Jakob Hinrichs

Late-night and low-dose dexamethasone-suppressed cortisol in saliva and serum for the diagnosis of cortisol-secreting adrenal adenomas.

OBJECTIVE In patients with adrenal incidentalomas, hormonally active masses need to be considered, particularly cortisol-producing adenomas (CPA), aldosterone-producing adenomas, and pheochromocytomas. The screening for hypercortisolism relies on confirming excess cortisol secretion and insufficient suppression after dexamethasone. Because of its high correlation with free cortisol and its stress-free collection, salivary cortisol (SaC) may offer advantages over serum cortisol (SeC). We evaluated the value of SaC and SeC for the diagnosis of CPA. Design Comparative study between 2001 and 2006. METHODS Thirty-eight patients with confirmed CPA were compared with 18 healthy subjects as well as 48 control patients suffering from aldosterone-producing adenomas (n=13), pheochromocytomas (n=16), or nonfunctioning adenomas (n=19). Sampling of saliva and serum was performed at 2300 and at 0800 h following low-dose dexamethasone suppression. Receiver operating characteristics analysis was used to calculate thresholds with at least 95% sensitivity for CPA. RESULTS Regarding the cutoffs for late-night cortisol, SaC (4.8 nmol/l, sensitivity 97%, specificity 69%) was slightly more specific than SeC (115 nmol/l, sensitivity 97%, specificity 63%). In contrast, the cutoff for dexamethasone-suppressed SaC (3.7 nmol/l, sensitivity 97%, specificity 83%) was slightly less specific than SeC (94 nmol/l, sensitivity 97%, specificity 88%). However, the latter cutoffs demonstrated greater specificity when compared with the cutoffs for late-night cortisol. CONCLUSION The diagnostic accuracy of SaC is as good as SeC. Owing to its higher specificity, dexamethasone-suppressed cortisol is preferable to late-night cortisol when screening for Cushings syndrome in patients with adrenal incidentalomas.

Long-term Results After Stapled Hemorrhoidopexy: A Prospective Study With a 6-Year Follow-up

BACKGROUND: Stapled hemorrhoidopexy was introduced in 1998 as a new technique for treating advanced hemorrhoidal disease. Despite a clear perioperative advantage regarding pain and patient comfort, literature reviews indicate a higher recurrence rate for stapled hemorrhoidopexy than for conventional techniques. OBJECTIVE: Our aim was to present long-term on the use of this technique. DESIGN: Observational study. SETTING AND PATIENTS: Consecutive patients with hemorrhoid prolapse treated at a regional surgical center from May 27, 1999, through December 31, 2003. INTERVENTION: Stapled hemorrhoidopexy with accompanying resection of residual hemorrhoidal nodules if necessary. MAIN OUTCOME MEASURES: Standardized patient questionnaire regarding satisfaction, resolution of symptoms, and performance of further interventions. RESULTS: Of 257 patients (82 female, 175 male, mean age 53 ± 13 years) undergoing stapled hemorrhoidopexy, follow-up data were available for 224 patients (87.2%) with a mean duration of 6.3 ± 1.2 years. Of these, 195 patients (87.1%) were satisfied or very satisfied with the operation outcome; 19 patients (8.5%) were moderately satisfied; and 10 (4.5%) were not satisfied. Regarding preoperative anal symptoms, complete relief was observed in 179 patients (80.6%) for prolapse, 172 (77.5%) for bleeding, 139 (85.3%) for mucus discharge, 139 (78.5%) for burning sensation, and 115 (75.5%) for itching. Considering all recorded symptoms, 194 patients (86.6%) reported absence and or an improvement at follow-up. Twelve patients (5.4%) reported newly developed incontinence in the sense of urge symptoms; 42 patients out of 51 patients (82.4%) with preexisting incontinence reported an improvement. Local or topical retreatment (ointment, suppositories, sclerotherapy) was performed in 48 patients (21.4%). Reoperation for residual or newly developed hemorrhoidal nodules was needed in 8 patients (3.6%). LIMITATIONS: Lack of a comparative group. CONCLUSION: Our long-term results show that this strategy for stapled hemorrhoidopexy can achieve a high level of patient satisfaction and symptom control, with a low rate of reoperation for recurrent hemorrhoidal symptoms.

