Jochen Lange

Impact of Intraoperative Parathyroid Hormone Monitoring on the Prediction of Multiglandular Parathyroid Disease

Optimal interpretation of the results of intraoperative parathyroid hormone (IOPTH) monitoring during neck exploration for primary hyperparathyroidism (pHPT) is still controversial. The reliability of the “50% rule” in multiglandular disease (MGD) is often disputed, mostly because of competing pathophysiologic paradigms. The aim of this study was to ascertain and corroborate the ability of IOPTH monitoring to detect MGD in a practice, combining conventional and alternative parathyroid-ectomy techniques. This is a retrospective single institution analysis of 69 consecutive patients undergoing cervical exploration for pHPT by various approaches. The IOPTH measurements were performed after induction of anesthesia but prior to skin incision and 10 minutes after excision of the first visualized enlarged parathyroid gland. In this series, 55 patients (80%) had single adenomas, and 14 patients (20%) had MGD. In 8 of the 14 patients with MGD, IOPTH levels were obtained sequentially after removal of every enlarged gland. Of these 8 patients, 6 (75%) had a false-positive decrease (decrease below 50% of baseline value in presence of another enlarged gland) failing to predict the presence of a second enlarged gland. In 2 cases IOPTH monitoring provided a true-negative result, correctly predicting MGD. If MGD is defined by gross morphologic criteria, IOPTH monitoring fails to predict the presence of MGD reliably. However, if MGD is defined by functional criteria, the course of these patients does not seem significantly affected. The importance of these findings must be further investigated, especially with regard to the outcome of minimally invasive parathyroid procedures.RésuméL’interprétation optimale peropératoire des résultats du dosage de l’hormone parathyroïdienne (IOPTH) pendant l’exploration cervicale pour hyperparathyroïdie primitive (pHPT) reste un sujet de controverse. La fiabilité de la règle des “50%” en ce qui concerne la maladie multiglandulaire (MGD) est souvent mise en défaut par rapport aux paradigmes physiopathologiques. Le but de cette étude a été de déterminer et de corroborer la capacité du monitorage IOPTH pour détecter la MGD dans une pratique qui combine les techniques de parathyroïdectomie conventionnelle et mini-invasive. Par une analyse rétrospective mono institutionnelle de 69 patients consécutifs ayant eu une exploration cervicale pour pHPT par des approches différentes, on a mesuré l’IOPTH après induction anesthésique mais avant l’incision cutanée et 10 minutes après excision de la première glande parathyroïde augmentée de volume. 55 patients (80%) avaient un seul adénome et 14 patients (20%) avaient une MGD. Chez huit des 14 patients MGD, les taux d’IOPTH ont été obtenus de façon séquentielle après l’ablation de chaque glande augmentée de volume. Six de ces huit patients (75%) avaient une diminution faussement positive (diminution des valeurs de base inférieure à 50% en présence d’une autre glande augmentée de volume) un échec dans la prédiction de la présence d’une deuxième glande augmentée de volume. Dans deux cas, le monitorage IOPTH a montré un résultat négatif vrai prédisant correctement la MGD. Si la MGD est définie par des critères morphologiques macroscopiques, le monitorage par l’IOPTH ne prédit pas fidèlement la présence de MGD. Cependant, si la MGD est définie par des critères fonctionnels, l’évolution de ces patients ne semble pas être affectée. L’importance de ces données doit être explorée d’avantage surtout eu égard à l’évolution de la chirurgie mini-invasive pour cette pathologie.ResumenLa optima interpretación de los resultados de la monitoria intraoperatoria de hormona paratiroidea (PTHIO) en el curso de una exploration cervical por hiperparatiroidismo primario (HPTp) todavía es motivo de controversia. La confiabilidad de la régla de “50%” en los casos de enfermedad multiglandular (EMG) es frecuentemente disputada, generalmente en relación con compétentes paradigmas fisiopatológicos. El propósito del présente estudio tue comprobar y corroborer la capacidad de la monitoria de la PTHIO en la detección de EMG en una práctica que combina técnicas de paratiroidectomía convencionales y alternativas. Es un estudio retrospectivo realizado en una sola institution sobre 69 pacientes consecutivos sometidos a exploratión cervical por HPTp por abordajes diversos. Las mediciones de PTHIO fueron realizadas luego de la inductión de la anestesia pero antes de la incision de la piel y a los 10 minutes después de la resección de la primera glándula que aparecía aumentada de tamaño. 55 pacientes (80%) tuvieron adenomas únicos y 14 20%) EMG. En 8 de los 14 pacientes con EMG, los niveles de PTHIO fueron determinados en forma secuencial luego de la resección de cada glándula hipertrófica; 6 de estos 8 patientes (75%) exhibieron un descenso falso positivo (descenso mayor de 50% sobre el nivel de base en presencia de otra glândula hipertrófica) fallando así en la predictión de la presencia de una segunda glándula hipertrófica. En 2 casos la monitoría de PTHIO constituyó un resultado negativo real, con lo cual se predijo EMG. Si la EMG se define por macrocriterios morfológicos, la monitoría de PTHIO falla en la predictión confiable de la presencia de EMG. Sin embargo, si la EMG es definida por criterios funcionales, la evolutión de estos pacientes no parece afectarse en forma signitïcativa. La importancia de estos hallazgos deber ser investigada más a fondo en relatión con el resultado de los procedimientos de cirugía paratiroidea minimamente invasora.

