expression of CD14+ monocytes was lower in the conventional group on the 4th postoperative day (p < 0.05). The laparoscopic group showed higher values in cytokine production of mononuclear blood cells after LPS stimulation. Postoperative plasma peak concentrations of IL-6 and TNF-a were lower after laparoscopic resection. Conclusion: Postoperative cell-mediated immunity was better preserved after laparoscopic than after conventional colorectal resection. Cellular cytokine production was preserved only in the laparoscopic group, while cytokine plasma levels were significantly higher in the conventional group. These findings may have important implications for the use of laparoscopic colorectal resection, especially in patients with malignant disease.

Pulmonary function after thoracoscopic thymectomy versus median sternotomy for myasthenia gravis

BACKGROUND Impaired pulmonary function due to myasthenia gravis (MG) is further compromised by thymectomy, which is necessary in most cases. Thoracoscopic thymectomy (tThx) can achieve the same resection and functional improvement of MG as median sternotomy (sThx). The possible advantage of tThx in maintaining better perioperative lung function was quantified. METHODS In a prospective trial, 20 patients with MG were randomly allocated to undergo tThx (n = 10) by three-trocar left-sided approach or sThx (n = 10) performed as an extended procedure. Complete pulmonary function was measured at 12-hour intervals, beginning 6 hours postoperatively. Effective postoperative pain control in both groups was achieved by patient-controlled analgesia with morphine sulfate assessed by a visual analogue scale. Statistical analysis for comparison of tThx and sThx was performed using the Mann-Whitney U test. RESULTS Postoperative vital capacity, forced vital capacity, forced expiratory volume per second, and peak expiratory flow, measured as a percentage of the individual preoperative capacity, were significantly better with tThx compared with sThx. Immediate postoperative lung function was reduced to 35% and 65% after tThx and sThx, respectively. By the third postoperative day, recovery of pulmonary function was complete after tThx but only 55% after sThx. CONCLUSIONS Less pronounced impairment and faster recovery of pulmonary function after tThx characterize this new approach for thymectomy as minimally invasive. These results could make tThx the preferred surgical treatment of MG, which was improved to the same extent as after sThx.

Identification of six methylenetetrahydrofolate reductase (MTHFR) genotypes resulting from common polymorphisms: impact on plasma homocysteine levels and development of coronary artery disease

Although three common MTHFR polymorphisms (C677T, A1298C, T1317C) have been reported, only polymorphism C677T has been investigated intensively as a risk factor for coronary artery disease (CAD). We investigated polymorphism frequencies, allelic associations and the effect of the resulting MTHFR genotypes on total plasma homocysteine (tHcy) levels and on coronary risk in a case-control study with 1000 angiographically confirmed Middle-European CAD patients and 1000 matched controls. Three out of four theoretically possible MTHFR haplotypes were detected: *1 (677C, 1298A), *2 (677T, 1298A), and *3 (677C, 1298C). The frequencies were *1: 36.4 and 34.4%; *2: 30.8 and 32.3%; and *3: 32.8 and 33.3%, in cases and controls, respectively. Only one patient was heterozygous for 1317C. None of the six resulting genotypes showed significant influence on tHcy levels. Moreover, there was no significant association with CAD risk or with disease severity or early disease manifestation. In the subgroup presenting with acute coronary syndromes, MTHFR genotypes *2/*3 and *3/*3 were surprisingly underrepresented (relative risk of *3/*3, 0.40; 95% confidence interval 0.20-0.79, P=0.009). We conclude from our genotype-based analysis that, in this well-fed Middle-European population, the observed common allelic variants of the MTHFR gene have no significant influence on tHcy levels or on the chronic process of CAD development.

Quality of life after gastrectomy: Longmire's reconstruction alone compared with additional pouch reconstruction.

The optimal reconstruction protocol aftertotal gastrectomy is still a matter of debate. Pouch reconstructionsare developed to create a larger reservoir for food, to provide abarrier against intestinoesophageal reflux, and to lengthen the foodtransit time. Preservation of the duodenal passage should result inbetter physiologic regulation of the ingested food. Controlledrandomized clinical studies must be conducted to assess the quality oflife after gastrectomy and various types of reconstruction. In thepresent trial, which compared Longmire’s reconstruction without apouch and Longmire’s reconstruction with a pouch of varying sizes, weevaluated the quality of life for 41 patients during the firstpostoperative year. The quality of life was examined by an EORTCquestionnaire and an organ-specific module. There were no statisticallyproven benefits for pouch reconstruction in comparison with Longmire’sreconstruction alone. Some benefits are shown for the large pouch butit was only a trend. This is especially so with regard to diarrhea andfood consumption. A definitive answer to the question about the valueof a pouch reconstruction after gastrectomy has not yet been attained.It is possible that there will be significant differences betweenreconstruction groups during the long-term follow-up.

