Jörg-Peter Ritz

Outcome of patients with acute sigmoid diverticulitis: Multivariate analysis of risk factors for free perforation

BACKGROUND Sigmoid diverticulitis (SD) is common in the West; its incidence is increasing as the average age of the population increases. The aim of this study was to assess the clinical outcomes of patients with acute SD and to determine whether emergency operation was associated more often with previous episodes of acute diverticulitis. METHODS All consecutive patients admitted for acute SD were recruited prospectively over an 11-year period from January 1998 to December 2008. Multiple logistic regression was used to identify risk factors for free perforation. RESULTS We included 934 patients (490 men and 444 women; median age, 59.2 years): 450 (48.2%) presented for their first SD episode and 484 (51.8%) had a prior history of SD. Free perforation occurred in 152 patients: during the first episode of SD in 114 patients (25.3%), during the second in 29 (12.7%), during the third in 8 (5.9%), and during the fifth in 1 patient (0.9%; P < .001). No patient with >5 previous episodes of SD had free perforation. All 152 patients with free perforation required emergent operative intervention. After initial conservative therapy in 782 patients, 82 required early elective operative intervention owing to exacerbation of infection under antibiotic treatment. Late elective colectomy was performed in 299 patients during the inflammation-free interval, and operative intervention was recommended in 345 patients owing to complicated diverticulitis. Uncomplicated SD in 56 patients was managed conservatively. Comorbidity (>1 disorder) and the first episode of SD were identified as risk factors for free perforation on multiple logistic regression. CONCLUSION The risk of free perforation in acute SD decreases with the number of previous episodes of SD. The first episode thus is the most dangerous for a free perforation. The indication for colectomy should not be made based on the potential risk of free perforation.

Can laparoscopically assisted sigmoid resection provide uncomplicated management even in cases of complicated diverticulitis

BackgroundLaparoscopically assisted sigmoid resection has become an accepted method for treating uncomplicated diverticulitis. This prospective study aimed to compare the results of laparoscopic sigmoid resection for uncomplicated and complicated sigmoid diverticular disease used to check the indication for the complicated stages of diverticulitis.MethodsAll patients who underwent laparoscopic resection for sigmoid diverticulitis at the authors’ hospital between 1999 and 2005 were divided into two groups: group 1 (uncomplicated diverticular disease) and group 2 (complicated diverticular disease). The exclusion criteria specified generalized peritonitis, signs of sepsis, and extensive previous abdominal surgery.ResultsOf the 203 patients (108 men and 95 women) who underwent laparoscopically assisted resection during the examination period, 112 were assigned to group 1 and 91 to group 2. Differences in favor of group 1 were found for the duration of surgery (154 vs 166 min), the conversion rate (1.8% vs 9.9%), the postoperative wound infections (2.7% vs 13.2%), and the postoperative hospitalization period (12.3 ± 3.9 vs 15.0 ± 5.6 days). No significant differences were seen in any other areas such as completion of nutritional buildup (4.6 vs 5.0 days) or time until the first postoperative bowel movement (2.8 vs 3.3 days). Total postoperative morbidity (16.1% vs 26.4%; p = 0.10) tended to be increased in group 2, but this difference was not statistically significant.ConclusionsLaparoscopic sigmoid resection can be performed for patients who have complicated diverticulitis without significantly increasing their overall morbidity. This group of patients could benefit from the advantages of the minimally invasive procedure despite a longer operating time and a higher conversion rate.

Preoperative CT staging in sigmoid diverticulitis—does it correlate with intraoperative and histological findings?

PurposeThis study was designed to evaluate whether the computed tomography (CT) reflects the extent of the inflammation in sigmoid diverticulitis (SD) in order to draw conclusions for selecting the appropriate treatment.MethodsTwo hundred four patients who underwent resection for SD from January 2003 to December 2008 were included. The preoperative CT stage was compared with intraoperative and histological findings. Patients were classified into phlegmonous (Hansen–Stock IIa), abscess-forming (HS IIb), and free perforated (HS IIc) forms of SD. Patients with a recurrent type of diverticulitis were excluded.ResultsIn the phlegmonous type (HS IIa; n = 75), we found a correlation with the preoperative stage in 52% (intraoperative) and 56% (histological), an understaging in 12% (intraoperative) and 11% (histological), and an overstaging in 36% (intraoperative) and 33% (histological). In the abscess-forming type (HS IIb, Hinchey I/II; n = 87), we found conformity in 92% (intraoperative) and 90% (histological), understaging in 3% (intraoperative) and 0% (histological), and overstaging in 5% (intraoperative) and 10% (histological). In the presence of a free perforation (HS IIc, Hinchey III/IV; n = 42), we saw conformity in 100% (intraoperative and histological). The positive predictive value for correctly diagnosing of phlegmonous type (HS IIa), abscess-forming type (HS IIb), and free perforation (HS IIc) by CT was intraoperatively (histologically) 52% (56), 92% (90), and 100% (100), respectively.ConclusionsThe CT is one of the most accurate methods for staging in SD. However, in the phlegmonous type (HS IIa), it leads to an overestimation of the findings in every third patient. It must be clarified whether this pronounced low inflammation should really be regarded as a complicated form of SD. In contrast, the abscess-forming (HS IIb) and free perforated (HS IIc) type of complicated SD is very well reflected by CT.