Risk Factors for Anastomotic Leakage after Rectal Cancer Resection and Reconstruction with Colorectostomy. A Retrospective Study with Bootstrap Analysis

BackgroundThis study was designed to apply modern statistical methods to evaluate risk factors for anastomotic leakage after rectal cancer resection in a retrospective cohort of patients who received a colorectostomy. Whereas a diverting stoma and tumor height are considered proven risk factors for anastomotic leakage, a lack of evidence about additional risk factors persists.MethodsIn a single-center study, 527 consecutive patients who received a colorectostomy after rectal cancer resection between 1991 and 2008 were retrospectively assessed. In addition to traditional uni- and multivariate regression, locally weighted scatterplot smoothing (LOWESS) regression and bootstrap analysis were applied to increase internal validity.ResultsAnastomotic leakage occurred in 70 patients (13.3%; 95% confidence interval (CI), 10.5–16.5%) and mortality was 2.5% (95% CI, 1.4–4.2%). Diverting stoma (odds ratio (OR), 0.4; 95% CI, 0.17–0.61) and tumor height (OR, 0.88; 95% CI, 0.8–0.94) were proven to be protective. Neoadjuvant radiotherapy (OR, 2.15; 95% CI, 1.58–4.24) and intraoperative blood loss (OR, 1.05; 95% CI, 1.02–1.09) had a derogatory effect. Bootstrap analysis identified pre-existing vascular disease (95.5%), more advanced UICC stage III or IV tumors (95.7% or 91.5%, respectively), and intraoperative (96.1%) and postoperative (99.4%) blood substitution as harmful. Both intraoperative and postoperative blood substitution caused a dose-dependent increase in risk.ConclusionsApplying statistical resampling methods identified intraoperative blood loss, blood substitution, vascular disease, and advanced UICC stage as risk factors for anastomotic leakage. Greater distances between the tumor and the anal verge and performance of a diverting stoma were associated with a decreased risk of anastomotic leakage.

Endoscopic Posterior Mesorectal Resection After Transanal Local Excision of T1 Carcinomas of the Lower Third of the Rectum

PurposeThe rectum-sparing transanal local excision is a well-established treatment of T1 carcinomas of the lower third of the rectum. A potentially increased locoregional recurrence rate by this procedure is tolerated because of the high morbidity and mortality risk of transabdominal rectal resection. Dorsoposterior extraperitoneal pelviscopy makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum minimally invasively, in the sense of a rectum-sparing endoscopic posterior mesorectal resection. It has to be considered whether endoscopic posterior mesorectal resection in combination with transanal local excision allows for local radicality and an adequate tumor staging in T1 carcinomas of the lower third of the rectum, in terms of better-directed therapy planning compared with transanal local excision alone.MethodsWe operated on 11 consecutive patients with T1 carcinomas of the lower third of the rectum by transanal local excision in combination with endoscopic posterior mesorectal resection as a two-stage procedure in the period from 1998 to 2005.ResultsIt was possible to perform a complete excision of the primary and to resect the posterior part of the mesorectum in all cases. Postoperative morbidity consisted of two transient neurologic complications and a pulmonary embolism. There was no mortality. Histologic analysis revealed a median of eight (range, 4–20) lymph nodes. Two patients diagnosed with lymph-node metastases received adjuvant radiochemotherapy. After a median follow-up of 48 (range, 4–60) months, there was noevidence for locoregional recurrence. In one patient liver metastasis was detected eight months postoperatively.ConclusionsRadical excision of the primary tumor and an adequate tumor staging in T1 carcinomas of the lower third of the rectum seems to be achievable by means of transanal local excision and endoscopic posterior mesorectal resection.