Minimally invasive video-assisted parathyroidectomy (MIVAP) for secondary hyperparathyroidism: report of initial experience

BACKGROUND Minimally invasive video-assisted parathyroidectomy (MIVAP) has become a well-accepted procedure for patients with primary hyperparathyroidism. Because it allows bilateral neck exploration, the authors began using this technique for patients with secondary hyperparathyroidism. In this preliminary study, the authors report their initial experience. METHODS From July 2006 to November 2008, 12 patients (6 women, 6 men; mean age, 45.5 +/- 16.9 years (range, 23-71 years) underwent MIVAP with bilateral exploration for secondary hyperparathyroidism. The operation was performed through a central 2-cm to 3-cm skin incision; a 30 degrees 5-mm endoscope was used for magnification. RESULTS MIVAP was successfully completed in 11 patients (92%). The mean operative time was 81 +/- 37 minutes (range, 35-130 minutes). No major complications were registered. After a mean follow-up period of 11.4 months (range, 3-30 months), 1 patient showed recurrence. CONCLUSIONS MIVAP appears to be a safe and feasible procedure in patients with secondary hyperparathyroidism.

The impact of type and number of bowel resections on anastomotic leakage risk in advanced ovarian cancer surgery

OBJECTIVE To identify risk factors for anastomotic leakage (AL) in patients undergoing primary advanced ovarian cancer surgery and to evaluate the prognostic implication of AL on overall survival in these patients. METHODS We analyzed our institutional database for primary EOC and included all consecutive patients treated by debulking surgery including any type of full circumferential bowel resection beyond appendectomy between 1999 and 2015. We performed logistic regression models to identify risk factors for AL and log-rank tests and Cox proportional hazards models to evaluate the association between AL and survival. RESULTS AL occurred in 36/800 (4.5%; 95% confidence interval [3%-6%]) of all patients with advanced ovarian cancer and 36/518 (6.9% [5%-9%]) patients undergoing bowel resection during debulking surgery. One hundred fifty-six (30.1%) patients had multiple bowel resections. In these patients, AL rate per patient was only slightly higher (9.0% [5%-13%]) than in patients with rectosigmoid resection only (6.9% [4%-10%]), despite the higher number of anastomosis. No independent predictive factors for AL were identified. AL was independently associated with shortened overall survival (HR 1.9 [1.2-3.4], p=0.01). CONCLUSION In the present study, no predictive pre- and/or intraoperative risk factors for AL were identified. AL rate was mainly influenced by rectosigmoid resection and only marginally increased by additional bowel resections.

Continuous intraoperative neuromonitoring in minimally invasive video assisted thyroid surgery: first experience

Background: Visual identification of the recurrent laryngeal nerve (RLN) is mandatory in thyroid surgery independent of the approach. Intermittent intraoperative neuromonitoring (ioNM) is broadly in open and minimally invasive thyroid surgery. However, the use of continuous intraoperative neuromonitoring (C-ioNM) has yet not been described for minimally invasive video-assisted thyroidectomy (MIVAT). The correct placement of the vagal electrode and the problem of its dislocation represent the limiting factor due to the narrow space. We describe the technique for correct electrode positioning and report on our first experiences with the C-ioNM in MIVAT. Methods: C-ioNM was used in 9 patients eligible for MIVAT. To avoid dislocation of the electrode due to traction or interference with the electrode-wires during dissection both the wires and the electrode were pulled through an additional skin incision. MIVAT was then performed using a 5 mm 30° optical device and special instruments according to the original description from Miccoli. Video assisted hemithyroidectomy was performed in 3 patients, while 6 patients underwent total thyroidectomy. Results: Video-assisted application of the vagal electrode and positioning of the wires via an additional access was feasible in all patients without complications. In 6 cases, the electrode-wires were pulled through an additional skin incision on the dominating side lateral to the sternocleidomastoid muscle. In two patients the wires were pulled through an additional incision in the midline below the surgical approach. In one patient the wires were diverted directly through the primary incision. A significant intermittent decrease of the electromyographic (EMG) amplitude was observed in one patient. However, postoperative RLN palsy rate was zero. Conclusions: C-ioNM in MIVAT is feasible. An additional skin incision is helpful to avoid electrode dislocation. Traction of the thyroid lobe during thyroid lobe mobilization does not seem to affect RLN function. However, more data has to be collected to definitely estimate the significance of C-ioNM in MIVAT.