Determination of the temperature-dependent electric conductivity of liver tissue ex vivo and in vivo: Importance for therapy planning for the radiofrequency ablation of liver tumours

Introduction: Knowledge about the changes in the electric conductivity during the coagulation process of radiofrequency ablation of the liver is a prerequisite for the predictability of produceable thermonecrosis in the liver. Materials and methods: Continuous measurements of the electric conductivity σ in ex vivo porcine liver (n = 25) were done during the coagulation and cooling process at the temperature range of the radiofrequency ablation at a frequency of 470 kHz relevant for the radiofrequency ablation. Measurements of the electric conductivity were performed in both perfused porcine liver (n = 3) and a human surgical specimen from a colorectal liver metastasis. Results: At a body temperature of 37°C, conductance σ was 0.41 siemens per metre (0.32 S/m; 0.52 S/m). Conductance σ increased continuously and uniformly at a temperature of 77°C. Maximum conductance σ with 0.79 S/m (0.7 S/m; 0.87 S/m) was reached at 80°C. A continuous reduction of conductance was observed during the cooling phase. At 37°C, the specific conductance σ in the healthy perfused porcine liver was 0.52 S/m, 0.55 S/m and 0.57 S/m (mean 0.55 S/m). The electric conductivity of the human colorectal liver metastasis was clearly higher. Conclusion: Changes in the specific conductivity during the coagulation and the cooling phase play an important role for the produceable size of a coagulation necrosis and necessitates an adaptation of the therapy parameters during radiofrequency ablation.

Expression of catalytic proteasome subunits in the gut of patients with Crohn's disease

Background and purposeActivation of the transcription factor NF-κB by proteasomes and subsequent nuclear translocation of cytoplasmatic complexes play a crucial role in the intestinal inflammation. Proteasomes have a pivotal function in NF-κB activation by mediating degradation of inhibitory IκB proteins and processing of NF-κB precursor proteins. This study aims to analyze the expression of the human proteasome subunits in colonic tissue of patients with Crohn’s disease.Materials and methodsThirteen patients with Crohn’s disease and 12 control patients were studied. The expression of immunoproteasomes and constitutive proteasomes was examined by Western blot analysis, immunoflourescence and quantitative real-time PCR. For real-time PCR, AK2C was used as housekeeping gene.ResultsThe results indicate the influence of the intestinal inflammation on the expression of the proteasomes in Crohn’s disease. Proteasomes from inflamed intestine of patients with Crohn’s disease showed significantly increased expression of immunosubunits on both protein and mRNA levels. Especially, the replacement of the constitutive proteasome subunit β1 by inducible immunosubunit β1i was observed in patients with active Crohn’s disease. In contrast, relatively low abundance of immunoproteasomes was found in control tissue.ConclusionsOur data demonstrate that in contrast to normal colonic tissue, the expression of immunoproteasomes was evidently increased in the inflamed colonic mucosa of patients with Crohn’s disease. Thus, the chronic intestinal inflammation process in Crohn’s disease leads to significant alterations of proteasome subsets.

The vascular cooling effect in hepatic multipolar radiofrequency ablation leads to incomplete ablation ex vivo

Abstract Purpose: Major limitations of conventional RFA are vascular cooling effects. However, vascular cooling effects are supposed to be less pronounced in multipolar RFA. The objective of this ex vivo study was a systematic evaluation of the vascular cooling effects in multipolar RFA. Materials and methods: Multipolar RFA with three bipolar RFA applicators was performed ex vivo in porcine liver (applicator distance 20 mm, energy input 40 kJ). A saline-perfused glass tube (‘vessel’) was placed parallel to the applicators in order to simulate a natural liver vessel. Five applicator-to-vessel geometries were tested. A liquid-filled glass tube without perfusion was used as a dry run. Ablations were orthogonally cut to the applicators at a defined height. Cooling effects were analysed qualitatively and quantitatively along these cross sectional areas. Results: Thirty-six ablations were performed. A cooling effect could be seen in all ablations with perfused vessels compared to the dry run. While this cooling effect did not have any influence on the ablation areas (859–1072 mm2 versus 958 mm2 in the dry run, p > 0.05), it had a distinctive impact on ablation shape. A vascular cooling effect could be observed in all ablations with perfusion directly around the vessel independent of the applicator position compared to the dry run (p < 0.01). Conclusions: A vascular cooling effect occurred in all multipolar RFA with simulated liver vessels ex vivo independent of the applicator-to-vessel geometry. While the cooling effect did not influence the total ablation area, it had a distinctive impact on the ablation shape.