Laparoscopic mesh-augmented hiatoplasty as a treatment of gastroesophageal reflux disease and hiatal hernias–preliminary clinical and functional results of a prospective case series

BACKGROUND Because fundoplication-related side effects are frequent, we evaluated laparoscopic mesh-augemented hiatoplasty (LMAH) as a potential treatment option for gastroesophageal reflux disease and/or symptomatic hiatal herania. LMAH aims to prevent reflux solely by mesh-reinforced narrowing of the hiatus and lengthening of the intra-abdominal esophagus. METHODS Twenty-two consecutive patients with LMAH were evaluated prospectively using a modified Gastrointestinal Symptom Rating Scale questionnaire, pH measurement, manometry, and endoscopy. Follow-up was scheduled at 3 and 12 months after surgery. RESULTS Total reflux decreased from 16.3% before surgery to 3.5% 3 months after surgery (P = .001). The reflux score decreased from 3.8 before surgery to 2.1 1 year after surgery (P = .001). The respective values of the indigestion score were 3.4 and 2.0 (P < .001). After surgery, all patients were able to belch. Vomiting was impossible only for 2 patients, and 90% of patients assessed their results as good to excellent. CONCLUSIONS LMAH seems to be feasible, safe, and has no significant side effects.

Functional outcome and quality of life after stapled transanal rectal resection for obstructed defecation syndrome.

PURPOSE: Clinical studies have demonstrated that stapled transanal rectal resection with Contour Transtar (Transtar procedure) is a safe and effective treatment for patients with obstructive defecation syndrome. The aim of this study was to determine functional outcome and quality of life after the procedure. METHODS: Female patients with obstructive defecation syndrome were enrolled prospectively for the Transtar procedure. Intussusception and anterior rectocele were confirmed by clinical investigation and by magnetic resonance defecography. Functional outcome was measured by obstructed defecation syndrome score, severity of symptoms score, and Wexner score preoperatively and postoperatively. Quality of life was assessed by the Cleveland Clinic constipation score, the fecal incontinence quality of life scale, and the SF-36v2 health survey. RESULTS: Between January 2007 and November 2008, 52 consecutive patients (median age: 64 years) were included in the study. Before the surgery, 12 patients experienced fecal incontinence. Functional scores improved significantly: 6 weeks after surgery, the obstructed defecation syndrome score decreased from a median of 16 (range, 9–22) to 5 (range, 2–10) and the severity of symptoms score, from 16 (range, 9–21) to 4 (range, 0–9) (each P < .0001). After 6 weeks, 10 patients had fecal incontinence and 12 patients experienced fecal urgency. At 3 months, 6 patients were still incontinent, 3 of whom were treated successfully with sacral neuromodulation. Fecal urgency resolved in all cases after 6 months. Quality of life improved, particularly in the mental components. CONCLUSION: Despite the described postoperative symptoms, most of which can be treated conservatively, the Transtar procedure is an effective treatment for patients with obstructive defecation syndrome and improves quality of life significantly.

Does hyperthermic intraoperative chemotherapy lead to improved outcomes in patients with ovarian cancer? A single center cohort study in 111 consecutive patients

BackgroundFor recurrent disease or primary therapy of advanced ovarian cancer, cytoreductive surgery (CRS) followed by adjuvant chemotherapy is a therapeutic option. The aim of this study was to evaluate the outcome for patients with epithelial ovarian cancer treated with hyperthermic intraoperative chemotherapy (HIPEC) and completeness of cytoreduction (CC).MethodsData were retrospectively collected from 111 patients with recurrent or primary ovarian cancer operated with the contribution of visceral surgical oncologists between 1991 and 2006 in a tertiary referral hospital.ResultsNinety patients received CRS and 21 patients CRS plus HIPEC with cisplatin. Patients with complete cytoreduction (CC0) were more likely to receive HIPEC. Overall, 19 of 21 patients (90.5 %) with HIPEC and 33 of 90 patients (36.7 %) with CRS had a complete cytoreduction (P < 0.001). Incomplete cytoreduction was associated with worse survival rates with a hazard ratio (HR) of 4.4 (95%CI: 2.3-8.4) for CC1/2 and 6.0 (95%CI: 2.9-12.3) for CC3 (P < 0.001). In a Cox-regression limited to 52 patients with CC0 a systemic concomitant chemotherapy (HR 0.3, 95%CI: 0.1-0.96, P = 0.046) but not HIPEC (HR 0.98 with 95 % CI 0.32 to 2.97, P = 0.967) improved survival. Two patients (9.5 %) developed severe renal failure after HIPEC with absolute cisplatin dosages of 90 and 95 mg.ConclusionsCompleteness of cytoreduction was proved to be crucial for long-term outcome. HIPEC procedures in ovarian cancer should be performed in clinical trials to compare CRS, HIPEC and systemic chemotherapy against CRS with systemic chemotherapy. Concerning the safety of HIPEC with cisplatin, the risk of persistent renal failure must be considered when dosage is based on body surface.