Langzeitergebnisse nach Staplerhämorrhoidopexie

ZusammenfassungHintergrund:Die Staplerhämorrhoidopexie wurde vor rund zehn Jahren als neues Verfahren zur Behandlung des fortgeschrittenen Hämorrhoidodalleidens eingeführt. Während im perioperativen Verlauf ein klarer Vorteil in Bezug auf Schmerzen und Patientenkomfort nachgewiesen wurde, deuten die Auswertungen aktueller Reviews der Literatur auf eine höhere Rezidivrate gegenüber den konventionellen Verfahren hin.Patienten und Methodik:Im Zeitraum von Mai 1999 bis Dezember 2003 wurde bei 257 Patienten (weiblich 82, männlich 175, mittleres Alter 53 ± 13 Jahre) eine Staplerhämorrhoidopexie durchgeführt. 224 Patienten (87,2%) konnten mit einem mittleren Follow-up von 6,2 ± 1,2 Jahren mithilfe eines standardisierten Fragebogens nachuntersucht werden.Ergebnisse:195 Patienten (87,1%) gaben an, mit dem Operationsergebnis zufrieden oder sehr zufrieden zu sein. 19 Patienten (8,5%) waren nur mäßig und die übrigen zehn (4,5%) nicht zufrieden. Beschwerdefreiheit in Bezug auf typische anale Probleme wurden wie folgt beobachtet: Prolaps 80,6%, Blutung 77,5%, Nässen 85,3%, Brennen 78,5% und Juckreiz 75,7%. Unter Berücksichtigung aller erfassten Symptome berichteten 86,6% über Beschwerdefreiheit oder Besserung. Eine neu aufgetretene Kontinenzstörung im Sinne einer Urge-Symptomatik beklagten elf Patienten (4,9%). Gleichzeitig berichteten 42 Patienten (28,8%) über eine Besserung einer vorbestehenden Kontinenzstörung. Bei 48 Patienten (21,5%) wurde im Verlauf erneut eine lokale Therapie (Salbe, Suppositorien, Sklerotherapie) durchgeführt. Eine Nachoperation von residuellen oder neu aufgetretenen Hämorrhoidalknoten erfolgte bei sieben Patienten (3,1%).Schlussfolgerung:In unserem Patientengut konnte auch im Langzeitverlauf eine hohe Patientenzufriedenheit und Symptomkontrolle nach Staplerhämorrhoidopexie beobachtet werden. Die Rate der Reoperationen wegen erneuter Hämorrhoidalbeschwerden war niedrig.AbstractBackground:Stapled haemorrhoidopexy has been introduced about ten years ago as a new operative procedure in the treatment of advanced haemorrhoidal disease. Whereas in the perioperative course a significant advantage in relation to pain and patient’s comfort has been demonstrated, actual reviews of the literature indicate a higher rate of recurrences compaired with conventional techniques.Patients and Methods:Between May 1999 and December 2003 stapled haemorrhoidopexy had been performed in 257 patients (female 82, male 175, mean age 53 ± 13 years). 224 patients (87.2%) could be archived for follow-up (mean 6.2 ± 1.2 years) by means of a standardised questionnaire.Results:195 patients (87.1%) reported good or excellent results after surgery. Nineteen patients (8.5%) had only moderate results and the other ten (4.5%) were not satisfied by the procedure. Free of symptoms concerning typical anal problems were as follows: prolaps 80.6%, bleeding 77.5%, weeping 85.3%, burning 78.5% and pruritus 75.7. Concerning all symptoms 86.6% of the patients reported improvement or even absence of symptoms. Eleven patients (4.9%) complained of new continence disorders like urge incontinence. Concurrently 42 patients (28.8%) reported an improvement of preexisting continence disorders. Forty eight patients (21.5%) received local therapy (ointment, suppository, injection sclerotherapy) during follow-up. Seven patients (3.1%) underwent surgery for residuell or new haemorrhoidal prolapse.Conclusion:Also in long term follow-up a high rate of content patients free of symptoms could be observed after stapled haemorrhoidopexy. The number of reinterventions for recurrent haemorrhoidal disease was low.