Immunomodulatory changes in patients with colorectal cancer.

Abstract.Background and aims: Solid tumors are frequently accompanied by a depressed cellular and humoral immunity. This study analyzed changes these factors in colorectal cancer patients. Patients and methods: We compared cellular (leukocytes, lymphocytes, HLA-DR expression on monocytes) and humoral immune parameters (interleukin-6, interleukin-10, tumor necrosis factor α) in 40 patients with colorectal cancer and in 18 healthy controls. Results: Leukocytes were in the normal range in patients and controls. However, tumor patients showed significant lymphopenia in comparison to controls. HLA-DR antigen expression on CD14+ monocytes was reduced in the cancer patients while IL-6 and IL-10 plasma levels were increased. Patients with UICC stage III had IL-6 and IL-10 concentrations were significantly increased as well. Conclusions: These findings suggest that colorectal tumor establishment and progression results in a malfunction of the immune system, and underline the importance of elucidating in detail the mechanisms of immune modulation in cancer patients.

Matched-pair comparison of three different approaches for thymectomy in myasthenia gravis

Background: Because of the lack of evidence-based data comparing different techniques for thymectomy (Thx), a matched-pair study was conducted to evaluate the role of thoracoscopic Thx (tThx) more objectively. Methods: Of 182 patients who underwent Thx, 3 groups according to the operation technique were matched for myasthenia gravis (MG) without thymoma, age, gender, and severity of MG. Twenty patients each who had Thx through anterolateral thoracotomy (aThx), extended median sternotomy (sThx), and tThx were compared for length of operation, postoperative morbidity, complete remission, quantification of improvement of MG, and cosmetic results. Results: Complete tThx required 197 ± 35 min as compared to 113 ± 43 min for sThx and 82 ± 27 min for aThx (P < 0.001). With zero mortality the overall postoperative morbidity rate was 25% for sThx versus 15% for aThx and 5% for tThx (P < 0.05). There was no difference in complete remission of MG. The median activities of daily living (ADL) scores improved by 6.0 (1–19) after tThx, 5.5 (2–4) after sThx, and 7.5 (0–12) after aThx. Best cosmetic results were achieved after tThx. Conclusions: There was adequate cumulative medium-term improvement of MG and less postoperative morbidity after tThx, which may become the preferred technique for Thx.

Radicality of thoracoscopic thymectomy--an anatomical study.

Jens C. RuEckert*, Damian Czyzewski, SoEren Pest, Joachim M. MuEller Department of General, Thoracic, Vascular, and Visceral Surgery, Humboldt University Medical School (ChariteÂ), Campus Mitte, Schumannstrasse 20/21, D-10117 Berlin, Germany Department of Thoracic Surgery, Silesian Medical Academy, Zabrze, Poland Institute of Pathology, Humboldt University Medical School (ChariteÂ), Campus Mitte, Berlin, Germany

Réhabilitation rapide en chirurgie colique : résultats d'une étude prospective

Objective. – In elective large bowel surgery the incidence of general complications with standard perioperative care is up to 27%. Hospital discharge occurs 10 to 15 days after a conventional or laparoscopic colonic resection. The aim of a fast track management is to reduce the number of general complications and the length of hospital stay. Material and methods. – We prospectively evaluated a multimodal protocol in our service utilizing a combined thoracic epidural analgesia, an early mobilization and oral nutrition to accelerate postoperative recovery after elective colonic surgery. Results. – One hundred thirty-two consecutive patients aged an average of 66 years (range 22–88) were operated by laparotomy (n =71) or laparoscopy (n =61) and treated with the fast track rehabilitation protocol. Surgical complications occurred in 15 patients (11 %), four of these had an anastomotique leakage (3%). General complications occurred in 11 patients (8 %), the mortality was 1 %. The median length of hospital stay was four days (range 3–77) and 14 patients (11%) had to be readmitted. Conclusion. – Application of a fast track rehabilitation protocol lowered the number of general complications and reduced the duration of hospital stay in our study.