Selective decontamination of the gastrointestinal tract in patients undergoing esophageal resection

BackgroundSelective decontamination of the digestive tract (SDD) to eliminate gram-negative bacteria is still not widely accepted, although it reduces the incidence of nosocomial infections. In a previous retrospective study, a clear benefit to perioperative morbidity, and a reduction in nosocomial infections were found in patients who underwent an esophageal anastomosis. Thus, SDD was applied routinely for esophageal anastomoses. We report the outcome of a cohort of 81 patients who underwent this treatment.MethodsFrom 2002, patients who underwent an esophageal anastomosis (esophagojejunostomy) were prospectively recorded. Perioperatively, patients received polymyxin, tobramycin, vancomycin and nystatin by mouth four times a day. Outcome was compared to a control group that was treated before 2002 (68 patients without SDD and 53 patients with SDD). Postoperative morbidity and mortality were assessed.ResultsBetween 2002 and 2007, 81 patients who underwent an esophageal anastomosis received SDD. Compared to a retrospective control group, patients with SDD had significantly less pneumonia (OR 0.06 (0.01-0.46), p < 0.001) and lower morbidity (OR 0.16 (0.05-0.49), p < 0.001). Furthermore, fewer anastomotic insufficiencies and complications were found. Similar results were found in the analysis of the patients treated before 2002.ConclusionsSDD significantly reduces perioperative morbidity and mortality in patients who undergo a distal esophageal anastomosis compared to a historical control group. In patients with an anastomotic leakage, there was a strong tendency of SDD to reduce postoperative mortality.

Evaluation of endoscopy in localizing transgastric access for natural orifice transluminal endoscopic surgery in humans

BACKGROUND To date, transgastric access in humans for natural orifice transluminal endoscopic surgery (NOTES) has been poorly evaluated. OBJECTIVE To compare endoscopic visualization of the transgastric access point with the laparoscopically defined ideal entrance to the peritoneal cavity. DESIGN Prospective pilot study in humans. SETTING Single tertiary-care center. PATIENTS This study involved 31 patients referred for laparoscopic cholecystectomy. INTERVENTION Access points were marked by endoscopy alone, endoscopy combined with diaphanoscopy, and endoscopy after pneumoperitoneum. Points were correlated with a laparoscopically visualized, previously defined ideal access area. MAIN OUTCOME MEASUREMENTS To choose the appropriate access point within the laparoscopically defined ideal access area to the peritoneal cavity away from major vessels and adjacent organs, by using endoscopy and to establish landmarks for the endoscopist, look for a learning curve, and identify potential problems. RESULTS The percentage of access points within the laparoscopically defined ideal area was 35.5% with endoscopy alone, 13.8% using the diaphanoscopy method, and 45.2% after transcutaneous pneumoperitoneum. A safe access point (> or = 3 cm from major gastric vessels) could be achieved with the 3 techniques in 83.9%, 65.5%, and 87.1% of patients, respectively. A positive learning curve for endoscopic localization was identified before (P = .008) and after (P = .014) pneumoperitoneum. Virtual complications were greater in obese patients. LIMITATIONS This was a small pilot study with hypothetical complications and problems, because actual transgastric access was not performed. The criteria for an ideal access area were very strict. CONCLUSION Endoscopy, especially with the use of pneumoperitoneum, can reliably locate a safe transgastric entrance point. However, the endoscopically chosen site correlates poorly with the ideal laparoscopically determined site for transgastric access.

Medial mobilisation of the left hemicolon

INTRODUCTION Laparoscopic surgery of the colon is becoming more and more popular. However, regarding sigmoid resection, controversy remains concerning the extent of mobilisation, particularly regarding the splenic flexure. We developed a technique for anterior resection that meets all surgical standards: the anterior approach. MATERIALS AND METHODS From October 1999 to March 2001, 50 patients with benign diseases of the colon underwent laparoscopically assisted sigmoid resection. A completely anterior approach for mobilisation of the left hemicolon was used in all cases. Positioning the patients in Trendelenburg position on the extreme right side enabled primary ligation of the inferior mesenteric vein and artery as well as complete mobilisation of the splenic flexure from the middle. A transanal circular stapling device was used to reanastomose the colon 10-12 cm from the anus. RESULTS There were conversion and complication rates of 10% each, and three patients needed to be reoperated. The median operating time was 180 min. Patients could be dismissed on the 14th postoperative day. CONCLUSION To establish an operative standard, this technique has so far been used only for benign colon diseases. According to our experience, we think that it meets all oncological standards. Use of this technique in the treatment of malignant diseases seems therefore justified.