Complications after end-to-end vs. side-to-side anastomosis in ileocecal Crohn's disease--early postoperative results from a randomized controlled multi-center trial (ISRCTN-45665492).

BackgroundRecurrent Crohn’s disease activity at the site of anastomosis after ileocecal resection is of great surgical importance. This prospective randomized multi-center trial with an estimated case number of 224 patients was initially planned to investigate whether stapled side-to-side anastomosis, compared to hand-sewn end-to-end anastomosis, results in a decreased recurrence of Crohn’s disease following ileocolic resection (primary endpoint). The secondary endpoint was to focus on the early postoperative results comparing both surgical methods. The study was terminated early due to insufficient patient recruitment and because another large study investigated the same question, while our trial was ongoing.Methods and study designPatients with stenosing ileitis terminalis in Crohn’s disease who underwent an ileocolic resection were randomized to side-to-side or end-to-end anastomosis. Due to its early discontinuation, our study only investigated the secondary endpoints, the early postoperative results (complications: bleeding, wound infection, anastomotic leakage, first postoperative stool, duration of hospital stay).ResultsFrom February 2006 until June 2010, 67 patients were enrolled in nine participating centers. The two treatment groups were comparable to their demographic and pre-operative data. BMI and Crohn’s Disease Activity Index were 22.2 (±4.47) and 200.5 (±73.66), respectively, in the side-to-side group compared with 23.3 (±4.99) and 219.6 (±89.03) in the end-to-end group. The duration of surgery was 126.7 (±42.8) min in the side-to-side anastomosis group and 137.4 (±51.9) min in the end-to-end anastomosis group. Two patients in the end-to-end anastomosis group developed an anastomotic leakage (6.5%). Impaired wound healing was found in 13.9% of the side-to-side anastomosis group, while 6.5% of the end-to-end anastomosis group developed this complication. The duration of hospital stay was comparable in both groups with 9.9 (±3.93) and 10.4 (±3.26) days, respectively.ConclusionsBecause of the early discontinuation of the study, it is not possible to provide a statement about the perianastomotic recurrence rates regarding the primary endpoint. With regard to the early postoperative outcome, we observed no difference between the two types of anastomosis.

Clostridium difficile infection of the small bowel—two case reports with a literature survey

IntroductionDiseases associated with Clostridium difficile range from antibiotic-related diarrhea to pseudomembranous enterocolitis, and are serious nosocomial infections with high morbidity and mortality. The C. difficile infection has thus far been regarded as a disease typically affecting the colon. However, the literature contains an increasing number of reports describing infections of the small bowel with fulminant clinical courses and high mortality rates of 60–83%. We think this situation is not very well known.MethodsWe present two cases of confirmed C. difficile enteritis and a survey of the literature.ConclusionC. difficile enteritis is characterized by a rising incidence, a sometimes fulminant clinical course, and high mortality rates. Early diagnosis of the disease by toxin detection and endoscopy is of paramount importance and can play a substantial role in improving outcomes.

Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group

PurposeCorrect diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year.Materials and methodsThe Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement).ResultsFull or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy.ConclusionThe GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.

[Results of sigma resection in acute complicated diverticulitis : method and time of surgical intervention].

BACKGROUND The aim of this study was to check the results of laparoscopic sigmoid resection for sigmoid diverticular disease with respect to stage of inflammation and time of surgical intervention. PATIENTS AND METHODS All patients were divided into four groups: uncomplicated (Group 1) vs complicated diverticular disease (Group 2), and depending on surgical intervention in early elective (4-8 days, Group A) vs late elective sigmoid resection (4-6 weeks, Group B). RESULTS At total of 244 patients underwent laparoscopically-assisted resection during the examination period. Differences in favor of Group 1 were found in duration of surgery (153 min vs 167 min), postoperative wound infections (3.55% vs 15.5%), and postoperative hospitalization period (12.2 days vs 14.6 days). Group A had more conversions (7.8% vs 0.9%), more minor complications (25.9% vs 12.9%), and more wound infections (16.4% vs 4.6%) than Group B. CONCLUSIONS Laparoscopic sigmoid resection can be performed in cases of complicated diverticulitis without significantly increasing their overall morbidity. Because of the lower complication rate, we recommend that patients with acute sigmoid diverticulitis receive initial antibiotic treatment and then undergo late elective laparoscopic sigmoid resection.