Die dorsoposteriore extraperitoneale Pelviskopie (DEP)

ZusammenfassungHintergrund: Die lokale Rektum erhaltende Resektion des Low-Risk-T1-Rektumkarzinoms ist heute ein als Standard akzeptiertes Verfahren. Bei den High-Risk-T1-Tumoren ist bei nicht bekanntem Lymphknotenstatus eine Rektumresektion zu fordern. Mit der dorsoposterioren extraperitonealen Pelviskopie (DEP) wurde eine Methode entwickelt, mit der das Mesorektum in minimalinvasiver Technik unter Erhaltung des Rektums reseziert werden kann, um so auch das nodale Stadium zu diagnostizieren. Patienten und Methodik: Bei bisher zehn Patienten mit High-Risk-T1-Rektumkarzinom wurde nach transanaler R0-Resektion und konventionellem Staging mit CT, Abdomensonographie und transanaler Sonographie in der Regel zweizeitig eine DEP durchgeführt. Die Eingriffe erfolgten in Allgemeinnarkose in Bauchhängelage (Götze-Lagerung). Das Spatium retrorectale wurde mit einem Dilatationsballonsystem von perineal aufgedehnt, ein Pneumoextraperitoneum angelegt und das Mesorektum über drei Ports reseziert. Ergebnisse: Es gelang problemlos und unter Sicht, das Spatium retrorectale zu dilatieren. Der entstandene Arbeitsraum konnte unter hervorragenden Sichtverhältnissen bis zum Promontorium sacri erweitert werden. Das Mesorektum wurde im Sinne einer Staging-Operation vollständig reseziert. Bei der histologische Aufarbeitung der Resektate fanden sich zwischen vier und 20 Lymphknoten. Bei einer Patientin bestand histologisch eine Mikrometastasierung. Im Verlauf zeigte sich bei dem einmalig durchgeführten, einzeitigen Vorgehen eine Wundheilungsstörung im Bereich der Vollwandexzision mit Ausbildung einer rektrovaginalen Fistel. Bei einer weiteren Patientin fanden sich bei der 6 Wochen postoperativ durchgeführten Analmanometrie Zeichen einer Inertia recti. Schlussfolgerung: Mit keiner diagnostischen Maßnahme außer der Histologie lassen sich befallene Lymphknoten ausschließen oder beweisen. Bei der mesorektalen Resektion mittels DEP ist ein adäquates Lymphknoten-Staging erzielbar. Das Rektum erhaltende Vorgehen kann auch auf die Gruppe der High-Risk-T1-Rektumkarzinomen ausgedehnt werden und eine differenziertere Therapieplanung ermöglichen.AbstractBackground: Local resection of low-risk T1 carcinoma of the rectum is an accepted standard of treatment. In high-risk T1 tumors a standard resection should be considered due to the possibility of lymph node metastasis. The dorso-posterior extraperitoneal pelviscopy (DEP) is a method to explore and dissect the mesorectum as a staging procedure. Patients and Methods: We describe the results of ten patients with high-risk T1 rectal cancer in whom, following transanal R0 resection and conventional staging (CT scan, transanal endosonography and abdominal sonography) DEP was performed. The operation was carried out in general anesthesia, the patient in prone jack-knife position. The retrorectal space was dilated with a balloon through a dorso-posterior approach. The extraperitoneal pelvic structures were dissected with a three-port technique and CO2 insufflation. Results: The procedures were performed without technical difficulty. With this method we could extract between four and 20 lymph nodes. In one patient micrometastases where detected. In the only one-stage procedure the patient developed an insufficiency of the transanal suture and a rectovaginal fistula. In a second patient we found an inertia recti 6 weeks postoperatively. Conclusion: A positive lymph node stage can only be diagnosed histologically. DEP is a method that aspires to achieve histological lymph node staging following local resection of high-risk T1 tumors, so that rectum-sparing treatment can be supported. Indications for rectum-sparing surgery could possibly also be extended to high-risk T1 tumors with this method.